Blackpool Victoria Hospital NewApproachFocused Report ... · LetterfromtheChiefInspectorofHospitals...

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Ratings

Overall rating for this hospitalUrgent and emergency services Requires improvement –––

Maternity and gynaecology Good –––

Blackpool Teaching Hospitals NHS Foundation Trust

BlackpoolBlackpool VictVictoriaoria HospitHospitalalQuality Report

Whinney Heys RoadBlackpoolLancashireFY3 8NRTel: 01253 655520Website: www.bfwh.nhs.uk

Date of inspection visit: 21,22 September 2015Date of publication: 29/01/2016

1 Blackpool Victoria Hospital Quality Report 29/01/2016

Letter from the Chief Inspector of Hospitals

Blackpool Victoria Hospital is the largest acute hospital of the Blackpool Teaching Hospitals NHS Foundation Trust. Ittreats more than 80,000 daycase and inpatients and more than 200,000 outpatients from across Blackpool, Fylde andWyre every year. The Urgent care service is one of the busiest in the country with more than 80,000 attendances everyyear in the emergency department. The hospital has 767 beds and employs more than 3,000 members of staff. Itprovides a wide range of services from Maternity to Care of the Elderly, and from Cancer Services to Heart Surgery.

The trust was one of the trusts identified for Professor Sir Bruce Keogh’s review of trusts in 2013 as the trust had asignificantly higher than expected mortality rate from April 2012 to March 2013. CQC inspected the trust in January 2014and found overall the hospital required improvement. Intensive/ critical care; children and young people and end of lifeservices were rated as Good. Accident and Emergency; Medical care; Surgery and Outpatients services requiredimprovement and Maternity and Family planning services were rated as inadequate.

This inspection was a follow up and was conducted on 21 and 22 September 2015. We only reviewed Maternity services,to review progress against the inadequate rating, we did not review the gynaecology service. We also reviewed theUrgent care services as continued intelligence had raised concerns with regards to the department. We also looked atthe governance and risk management support for the services we inspected. We did not undertake an unannouncedinspection as the team were confident they had gathered sufficient evidence at the announced inspection. We will applyratings to the maternity and urgent care services but these will not affect the hospital overall rating of requiresimprovement.

Our key findings were as follows:

In urgent care services we found some areas had improved since the last inspection however, the results of nationalCEM audits showed that there were improvements to be made in a number of areas where they were in the bottom 25%of participating trusts nationally. Plans were in place to improve and these were having an effect and were regularlymonitored. However, the time to mental health assessment remained a concern with many patients waiting over fourhours for assessment although the trust was working with external partners providing mental health services to addressthis.

We also found that systems for checking essential equipment continued to require improvement since the lastinspection when this was raised. The hospital managers took mitigating action before we left the site. However, therewere some basic equipment shortages which were having a minimal effect on patients but are worthy of the hospitalsattention.

We also noted an induction loop system to help hearing aid users was not working at the time of our inspection. Staffdid not always utilise the language support for patient whose first language was not English and were satisfied for arelative to translate.

Leadership of the service had been improved through the employment of a matron with sole responsibility for the A&Edepartment. The new matron however, had only been in post for two months. We noted that nurse appraisal rates werebelow the expected and the frequency of departmental meetings was very low. Although the team meetings had beenreintroduced it was too early to understand the efficacy of them or the matrons role on the culture and understanding ofrisk and improvement in the department. However, there was a strong multidisciplinary team in the department andstaff were positive and proud of the work they did.

Summary of findings


The organisational vision and values had been cascaded but there was a lack of documented service level strategyalthough the direction of travel was planned with eight key actions highlighted by the A&E leadership team. A trust widestrategic review was underway at the time of the re inspection. There was a current A&E strategy, developed inDecember 2014, which was under review at the time of the inspection. The current work underway in developing a trustwide strategy would inform the future A&E strategy.

The lead consultant and senior managers were aware of their challenges and there were escalation processes in placefor dealing with additional demand.

The layout of the department continued to hinder the flow of patients, bed management ensured capacity wasmonitored and managed but when the department became busy patients waited on trolleys in the walkway whilstwaiting for a cubicle. The service had escalation processes in place. The 4 hour wait standard was not always met but itwas better than the England average. The percentage of patients leaving the department before being seen was slightlyhigher than the England average however the re-admission rate and percentage of patients waiting 4 to12 hours beforebeing admitted were similar to the England average.

The separate, newly refurbished children’s department was not as busy as the adult side. Patient flow was good and itwas rare for patients not to be treated within the four hour target. However, the average time each patient spent in theemergency department was above the England average between April 2013 to March 2015.

Staffing levels for both doctors and nurses had improved although bank and agency staff continued to be utilised. Theemergency department was visibly clean. Patients nutrition and hydration needs had been assessed and patients hadfood and drinks where appropriate. Staff followed infection prevention protocols. There was a good skill mix ofcompetent staff for both adult and paediatric patients. We saw effective collaboration and communication among allmembers of the multidisciplinary team and services were set up to run 7 days a week. Compliance with mandatorytraining did not yet meet the trust’s target but was on track to meet it by year end. Risks and complaints were managedwell and there was evidence of learning from them. The trust was investing in the senior staff through leadershiptraining and coaching. Staff were positive and proud of the work they did.

Patients described a positive experience and we observed staff treating patients with compassion, respect and dignity.The department Friends and Family test scores were consistently above the national average.

In maternity services the last inspection had identified areas which were inadequate and others that requiredimprovement and an action plan had been developed to address these which has been monitored regularly. At thisinspection we found improvements had been made in the number of incidents being reported and the number ofpost-partum haemorrhages had reduced at the trust. Staffing levels in maternity services were being safely managedand a new midwifery staffing model had been introduced which had impacted positively on the department.

We found that women using maternity services had a high regard for staff and clinical teams, who were caring andtreated patients with dignity and respect. There was a good incident reporting culture and systems were in place toensure lessons were learned. Policies and procedures were up to date and in line with NICE guidance. The outcomes forpatients were in line with the England average on most of the compared measures. Where they were worse this hadbeen investigated and actions taken. There was a good system to triage patients who were admitted to the unit.Patients were offered choice of place for delivery and were included in the decision making for their care. There wasgood inclusion of the patients and systems for engagement with patients and staff were in place.

However, not all areas of the maternity unit or equipment met with infection prevention and control guidance. Thesystems for checking the maintenance of equipment and its readiness for use in an emergency were not robust. Trainingcompliance in some key areas including skills and knowledge in emergency situations did not yet meet the trust’starget.

We saw the following area of outstanding practice:

Summary of findings


• The trust was actively trying to support breastfeeding and there was a network of experienced breast feedingmothers called star buddies, who supported new mothers wanting to breastfeed. The star buddies were mostlyvolunteers and attended antenatal classes to provide information and advice, as well as meeting women on thematernity ward. There was a monthly rota in place covering seven days and five nights of the week. The women wespoke to were impressed with this service and had found it helpful.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the hospital must:

• Improve the outcomes for patients through the improvements demonstrated through the national CEM audits inparticular, reduce the number of patients attending urgent care services waiting for mental health assessment forover four hours.

In addition the hospital should:

• Maintain all equipment in both urgent care and maternity is checked as per the policy and kept clean within theinfection prevention and control guidance for each specific item.

• Consider improving the monitoring of the impact of actions taken as a result of incident investigations in maternityservices.

• Maintain training for all staff working in the maternity department with basic life support, blood transfusion andCTG training by the year end.

• Address the insufficient supply of basic equipment e.g. thermometers in A&E.

• Review the computer equipment in ‘minors’ area of A&E to ensure consistent recording of patients’ treatment.

• Try to improve patient confidentiality at the reception.

• improve staff utilisation of translation support when dealing with patients in A&E who require communicationsupport.

Professor Sir Mike RichardsChief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Urgent andemergencyservices

Requires improvement ––– We rated urgent and emergency service overall asrequires improvement. We rated the services asgood for being safe, caring and responsive andrequires improvement for being effective andwell-led.At this inspection in September 2015 we foundsome areas had improved since the last inspection.However, the results of national CEM audits showedthat there were improvements to be made in anumber of areas where they were in the bottom25% of participating trusts nationally. Plans were inplace to improve and these were regularlymonitored. The time to mental health assessmentremained a concern with many patients waitingover four hours for assessment although the trustwas working with external partners providingmental health services to address this.We also found that systems for checking essentialequipment continued to require improvement sincethe last inspection when this was raised. Thehospital managers took mitigating action before weleft the site. However, there were some basicequipment shortages which were having a minimaleffect on patients but are worthy of the hospitalsattention.We also noted a shortage of hand sanitizers in theentrance and an induction loop system to helphearing aid users was not working at the time of ourinspection. Staff did not always utilise the languagesupport for patient whose first language was notEnglish and were satisfied for a relative to translate.Leadership of the service through the servicemanager and lead consultant had been improvedthrough the employment of a matron with soleresponsibility for the A&E department. The newmatron however, had only been in post for twomonths. We noted that nurse appraisal rates werebelow the expected and the frequency ofdepartmental meetings was very low. Although themeetings had been reintroduced it was too early tounderstand the efficacy of them or the matrons roleon the culture and understanding of risk and

Summaryoffindings

Summary of findings


improvement in the department. However, therewas a strong multidisciplinary team in thedepartment and staff were positive and proud ofthe work they did.The layout of the department continued to hinderthe flow of patients, bed management ensuredcapacity was monitored and managed but when thedepartment became busy patients waited ontrolleys in the walkway whilst waiting for a cubicle.The service had escalation processes in place. The 4hour wait standard was not always met but it wasbetter than the England average. The percentage ofpatients leaving the department before being seenwas slightly higher than the England averagehowever the re-admission rate and percentage ofpatients waiting 4 to12 hours before being admittedwere similar to the England average.The separate, newly refurbished children’sdepartment was not as busy as the adult side.Patient flow was good and it was rare for patientsnot to be treated within the four hour target.However, the average time each patient spent in theemergency department was above the Englandaverage between April 2013 to March 2015.Staffing levels for both doctors and nurses hadimproved but bank and agency staff continued tobe needed to cover vacancies. The emergencydepartment was visibly clean. Patients nutritionand hydration needs had been assessed andpatients had food and drinks where appropriate.Staff followed infection prevention protocols. Therewas a good skill mix of competent staff for bothadult and paediatric patients. We saw effectivecollaboration and communication among allmembers of the multidisciplinary team and serviceswere set up to run 7 days a week. Compliance withmandatory training did not yet meet the trust’starget but was on track to meet it by year end.Complaints were managed well and there wasevidence of learning from them. The trust wasinvesting in the senior staff through leadershiptraining and coaching. Staff were positive andproud of the work they did.Patients described a positive experience and weobserved staff treating patients with compassion,respect and dignity. Patients were involved in their

Summaryoffindings

Summary of findings


care and treatment being supported to makeinformed choices. The department Friends andFamily test scores were consistently above thenational average.The organisational vision and values had beencascaded to all staff however there was a lack ofdocumented service level strategy although thedirection of travel was planned with eight keyactions highlighted by the A&E leadership team. Atrust wide strategic review was underway at thetime of the re inspection.There was a current A&Estrategy, developed in December 2014, which wasunder review at the time of the inspection. Thecurrent work underway in developing a trust widestrategy would inform the future A&E strategy.Thelead consultant and senior managers were aware oftheir challenges and there were escalationprocesses in place for dealing with additionaldemand.The department risks were monitored through theunscheduled care risk register which was up todate. These risks, incidents and performance werereviewed through the regular clinical governancemeetings and appropriate actions taken.

Maternityandgynaecology

Good ––– At the last inspection areas were identified in thematernity services which were inadequate andothers that required improvement and an actionplan had been developed to address these whichhas been monitored regularly. At this inspection inSeptember 2015 we found improvements had beenmade in the number of incidents being reportedand the number of post-partum haemorrhages hadreduced at the trust. Staffing levels in maternityservices were being safely managed and a newmidwifery staffing model had been introducedwhich had impacted positively on the department.We found that women using maternity services hada high regard for staff and clinical teams, who werecaring and treated patients with dignity andrespect. There was a good incident reportingculture and systems were in place to ensure lessonswere learned. Policies and procedures were up todate and in line with NICE guidance. The outcomesfor patients were in line with the England averageon most of the compared measures. Where theywere worse this had been investigated and actions

Summaryoffindings

Summary of findings


taken. There was a good system to triage patientswho were admitted to the unit. Patients wereoffered choice of place for delivery and wereincluded in the decision making for their care. Therewas good inclusion of the patients and systems forengagement with patients and staff were in place.However, not all areas of the maternity unit orequipment met with infection prevention andcontrol guidance. The systems for checking themaintenance of equipment and its readiness for usein an emergency were not robust. Trainingcompliance in some key areas including skills andknowledge in emergency situations did not yetmeet the trust’s target.

Summaryoffindings

Summary of findings


BlackpoolBlackpool VictVictoriaoria HospitHospitalalDetailed findings

Services we looked atUrgent and emergency services; Maternity


Contents

PageDetailed findings from this inspectionBackground to Blackpool Victoria Hospital 10

Our inspection team 10

How we carried out this inspection 11

Facts and data about Blackpool Victoria Hospital 11

Our ratings for this hospital 11

Findings by main service 12

Action we have told the provider to take 49

Background to Blackpool Victoria Hospital

Blackpool Victoria Hospital is the largest acute hospital ofthe Blackpool Teaching Hospitals NHS Foundation Trust.It treats more than 80,000 day-case and inpatients andmore than 200,000 outpatients from across Blackpool,Fylde and Wyre every year. Its Emergency Department isone of the busiest in the country with approximately85,000 attendances every year. The hospital has 767 bedsand employs more than 3,000 members of staff. Itprovides a wide range of services from Maternity to Careof the Elderly, and from Cancer Services to Heart Surgery.

Blackpool Victoria is one of four hospitals in the NorthWest that provides specialist Cardiac Services and servesHeart Patients from Lancashire and South Cumbria.

The trust was one of the trusts identified for Professor SirBruce Keogh’s review of trusts in 2013 as the trust had a

significantly higher than expected mortality rate fromApril 2012 to March 2013. CQC inspected the trust inJanuary 2014 and found overall the hospital requiredimprovement. Intensive/ critical care; children and youngpeople and end of life services were rated as Good.Accident and Emergency; Medical care; Surgery andOutpatients services required improvement andMaternity and Family planning services were rated asinadequate.

This inspection was a follow up and only coveredMaternity services to review progress against theinadequate rating and the Urgent care services ascontinued intelligence had raised concerns with regardsto its performance. We also looked at the governance andrisk management support for the services we inspected.

Our inspection team

Our inspection team was led by:

Hospital Inspection Manager: Lorraine Bolam, CareQuality Commission

The team included six CQC inspectors, three who wereobserving as part of their induction to the organisation,and a variety of specialists including a Midwife;

Consultant Midwifery Advisor, with experience as aCommunity Midwifery and Antenatal Clinic Matron;Consultant Obstetrician and Gynaecologist; a NurseManager with experience in Emergency Care, both adultand paediatric and a Director of Clinical Quality. We werealso supported by two experts by experience.

Detailed findings


How we carried out this inspection

To get to the heart of patients’ experiences of care, wealways ask the following five questions of every service

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well led?

Before visiting, we reviewed a range of information weheld and asked other organisations to share what theyknew about the hospitals. These included the clinicalcommissioning group (CCG) and the local Healthwatch.

The inspection team inspected the following coreservices at Blackpool Victoria Hospital:

• Accident and emergency

• Maternity

We carried out an announced inspection visit of thehospital on 21 and 22 September 2015. We held focusgroups with a range of staff in the hospital, includingobstetricians, A&E Consultants, Midwives, Communitymidwives and A&E nursing staff. We also spoke withmembers of the executive team.

We talked with patients and staff from all the ward areaswe visited. We observed how people were being caredfor, talked with carers and/or family members, andreviewed patients’ records of personal care andtreatment.

We did not carry out an unannounced inspection at thishospital.

Facts and data about Blackpool Victoria Hospital

Blackpool Victoria Hospital is the main site of BlackpoolTeaching Hospitals NHS Foundation Trust which wasestablished in December 2007, and serves a populationof approximately 330,000 residents and 10 million visitorsto the area every year. The Trust also provides servicesfrom Clifton Hospital and Fleetwood Hospital andCommunity services across Blackpool Fylde Coast andNorth Lancashire.

