All inspections: Queen's Hospital, Burton Upon Trent

Queen’s Hospital is part of Burton Hospitals NHS Foundation Trust. The hospital provides a full range of district general hospital services and also has a treatment centre which provides day case ophthalmology, outreach and community-based clinics to the population.

We inspected this hospital in July 2015 as part of the comprehensive inspection programme. We inspected all core services provided by the trust.

We visited the hospital on 7, 8 and 9 July 2015 as part of our announced inspection. We also visited unannounced to the hospital on Friday 24 July 2015.

Overall we have rated this hospital as requires improvement. We saw that services were caring and compassionate. We also saw that people have good outcomes because they receive effective care and treatment that met their needs. We saw a number of areas that required improvement for them to be assessed as safe and responsive. We saw that leadership of services in some areas also required improvement.

Our key findings were as follows:

The hospital had made significant progress since our last inspection in April 2014. Improvements in safety and leadership were evident, but there was still more work to be done.
Staff were caring and compassionate towards patients and their relatives. Patients’ dignity and privacy was ensured and we saw many examples of good care right across the trust for staff at all levels.
There was a strong open culture and staff were encouraged and supported to report incidents. There were clears systems in place to ensure lessons were learnt and services developed as a result.
The pathway for patients requiring emergency gynaecology care was ineffective.
End of life care services had improved and there were clear plans in place to develop the service further.
Nurse staffing was a challenge in some areas of the trust. There was heavy reliance on agency staff to ensure staffing levels were kept safe. The trust was working hard to address this.

We saw several areas of outstanding practice

Critical care had developed an organ donation group to improve and promote organ donation within the hospital and the local community.
The maternity service was awarded the Excellence in Maternity Care award by CHKS in 2014. The quality of care at Burton Hospitals NHS Foundation Trust was judged to be the best out of 148 NHS maternity providers in England, Wales and Northern Ireland.
Innovative practice to increase hand hygiene, using the latest technology monitoring the use of alcohol sanitising gel.

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

Importantly the trust must:

The trust must ensure that ward assurance targets, such as hand hygiene practice and recording of patient observations, is achieved at a consistent level in the emergency department.
The trust must review the use of agency staff on surgical wards to ensure staffing levels and skills mix are maintain and all staff have access to the relevant records.
The trust must develop a clear vision and strategy for critical care services which is shared with staff and clinical leaders and demonstrates how the service will develop in the medium and long term.
The trust must ensure that all identified learning points from the investigations into recent Never Events are fully implemented and signed off to ensure that learning and changes to practice have been put in place.
The trust must develop a strategy and long term vision for gynaecology services at the trust to ensure that patient services can improve and develop.
The trust must ensure that a rapid discharge pathway for end of life patients is formalised to ensure that people can leave hospital in an effective way that meets their wishes.
The trust must review policies and procedures for planning and booking outpatient clinics to ensure that waiting times for appointments are minimise and patients are not subject to long delays in waiting for appointments. Waiting times in outpatient clinics should be re routinely monitored.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Queen’s Hospital is part of Burton Hospitals NHS Foundation Trust. The trust serves a population of more than 360,000 people in Burton upon Trent and surrounding areas, including South Staffordshire, South Derbyshire and North West Leicestershire.

The trust provides services from three locations. Queen’s Hospital is the largest of these. The trust also took over the management of the treatment centre in 2011, which is based on the Queen’s Hospital site providing day-case and ophthalmology services to the immediate area and beyond.

The trust employs over 3.000 staff and has 496 inpatient beds across all three locations. Queen's Hospital, Burton Upon Trent provides accident and emergency (A&E) services, medical and surgical services for adults and children, it has a critical care unit and a maternity unit. It also sees over 300,000 outpatients each year.

The trust carries out 47,000 planned and emergency operations and undertakes around 13,000 day-case procedures annually. In the last 12 months there were more than 60,000 accident and emergency attendances.

The trust has a stable board with only two of the executive directors having been appointed in the last 18 months.

We inspected Queen’s hospital on 24 and 25 April 2014. We undertook an unannounced inspection on 6 and 7 May 2014.

Before and during our inspection we heard from patients, relatives, senior managers and other staff about some key issues that were having an impact on the service provided at this trust. We also held a listening event in Burton where patients and members of the public were given an opportunity to share their views and experiences of all the trust locations.