It is also one of four tertiary cardiac centres in the NorthWest, providing specialist cardiac services to heartpatients from Lancashire and South Cumbria.

The hospital is located in the Blackpool District which isin the 5th quintiles of the 2010 English Indices ofDeprivation where the 1st quintile is the least deprived.

Our ratings for this hospital

Our ratings for this hospital are:

Safe Effective Caring Responsive Well-led Overall

Urgent and emergencyservices Good Requires

improvement Good Good Requiresimprovement

Requiresimprovement

Maternity andgynaecology

Requiresimprovement Good Good Good Good Good

Overall trust Requiresimprovement N/A N/A N/A N/A N/A

Detailed findings


Safe Good –––

Effective Requires improvement –––

Caring Good –––

Responsive Good –––

Well-led Requires improvement –––

Overall Requires improvement –––

Information about the serviceEmergency and urgent services for Blackpool TeachingHospitals NHS Trust were provided from Blackpool VictoriaHospital. The emergency department was open 24 hours aday, seven days a week.

During April 2014 and March 2015, just over 85,000 patients(adults and children) attended the emergency department.About 15,300 (18%) were children. The department had twoentrances - one for ambulances and one for walk-inpatients. Reception staff received patients and started theircare pathway.

The emergency department had a triage and ambulatorycare area, cubicle and side room areas, and a ‘majors’ areafor more serious cases. The reception staff also signpostedpatients to the urgent care centre, which was on thehospital site but operated by a different provider (FCMS(NW) Ltd) and so we did not inspect this service.

The emergency department included the observationward. This was a short-stay nurse-led ward with two bayedareas that accommodated four patients each, two siderooms and a treatment room, making 10 beds in total.Support was provided by the enhanced discharge team ofphysiotherapy and occupational therapy staff, whoprovided prompt and focused care to support rapiddischarge of patients.

The ward was intended for short-stay patients who did notrequire formal admission to hospital, such as those who

required longer observation than could be provided in theemergency department (for example, patients with headinjuries) patients awaiting transfer home or for otherservices to commence.

We visited the emergency department at Blackpool VictoriaHospital during our follow-up announced inspection on 21and 22 September 2015.

We spoke with 15 patients and nine relatives or carers, and25 staff of different grades, including doctors, nurses,consultants, senior managers, a therapist, emergencynurse practitioners, support staff and ambulance staff. Weobserved care and treatment and looked at care recordsfor 10 patients. We received comments from people whocontacted us to tell us about their experiences and wereviewed items from the trust’s quality monitoringinformation and data.

Urgentandemergencyservices

Urgent and emergency services


Summary of findingsWe rated urgent and emergency service overall asrequires improvement. We rated the services as good forbeing safe, caring and responsive and requiresimprovement for being effective and well-led.

At this inspection in September 2015 we found someareas had improved since the last inspection. However,the results of national CEM audits showed that therewere improvements to be made in a number of areaswhere they were in the bottom 25% of participatingtrusts nationally. Plans were in place to improve andthese were regularly monitored. The time to mentalhealth assessment remained a concern with manypatients waiting over four hours for assessmentalthough the trust was working with partners to addressthis.

We also found that systems for checking essentialequipment continued to require improvement since thelast inspection when this was raised. The hospitalmanagers took mitigating action before we left the site.However, there were some basic equipment shortageswhich were having a minimal effect on patients but areworthy of the hospitals attention.

We also noted an induction loop system to help hearingaid users was not working at the time of our inspection.Staff did not always utilise the language support forpatient whose first language was not English and weresatisfied for a relative to translate.

Leadership of the service through the service managerand lead consultant had been improved through theemployment of a matron with sole responsibility for theA&E department. The new matron however, had onlybeen in post for two months. We noted that nurseappraisal rates were below the expected and thefrequency of departmental meetings was very low.Although the meetings had been reintroduced it wastoo early to understand the efficacy of them or thematrons role on the culture and understanding of riskand improvement in the department. However, therewas a strong multidisciplinary team in the departmentand staff were positive and proud of the work they did.

The layout of the department continued to hinder theflow of patients, bed management ensured capacity

was monitored and managed but when the departmentbecame busy patients waited on trolleys in the walkwaywhilst waiting for a cubicle. The service had escalationprocesses in place. The 4 hour wait standard was notalways met but it was better than the England average.The percentage of patients leaving the departmentbefore being seen was slightly higher than the Englandaverage however the re-admission rate and percentageof patients waiting 4 to12 hours before being admittedwere similar to the England average.

The separate, newly refurbished children’s departmentwas not as busy as the adult side. Patient flow was goodand it was rare for patients not to be treated within thefour hour target. However, the average time each patientspent in the emergency department was above theEngland average between April 2013 to March 2015.

Staffing levels for both doctors and nurses hadimproved but bank and agency staff continued to beneeded to cover vacancies. The emergency departmentwas visibly clean. Patients nutrition and hydration needshad been assessed and patients had food and drinkswhere appropriate. Staff followed infection preventionprotocols. There was a good skill mix of competent stafffor both adult and paediatric patients. We saw effectivecollaboration and communication among all membersof the multidisciplinary team and services were set up torun 7 days a week. Compliance with mandatory trainingdid not yet meet the trust’s target but was on track tomeet it by year end. Complaints were managed well andthere was evidence of learning from them. The trust wasinvesting in the senior staff through leadership trainingand coaching. Staff were positive and proud of the workthey did.

Patients described a positive experience and weobserved staff treating patients with compassion,respect and dignity. Patients were involved in their careand treatment being supported to make informedchoices. The department Friends and Family test scoreswere consistently above the national average.

The organisational vision and values had beencascaded to all staff however there was a lack ofdocumented service level strategy although thedirection of travel was planned with eight key actionshighlighted by the A&E leadership team. A trust widestrategic review was underway at the time of the re




inspection.There was a current A&E strategy, developedin December 2014, which was under review at the timeof the inspection. The current work underway indeveloping a trust wide strategy would inform the futureA&E strategy.The lead consultant and senior managerswere aware of their challenges and there wereescalation processes in place for dealing with additionaldemand.

The department risks were monitored through theunscheduled care risk register which was up to date.These risks, incidents and performance were reviewedthrough the formal departmental meetings held sixweekly alternating between Directorate meetings andGovernance meetings and appropriate actions taken.

Are urgent and emergency services safe?

Good –––

We rated urgent and emergency services as good forprotecting people from harm.

There were good incident reporting systems and lessonswere learnt. Medicines were stored and administered safelyalthough checking of fridge temperatures were not alwayscompleted. Patient records were complete,contemporaneous and maintained securely. Systems andprocesses were in place to protect patients from abusewith staff trained to appropriate levels. Patients receivedinitial assessments in a timely way and this had improvedsince the last inspection although there had been delays inline with the England average over the winter months.

We found the nurse staffing levels had improved since thelast inspection through a positive response to arecruitment drive. The department used bank and agencystaff to ensure adequate numbers. All temporary staffunderwent a comprehensive induction programme. Therewere paediatric nurses providing care to for children.

Medical staffing had also improved, although recruitmentremained a challenge. The emergency department had 2.5full-time equivalent consultant vacancies and plans were inplace to fill them. One of the newly recruited consultantswas to take the lead in paediatrics. The department had ahigher number of junior grade doctors to mitigate the riskof less consultants.

The cleanliness of the emergency department had alsoimproved since the last inspection, it was visibly clean andwe observed staff cleaning trolleys between patients andusing the aseptic no-touch technique. Staff had receivedtraining in infection control, including hand hygiene.

Similar to the last inspection the portable appliance testing(PAT) system for monitoring and recording the testing andservicing of electrical equipment such as cardiac monitorsand resuscitation equipment (defibrillators) was notrobust. We also found the department did not havesufficient basic equipment to monitor patients’temperature for example and equipment that wasavailable was not checked regularly. When we highlightedthis to the trust they informed us that new defibrillatorswere currently being checked before being distributed. All




equipment had been checked in the department before weleft the site and post the inspection the trust providedassurance that the risk had been mitigated. All defibrillatorswere in working order and daily checks and spot checkswere being conducted.

Incidents

• Staff reported incidents of harm or risk of harm usingthe trust-wide electronic incident reporting system.Learning from incidents was shared with the seniorteam and with staff at handovers or team meetings. Thiswas confirmed in minutes we reviewed. In addition, thetrust included a summary of lessons learnt in the staffnewsletter.

• The strategic executive information system data showedthere were two serious untoward incidents in relation toemergency and urgent care services reported during2015, both of which had been the subject of a full rootcause analysis (a detailed investigation of thecircumstances leading to the incident). These wereregarding a delay in patient diagnosis and an accidentaloverdose of medication. Nursing and medical staff wespoke with were able to describe the two seriousuntoward incidents and actions taken by thedepartment to help to minimise the risk of recurrence.Staff also told us about learning from drug errors made.

• Staff said there was an ‘open culture’ about raisingconcerns. Junior staff said they were able to shareconcerns directly with both medical and nursing staff.

• An action plan had been developed following the visitby the Emergency care intensive support team (ECIST) inJune 2014. The trust ECIST Outcome report dated June2015 showed the emergency department had seen a63% reduction in minor (level 2) harms and a 27%reduction in moderate/serious (level 3) harms. Inaddition there had been a 16% increase in the reportingof incidents in 2014/15 falling into the near miss or lowharm categories. This showed a positive reduction inharms which were not a result of a reduction inreporting.

• Staff took part in mortality and morbidity meetingswhere individual cases of patient deaths were presentedand discussed. Staff said there was always a debrieffollowing the death of a child or a distressing situationin paediatrics, which was good practice.

• Staff were aware of the duty of candour regulationwhich identifies specific action to be taken to notify therelevant person, as soon as is reasonably practicable

after becoming aware that a notifiable safety incidenthas occurred, firstly in person and then in writing. Therewas a Patient Safety Including Being Open and Duty ofCandour Policy in place which had been supported bytraining.

Cleanliness, infection control and hygiene

• The emergency department, including bed areas andcommodes, was visibly clean. We observed staffcleaning trolleys between patients and using the asepticno-touch technique. Mandatory training recordsshowed 83 % of staff had received training in infectioncontrol, including hand hygiene.

• Staff followed hand hygiene and ‘bare below the elbow’guidance and they wore personal protective equipment,such as aprons and gloves, as they delivered care.

• The infection control policy included screening allpatients who were to be admitted to a ward forMethicillin-Resistant Staphylococcus Aureus (MRSA) orClostridium difficile. Staff made a note on the electronicrecord for any patients with infectious conditions sopatients could be readily identified and treatedappropriately.

• Staff handled, stored and disposed of clinical waste,including sharps bins, appropriately. Managersmonitored compliance checks weekly and monthly andreported their findings as ‘Knowing how we are doing’.Information shared included cost, safety, people,delivery and quality. Audits included the cleanliness ofthe environment and equipment and hand hygiene. Thehand hygene audit for June 2015 identified thatalthough staff adhered to the policy patients were notalways supported to do so. Green ‘I am clean’ stickerswere attached to cleaned equipment and commodeswere visibly clean.

Environment and equipment

• Patients taken to the emergency department byambulance entered through a separate entrance fromother patients. The main department was separatedinto three areas: ambulatory care, minors (for minorinjuries or illnesses) and majors (for more serious cases).Patients assessed as being at risk of deterioration orthose with a high level of need were accommodated incubicles visible from the nursing stations so staff wereable to intervene rapidly if necessary. The emergencydepartment used 10 short-stay beds on the observationward if a patient required further monitoring. Since our




last inspection in April 2014, the service had refurbishedpart of the emergency department to provide a separatechildren’s department. However, this had no separateaccess so children had to pass through the adultdepartment.

• Staff had access to security alarms in each cubicle toprotect them in the event of an emergency.

• The resuscitation area had three cubicles, with onedesignated for children. The cubicles were allwell-equipped with general equipment for both adultand paediatric patients. However, The threedefibrillators in the resuscitation area had stickerssaying they were last serviced in 2011 and two of themhad no asset number. One of the storage cabinets hadthe drawer missing and there was exposed chipboard atthe front. There were no service dates or electrical safetystickers on either of the electrocardiograph (ECG)machines.

• We raised with the trust that the portable appliancetesting (PAT) system for monitoring and recording thetesting and servicing of electrical equipment such ascardiac monitors and resuscitation equipment(defibrillators) was not effective. They assured us that allequipment had been maintained correctly by themanufacturers and was tracked appropriately either byasset numbers or serial numbers. The trust sent amedical engineer to the department to test alldefibrillators, label them and update the equipmentregister and they contacted us post the inspection toconfirm this had been completed.

• The directorate manager gave us assurance that all theequipment had planned preventative maintenancechecks and the medical engineering team werecompiling a report of all equipment that had recentlybeen back to manufacturers so they could be labelledcorrectly with service dates. This was completed by thetrust after the inspection.

• Clinical staff had checked daily that defibrillators were inworking order and recorded the results. The matron saidthe resuscitation team were doing spot checks to makesure the daily checks were taking place.

• Defibrillators were being replaced and the emergencydepartment was due to be the first to receive new oneswithin a few weeks. This was expedited and the newequipment was in the department before we left theinspection.

• The department did not have enough basic equipmentto monitor patients. Staff told us some equipment (for

example, thermometers) was not always readilyavailable. We saw staff having to leave the triage area tolook for thermometers, which they borrowed from thechildren’s area. This did not have a significant impact onpatients.

• There were only two cardiac (ECG) machines. If bothwere being used in the resuscitation area, this had thepotential to cause delay if one were needed elsewherein the emergency department.

• The emergency department had a secure room that wasused to assess patients with mental health needs. Thismet the Section 136 room guidelines (a designatedplace of safety) under the Mental Health Act 1983. Staffwere not aware of the NHS Protect guidance ondistressed patients, which could mean that patientswith mental health problems would not be treatedappropriately.

Medicines

• Medicines, including controlled drugs, were storedsecurely and in line with legal requirements.

• Staff we spoke with were familiar with policies formanaging medication and there were printed copiesavailable in the department.

• The fridges used to store medication were within therequired temperature range but temperatures were notchecked daily in line with trust policy. We saw that onoccasional days the fridge temperature had not beenchecked. Keeping fridges at the right temperature isimportant because some drugs deteriorate if not keptcold enough.

• Pharmacy staff maintained minimum stock levels andchecked medication expiry dates.

• Medicines were ordered and returned to pharmacysafely. We checked the controlled drugs in theemergency department and found the stock balanceswere correct and the registers had been signed by twomembers of staff when drugs were dispensed. Thevolume of any wasted drugs was recorded accuratelywhere necessary.

• Nursing staff in the emergency department routinelyadministered a select range of medications usingpatient group directions (written instructions that allownon-prescribing healthcare professionals to supply andadminister specific medications to patients who meetset criteria). The practice complied with the relevantlegislation (Human Medicines Regulations 2012).




• We saw that any known allergies were clearly recordedin the patient’s records.

Records

• We reviewed six sets of adult and four sets of paediatricpatients’ records and saw clinical assessment, diagnosisand treatment plans clearly documented.

• All nursing and medical documentation was recordedon the computer. For patient observations, paperrecords were used. Records included a tracker alert forrisks, including safeguarding from abuse, infections andallergies.

• Two patients had been reviewed by an alcohol specialistnurse, who had filled in the associated observationcharts. Another patient was allergic to penicillin, whichwas clearly identified and highlighted in their notes.

• We saw evidence that patients who were admitted tothe emergency department after having been initiallyassessed and treated underwent risk assessments.Examples included, nutrition, pressure care and falls riskassessment.

• Staff said the computer equipment in ‘minors’ area didnot always work, which led to problems recordingpatients’ treatment.

• Records were held securely.

Safeguarding

• The department had appropriate processes forsafeguarding patients from abuse.

• The emergency department had a consultant lead forvulnerable adults and there was a trust lead forvulnerable children.

• Staff knew where to find policies for safeguardingvulnerable adults and children from abuse. The policycovered issues including domestic and sexual abuse,female genital mutilation, radicalisation, forcedmarriage, sexual exploitation and honour-basedviolence.

• An emergency department nurse described howpatients were checked on admission for signs of abuseor neglect, such as marks on their body or dehydration.Staff knew how to identify abuse and confirmed theywere familiar with the referral process if they hadconcerns that an adult or child was at risk of abuse.They had good relationships with the local safeguardingteams for making referrals.

• The electronic patient record system alerted staff to anyprevious safeguarding issues. Safeguarding recordswere well completed.

• The training report provided by the trust for September2015 showed 97% of nursing staff had completed Level 1safeguarding children training; 87% had completed level2 training and 88% were trained to level 3.

• Of the additional clinical services staff over 98% hadcompleted level 1 safeguarding children training; 80%level 2 and 100% level 3 training.

• Safeguarding adults training had been completed by98% of nursing staff and over 98% of additional clinicalservices staff.

• The matron reminded staff who had not yet completedthis training.

Mandatory training

• Staff received mandatory training in areas such asinfection prevention and control, moving and handling,equality and diversity and human rights, harassmentand bullying, manual handling, consent, risk awareness,dementia awareness, and safeguarding children andvulnerable adults.

• Mandatory training was calculated in year as opposedto staff being in date with their training updates.

• Across the emergency and urgent services division lessthan 80% of staff had completed most mandatorytraining in year. This did not meet with the trust’s targetof 90%.

• Information provided by the trust showed only 61.4% ofstaff had completed training in adult basic life supportbut the trust did not supply data regarding thepercentage of staff who had completed Paediatric lifesupport but their nursing resource plan assured thatthere was always staff on duty with these skills.

• All the paediatric team were RSCN and supported tocomplete their Advanced Paediatric Life Support.

• In addition, all the main department band 7 nurses andband 6 nurses were supported to complete AdvancedPaediatric Life Support and a number of these were oneach shift which was supported by the nursing resourceplan we reviewed.

• All the Emergency department qualified nurses weretrained in Paediatric Life Support prior to working in theresus area, and these nurses would be used to supportthe paediatric nurses if required.

Assessing and responding to patient risk




• Staff followed clear processes to assess patients.• The rapid assessment and treatment initiative (RAT) had

been fully in place from December 2014. A directcomparison of time to initial assessment between 2013/14 and December 2014 toJune 2015 showed a 10minute improvement, moving the time to initialassessment from an average of 24 minutes to 14minutes.

• Patients arriving on foot checked in at a reception deskand their condition was assessed by a triage nurseassigned them to the minor or major injuries areasdepending on their clinical need. The median time toinitial assessment was in the range 5-8 minutes(Jan'13-Feb'15), and above the England average for 22of the 25 months.

• An early warning score (EWS) was part of the patientrecord, with clear instructions for staff on how toescalate a patient whose condition was deteriorating.EWS is a system that scores vital signs and is used foridentifying patients who are deteriorating clinically. Forpaediatrics, there were five different EWS forms in use tocover the different age ranges. Records we revieweddemonstrated this system was effective.

• During part of the inspection the department becamebusy and there were insufficient cubicles toaccommodate patients. Patients waited on trolleys linedup in the department but remained in view of staff andbeing constantly monitored whilst awaiting cubiclespace. However it was unclear if patients started anyappropriate treatment before a cubicle was available,for example started antibiotics.

• Senior clinician advice was available at all times.Consultants were based in the department until at leastmidnight or available on call with the ability to attendwithin approximately 30 minutes if required.

• Paediatric patients (babies and children) were assessedby childrens nurses and waited in a separate areadesignated for children. A consultant to lead paediatriccare had been recruited although was not in post at thetime of the inspection.

• Staff in the emergency department could call securityfor immediate support and would also dial 999 forpolice assistance if required. Although there was limitedpresence of security staff in the emergency department,staff reported they felt safe. Six staff told us they had

received conflict resolution training. Informationprovided by the trust showed 63% of emergencydepartment staff had completed training in conflictresolution.

• We observed the effective management of a scenariowhereby security and the police were called to supportthe staff with a patient whose behaviour waschallenging. The patient was supported with dignity andrespect by all staff involved and the outcome wasfavourable in meeting the needs of the patient.

Nursing staffing

• Staffing levels were appropriate during the inspection.Nursing staff of different grades were assigned to thedifferent patient areas. A senior staff member was incharge as the shift lead and coordinator. In addition, asenior nurse covered the resuscitation room and theassessment area. Since the last inspection managershad changed shift patterns to provide more staff at busyperiods, for example 6pm-2am,11.00am-midnight and9.30 am-7pm and to make recruitment more attractiveand to help improve the service for staff and patients.

• The department did not use a specific acuity tool todetermine the nursing establishment but monitoring ofthe emergency department over a period of time hadgiven management sufficient information to staff itappropriately. The department used an electronic rostersystem which highlighted where the shortages were.

• Paediatrics was well staffed with sufficient paediatrictrained staff. The shifts essentially ensured that therewas a paediatric qualified nurse on duty 24 hours a day,with double cover at busy periods. Within thisestablishment there was a band 7 lead nurse and band6 senior nurse that were RSCN trained.

• The main children’s ward also supported thedepartment at times of pressure and responded withappropriately trained nurses when there were seriouslyill children on the department. These are automaticallycalled upon as part of the ‘crash’ bleep for PaediatricEmergencies.

• The lead nurse is currently being supported to completeher advanced nurse practitioner training, in partnershipwith the Children’s Directorate.

• In addition a number of general qualified nurses havebeen supported to successfully to complete the sickchildren’s module at university.

• The expected and actual staffing levels were displayedand updated on a daily basis on notice boards in the




emergency department. Senior staff carried out checksthroughout the day to monitor the flow through thedepartment of patients and escalated staffing shortfallsdue to unplanned sickness or leave.

• Cover for staff leave or sickness was provided by bank oragency staff. Duty rotas confirmed that agency staff werefamiliar with the emergency department or they usedstaff from the ‘pool’ or bank, which eased pressure onthe permanent staff. We looked at four weeks of thenursing rota and saw there was consistency in thetemporary staff used. Agency staff had a competencybased induction prior to working in the emergencydepartment. An agency nurse spoken with confirmedthey had received it.

• The emergency department had two vacancies at Band7 and five vacancies at Band 5. These posts had beensubject to recruitment, two new paediatric nursesmeant the department would be three band 5 nursesshort.

• Nursing staff of differing grades were assigned to eachpatient area to ensure patients were protected fromavoidable harm and received appropriate care. Staffinglevels on the observation ward were good. For 10patients there were two trained nurses and one healthcare assistant. Five new staff had started recently. The‘See and treat’ area (a treatment area with one bed forpatients who could be treated rapidly for example,X-rays, injuries and wounds) was adequately staffed.Staff would escalate issues to the duty matron if theywere concerned about capacity to cope with patients.

• Recruitment had started to fill nursing vacancies.Paediatric nursing staff spoke positively about havingfour new recruits, who were at different stages of theirinduction. The paediatric service had improved nowthere was a paediatric nurse 24 hours a day, which hadbuilt up the team’s skill set. Nursing staff spokefavourably of the input from a new consultant with akeen interest in paediatrics.

• The department had developed a specific inductionpack for new nursing staff including a skills log to assessstaff competencies.

• The lead nurse in paediatrics was undertaking theadvanced nurse practitioner (ANP) course to learnspecialist skills. Although they had two years still tocomplete this, management confirmed this wouldbenefit the minor injuries side of paediatrics as therewas a demand for this service.

Medical staffing

• The emergency department employed 6.5 full timeequivalent consultants plus one full time locumconsultant who had been in the department for over sixmonths. The establishment was for 10 consultants.However at September 2014 they had a higherproportion of junior doctors (33%) compared to theEngland average (24%) which offset the lowerproportion of Consultants (11% v 23%). Medical staffworked various shift patterns to cover the emergencydepartment over a 24 hour period. Consultant hoursduring the week were from 9am to 10pm with 24 hour/seven days a week on-call cover.

• There was no specific paediatric consultant howeverone of the more recently recruited consultants was totake the lead in this specialty. A junior doctor wasallocated to support the paediatric emergencydepartment each day. Junior doctors were supported bythe lead emergency department consultant and thepaediatric registrar from the paediatric ward.

• The lead consultant told us the department facedchallenges in recruiting middle grade doctors. Onlythree out of eight substantive posts were filled last year.A fourth doctor was due to start. The trust had triedrecruitment overseas but struggled to fill posts to workfrom 1pm to 10pm seven days a week. Locum doctorswere covering the vacancies.

• Staffing levels had improved with an extra registrarovernight and weekends through locum cover. Medicaland nursing staff said this had improved leadership.Despite a high turnover of junior staff there were anumber of established staff, particularly with the seniorand middle grade doctors.

Major incident awareness and training

• There was a major incident and business continuityplan available for staff. This included the key risks thatcould affect the provision of care and treatment.Guidance for staff in the event of a major incident wasreadily available and staff were aware this had recentlybeen updated.

• The emergency department had a lead consultant todeal with patients who may be contaminated withchemicals and other hazardous substances (HAZMAT).

• Three senior staff had attended simulation training inthe last 6 weeks with involvement from fire safety. Staff




were able to tell us the actions they would take in theevent of a major incident occurring. Training materialswere available included a pathway manual and video totrain staff in usage of equipment used in a majorincident.

• The department was taking special measures forpatients with symptoms of Ebola (a serious virusoriginating in Africa, which can be passed betweenpeople). Reception staff checked whether patients hadtravelled recently and knew what action to take if Ebolawas suspected. Clinical isolation rooms were availablein the paediatric area.

Are urgent and emergency serviceseffective?(for example, treatment is effective)

Requires improvement –––

We rated urgent and emergency services as requiresimprovement for being Effective.

At the previous inspection we did not rate the service forbeing effective as our methodology did not support therebeing sufficient evidence to make a judgement at that time.It has since been developed.

The department participated in national College ofEmergency Medicine audits however, the results showedthat there were improvements to be made in a number ofareas where they were in the bottom 25% of participatingtrusts nationally. These were being monitored through theClinical Governance monthly meetings.They had notparticipated in the CEM Severe sepsis and septic shocksince 2013-14 but instead were engaged with the NCEPODaudit.

However, we saw that there were up to date policies andprocedures. Clinical pathways were in place which staffused effectively and supported appropriate and timelycare. Patients were assessed for pain relief following triageand patient records demonstrated timely assessment andadministration of pain relief. Patients nutrition andhydration needs had been assessed using a MUST riskassessment and we saw patients had food and drinkswhere appropriate. There was a good skill mix ofcompetent staff for both adult and paediatric patientsattending the service. Staff had the skills and knowledge

regarding consent, MCA and DoLS. We saw effectivecollaboration and communication among all members ofthe multidisciplinary team and services were set up to run7 days a week. Nursing staff told us they receivedsupervision but less than half had received annualappraisals.

Evidence-based care and treatment

• Policies, procedure and guidelines in the emergencydepartment were based on nationally recognised bestpractice guidance from the National Institute for Healthand Care Excellence (NICE) and the Clinical Standardsfor Emergency Departments.

• Nursing and medical staff we spoke with confirmedpolicies and procedures reflected current guidelines. Welooked at four policies and procedures and these hadbeen updated and reflected national guidelines.

• A range of care pathways were followed in theemergency department, in line with national guidance,examples included trauma, sepsis, fractured neck offemur, stroke, asthma, alcohol dependency andpneumonia. We saw some of the protocols for theclinical pathways were displayed for the most frequentconditions that patients presented with at theemergency department.

• Pathways are interlinked clinical questions arrangedinto ‘pathways’. These pathways provided safe andeffective clinical decision support to trained users whoprovide assessment for patients visiting emergencydepartments. Reception staff could then direct patientsto the correct area for treatment.

Pain relief

• A screening process was in place to identify any patientsrequiring pain relief. Patients were assessed for pain andprovided with analgesia after contact with nurseprescribers during triage when they attended theemergency department.

• There was evidence in patients records that pain reliefhad been prescribed appropriately and wasadministered when pain relief was required.

• The majority of patients we spoke with told us they wereasked about pain levels and were given analgesia whenrequired.

• Within the paediatric area, we noted a behavioural painscoring tool for younger children.

• A behavioural pain scoring tool was used for patientswith a learning disability.




Nutrition and hydration

• Patients nutrition and hydration needs had beenassessed and a MUST risk assessment was recorded onthe nursing record for those patients who had been inthe department for four hours or more. Healthcareassistants were responsible for ensuring food and drinkswere provided for patients with diabetes as necessary.

• We observed staff providing drinks or snacks to patients.A vending machine was available to patients, relativesand other visitors. Prior to offering food or drinks staffchecked patients were allowed this due to the reasonfor their admission or condition.

• On the observation ward patients were offered a choiceof food and drink. Referrals were made to dieticians ifrequired. We saw staff followed care plans if patients’specific needs were identified, for example, if a patientrequired assistance at mealtimes.

Patient outcomes

• The emergency department participated in the Collegefor Emergency Medicine (CEM) national audits includingAssessing for cognitive impairment in older people;Paracetamol overdose; Mental health in the ED; Initialmanagement of the fitting child and Asthma in Childrenover the last two years.

• The results for the CEM Paracetamol Overdose 2013/14audit showed 82% of patients received treatment in linewith MHRA guidelines however, there was one form oftreatment where they did not meet the standard toadminister within one hour.

• The results for the CEM, Asthma in Children 2013/14audit showed they fell within the lower quartile (worsethan other trusts, bottom 25 %) for two of the sevenobservations expected to be recorded and in theadministration of steroids in the department andprescribing them on discharge.

• The results of the CEM, Assessing for cognitiveimpairment in older people 2014/15 audit showed theywere in the lower quartile (worse than other trusts,bottom 25 %) for early warning score documentationand undertaking a cognitive assessment.

• The results of the CEM, Mental health in the ED audit2014-15 showed they fell within the lower quartile(worse than other trusts, bottom 25 %) for riskassessment taken and reported in the patients clinicalrecord; provisional diagnosis being recorded; patientassessed by a mental health practitioner (MHP) from

organisation’s specified acute psychiatric service anddetails of any referral or follow-up arrangementsdocumented. It was also noted that there was nodedicated assessment room for mental health patientswhich has now been addressed.

• The results of the CEM, Initial management of the fittingchild 2014/15 audit showed they were about the sameas other trusts in the areas where there was a significantsample size.

• The trust had participated in the national Severe sepsisand septic shock audit in 2013-14 but had made adecision not to participate in the 2014/15 audit as thetrust was committed to the NCEPOD sepsis study andtrust wide implementation of the sepsis pathway withmonthly performance monitoring. All NICE, NCEPODSepsis 6 and CEM recommendations were implementedwithin the pathway.

• The findings from audits were reviewed, action plansdeveloped to improve the areas where shortfalls wereidentified and progress monitored. For exampleregarding care of the fitting child documentation wasimproved to make GCS / AVPU easier to record andregarding care of patients with mental health needs thedevelopment of a proforma for mental healthassessment and review of the recommendations of thePsychiatric Liaison Accreditation Network regarding theassessment room features and layout by January 2016.

• The directorate manager told us staff would beencouraged to undertake additional clinical audits toassess how well NICE and other guidelines wereadhered to. This was with a view to increasing staffeducation and changes in practice to improve patientcare.

• In July 2015, the re-attendance rate was 7.9% comparedto the England average of 7.7%.

• The clinical quality indicator for July 2015 showed 95%of patients waited under 12 minutes from arrival toinitial assessment.

• The trust ranked ‘about the same’ as other trusts for thethree questions on effectiveness in the 2014 A&E survey.

Competent staff

• Staff we spoke with in the emergency departmentreported they had received an appraisal within the last




year. An appraisal gives staff an opportunity to discusstheir work progress and future aspirations with theirmanager. Data the trust supplied showed only 45% oftrained nurses had received an annual appraisal.

• A band 5 nurse told us their objectives had been set andthey had an assigned mentor. Although their mentorwas pressured when at work, they felt able to accesssupport and guidance when needed from other staff.

• The junior and middle grade doctors we spoke with toldus they felt well supported by the consultants, theyreceived medical supervision, regular teaching sessionsand they were able to discuss any issues or concerns asrequired.

• Nursing and medical staff spoke positively about thelearning and development opportunities they were ableto undertake.

• Newly appointed staff completed an induction and hadtheir competencies assessed before workingunsupervised.