Why we carried out this inspection

The trust had a significantly higher than expected mortality rate from April 2012 to March 2013. As a result, the trust was included in Professor Sir Bruce Keogh’s review of trusts in 2013. The overview report Review into the Quality of Care and Treatment provided by 14 Hospital Trusts in England is available on the NHS Choices website.

The review identified a number of areas of good practice. However, the report identified a number of areas of concern, such as no systematic approach for ensuring the collection, reporting and action on information about the quality of services. It also found that there was a lack of support for junior doctors, medical staffing levels and skill mix was not appropriate, and equipment safety checks had not been carried out.

We inspected this hospital as part of our in-depth hospital inspection programme. Burton Hospitals NHS Foundation Trust was considered to be a high-risk service. When we inspected the trust in April 2014, 14 of the 61 recommended actions following the Keogh inspection had still to be completed.

Overall, Queen's Hospital, Burton Upon Trent was rated as requires improvement. We rated this hospital as requires improvement for providing safe, effective, and responsive care, and good for being caring, but we rated it as inadequate for being well-led.

Our key findings were as follows:

Ward staff were committed to the delivery of high quality care and saw patient experience as a priority.
Recruitment is a recognised challenge for the trust, with some wards below establishment. Bank, agency and locum staff were used to fill vacant posts and some staff worked additional hours. In some areas there was a high dependency on temporary nursing staff.
The significant number of medical outliers is contributing to patients experiencing several bed moves during their inpatient stay. Between January and March 2014, 7% of inpatients spent time on three or more wards during their time in hospital.
Dementia care was not delivered consistently across the trust. While nurse and healthcare assistant ‘dementia champions’ were available on some wards to support patients with dementia and initiate the most appropriate care for them, this was not available in other wards.
Incident reporting systems were in place. However, learning was not always shared across the trust and staff use of the system was variable.
Not all staff had appropriate knowledge of the Mental Capacity Act and Deprivation of Liberty Safeguards to ensure that patients’ best interests were protected.
The trust’s end of life provision was not clearly defined and information relating to the service was not used to inform resources. There was a designated board lead, but there were no clear lines of accountability and assurance of delivery of end of life care.
Do Not Attempt Cardio Pulmonary Resuscitation (DNA CPR) paperwork was not fully completed and there was a lack of guidance for staff to follow on the action they should take if they suspected that a person lacked mental capacity.
The current Resuscitation Council Guidelines were not reflected in trust’s resuscitation policy or in the resuscitation department’s staffing levels. The resuscitation committee had not met since November 2013.
Not all policies reflect national guidance or best practice. For example the trust’s safeguarding policy was not in line with best practice set out in Working Together to Safeguard Children (March 2013).
Not all medical and nursing staff delivering care to children and young people were trained to the appropriate level in paediatric life support and also safeguarding children.
There was no identified high dependency area to stabilise children on the paediatric ward and not all relevant staff were trained in paediatric life support.
There were systems and processes in place to reduce the risk of infection. Most staff followed the trust’s infection control policy, including being bare below the elbow, observing hand hygiene and wearing personal protective equipment, such as aprons and gloves, when appropriate.
There was no clear ownership of the risks on the risk register and little sense of pace about making improvements.
Patients we spoke with told us that they’d experienced long delays for appointments in the outpatients department.
Action was not always taken to ensure staffing was in line with national guidelines. This includes staffing in the neonatal unit, which did not currently meet the requirements of the British Association of Perinatal Medicine (BAPM), and the numbers of junior doctors on the labour ward between midnight and 7am did not meet guidelines as set out in Towards Safer Childbirth.

We saw the following areas of outstanding practice:

The maternity services were recognised in May 2014 as providing excellent care by an independent provider of healthcare intelligence and quality improvement.
The service was one of the only maternity services nationally to use the enhanced recovery programme for women following a caesarean section, if it was clinically appropriate for them. The aim of the programme was to speed up the recovery process, so that women could be discharged the day after a post-elective caesarean section if it was safe to do so.
There was a seven-day therapy service available from 7am to 7pm, with a focus on patient care within medical services.
A tool developed by a nurse and a pharmacy colleague that assessed the impact of certain medicines in contributing to the risk of falls had been shortlisted for a national award. This tool was used on wards and had significantly reduced the number of falls.
The orthopaedic team had introduced an enhanced recovery pathway for hip and knee replacements, which had reduced the length of stay. National data demonstrated that their hip and knee revision rates were significant lower than other trusts.
The bereavement office participated in the doctors’ training programme, delivering joint training with coroners on a range of issues, including completion of death certificates. This significantly reduced the number of death certificates that were completed incorrectly.

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

Complete the 16 outstanding actions from the Keogh review that had not been delivered and were overdue in April 2014.
Ensure that all relevant staff in the trust are trained in paediatric life support and staff in the neonatal unit are confident in neonatal resuscitation.
Review the arrangements and facilities for the stabilisation of high dependency children on the paediatric ward.
Review the arrangements for junior doctor cover on the labour ward between midnight and 7am, to ensure it meets nationally recommended guidelines as set out in Towards Safer Childbirth.
Review which staff require training to Level 3 in child protection and provide this training.
Review staffing in the neonatal unit and ensure that it meets the requirements of the British Association of Perinatal Medicine of one nurse per nursery.
Review the resuscitation committee and consider whether the current frequency of meetings is sufficient to mitigate the risks.
Ensure that all resuscitation trolleys are easily accessible in an emergency and that all oxygen cylinders are in date and fit for use.
Ensure that the trust’s resuscitation policy reflects current best practice.
Review the Do Not Attempt Resuscitation (DNA CPR) paperwork currently in use and take action on the findings to ensure that this is fit for purpose and that staff are trained to complete this paperwork.
Review the pathway of care for patients at the end of their life and ensure that all nurses know who to contact and when.
Review bed capacity to reduce the number of medical outliers and minimise the number of times patients are moved during their stay in hospital.
Take action to ensure that the care for people living with dementia is embedded in all divisions across the trust.
Take action on the findings of the WHO surgical safety checklist audit and strengthen the assurance process.
Review the training provided to staff in the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards, as not all staff had appropriate knowledge of these areas to ensure that patients’ best interests were protected.

In addition the hospital should:

Consider reviewing the maternity targets, such as the numbers of women having either elective or emergency caesareans and the maternity dashboard, as the current targets are not stretching.
Consider developing and using a tool to monitor the quality of paediatric services.
Review and amend the hospital’s safeguarding policy so that it is in line with best practice set out in Working together to safeguard children (March 2013).
Take action to mitigate or resolve risks identified on department’s risk registers in a timely manner.
Review capacity in outpatients to minimise the long waiting times for patients when attending outpatient appointments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We carried out this inspection because we received information of concern from the Rapid Responsive Review team (RRR). The RRR was being completed as part of the Professor Sir Bruce Keogh review into the quality of care and treatment provided by those NHS trusts and NHS foundation trusts that are persistent mortality indicators. This trust is one of 14 hospital trusts being reviewed on the basis that they have been outliers for the last two consecutive years on either the Summary Hospital Mortality Indicator or the Hospital Standardised Mortality Ratio.

We were told that some staff responsible for completing patients' death certificates had been asked to alter patients' death certificates and in some cases complete death certificates for patients they had not recently seen or treated.

We spent time during our inspection speaking with staff, looking at deceased patients' care records and reviewing completed death certificates. We found that in each case we looked at death certificates were completed correctly.

We inspected this service in September 2012 and we found they were not compliant in relation to medication practices. This meant the registered provider had to make improvements to deliver good outcomes for the people when they required support with their medication. The inspection was unannounced, which meant the registered provider and the staff did not know we were coming.

This inspection was to look at the evidence available following the action plan we had received from the registered provider, and to speak with people using the service and the staff, to see if improvements had been made in relation to medication practices.

We inspected three wards, Ward 3, 5 and 11, and the treatment centre, which had not been inspected previously. This is a separate building, but part of the hospital.

We spoke with five people and asked them about the staff and how their medication had been managed during their stay. One person said, 'The approach of the staff has been brilliant, they are courteous and listen. They have explained everything about the medication I am taking and have ensured I know what to do when I go home.' Another person said, 'They are better now than they have ever been, the staff are fantastic. They have written everything in my notes and I know why they are giving me my tablets.'

We saw the registered provider had put right what was required. This meant they were managing medicines as required for the people using their service.

We carried out an unannounced scheduled inspection in June 2012. During the inspection we made one compliance action about the management of medicines. This meant the trust had to make improvements and deliver good outcomes for the people who used their service when they required support with their medication.

This unannounced inspection was to look at the evidence available following the action plan we received from the trust, and to speak with people who used the service to see if improvements had been made in relation to medication practices. We visited two wards, Ward 11 which we had visited on our last inspection and Ward 3, which we chose at random and had not inspected previously.