• Staff confirmed that managers provided clinicalsupervision of their work performance.

Multidisciplinary working

• We saw effective communication between members ofthe multidisciplinary team to support the planning anddelivery of patient-centred care. Daily multidisciplinaryteam meetings, involving the medical staff, nursing staff,therapists as well as social workers, child health visitors,hospital discharge team and safeguarding leads, whererequired, ensured patients’ needs were fully explored.

• We observed handovers between shifts and found themto be comprehensive and confidential.

• The mental health and alcohol liaison teams reviewedpractices and provided interventions with patientswhose admission to hospital was alcohol related.

• There was a daily consultant led multidisciplinary wardround on the observation ward, which involved nurses,physiotherapists and occupational therapists.

Seven-day services

• Sufficient out-of-hours medical cover was provided topatients in the emergency department by junior andmiddle grade doctors, including on-site and on callconsultant cover.

• Since the last inspection there was now a separatepaediatrics unit within the emergency department,staffed 24 hours a day. Staff felt they could now givebetter care to children due to this increased provision ofthe service.

• The mental health and alcohol liaison teams hadprocesses to manage referrals out of hours.

• Staff rotas showed that medical and nursing staff levelswere sufficiently maintained out of hours and atweekends.

• The diagnostic services, for example X-rays wereavailable 24 hours a day, seven days a week specificallyto support the emergency department.

• A community mental health crisis team was accessiblefor patients with mental ill health through a single pointof access referral 24 hours a day, 7 days a week.

• Pharmacy services were not available 7 days a weekhowever a pharmacist was available on call out ofhours.

Access to information

• The emergency department used an electronicinformation system to track when patients wereadmitted to the department. Staff showed us howreadily they were able to access patient information.

• Patient information such as test results, x-rays ormedical information gathered during the booking inprocess, triage or in the emergency department wasavailable on the receiving wards so staff were able toprepare for their patient.

• Safety performance information, audit results and somepathways were displayed in the emergency departmentfor staff to access readily.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Staff had the skills and knowledge to ask patients forconsent to treatment and were able to explain how theysought consent. The training records demonstrated that91% of staff in the emergency department hadcompleted training on consent and mental capacity.

• Staff understood the legal requirements of the MentalCapacity Act 2005 (MCA), Deprivation of LibertySafeguards (DoLS) and consent arrangements. Staff wespoke with had a reasonable understanding of thetrust’s policy and of the legislation. Staff told us theywould consult with a senior member of the team for




advice and would seek the advice of appropriateprofessionals to ensure decisions were made in the bestinterests of patients and that carers and family wereinvolved.

• Paediatric staff were aware of Fraser guidelines (whetherdoctors should give contraceptive advice or treatmentto under 16-year-olds without parental consent) andGillick competence (a term used in medical law todecide whether a child [for these purposes a personunder 16 years of age] is able to consent to his or herown medical treatment, without the need for parentalpermission or knowledge) was used for children wheresuitable.

• There was on line mandatory training in consent MCAand DoLS. Some staff told us additional training may beof value to help them understand this better.

• We observed nursing and medical staff gaining consentfrom patients prior to any care or procedure beingcarried out.

Are urgent and emergency servicescaring?

Good –––

We rated urgent and emergency services as good for beingcaring.

Patients described a positive experience attending theemergency department and receiving treatment. Duringthis inspection we observed staff treating patients withcompassion, respect and dignity. Patients were involved intheir care and treatment, and staff spent time explainingtreatment options to allow patients and relatives to makean informed choice. The department was working hard toincrease the Friends and Family test response rate and itsscores were consistently above the national average.

Compassionate care

• We observed good interaction and communicationbetween doctors, nurses and medical crews. Nursingstaff showed care and compassion towards patients.Staff dealt with a distressed and agitated patient in asupportive way. We saw staff providing reassurance torelatives while caring for a patient whose condition had

deteriorated. Relatives told us how assured they felt astheir loved ones’ condition was clearly explained tothem. Clerical and clinical staff were observed to becaring.

• Parents and children told us the staff were attentive totheir needs. One parent and their child told us the staffhad explained clearly exactly what treatment theyneeded.

• The trust performed consistently better than theEngland average for the Friends and Family Test. Thepatient experience dashboard showed the percentageof people who would recommend the service to theirfriends and family had gone up from 88% in April 2014to between 94 and 96% from November 2014 toFebruary 2015. The service’s results were consistentlyabove the England average. In August 2015 93.7% ofpeople were likely to recommend the services of theemergency department. Staff aimed to achieve 10patients per day to complete the survey.

• The trust ranked about the same as other trusts for the24 questions about caring in the 2014 A&E survey.

• Despite the layout of the reception making somepatients feel uncomfortable answering questions onarrival at the emergency department reception staffwere able to and tried to offer patients an opportunityto move to another area for privacy.

Understanding and involvement of patients and thoseclose to them

• Staff involved patients in their care. We saw consultantsand nursing staff keeping family members up to datewith information about patients where appropriate.Patients’ families reported good communication aboutcare. Patients and relatives we spoke with knew abouttheir family members’ diagnosis, treatment andinvestigations.

• Adult and paediatric patients and relatives spokefavourably about the information they received fromstaff both verbally and written, such as informationleaflets which were specific to their condition.

Emotional support

• We observed many episodes of patient and staffinteractions, during which staff demonstrated caringattitudes towards patients.

• Chaplaincy, bereavement or counselling services.wereavailable to support patients and their relatives.




• A family room was available to accommodate therelatives of patients who had been involved in traumaticincidents or the death of a family member/friend whichmeant that emotional support could be delivered inprivacy.

• Staff were able to access support from colleagues,managers or from counselling services. Medical andnursing staff confirmed they were able to accessdebriefing sessions after traumatic events.

Are urgent and emergency servicesresponsive to people’s needs?(for example, to feedback?)

Good –––

We rated urgent and emergency services as good for beingresponsive.

The department had guidance for staff when dealing withsurges in activity. Bed management meetings andmeetings to discuss patient flow and staffing ensuredcapacity was monitored and managed effectively. The 4hour wait standard was not met although it was better thanthe England average. The percentage of patients leavingthe department before being seen was slightly higher thanthe England average however the re-admission rate andpercentage of patients waiting 4 to12 hours before beingadmitted was similar to the England average.

Handovers from ambulance arrival to emergencydepartment that take longer than 60 minutes are alsoreferred to as ‘black breaches’. The trust was not meetingthis target between July 2014 and July 2015. Trust datashowed there were 66 black breaches during this periodbut the majority were over the winter months. The trusthad an ambulance liaison officer in post who was workingto improve these targets.

The rapid assessment and treatment initiative (RAT) andhaving a second senior trainee doctor overnight hadreduced the time patients waited before initial assessment.The median time to treatment was 63 minutes.

The paediatrics side of the emergency department was notas busy as the adult side. Patient flow was good and it wasrare for patients not to be treated within the four hour

target. However, the average time each patient spent in theemergency department was above the England average(130 to 140 minutes) for each month April 2013 to March2015 by an average of 36 minutes.

Staff demonstrated an understanding of the need torecognise the cultural, social and religious needs ofindividual patients. Complaints were managed well andtrends and themes were monitored and there was evidenceof learning from the complaints.

However, the trust ECIST outcomes report, following a visitin June 2014, highlighted the time to mental healthassessment remained a concern with 63% of patientswaiting over four hours for assessment in April 2015 whenthe report was compiled. The trust was working withexternal partners providing mental health services toaddress this.

We also noted that the induction loop system to helphearing aid users was not working at the time of ourinspection.

Service planning and delivery to meet the needs oflocal people

• The service provided care and treatment for patientsacross Blackpool and the Fylde coast. Trust datashowed that during 2014/15, approximately 85,000patients attended the emergency department.

• The Unscheduled Care Division, (the division theemergency department falls within) had an escalationpolicy that provided guidance for staff when dealingwith surges in activity, whether planned or unplanned.Twice-daily bed management meetings and meetings todiscuss patient flow and staffing took place to ensurecapacity was monitored so the flow of patients to andfrom the emergency department could be managedeffectively.

• The trust is one of the four tertiary cardiac centres in theNorth West, providing specialist cardiac services toheart patients from Lancashire and south Cumbria.

• Patients who required a stay in the hospital but not fulladmission were accommodated on the observationward. The observation ward was led by a nursing sisterand in-reach support was provided by the enhanceddischarge team of physiotherapy and occupationaltherapy staff who provided prompt and focused care tosupport rapid discharge.

Meeting people’s individual needs




• Staff demonstrated an understanding of the need torecognise the cultural, social and religious needs ofindividual patients. We observed a relative of a patientwhose first language was not English being asked by thestaff if they were satisfied for a relative to translate. Staffconfirmed language skill and appropriate translationwas assessed by clinical need. Staff said they had usedthe Language Line telephone translation service and thetrust staff with language skills to help themcommunicate with patients.

• Staff tried to assigned children with a learning disabilityto a cubicle straight away as the waiting room was notan appropriate environment. Staff had a list of childrenwho were seen regularly by the paediatrics team so theycould usually transfer them quickly to a ward wheretheir medical history and needs were known.

• An induction loop system to help hearing aid users wasinstalled in the emergency department reception areabut it was not working at the time of our inspection.

• Staff used the ‘butterfly scheme’ to help identifypatients living with dementia or otherwise in need ofmemory support.

• The waiting areas were busy but were appropriate tomeet the needs of the patients during this inspection aspeople were not left standing. We were told of plans toimprove the department.

• Patients’ privacy and confidentiality was compromisedat times. We observed how some patients feltuncomfortable answering questions on arrival at theemergency department because staff were behind awindow and other people behind them could hear whatthey were saying. In addition when the departmentbecame busy, the environment did not supportdignified care as there were not sufficient cubicles forpatients. Reception staff were able to offer patients anopportunity to move to another area for privacy.

• Information posters were displayed in the children’semergency area to help keep children safe. For example,posters gave recommendations regarding treatment fordog bites and keeping bleach out of reach.

• The Information screen in the Emergency Departmentwas constantly updated so that patients and relativeswere kept informed. It identified the staff and what theirroles were, along with the waiting times.

Access and flow

• The national standard for emergency departments is toadmit, transfer or discharge at least 95% of all patientswithin four hours of arrival. In Q2 2015/16 the 4 hourwait standard was not met at 91.8% although it was inline with the England average of 91.4%.

• Patients seen within four hours were met for themajority of weeks from April 2014 to March 2015;however, performance declined between December2014 and March 2015. Performance was above theEngland average for 42 of the 52 weeks (April 2014 toMarch 2015).

• From June 2014 to December 2014 there wereconsistent breaches. From February 2015 to the time ofthe inspection there had been a reduction in 4 hourbreaches. Senior nursing staff were aware of the reasonsfor the breaches, examples included unavailability of amedical bed and delays in access to the acute medicalbeds as discharges were happening too late in the day.Other reasons included patients waiting for mentalhealth assessments.

• The emergency department had created a detailedaction plan to improve their performance against the 4hour standard in response to an external review.Improvements included better access to intermediatecare, early supported discharges, enhancing mentalhealth services and improving the patient flow hadresulted.

• The latest figure available (July 2015) gave a Mediantime to treatment of 63 minutes.

• The percentage of patients leaving the departmentbefore being seen was above the England average foreach month from April 2013 to February 2015. The latestHSCIC published data figure available (July 2015)showed 3.8% of attendees left before being seencompared to an England average of 2.7%.

• The latest HSCIC published data figure available (July2015) gave a re-admission rate of 7.9% compared to anEngland average of 7.7%.

• In Q2 July to September 2015 the percentage of patientswaiting 4 to12 hours before being admitted was around4.3% compared to the England average of 4.5%

• The total time spent in the emergency department(average per patient) was above the England average foreach month April 2013 to March 2015 by an average of36 minutes. The England average during this period was130 to 140 minutes.

• The department saw a high number of patients withmental health problems and it could take a lengthy time




for them to be seen by external partners however thetrust was working to improve this. Patients were movedto the observation ward, where caring for them createdchallenges for the staff and other patients, many ofwhom were often older people. Some patients withmental health problems had become aggressive if keptwaiting for long periods.

• The trust ECIST outcomes report following the visit inJune 2014 highlighted the time to mental healthassessment remained a concern with 63% of patientswaiting over four hours for assessment in April 2015. Theconcerns have been raised with partner organisationand monthly meetings had been scheduled to helpdrive improvements forward. The extended waits wererecorded on the risk register. The matron confirmed staffhad a named contact for out of hours in the last monthto escalate concerns to which things had improved.

• The paediatrics side of the emergency department wasnot as busy as the adult side. Patient flow was good andit was rare for patients not to be treated within the fourhour target. When the target was exceeded it wasusually because of delays in admission to medicalwards.

• The directorate manager told us they had a specialistperson to provide advice regarding the flow of patientsacross medicine. The discharge lounge was apermanent arrangement. The trust had created ward 19as a short-stay ward.

• If the department was unusually busy a medical doctorwould come from a ward to help assess patients.

• The DH target for handovers between ambulance andemergency department is that they must take placewithin 15 minutes with no patients waiting more than 30minutes. The median time to initial assessment wasworse than the national average. However, nohandovers were taking longer than 30 minutes.

• Those arriving by ambulance as a priority weretransferred to the resuscitation area and were assessedby a nurse. The department had consistently beenaround 5 minutes for their Median time to initialassessment for ambulance arrivals.

• The trust was ranked in the middle of the range of alltrusts for delayed ambulance hand-overs in the 2014/15winter period.

• We observed five ambulance handovers, one took 17minutes and another took 34 minutes but the otherthree took under 15 minutes.

• Handovers from ambulance arrival to emergencydepartment that take longer than 60 minutes are alsoreferred to as ‘black breaches’. The trust was notmeeting this target between July 2014 and July 2015.Trust data showed there were 66 black breaches but 45of them occurred between January and March 2015, thewinter months.

• These ‘black breaches’ were mainly (39%) caused by nobeds being available, with a further 19% due to noclinical assessment capacity in the department.

• The rapid assessment and treatment initiative (RAT) andhaving a second senior trainee doctor overnight hadreduced the time patients waited before initialassessment. From December 2014 to June 2015 a14-minute improvement had been achieved, taking theaverage time to treatment from 79 minutes to 65minutes.

• Staff expressed frustration around the delaysencountered when there were no bed available to movepatients to and how this affected their ability to meetthe targets for the department.

• Medical and nursing staff felt the difficulties movingpatients through the department could be improved ifcare pathways were better embedded in the rest oftrust.

• We saw three ambulances arrive in emergencydepartment at the same time. The triage area was verybusy but the staff appeared to manage and process thepatients in a timely manner.

• We observed patients in the department thatself-presented or arrived via ambulance. We sawpatients were seen in a timely manner and the flow ofpatients was controlled and well managed by staff.There was sufficient capacity and bed space to treat thenumber of patients arriving in the emergencydepartment.

• The triage area where staff made initial assessments ofpatients’ needs had room for only two patients. Stafftold us that more cubicles would help them deal withpatients more effectively .

• We reviewed four records and saw that the patientswere triaged by a nurse within 15 minutes of arrival butnone of these patients were seen within an hour ofarrival by a doctor or practitioner.

Learning from complaints and concerns

• Information was available for patients and theirrepresentatives on how to make a complaint and how to




access the patient advice and liaison service (PALS). Thisincluded contact details for an independent advocacyservice. Patients we spoke with were aware of how toraise concerns with the trust.

• The trust’s policy stated that once investigations werecomplete complainants would receive a writtenresponse, normally within 25 working days but thatmight be extended to 35 days if it was a complexcomplaint.

• An action plan was developed following the visit by theEmergency care intensive support team (ECIST). Theemergency department had seen a significant reductionin complaints by 35%, comparing 2013/14 with 2014/15data.

• There were 56 complaints relating to the emergencydepartment between July 2014 and July 2015. Welooked at five in detail. All had been responded to withinthe expected timeframe. The reports includedinformation regarding lessons to be learnt. One exampleincluded the implementation of a new flowchart forpatients discharged with lower limb injuries.Information showed this had been discussed atgovernance meetings and had been validated andratified, which was good practice.

• Learning from complaints was shared during staffhandovers or recorded on file. Complaints were anagenda item at clinical governance meetings topromote learning and improve the patient experience.

• The complaints manager for unscheduled care told usthat informal and formal complaints were monitored fortrends and themes. Since April 2015 themes hadincluded communication, premises/facilities, staffattitude, and treatment issues and they had sharedthese results and actions being taken with staff in thedepartment.

Are urgent and emergency serviceswell-led?


We rated urgent and emergency services as requiresimprovement for being well led.

The organisational vision and values had been cascaded toall staff however there was a lack of documented servicelevel strategy although the direction of travel was planned

with eight key actions highlighted by the A&E leadershipteam. Development of the service was apparent with thedevelopment of the paediatric area and the employment ofa consultant to lead the paediatric work and development.The lead consultant and senior managers were aware oftheir challenges and there were escalation processes inplace for dealing with additional demand includingadditional medical support from the wards, improved shortstay arrangements to prevent lengthy admissions andinvestment in community care beds in winter. Thedepartment risks were monitored through theunscheduled care risk register which was up to date. Theserisks, incidents and performance were reviewed throughthe regular clinical governance meetings and appropriateactions taken.

However, the equipment concerns raised at the previousinspection had not been robustly addressed although thehospital managers took mitigating action before we left thesite. There were some basic equipment shortages whichwere having a minimal effect on patients but are worthy ofthe hospitals attention.

Leadership of the service through the service manager andlead consultant had been improved through theemployment of a matron with sole responsibility for theA&E department. The new matron however, had only beenin post for two months. We noted that nurse appraisal rateswere below the expected and the frequency ofdepartmental meetings was very low. Although themeetings had been reintroduced it was too early tounderstand the efficacy of them or the Matrons role on theculture and understanding of risk and improvement in thedepartment. However, there was a strong multidisciplinaryteam in the department and staff were positive and proudof the work they did.

Vision and strategy for this service

• Urgent and emergency care staff were aware of thetrust’s core values to engage with staff, to promote aculture that supported staff to be the best they could beand to achieve better care together for the benefit oftheir patients.

• The trust’s priorities, outlined in their 2014/15 strategyincluded specific strategic objectives applicable to theurgent and emergency care services such as a focus ona community centred, proactive, continuous approach,




to minimise the demand for true urgent and emergencyservices across the local health economy. Howeverthere was no specific strategy for the service based onthe trusts priorities.

• A trust wide strategic review was underway at the timeof the re inspection.There was a current A&E strategy,developed in December 2014, which was under reviewat the time of the inspection. The current workunderway in developing a trust wide strategy wouldinform the future A&E strategy.

• To ensure delivery of the shared vision, the trust had fivestrategic objectives: to provide a holistic model of care,to prevent unnecessary emergency admissions tohospital, to provide safe, high quality andpatient-centred care , to manage services withinavailable resources and to support and develop askilled, motivated and flexible workforce.

• The key objectives were driven by local and nationalpriorities and were promoted internally so that all staffwere aware of the trust‘s focus for the future. Managersconfirmed they were asked to use these key objectiveswhen setting annual objectives for individuals andteams.

• Staff were provided with a corporate induction thatincluded the trust’s and the service’s core values andobjectives. The trust’s vision, objectives andimprovement priorities were clearly displayedthroughout the department and staff could tell us whatthe vision and values meant for their practice.

Governance, risk management and qualitymeasurement

• The service held regular six weekly clinical governancemeetings, the agenda included the review of key risks,incidents and monitoring of the departmentsperformance and national audit reviews

• The manager with lead responsibility for the emergencydepartment reviewed incident reports and identifiedtrends and themes to look for ways to improve theservice.

• The unscheduled care risk register (covering the divisionof which the emergency department is part), includedrisks identified for the emergency department. Progressand improvements were monitored through acommittee, and then fed back at divisional, departmentand clinical leaders’ meetings.

• The lead consultant and senior managers were aware oftheir challenges; the flow of patients out of theemergency department and the changing needs of thelocal population, such as an ageing population;increasing numbers of people living with complex,long-term health and social care needs; risingexpectations about quality of life and the range ofservices that are provided and increasing costs ofproviding care for patients.

Leadership of service

• There was a manager with lead responsibility for theemergency department. A new matron, in post for onlytwo months, had made changes that had been ofbenefit to both staff and patients. There had previouslybeen a lack of department meetings, with only two inthe last 18 months.

• Band 7 staff were being sent on leadership courses andencouraged with personal development. An externalcompany was providing some coaching.

• A directorate managers met weekly to discussrecruitment and workforce planning.

• The numbers of patients that waited longer than 4 hoursto be seen, treated, transferred or discharged in thedepartment (‘breaches’) was analysed daily.

Culture within the service

• Staff we spoke with told us that they enjoyed working inthe emergency department despite the pressures of theworkload.

• There was a strong multidisciplinary team.• There was an open culture where staff could share

concerns and participate in the solutions.

Public engagement

• The friends and family test results were monitoredthrough the Clinical Governance meetings. Thedepartment had achieved the 20% return rate for March2015 and as such had achieved the CQUIN target for theyear.

• We observed suggestion boxes for people to completein the waiting areas.

Staff engagement

• Staff received communications via emails, newslettersand briefing documents and senior nurses sharedinformation with the staff teams.




• We observed information displayed on notice boardswhich included audit results and performanceindicators to keep staff informed. In addition staffreported they could access the intranet for updates topolicies and procedures and learning from incidents.

• The senior team now met fortnightly but there had beena lack of departmental meetings, with only two in the 18months prior to our inspection.

Innovation, improvement and sustainability

• Work was being done to improve patient flow utilisingflexible beds, improving discharge support and thecommissioning of care beds in winter.

• The trust was working with external partners to improvereferral times to mental health liaison services and toensure community beds were used appropriately. Therehad been some delays related to the partner trustmoving to new facilities which was improving.

• In addition work in the hospital included raisingawareness around discharge by ensuring discharges didnot happen too late in the day and a daily dischargereview meeting had been introduced to improveplanning and awareness. In addition the dischargelounge had become a permanent arrangement.

• The emergency department had had difficulties inrecruiting medics and nurses. Two national recruitmentcampaigns held during 2014 had led to substantiveappointments. Recently, an initiative had beenintroduced to expand posts and to develop staff, forexample trainee nurse practitioners, physicians’associates and development of the pharmacists’ role.




Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Overall Good –––

Information about the serviceThe trust offered pregnant women and their familiesantenatal, delivery and postnatal care at Blackpool VictoriaHospital. The department delivered approximately 3,000babies every year. A range of gynaecology services was alsoprovided.

There was a consultant led delivery suite with 12 rooms ontwo parallel corridors and a dedicated operating theatre.The delivery suite was interconnected to the midwifery ledFylde Coast birth centre which had four rooms, two withpools for water births.

Ward D was a 22 bedded maternity ward with antenataland postnatal admissions. There were six single side roomsand four bays, each with four beds. There was a transitionalcare unit with six en-suite rooms offering midwifery led carefor mothers who were well enough to be discharged homeand look after their babies but needed to stay for a shorttime due to the baby needing some extra care.

There was a maternity day unit, interconnected with thegynaecology unit. The antenatal unit had three singlerooms. There was also an early pregnancy foetalassessment unit which provided medical and surgicalmanagement for patients experiencing miscarriages orectopic pregnancies.

There were eight teams of community midwives, in threegeographical areas. Blackpool had North, South andCentral teams, Wyre had teams in Poulton, Fleetwood andThornton and Fylde had teams in St Ann’s and Kirkham.

We visited the maternity department during theannounced inspection on the 21st and 22nd September2015. During our visit we spoke with 61 staff, 18 patientsand two family members. We spoke with 19 of the staff atthree focus groups. We observed care and treatment toassess if patients had positive outcomes and looked at thecare and treatment records for 23 patients. We also lookedat 15 medication charts. We reviewed information providedby the trust and gathered further information during andafter our visit. We compared their performance againstnational data.


Maternity and gynaecology


Summary of findingsAt the last inspection areas were identified in thematernity services which were inadequate and othersthat required improvement and an action plan hadbeen developed to address these which has beenmonitored regularly. At this inspection in September2015 we found improvements had been made in thenumber of incidents being reported and the number ofpost-partum haemorrhages had reduced at the trust.Staffing levels in maternity services were being safelymanaged and a new midwifery staffing model had beenintroduced which had impacted positively on thedepartment.

We found that women using maternity services had ahigh regard for staff and clinical teams, who were caringand treated patients with dignity and respect. There wasa good incident reporting culture and systems were inplace to ensure lessons were learned. Policies andprocedures were up to date and in line with NICEguidance. The outcomes for patients were in line withthe England average on most of the comparedmeasures. Where they were worse this had beeninvestigated and actions taken. There was a goodsystem to triage patients who were admitted to the unit.Patients were offered choice of place for delivery andwere included in the decision making for their care.There was good inclusion of the patients and systemsfor engagement with patients and staff were in place.

However, not all areas of the maternity unit orequipment met with infection prevention and controlguidance. The systems for checking the maintenance ofequipment and its readiness for use in an emergencywere not robust. Training compliance in some key areasincluding skills and knowledge in emergency situationsdid not yet meet the trust’s target.

Are maternity and gynaecology servicessafe?


Maternity services at Blackpool Victoria hospital requiredimprovement in terms of protecting people from harm.

There had been serious incidents but they had been fullyinvestigated and actions taken to mitigate future risk. Therewas a good incident reporting culture and incidents werediscussed at a weekly multidisciplinary meeting where anynecessary follow-up actions were identified. However,these actions were not audited which meant theeffectiveness of changes to practice was not beingmeasured.

Safety information was used at departmental level to raisethe awareness of staff to current risks. Systems for cleaningwere in place and audit results suggested good compliancehowever we found examples of poor cleanliness wheresome equipment was not visibly clean and did not meetwith infection prevention and control guidance. Thesystems for checking and servicing equipment did notprovide assurance that all of the equipment was in fullworking order. Some emergency equipment had not beenchecked as frequently as expected. The trust was aware ofthis and were taking steps to address the compliance withchecks of equipment. Training compliance rates werebelow the trust’s targets in three key areas however theywere on track to meet the target by the year end.

A new staffing model had been introduced and this hadimproved the number and consistency of staff available foreach area of the maternity unit. Staff had good knowledgeof safeguarding and a multi-disciplinary approach wasestablished. Medicines were well managed. Records werelegible and up to date, however best practice guidance forrecord keeping was not always adhered to. There was agood understanding of duty of candour and there was anopen culture around errors.

Incidents

• There were six serious incidents during the period May2014 and April 2015, of which three were unexpectedneonatal deaths.

• We reviewed reports for the two most recent of theseincidents which had been thoroughly investigated with




recommendations actioned and changes to practice putin place. However, there were no plans for follow-upaudits to measure the impact of these changes, whichwould identify their effectiveness.

• Following the last inspection there had been acompliance action for the trust to improve incidentreporting. The trust had put processes in place toaddress this and increase incident reporting.

• Staff knew how to report incidents on the electronicsystem and gave examples of changes to practicefollowing incident investigations, for example theintroduction of postnatal cards providing delivery suitecontact details for women who had recently given birth.These were introduced following a complicationexperienced by one new mother who attended accidentand emergency.

• There was a trigger list which identified when to reportan incident. Staff were aware of this and used it toidentify incidents to report.

• Staff received individual feedback, by e-mail fromincidents they had reported. These were also discussedat local monthly team meetings when learning andchanges in practice were discussed.

• Incidents were discussed at an open forum everyThursday and attendance records between April 2015and July 2015 showed good representation by differentgrades of staff from various disciplines. Staff were alsoinvited to attend when an incident they had submitted,or an incident involving their patient was due to bediscussed.

• Outcome actions from the incidents were discussed anddocumented at the Thursday meetings, howeverspecific, measurable, achievable, realistic and timely(smart) principles were not always followed, for examplewhere a staff error had occurred some outcome actionswere that “staff were reminded to follow the policy” orthe “correct process was reiterated to staff”. Where theseactions had been taken there was no evidence thatfollow-up reviews or audits were planned to ensure thereminders had been effective and the same errors werenot recurring.

• A scoring system of one to five was used to identify thelevel of risk for incidents, with ‘one’ classified as aninsignificant risk, and ‘five’ being catastrophic. Incidentswith a score of three (moderate risk) or above wereallocated to a case review team for investigation andcompletion of a route cause analysis where appropriate.

Senior staff described an open door policy with thedirector of nursing and they could go and discuss moreserious incidents with a score of four or five when theyneeded to.

• The Supervisors of Midwives followed up incidents withindividual midwives and held quarterly meetingsattended by the clinical governance and qualitymanager who advised on the correct processes to befollowed.

• There were monthly community midwife meetingswhere any new policies were discussed, along withother governance matters including incidents andactions. We saw the minutes from the September 2015meeting. Minutes were circulated by email.

• Staff at different grades were aware of Duty of Candourand there was a Patient Safety Including Being Openand Duty of Candour Policy in place.

Safety thermometer

• The Maternity Safety Thermometer measures harm fromPerineal and/or Abdominal Trauma, Post-PartumHaemorrhage, Infection, Separation from Baby andPsychological Safety. In addition, those babies with anApgar score of less than seven at five minutes and/orthose who are admitted to a Neonatal Unit areidentified. This is a point of care survey that is carriedout on one day per month in each maternity service onall postnatal mothers and babies who consent to takepart. Data provides a ‘temperature check’ on harm thatcan be used alongside other measures of harm tomeasure progress in providing a care environment freeof harm for patients.

• Between February 2015 and October 2015 theproportion of women who had a maternal infectionranged between 12 and three per cent. Data showingthe proportion of women who had a 3rd/4th degreeperineal trauma was available between November 2014and August 2015 and ranged between two and six percent. The proportion of women who had a PPH of morethan 1000mls was 17 per cent in January 2015 but hasbeen consistently lower since then, dropping to four percent in June 2015.

• There was little data available for the proportion of termbabies with an Apgar score less than seven at fiveminutes but the four data points showed a rangebetween 3 and 9% since February 2015. The proportionof women who were left alone at a time that worried




them was usually around 5% but reached 12% in May2015. There were only two months data for theproportion of women with concerns about safety duringlabour and birth not taken seriously, with the mostrecent result showing zero proportion.

• Midwives collected maternity safety thermometer dataon the last Wednesday of every month.

• Community midwives had not seen the results of theirsubmissions for the last few months. This meant theinformation collected was not being used to informmidwives about their performance in delivering harmfree care.

• The manager on Ward D had a comprehensiveunderstanding of the safety thermometer programmeand the results. There were plans to display the resultson their ‘knowing how we are doing’ board in the future,however this was not yet in place.

• A safety cross is a visual data collection tool in the formof a one-month colour-coded calendar that notes dailysafety incidents. The ‘knowing how we are doing’information board on Ward D displayed safety crossesfor medication errors, incidents, hand hygiene andinformation governance audit results so it was easy tosee on which days of the month these had occurred.There were certificates which showed compliance withthe annual health check and data protectionrequirements. There was no explanation of thisinformation for patients or visitors.

Cleanliness, infection control and hygiene

• A cleaning regime was in place on the wards and intheatres and monthly results for May 2015 through toAugust 2015 showed a compliance rate of between99.2% and 100% for all areas.

• However, some blood spots were seen on the foetalblood sampling machine and in the top drawer of theinstrument trolley on delivery suite and in one of thebathrooms on Ward D. This meant these areas had notbeen adequately cleaned. When we informed staff theywere cleaned immediately.

• There were patches of mould in several of thebathrooms on Ward D which staff had reported toestates. These had also been noted by three of thewomen we spoke to. One of the women said she hadnot been able to use the bathroom in her room as therewas a drain smell which she had reported to staff but

she was told it could not be fixed. Refurbishment ofthese bathrooms was planned for 2016/17 with someimmediate work for improvement completed followingthe inspection.

• The drugs trolley in the office on Ward D was dusty, aswas the foetal blood sampling machine in the deliverysuite. This showed these areas had not been adequatelycleaned.

• Three of the four sharps bins in the clean utility room onWard D had not been signed and dated when they wereset up. One had a pair of scissors sticking out of it due toit being overfilled. This presented a risk of harm to staff,patients and visitors and meant the guidelines for safeuse of sharps boxes were not being followed.