We found that although improvements had been made in the areas we had identified there were new areas of concern. These included medication storage and current administration practices.

We spoke with people using the service on Ward 11 and asked them about the staff and about how their medication had been managed during their stay. Comments included, 'The nurses here couldn't do enough for me.' Another person said, 'They always ask me if I have any pain and offer me my paracetamol.'

We saw the trust had put right what was required following our last inspection, but needed to ensure their systems and structures across all areas of medicine management were suitable and safe.

We carried out this inspection to check on the care and welfare of people using this service. We visited Queens Hospital to ensure that the needs of people using the service were being met. The visit was unannounced which meant the hospital and the staff did not know we were coming. The visit consisted of a team of five inspectors, an expert by experience, a pharmacist inspector and a regional intelligence and evidence officer from the Care Quality Commission (CQC). We visited four wards providing adult inpatient care across the hospital. We spoke with 31 people who were receiving a service, four visitors, two volunteers and 36 staff from different disciplines.

We involve people who use services and family carers to help us improve the way we inspect. These people have experience of using health and social care services and we call them experts by experience. An expert by experience took part in this inspection and talked to the people who used the service. They took some notes and wrote a report about what they found. Their information is included within this report.

Everyone we spoke with told us that they were getting the care and support they needed. Comments included, 'I feel I have been treated in a dignified manner. The care is absolutely fine, and the staff attitude was professional.' Another person told us; 'I am very satisfied; they have looked after me very well.'

People said the staff supported them sensitively and discreetly. When we spoke with the staff they were able to provide good examples of how they promoted people's privacy and dignity in their work. People who used the service felt they were treated with respect. One person said; 'They closed the curtains during the doctor's visit. The care so far has been 100%, very dignified; I am very satisfied with my treatment.'

Everyone we spoke with told us that they liked the meals. People said there was always a choice and that food arrived hot. One person told us, 'I have been here a week, food is good, four lunch choices, so you cannot fault it.' The staff told us protected mealtimes had ensured people were not disturbed when eating their meals, and that staff were able to assist people who required support and supervision with eating and drinking. We evidenced this at lunchtime, and saw people received the support they required from the staff to eat and drink in a calm and relaxed manner.

We looked at medication management and found that medication was not stored securely and not always administered or recorded in a suitable manner. This meant people using the service were placed at risk because the management of medicines was not as safe as it needed to be.

We observed people being cared for in a clean environment. There was evidence available to confirm suitable practices were in place regarding infection control and its management.

Everyone we spoke with told us that the nurses were are always asking them if they were happy with everything. They said that they were able to express their wishes and share their views about how they were feeling and what could be done to make them feel more comfortable. One person said, 'I have been in here three months, they have all been so kind and understanding, they have saved my life.'

We looked at ways in which the hospital assessed it own quality and safety and saw suitable systems were in place. However, when issues within the hospital had been identified there were not always records to support how these had been dealt with and/or improved upon. This meant the outcome of audits were not always available.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Most people who used the service (patients) told us all the staff involved them in their care, treatment and support. They confirmed their privacy and dignity was respected. Most people told us that staff responded to their needs quickly and verified the staff were kind and explained what was happening to them.

Comments included:

'I am more than happy with the staff; their treatment is superior.'

'I am treated well. They do come and check on me regularly.'

'Normally they discuss things with me but when they take blood they just say; 'I have come to take your blood', I am not given a choice about having it done.'

We talked to people about meals and mealtimes and observed the lunch being served on two wards. People said they were offered a good choice at mealtimes. All but one person we spoke with were happy with the food, choice, portion size and how their food was presented.

Comments included:

'The food is really nice, loads of choice and not repetitious.'

'They have talked to me about diet and food, I am quite happy with the menu.'

'I only eat breakfast here my family bring my other meals in. The food is awful I can't eat it. I get plenty of drinks though, including hot drinks.'

Archived: Queen's Hospital, Burton Upon Trent

All Inspections

7 - 9 July 2015

During an inspection looking at part of the service

Professor Sir Mike Richards

24-25 April and 6-7 May 2014

During a routine inspection

Why we carried out this inspection

Professor Sir Mike Richards

31 May 2013

During an inspection in response to concerns

18 December 2012

During an inspection looking at part of the service

10 September 2012

During an inspection looking at part of the service

19 June 2012

During a routine inspection

20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

6 April 2011

During a themed inspection looking at Dignity and Nutrition