• Hand gel was available in all the areas we visited. Wesaw staff using the gel.

• There was a hand hygiene champion on Ward D whocarried out monthly covert audits on staff following thefive moment’s technique for hand hygiene at the pointof care. The results of this audit were displayed on the‘knowing how we are doing’ board. When the scoredropped below green for full compliance follow-upactions were taken with the relevant staff group toaddress any identified issues, for example thehealthcare assistants had scored amber in the currentaudit so this was discussed at the team meeting.

• There were four single rooms on Ward D, one with anen-suite bathroom and one next to a toilet. Whenisolation facilities were required one of these two roomswere used and other patients would use separate toiletfacilities to avoid cross-contamination.

Environment and equipment

• The emergency trolley on the delivery suite had achecklist attached. This had not been signed daily toindicate the contents had been checked which couldmean all of the equipment required in an obstetricemergency, such as eclampsia, may not be readilyavailable. Staff told us the checklist was not completedon days when then trolley was sealed, however the trustpolicy requires daily checks of the intact coded seal witha name and signature recorded.

• The resuscitation trolleys on Ward D were checked dailyagainst a checklist and signatures were recorded toindicate these checks had been fully completed daily.However, in one trolley we found out of date equipmentand an infusion set with damaged packaging. Thismeant the system for checking equipment was not




robust and the equipment was not adequately checkedto ensure it was safe for use. This was brought to theattention of the ward manager and immediatelyrectified during the inspection.

• In one room on the delivery suite the resuscitaire had a“Daily room check” record present. This had not beensigned or dated for two of the previous seven days. Thismeant the system in place for checking equipment wasnot being used in practice.

• The rooms on delivery suite were not all fully equipped.We were unable to look in occupied rooms however inthe room we looked in there was no hand-held Doppler(Sonicaid) or Pinard stethoscope used for listening to ababy’s heartbeat and no Cardiotocography (CTG) whichmeasures a baby's heart rate. Staff had to fetchequipment from the store room when they needed it,including the foetal scalp electrode (FSE) used tomonitor foetal heart rate. This may cause a delay in theassessment of foetal wellbeing.

• The fridge and steriliser on Ward D had a daily checkingsheet but had not been checked between 10thSeptember and 13th September 2015. This meant thesystem for checking this equipment was in goodworking order was not robust.

• The blood gas machine was in the sluice room on thedelivery suite. This meant blood samples were beinghandled in an unclean environment.

• Portable appliance testing (PAT) is the examination ofelectrical appliances and equipment to ensure they aresafe to use. There were no clear systems in place toensure that electrical equipment such as monitors andResuscitaires were regularly tested and serviced. Weraised this with the trust who reported that allequipment had been maintained correctly by themanufacturers but that paper labels with thisinformation on had been removed or worn off over time.We were told that the medical engineering team werecompiling a report of all pieces of equipment that hadrecently been back to manufacturers so they could belabelled correctly with service dates, this was supportedby a confirmation of completion post inspection fromthe trust.

• There was a system in place with an external companyto calibrate the weighing scales in the maternitydepartment and in community clinics. The calibrationcertificates were registered on an online system ratherthan with labels on the equipment. The trust reportedthat these were up to date.

• Although the required equipment was available toevacuate a patient from the birthing pool in anemergency this was not stored so as to be immediatelyaccessible. Staff were not aware exactly where it waslocated.

• There was a clean goods store where equipment waskept. This was visibly clean, tidy and well stocked.

Medicines

• On Ward D there was a clean utility room where drugswere stored. Controlled drugs were stored appropriatelyand the keys for the controlled drugs cabinet were heldby the shift leader who was supernumerary wherepossible.

• On Ward D and on the delivery suite drugs were storedin refrigerators where appropriate, and these werevisibly clean.

• 15 drugs charts we reviewed on Ward D all wereappropriately completed.

• Staff were able to articulate the correct controlled drugsadministration procedures and what action to takewhen an error was discovered.

• On Ward D there was a ‘hypo box’ stocked withequipment to treat hypoglycaemia including lucozade,biscuits and dextrogel. The glucagon pack and IVglucose were stored in a locked fridge which couldcause a time delay if it was needed for an unconsciouspatient although we had no evidence of such anincident.

• The transitional care unit had introduced new lockablemedication boxes in the rooms to allow the women tomanage their own medication in preparation for goinghome.

Records

• We reviewed a total of 18 care records, includingantenatal, postnatal and surgical records.

• In 10 patient records reviewed there were two in whichthe foetal monitoring records had not been signed ordated. This meant good practice guidance for recordkeeping was not met on these occasions.

• Antenatal patient information was recordedelectronically and women also had some handheldnotes which contained information such as recentblood test results and scan information which would berequired if they attended another hospital.




• Antenatal test results were in the notes in specificplaces, with specialised information such as diabeticblood sugar tests easily identifiable.

• We looked at eight sets of records on Ward D and foundthem to be legible with comprehensive risk assessmentsand clear plans around birth and postnatal care.

• Five venous thromboembolism (VTE) forms werereviewed and all were correctly completed.

• We looked at a number of other patient records andfound them to be clear and appropriate but not alwaysfiled in chronological order which meant that it couldtake some time to find the most up to date information.

• We looked at a record for the wound care pathwaywhere good practice had been followed, with input fromthe tissue viability nurse.

• When care was transferred between consultants it wasnot always clear from the notes who was the leadconsultant for the patient. Staff said that if they neededadvice for a patient they would contact the consultanton call and they received a timely response.

• Handover documentation included situation,background, assessment, recommendation (SBAR)charts which were all completed in the notes. Thismeant appropriate information was transferred with thepatient.

• Personalised birth plans were present in the recordswhere appropriate.

Safeguarding

• The training report provided by the trust for September2015 showed 76% of midwives were up to date withsafeguarding training to level 3. The projection was that100% would be trained in the current year. We did nothave data regarding the number of doctors trained tolevel 3.

• Staff had good knowledge of potential safeguardingconcerns and were experienced with dealing withvulnerable families, for example babies who were beingplaced in foster care. They were able to give examples ofrecent cases and how these were managed such asmulti-disciplinary, discharge planning meetings.

• Next to the delivery suite was the Victoria Centre, amulti-agency safeguarding unit with input from differentservices including the police. Maternity staff had closelinks with this unit.

• There was a safeguarding midwife on call and theoption to refer to the complex cases team whereappropriate.

• We reviewed safeguarding paperwork and foundmanagement plans were well documented.

• Staff were aware of female genital mutilation and ofhow to identify and report any concerns they may have.

• Community midwives had lone worker devices whichwere electronic buttons on their badges. When theyarrived on a visit they pressed a small button whichwould pinpoint their location for the security teammonitoring their whereabouts. Should an incident orthreat occur, staff pressed a large button on their IDbadge which triggered an alarm with the securitycompany. The alarm was also triggered if the badge waspulled off.

• Babies did not wear security tags, however there werelocked doors on the delivery suite and maternity unit,with cameras in situ at points of entry. There had beenno incidents reported or complaints made to suggestthis placed babies at risk.

Mandatory training

• Across the families division there was over 80%compliance with most mandatory training. This did notyet meet with the trust’s target of 90% however theywere on track to meet the target by the year end.

• 73.2% of nursing and midwifery staff were up to datewith basic life support training. This meant some staffmay not have the knowledge and skills required toassist patients in an emergency situation.

• 61% of nursing and midwifery staff had completed up todate training in the safe administration of bloodtransfusions. Staff told us that there was a practicalcompetence element to this training which could onlybe completed when they administered a bloodtransfusion which was the reason compliance with thistraining was low. However this meant staff may not becompetent to safely administer a blood transfusion.

• CTG training compliance was flagging as ‘red’ (high risk)on the projection, with 61% compliance for midwivesand 64% for doctors. This had been identified by thetrust however the action plan stated there would be“more robust encouragement of CTG updates.” This didnot present a clear plan of how the target of 80% wouldbe reached.

Assessing and responding to patient risk




• In the records we saw on Ward D, Modified EarlyObstetric Warning Scores (MEOWS) were completed andappropriate action was taken when this indicated apatient was at high risk.

• Up to date risk assessments, for example safeguardingand diabetes care, were completed antenatally in therecords that we checked and were discussed athandover and safety huddles.

• The World Health Organisation (WHO) checklist wascompleted and documented on a board in theatre. Wesaw these records were kept in the notes of patientswho had a Caesarean section.

• Spot checks of the WHO checklists had taken place inMay and August 2015. This showed 100% compliance inthree of the four areas audited with 87.5% compliancefor the sign in completion. Actions resulting from thisconsisted of identification of “focus areas” rather than ameasurable action plan.

• Situation, background, assessment, recommendation(SBAR) is a structured method for communicatingimportant information. An SBAR handover wascompleted in theatre which meant the transfer of carefor a patient between the ward and theatre areas wasrecorded and discussed.

• We observed a safety huddle at 8.45 am. Theanaesthetic consultant and registrar reviewed thepatient status with the obstetric team before proceedingwith the theatre list.

• Clinical observations for women who had hadCaesarean sections were recorded on a portableelectronic data pack which could be taken from themonitor in theatre and inserted into the monitor indelivery suite, allowing different staff access to theinformation and enhancing continuity of care.

• Women who needed high dependency care, for exampleventilation, were transferred to the intensive therapyunit.

• Cell salvage was used in theatre. This is a medicalprocedure involving recovering blood lost duringsurgery and re-infusing it into the patient. This reducedthe need for blood transfusions.

• When babies were transferred from delivery suite to theneonatal unit a public lift was used. This meant therecould be a delay in transferring a new-born to the unit inan emergency.

Midwifery staffing

• Since the last inspection there had been a review ofmidwifery staffing across the different teams. This hadresulted in the introduction of a new midwifery staffingmodel in July 2015. Within this model staff wereallocated to either the inpatient or community teams.This meant the delivery suite and birthing centre wasstaffed by a dedicated team of midwives (intrapartumteam) and the community midwives were no longerresponsible to attend births in the birthing centre. Stafffelt this was a positive change which had resulted inimproved continuity of care for patients.

• Establishment figures had been assessed using birthrate plus and were always set at 3 midwives and twosupport workers for the early and late shifts on Ward D,with two midwives and two support workers for nightshifts. The maximum number of patients on this wardwas 22 which meant this met the safer staffing inchildbirth standards.

• Additional health care assistants and midwifery supportworkers had been employed. Their roles had beenclarified and two development days to offer support andguidance had taken place. This meant some of the taskspreviously undertaken by qualified midwives were nowcompleted by these support workers, releasing moretime for clinical care by the midwives.

• The ratio of all midwifery staff to births was in the range1:28 to 1:30 between October 2013 and May 2015. Thiswas slightly worse than the England average which hadreduced from 1:30 to 1:27 over the same period. Themidwifery staffing changes to improve this ratio hadtaken place after this date and these were due to bereviewed after three months.

• There were seven midwives on duty as the intrapartumteam from 10.00am to midnight on weekdays and11.00am to 7.00pm at weekends in the delivery suite.There was always one supernumerary band 7 on duty inthe delivery suite and an extra senior midwife (band 6)between 4pm and midnight allocated to triage.

• The intrapartum team included a mix of experiencedand newer midwives. It was managed by theintrapartum manager who was both a senior midwifeand a nurse.

• Staff from the intrapartum team worked in the birthcentre and the delivery suite, and helped on Ward D ifthe delivery suite was not busy. At morning handoverthe status of the patients was discussed and staff wereallocated to either the birth centre or the delivery suitedependant on patients’ needs at that time.




• Shift handovers took place at 7.30am, 1.00pm and8.45pm. At this time staff discussed the managementneeds for the patients and any potential admissions tothe unit.

• There was a safety huddle at 8.30am and 3.30pm everyday where patient status was discussed. An extra huddletook place at 12.00pm when necessary. As a result ofthis staff would move between the areas to ensurestaffing levels were kept adequate.

• There was a white board on Ward D with a traffic lightsystem indicating which patients were due to bedischarged home. The ward manager and the teamleader reviewed the board every morning and planningfor bed management took place.

• The electronic system was used to monitor staffinglevels in the maternity unit. There were criteria tomeasure the level of need for each patient and staffnumbers were entered at the end of each shift. Every 24hours a work flow activity was completed whichmonitored admissions, discharges, transfers and wardattenders. Other ward activity was also monitored,including time spent escorting patients and onsafeguarding. This information was analysed and thered flag system was used which identified when theneeds of patients meant staff levels were not adequate.This meant they were following the recommendationsof the National Institute for Clinical Excellence (NICE)guidance “Safe midwifery staffing for maternity settings”.

• If there was a shortage of midwives in the hospital, theescalation policy meant that community midwives werecalled in to help out. The on call community midwiveswere asked first. The intrapartum team at the hospitalensured the community midwives worked in an areaappropriate to their competencies and if necessarywould move people around to accommodate this.

• Midwives said they did their best to deliver one to onecare during labour and would always stay with a patientduring birth.

• Staff felt that pressures on midwife numbers had easedwith the introduction of the new model. Five new bandfive midwives had been recruited and were starting inSeptember. Recruitment was underway for a further 2.4whole time equivalent midwifery support workers.

• There was a discharge planning facilitator Monday toFriday 9.00am to 5.00pm. This staff member had been in

post since August 2015 and carried out theadministration duties for safe discharge many of whichhad been completed by midwives previously. This wasseen as a positive development by the staff.

• Registered nurses assisted in obstetric surgicalprocedures and an extra midwife was on duty between10.00am and 6.00pm to deliver care to the babies.

• Operating department practitioners were available atnight to help with recovery but out of hours themidwives had to undertake the role of nurses assistingin theatre. When this occurred this midwife was nolonger available to work on the delivery suite.

• The e-rostering systems automatically identified if therewas a shortage of maternity support assistants on anyshift. These were then filled by internal bank (bench)staff which meant there was continuity of staff to fillthese gaps.

• Community midwives had the option of joining theintrapartum team for a period of time. This wasintended to enable the teams to work together, ratherthan in isolation, and would enable the communitymidwives to increase their skill level for lessstraightforward births occurring in the hospital ratherthan at home. At the time of our inspection this optionhad not yet been taken up by any of the staff we spoketo; however a focus group for community midwives todiscuss their involvement with the intrapartum teamwas in the planning stage.

• There were no vacancies in the community teams.• Full time community midwives had caseloads of 90-100

defined by geographical areas of the patients’ GPs.Previously, community midwives were responsible forstaffing the birth centre at the hospital but theintroduction of the new midwifery model meant thiswas now undertaken by the intrapartum team, allowingcommunity midwives more time with their patients. Ithad improved continuity of care and clinics werecovered by the named midwife, rather than whoeverwas available. All midwifery staff we spoke with at thehospital and in the community were positive about thenew model and felt that it had eased pressure on theirworkload and increased staff morale.

Medical staffing

• There were 60 hours per week consultant cover for thematernity services which met national guidance for thenumber of births at the unit.




• There were seven obstetric and gynaecologyconsultants employed by the trust and one locumconsultant. There were plans to increase the numbers toeight full time consultants employed by the trust.

• There were 7.6 whole time equivalent middle gradedoctors which was equivalent to the England average.One of these doctors was a locum, however they workedfor the trust on a long term basis which meant thelocum cover was consistent.

• There was a consultant who was allocated to be on callfor the week and they were in the hospital from 8.00amto 6.00pm Monday to Friday and for five hours onSaturdays and Sundays. They were available to attend ifrequired the rest of the time. 24 cover was provided by amiddle grade doctor who had access to the consultanton call should they be required. The doctors we spokewith said the current system worked well and all feltsupported by their colleagues.

• The anaesthetist on call out of hours could also berequired as a second anaesthetist for the cardiac unit.There was a standard operating procedure in place forthis which included the obstetric and gynaecologydepartment always taking priority. This use of theanaesthetist was monitored and it had occurred once ortwice per month on average and had never caused adelay for the delivery suite. A third anaesthetist was oncall and would attend to relieve the obstetricanaesthetist as soon as possible should they berequired.

• Doctors had handover with the shift lead at 8.00am,1.00pm and 9.00pm. At 8.00am handover on the deliverysuite they reviewed the operating list for the day tomake sure they had all necessary equipment available.

• There was a consultant ward round seven days per weekon both the delivery suite and Ward D between 9.30amand 10.00am where discharges were agreed.

• An electronic handover was updated at 8.00am, 1.00pm,5.00pm and 9.00pm for gynaecology patients. This waspassword protected and saved so that it could bereferred to again when necessary, for example juniordoctors could look back to see what had happened withtheir patients. Management of patients was discussedwith both consultants present and we saw themanagement plan for one patient being changed by theconsultant with a full explanation of why, and someteaching provided as to the reasons for the change.

• A consultant paediatrician reviewed babies on thetransitional care unit every day.

Major incident awareness and training

• There was limited staff awareness of major incident orbusiness continuity plans. The staff we spoke with werenot able to provide examples of actions to take should amajor incident occur.

• In practice, however, there had recently been anincident where local drinking water could not be usedwithout boiling due to contamination. As well asimpacting on the availability of drinking water this alsoaffected use of the birthing pools. The situation hadbeen managed well, with very little disruption forpatients.

Are maternity and gynaecology serviceseffective?

Good –––

Maternity services at Blackpool Victoria hospital were goodin terms of being effective, an improvement from theinadequate rating in April 2014.

The outcomes for patients were in line with the Englandaverage on most of the compared measures. Where theywere worse this had been investigated and actions taken,for example with post-partum haemorrhage. The policiesand procedures reflected national guidance, were up todate and available for staff. Support to encourage andassist breast feeding included the use of star buddies whowere well regarded by patients and staff alike.

There were good examples of multi-disciplinary workingbetween all professionals. There were some servicesavailable at the weekends including scanning on Sundaymornings in the early pregnancy unit. There was sufficientmedical cover including out of hours. Doctors andmidwives had access to the information they required andall staff had an understanding of the Mental Capacity Actand how it may affect their work.

However, pain scores were not always recorded. Appraisalrates were lower than expected across the families divisionalthough the data could not be disaggregated to midwivesit suggested that uptake by midwives was lower thanexpected. There was an audit programme in place;however the summary report provided by the trust wasunclear, with some key dates and actions incomplete andfollow up review was not clearly demonstrated.




Evidence-based care and treatment

• The antenatal, Caesarean section and postnatal carepolicies and practices were in line with the relevant NICEguidance.

• Policies and procedures for the management ofpost-partum haemorrhage were in line with nationalguidance. The antenatal guideline was updatedfollowing the Royal College of Obstetrics andGynaecology (RCOG) review in April 2014.

• It was documented in the risk governance groupminutes of July 2015 that policies were to be reviewedto ensure they were in line with updated antenatal careguidance and NICE pre-term labour guidance.Information provided by the trust showed that this wason-going.

• Proformas for specific emergency procedures such aspost-partum haemorrhage, pre-eclampsia and shoulderdystocia were available for staff reference in the patienttreatment rooms. Those we saw were up to date withthe latest guidance.

• Policies were stored electronically.• The assessment of CTG met with best practice guidance

from the Royal College of Midwives in that they wereassessed hourly using ‘fresh eyes’ stickers. ‘Fresh eyes’means another midwife views the heart-rate trace of theunborn baby on an hourly basis which means that anypotential changes are more likely to be identified.

• The antenatal pathway had been revised to formalisethe identification of vulnerable women and provideclarity on when to refer to the complex social needsteam. The new pathway was taken through maternityservices liaison for women to check that they werehappy with the content. It was cascaded to staff throughthe weekly brief.

• There was a new stillbirth policy which was part of thenew integrated pathway adopted across the North West.There was a separate pathway for the loss of a baby atless than 24 week gestation, and for 16 weeks and underthere was a pathway which nurses and midwives coulduse to navigate bereavement management if thebereavement nurse was not available.

Pain relief

• Of the ten sets of records we reviewed, pain scores werenot recorded in five. This meant patients were notconsistently having their level of pain documented andthe effectiveness of pain relief was not monitored.

• One patient we spoke to was given effective analgesiawhen in pain and was given an epidural when sherequested it without delay.

• Staff reported administration of epidural pain reliefbegan within 30 minutes of request. This was confirmedvia audit results which showed 89% of women receivedpain relief within 30 minutes, from 1 June 2014 to 8 July2015.This exceeded the Royal College of Anaesthetists.Raising the standard 3rd edition 2012 standard that atleast 80% of women attended by anaesthetist within 30minutes of requesting labour regional analgesia.

• Entonox (pain relieving medical gas) was available in thedelivery rooms.

• There was a consultant who specialised in pain reliefand provided weekly clinics and support for patientswith complex pain management needs.

Nutrition and hydration

• The UNICEF UK Baby Friendly Initiative provides aframework for the implementation of best practice withthe aim of ensuring that all parents make informeddecisions about feeding their babies and are supportedin their chosen feeding method. Blackpool communityservices were accredited as baby friendly through thisinitiative.

• The trust had achieved Baby Friendly status level three.Stage three was the final stage of assessing theimplementation of the baby friendly standards. This waspart of the United Nations International Children’sEmergency Fund of the United Kingdom (UNICEF UK)baby friendly initiative and the assessment was carriedout in May 2014. The initiative worked to ensure a highstandard of care for pregnant women and breastfeedingmothers and babies.

• Information provided by the trust showed the targetthey had set for initiating breast feeding within 48 hoursof birth had only been met twice in the previous 15months. Staff were aware of this and an action plan wasin place which included infant feeding workshops formothers and training for midwives. .

• There was a network of experienced breast feedingmothers called star buddies, who provided support tonew mothers wanting to breastfeed. The star buddieswere mostly volunteers and attended antenatal classesto provide information and advice, as well as meetingwomen on the maternity ward. They worked on a rotasystem and covered seven days and five nights of theweek.




• Information with details of breast feeding groups heldacross the community was provided to patients ondischarge.

• Patients we spoke with had received support on theward and were aware of how to express and store breastmilk safely.

• Bottled milk for babies was stored in a designated milkkitchen, with several varieties available. All were in date.

• There was information on display for women who weresupplementing breastfeeding with formula milk.

• Sterilisers and breast pump kits were available forwomen to use.

• Patients had access to food and drink. Mothers in labourhad their fluid balance monitored and this was recordedon the Partogram documentation.

Patient outcomes

• At the time of the last inspection there were concernsthat the post-partum haemorrhage rate was higher thanexpected. Following that inspection in April 2014 RCOGundertook a review of 31 sets of case notes. The reviewconcluded there were no serious problems within theunit however some recommendations to changes inpractice were made. At the time of this inspection thoserecommendations had been actioned and thepost-partum haemorrhage (PPH) rates had remainedwithin the trust’s target in the past 15 months.

• In September 2014 the trust had completed a review of23 PPH cases and an audit of a further 43 cases wascompleted in March 2015. An action plan was in placewith plans to re-audit cases of PPH above 1000mlsannually and review PPH cases of above 2000mls on anon-going basis.

• Audits had been completed to measure complianceagainst a range of trust policies and national guidelinesincluding for Induction of labour, Consultantinvolvement in the intrapartum care of women,Caesarean sections and Operative vaginal births. Actionplans were in place and set out with re-auditing planson the Monitoring and Performance Dashboard –Quality Improvement Action Plan 14/15 (updatedAugust 2015).

• There was a wider audit programme in place howeverthe summary report provided by the trust was unclear,with some key dates and information about actionsincomplete.

• The most recent NHS Maternity Statistics published bythe Health and Social Care Information Centre (HSCIC)

showed that 25% of women who gave birth in Englandunderwent induction of labour between April 2013 andMarch 2014. Information provided by the trust showedinduction rates had been above this national averageand the trust’s target of less than 25% of total births in11 of the last 15 months. It rated as high risk of over 30%in six of these months. An audit showed a multifactorialrelated rise in the incidence of induction of labourwithout significant rise in other maternity processindicators ( e.g. Caesarean section rate, PPH). Outcomesfor the women who had been induced were good.

• The trust was in line with the England average forincidences of puerperal sepsis.

• There had been no stillbirths for six of the eight monthsfrom April to November 2015. In the remaining twomonths one had been within the trusts’ target of twoand one had been above.

• The modes of delivery including elective and emergencyCaesarean sections had been in line with the trust’s owntargets for nine of the past 15 months.

• The incidence of 3rd and 4th degree tears was below thetrusts’ target of 4% of births in 10 of the past 12 months.Where it had not been met it was slightly above thetarget at 4.3%.

• The trust confirmed that it achieved four of the fivestandards in the National Neonatal Audit Programme2014 due to be published in October 2015, the exceptionbeing that 100% of eligible babies should receive 1stretinopathy of prematurity screening in accordance withguideline recommendations.

Competent staff

• New midwives joined the trust on a preceptorshipprogramme. They attended trust induction, received aninduction pack and attended an introductory meetingwith a Supervisor of Midwives within their first week.

• Community midwives received community basedtraining including a ‘normal births’ study day.

• Skills and drills training for midwives includedcompetency assessments for breech births, shoulderdystocia and growth surveillance. Study days providedby the trust included suturing and water birth courses.

• Changes had been made to the programme for juniordoctors to hold the drills sessions during their inductionperiod which had significantly increased compliancewith training. Areas covered included sepsis, obstetrichaemorrhage and pre-eclampsia.




• In September 2015 the training projection for the yearshowed there would be 100% compliance with the fivemulti-disciplinary drills days for midwives, health careassistants, maternity support workers and doctors.Safeguarding level 3 training was also on course toreach 100% compliance.

• Neonatal updates were projected at 86% compliance formidwives and below target for health care workers andmaternity support workers at 74%.

• Information provided by the trust showed 51% ofnursing and midwifery registered staff in the familiesdivision were up to date with their annual appraisals.The trust could not disaggregate this information tomidwives so we were unable to ascertain how manymidwives had not had their performance, knowledgeand skills assessed and discussed with their linemanagers.

• Midwives received annual supervision from theirsupervisor of midwives but had 24 hour access to asupervisor via a bleep holder at the hospital should theyrequired it. The role of the supervisor is to protect thepublic through monitoring the practices of midwives toensure the mothers and babies receive good qualitysafe care. The ratio of supervisor to midwife ratio was1:11 which was better than the recommendation of1:15The bereavement nurse received externalsupervision from Cruse bereavement care to ensure herwellbeing was monitored

• Supervisor training was available to midwives, as well ascontinuing professional development (CPD) courses atthe University of Central Lancashire.

• Following their induction training, junior doctors had aninduction appraisal with their educational supervisorand their competency was assessed against a trainingmatrix which was recorded individually online.

• All junior doctors had an annual record of clinicalprogression. Consultants monitored competencies anddiscussed trainee progression at monthly meetings.

• A ‘vulnerability’ study day was delivered to all midwivesby the complex social needs team. This was also opento obstetricians.

• Ad hoc training drills were facilitated by the trust, withno prior warning for staff. A recent example of this wasan emergency buzzer had sounded during a quiet timeon the delivery suite, and staff took part in a drill torescue someone from the birthing pool using a net.

• Four midwives had attended external training onemergency procedures which may occur in thecommunity and had shared what they learned withteam members.

• Midwives had the opportunity to undergo ‘examinationof the new-born’ training by enrolling on a module atthe University of Central Lancashire. This examination isusually completed by a paediatrician so havingmidwives available who could undertake this meantsome women were able to be discharged from the wardearlier, without having to wait for a paediatrician.

• There was a trust bereavement nurse who liaised withthe Coroner to ensure the appropriate language wasused when dealing with bereaved parents. Shecoordinated meetings between the different staffinvolved when a baby died, including pathology,obstetrics and paediatrics. Bereaved parents wereoffered a meeting to discuss their baby’s death, at a timechosen by them.

• Training for midwives who may need to assist in theatrewas on-going as part of the progression from a band 5 toa band 6. This included undertaking training in the maintheatres for one week and a comprehensivecompetence assessment if not carrying this out forsome time.

• The trust has developed a socially complex pregnancyteam, led by a consultant obstetrician. Specialistmidwives in this team included substance misuse,perinatal mental health, homelessness, non-Englishspeaking, teenage pregnancy, travellers andSafeguarding. There was a pathway in place for referralto this team when appropriate

Multidisciplinary working

• The maternity and gynaecology services at BlackpoolVictoria hospital were part of the families division. Thispromoted close links with the other teams involved inwomen and children’s health including health visitors,school nurses and the paediatric and adolescentinpatient wards.

• We observed excellent multi-disciplinary working whichincluded the development of clear plans of care forpatients with complex health needs. We saw the leadmidwife for diabetes explain clearly to several othermidwives about a new plan of care for one patient withgestational diabetes.

• Midwives and doctors reported excellent workingrelationships between the two disciplines. Doctors




particularly praised the way the head of midwiferycommunicated between the two teams. Both said theywere confident to raise concerns about care orprocedures within the service and worked together toachieve positive changes in practice, such as thoseresulting from the RCOG report.

• The bereavement nurse had close links with SANDS(stillbirth and neonatal death society) and offered helpwith funeral arrangements, remembrance services andworked closely with the mortuary and three localcouncils who offered free cremation services.

• If patients required interventional radiology they wouldbe referred to St Mary’s in Manchester as this was notavailable on site at Blackpool. This policy wasdeveloped as part of the action plan following the RCOGreview into the care of patients at high risk ofpost-partum haemorrhage however we had noexamples of this in practice.

Seven-day services

• The obstetric consultant on call was present in thehospital for at least five hours on Saturdays andSundays.

• At weekends there were four midwives on call in thecommunity but no clinics. The birth centre at thehospital was where discharges were reviewed and homevisits were scheduled at weekends.

• On Ward D there was no discharge facilitator atweekends and no elective Caesarean sections.

• Pharmacy services were available seven days a week.• New-born blood spot screening tests were carried out

by community midwives at weekends to ensure theywere completed within the required timescale of withinfive days of birth.

• The early pregnancy unit offered scanning between9.00am and 4.00pm Monday to Friday for patientssuffering potential miscarriages, and on Sundaymornings when it was also available for emergencygynaecology patients. No scanning was available in theunit on Saturdays. Should these be required they wouldbe arranged through the emergency department.

• A community mental health crisis team which could beaccessed by all patients with mental health problemswas based in accident and emergency and wasavailable through a single point of access referral 24hours a day, 7 days a week.

Access to information

• There were paper based and electronic systems in placefor patient care records. Patients had their own handheld paper records and electronic ante-natal records.Paper records were kept for details of treatment andcare during admission.

• Information was accessible to staff and there weresystems in place to make particular sections of thepaper notes easily identifiable, for example purplecoloured notes signified to staff that there was asafeguarding concern.

• Copies of safeguarding plans were kept on the ward toensure that midwives had access to them and werefamiliar with them.

• Staff told us they had to rely on the hand held notes forpatients who were visiting Blackpool on holiday andpresented at the hospital.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Five sets of notes were reviewed for patients who hadundergone a Caesarean section. Consentdocumentation was correctly completed, with risksexplained, and the forms were signed and dated.

• There was a trust mental capacity act implementationlead who facilitated assessments around mentalcapacity.

• 96.58% of nursing and midwifery staff in the familiesdivision had completed training in the Mental CapacityAct and Deprivation of Liberty Safeguards.

Are maternity and gynaecology servicescaring?

Good –––

The maternity services were good in terms of caring.

The feedback from patients and their families was positivein terms of the caring, patient and supportive attitude ofthe maternity services staff. Privacy and dignity of thepatients was respected by staff. Patients and their familiestold us how they had been involved in making decisionsabout their own care and given clear informationthroughout their pregnancy and following delivery.

The Friends and Family Test (FFT) survey in August 2015showed 100% of patients’ responses recommended theantenatal services in the hospital and in the community to




friends and family. Results received for the labour ward andbirthing unit were 97% positive and the inpatient ward wasrecommended by 87% of patients who completed the test.Community postnatal care received 100% positiveresponses.

Healthwatch Blackpool published a Maternity ConsumerReview in July 2015 in which 84% of respondents reporteda very good or good overall experience and there were nomajor concerns highlighted.

There was good support for bereaved parents with accessto a specialist bereavement nurse when required. Therewere other specialist midwives who offered additionalemotional support to patients and guidance to staff.

Compassionate care

• Patients we spoke with said staff were kind, patient andcaring.

• Women told us they were not left alone during labourand that continuity of care by midwives in hospital wasgood, with “great support” offered.

• The Friends and Family Test (FFT) is a survey which givespatients an opportunity to give feedback on the qualityof the care they receive. In August 2015, 100% ofpatients’ responses recommended the antenatalservices in the hospital and in the community to friendsand family if they needed similar care or treatment.Results received for the labour ward and birthing unitwere 97% positive and the inpatient ward wasrecommended by 87% of patients who completed thetest. Community postnatal care received 100% positiveresponses.

• The percentage recommended for the Postnatal Wardelement of the Maternity FFT fell over time (March 2014to February 2015), and was below the England averagefor ten consecutive months to February 2015. It hassince improved each month to June 2015, when thepercentage recommended was 96% (above the Englandaverage).

• Healthwatch Blackpool published a MaternityConsumer Review in July 2015 in which 84% ofrespondents reported a very good or good overallexperience and there were no major concernshighlighted. 90% felt that having a named midwife wasimportant, yet only 44% reported seeing their namedmidwife consistently throughout their pregnancy. Thenew midwifery model has been introduced since this

report to improve continuity of care in the community.73% did not know there was a choice of where theirantenatal appointment could be held. 27% of newMums felt they were in hospital too long.

Understanding and involvement of patients and thoseclose to them

• The patients we spoke to were positive about theservice and felt well informed and involved in their care.Staff introduced themselves the majority of the timeand any concerns were listened to and taken seriously.

• Partners of women in labour were able stay on thedelivery suite for the duration of the labour. In the birthcentre women tended to go straight home rather thanbeing admitted to the maternity ward and partners werewelcome to be present.

• Patients told us they were given choices and wereinvolved in planning their births.

• Where a patient wanted a home birth but had riskfactors such as high BMI or a previous CaesareanSection delivery she would be referred to the consultantto discuss options.

• The women we spoke to had talked with doctors abouttheir experiences, what had happened and why, weregiven the opportunity to ask questions and feltsupported to ask further questions later if required.

Emotional support

• Good practice was observed when a patient whorequested personal information was taken into a sideroom by a member of staff, ensuring privacy.

• There was a birth ‘afterthoughts’ service where womenwho had given birth could submit feedback about theirexperiences.

• There was a bereavement nurse with mental healthexperience who took referrals from maternity serviceswhen there was a stillbirth or unexpected death. Sheoffered bereavement support across the trust.

• Children in a bereaved family where a baby had diedcould be referred to paediatric services.




Are maternity and gynaecology servicesresponsive?

Good –––

The maternity services were good in terms of beingresponsive.

Bed occupancy was low. Patients were encouraged to usethe birth centre when possible and this was next door tothe delivery suite should a transfer be necessary. There wasa new system for triaging patients which was working well.The new team for socially complex patients was takingreferrals for vulnerable women and provided good supportfor patients with complex physical and mental healthneeds. There were tertiary unit agreements with otherhospitals including Royal Preston and St Mary’s for womenwith complex conditions, for example interventionalradiology.

The trust had developed a socially complex pregnancyteam, led by a consultant obstetrician. Specialist midwivesincluded: substance misuse, perinatal mental health,homelessness, non-English speaking, teenage pregnancy,travellers and Safeguarding. There was a pathway in placefor referral to this team when appropriate. Their aim was tofacilitate a normal birth and use the birth centre wherepossible. In 2014 there were 319 babies born in the birthcentre. This year the number was between 350 and 400 atthe time of our inspection in September, whichrepresented 12% of births under the care of the trust.

Clinics were planned to engage vulnerable patientsincluding a clinic next to a school to facilitate antenatalchecks for pregnant teenagers and a clinic alongside thecommunity drugs team clinic so that women needed toattend for only one appointment.

There was a dedicated patient experience midwife in theintrapartum team who was available for patients to raisetheir concerns with. Bereaved parents had access to acomfortable, non-clinical environment in the Victoriacentre next door to the maternity services. They were ableto spend time in this area away from the general maternityenvironment. There was a strategy for the development ofservices to meet the better births campaign of the RoyalCollege of Midwives. Complaints and staffing issues had

eased since the introduction of the new maternity modelbut it was in its infancy so this had not yet been evidenced.There was a ‘birth afterthoughts’ service where womenwho had given birth could submit feedback.

Service planning and delivery to meet the needs oflocal people

• There was a midwifery led unit which meant low riskpatients had the choice of this option for delivery oftheir baby. This met NICE guidance CG 190 ‘Intrapartumcare: care of healthy women and their babies duringchildbirth.’

• There were two birthing pools in the birthing unit andanother on the delivery suite. Midwives told us theyencouraged use of the birthing pools, especially in themidwifery led unit.

• Between April and June 2015 around 10% of births wereeither birth centre deliveries or planned home births.

• We observed that patients were offered a real choice ofwhere to give birth.

• The labour ward had a soundproofed room with aseparate entrance for use by women who had delivereda stillborn baby. This protected them from hearingactivity on the delivery suite and allowed access to theroom without passing through the delivery suite. Thetelevision and stereo in this room had been donated byparents, and there were memory boxes which had beendonated by the stillbirth and neonatal death charity,Sands.

• There was a strategy for the development of services tomeet the normality in childbirth vision of the RoyalCollege of Midwives through the better births campaign.This was reflected in the compassionate care strategyand the clinical strategy.

Access and flow

• Ward D had 22 beds with no set allocation for antenataland postnatal patients. This flexibility meant patientscould be accommodated on this ward regardless of thestage of their pregnancy care.

• Following the last inspection work was undertaken toreduce bed occupancy at high risk times. An audit ofward occupancy completed by the trust showed at07:30am on Ward D from January to August 2015 it was73%. NHS England data reported 48% bed occupancy.

• Triage for the delivery suite was based in the antenatalday unit between 8.30am and 6.00pm. There was aspecific senior midwife (band 6) from the intrapartum




team allocated to a triage shift between 4.00pm andmidnight. This meant midwives were not interruptedfrom their work on the delivery suite to assist patientswho arrived in the unit.

• In the birth centre there were two rooms used for triagewith a third available if required.

• Community midwives saw their patients throughouttheir antenatal care and for ten to 14 days postnatally.Discharge forms identified any risks and support was forlonger if required.

• There was no set length of stay on Ward D and staff wereguided by the new mother, but a 6-12 hour transfer wasconsidered ideal. Patients who had an electiveCaesarean section generally stayed for around 24 hoursand women who had had an emergency Caesarean orhad complications stayed longer. Discharge times weresometimes challenged where involvement was requiredfrom other agencies, such as social work or legal teams.

• Discharge from the transitional care unit was agreedwhen the paediatrician was happy for the baby to gohome. The mothers in those beds were already fit fordischarge.

• There was an appointment system on the maternity dayunit and if no appointments were available, womencould attend the delivery suite.

• There were tertiary unit agreements with other hospitalsincluding Royal Preston and St Mary’s for women withcomplex conditions, for example interventionalradiology. This had been developed as part of the actionplan for the management of post-partum haemorrhageand complex surgical cases which resulted from theRCOG report.

Meeting people’s individual needs

• The trust had developed a socially complex pregnancyteam, led by a consultant obstetrician. Specialistmidwives included: substance misuse, perinatal mentalhealth, homelessness, non-English speaking, teenagepregnancy, travellers and Safeguarding. There was apathway in place for referral to this team whenappropriate.

• The head of department took the lead on antenatalplanning for patients with complex social needs. Theaim was to facilitate a normal birth and use the birthcentre where possible. In 2014 there were 319 babies

born in the birth centre. This year the number wasbetween 350 and 400 at the time of our inspection inSeptember, which represented 12% of births under thecare of the trust.

• Midwives had some awareness of female genitalmutilation (FGM) and there was a routine questionincluded on the antenatal booking system.

• Where women had surgery, the gowns were put on insuch a way to allow skin to skin contact between motherand baby after delivery.

• Six clinics were held across the local area for glucosetolerance and there were two satellite consultant clinicswith at least two midwives.

• The transitional care unit had six beds for women whosebabies needed to stay in hospital a little longer, forexample they were on intravenous antibiotics, wereslightly jaundiced or needed phototherapy. Theserooms had an extra bed allowing the mother’s partnerto stay if required.

• Mothers who had given birth to twins pre-term andneeded extra support with breastfeeding stayed on thetransitional care unit. This unit was also used toaccommodate parents who had a very poorly baby onthe neonatal unit which was adjoined to the transitionalcare unit.

• Clinics were planned to engage vulnerable patientsincluding a clinic next to a school to facilitate antenatalchecks for pregnant teenagers and a clinic alongside thecommunity drugs team clinic so that women needed toattend for only one appointment.

• Similarly, flu and MMR vaccines were offered at babyclinics to reduce the number of appointments peopleneeded to attend.

• Patients with known mental health problems werereferred to the complex social needs team. There was apathway for the care of patients with mental healthneeds.

• Bereaved parents had access to a comfortable,non-clinical environment in the Victoria centre next doorto the maternity services. They were able to spend timein this area away from the general maternityenvironment.

• Community midwives assessed women’s mental healthduring visits using observations and continuity of care.They used assessment charts for postnatal anxiety and




depression and there was a mental health pathwaywhich could be used if required, which defined referraloptions to GPs, the crisis team and the complex socialneeds team.

Learning from complaints and concerns

• There was a complaint review panel which looked at thenumber of complaints per quarter. Upheld complaintswere reviewed at this meeting and actions identified forlearning and changes to practice.

• Community midwives felt that complaints and staffingissues had eased since the introduction of the newmaternity model but it was in its infancy so this had notyet been evidenced.

• The intrapartum team included a patient experiencemidwife who dealt with local complaints and incidentsand was available for patients to speak to with concerns.

• There was a ‘birth afterthoughts’ service where womenwho had given birth could submit feedback. The localstrategy for statutory supervision of midwives wasupdated in June 2015 and included a commitment fromsupervisors to monitor performance of patientexperience through reviewing the responses to thefriends and family test, birth afterthoughts, complaintsand case reviews.

Are maternity and gynaecology serviceswell-led?

Good –––

Maternity services were good in terms of being well-led.

Staff were familiar with the trust values however there wasno documented strategy for the maternity service despitemuch work in response to the last CQC inspection and theRCOG review. Staff were however aware of the changes tothe service and their role in the new model of care.

Governance systems were in place to monitor the quality ofthe service and escalation processes were in place. Thematernity service fed in to the families division risk registerwhich was regularly reviewed and updated.

Very senior managers were visible and staff knew who theywere. Staff enjoyed being part of the families division andstaff engagement and morale were good. Senior managerswere approachable and there was an ‘open door’ policy.

There was a system in place to include patients and engagewith them to develop the service.

Vision and strategy for this service

• Midwives at the hospital and in the community wereaware of the trust values and felt that they were part ofthe ‘together we care’ culture.

• The service did not have a documented strategy butchanges to the service had been based on the RCOGreview and staff were aware of the requirements and thechanges that had been implemented as part of theresponse to the review and the new model of care.

Governance, risk management and qualitymeasurement

• The families division had a performance dashboardwhich demonstrated safety, quality and activityinformation.

• There was a monthly performance ‘review’ meeting,chaired by exec directors, with senior managers fromthe Division in attendance. A team from the familiesdivision presented three key items from theirdashboard.

• There was a monthly trust management team meetingattended by the head of midwifery who cascaded to herteam any useful information she gathered there.

• There was one risk register for the family division serviceand this had been updated following review by externalauditors. There was a ‘5 T’s system in place to managethe register so each item was identified with a decisionto tolerate, treat, transfer, terminate or take the risk.Senior staff had a clear vision of working to keep theregister focused and strategic and there was input fromthe director of nursing for escalated risks.

• Every two months the top three risks were presented atthe Corporate Quality Committee where they would beaddressed and reviewed. Every quarter the risks wouldbe taken to the Health Care Governance meeting whereeach division presented their risk register and divisionalaction plan.

• The top three risks were related to the outcomes forpatients and babies in relation to reduced breastfeeding, smoking in pregnancy and lack of mentalhealth provision. The measures in place to managethese included new initiatives such as recruitment andjoint working and strengthening additional measuressuch as increased training.




• At a local level the risk register was regularly reviewedand updated. It was also discussed at the directoratemeeting and the directorate governance meeting.

• There was a programme of audits in place to measurecompliance against a range of trust policies andnational guidelines. Action plans including timescales tore-audit were in place where appropriate.

Leadership of service

• The head of department was the lead obstetrician. Theyworked alongside their colleagues, understood thechallenges in the service and offered support andleadership which was commended by the medical team.

• Staff felt listened to in terms of what their servicerequired, for example 12 new beds had recently beenacquired for the delivery suite which reduced patientsafety risks and allowed different positions for optimaldelivery.

• Doctors said the medical director was visible on theward.

• Senior managers had an open door policy and wereapproachable.

Culture within the service

• Staff felt that the director of nursing was veryapproachable. The chief executive had recently spenttime on the delivery suite and there was also supportfrom the chairman.

• The directorate had a human relations business partnerwho facilitates ‘one family’ work with the differentteams.

• Maternity services were part of the families division.Staff enjoyed the close links with the other teamsinvolved in women and children’s health includinghealth visitors, school nurses and the paediatric andadolescent inpatient wards.

• Communication was good between nursing staff andsenior midwives and there was an ‘open door policy’ todiscuss any issues. Staff felt able to report any concernsthey had and felt they would be listened to.

• The culture encouraged candour, openness andhonesty.

Public engagement

• There was an active group of patients who met monthlyto discuss the maternity services at the hospital. Theyhad representation on the monthly maternity wardforum meetings and told us they could present ideasand suggestions which were listened to and acted upon.

• The representation from this group includedinvolvement in guideline development as well as peersupport for the patients in the unit.

Staff engagement

• There were ‘good ideas’ boards where staff were able tomake suggestions, for example the acquisition of amobile phone for the delivery suite which enabledwomen to speak to language line from their roomswhen English was not their first language.

• Morale was good among the community midwives whofelt that the new midwifery model was allowing thembetter continuity of care with their patients.

Innovation, improvement and sustainability

• The new midwifery model introduced in July 2015 wasworking well and was due to be reviewed after threemonths, in October 2015. Staff felt pressures on staffnumbers had reduced since its introduction, and thatcontinuity of care for patients had improved.

• Patients were offered a choice of facilities within thematernity unit and this was reflected in their commentsto us.




Outstanding practice

The trust was actively trying to support breastfeeding andthere was a network of experienced breast feedingmothers called star buddies, who supported newmothers wanting to breastfeed. The star buddies weremostly volunteers and attended antenatal classes to

provide information and advice, as well as meetingwomen on the maternity ward. There was a monthly rotain place covering seven days and five nights of the week.The women we spoke to were impressed with this serviceand had found it helpful.

Areas for improvement

Action the hospital MUST take to improve

• Improve the outcomes for patients through theimprovements demonstrated through the nationalCEM audits in particular, reduce the number ofpatients attending urgent care services waiting formental health assessment for over four hours

Action the hospital SHOULD take to improve

• Maintain all equipment in both urgent care andmaternity is checked as per the policy and kept cleanwithin the infection prevention and control guidancefor each specific item.

• Consider improving the monitoring of the impact ofactions taken as a result of incident investigations inmaternity services.

• Maintain training for all staff working in the maternitydepartment with basic life support, bloodtransfusion and CTG training by the year end.

• Address the insufficient supply of basic equipmente.g. thermometers in A&E.

• Address the shortage of hand sanitizers and signs toencourage visitors to use the alcohol gel in theentrance to the emergency department.

• Review the computer equipment in ‘minors’ area ofA&E to ensure consistent recording of patients’treatment.

• Try to improve patient confidentiality at thereception.

• improve staff utilisation of translation support whendealing with patients in A&Ewho requirecommunication support.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

Regulated activity

Treatment of disease, disorder or injury Regulation 9 HSCA (RA) Regulations 2014 Person-centredcare

Performance regarding the number of patients waitingfor mental health assessment for over four hours did notalways meet the needs of the patient. Regulation 9(2)

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


Blackpool Victoria Hospital NewApproachFocused Report ... · LetterfromtheChiefInspectorofHospitals...

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Transcript of Blackpool Victoria Hospital NewApproachFocused Report ... · LetterfromtheChiefInspectorofHospitals...