Andover War Memorial Hospital

Hampshire Hospitals NHS Foundation Trust was established in January 2012 as a result of the acquisition by Basingstoke & North Hampshire NHS Foundation Trust of Winchester & Eastleigh Healthcare Trust.

The trust provides a full range of elective and emergency medical and surgical services to a local community of 600,000 patients in Basingstoke, Winchester, Andover and the surrounding areas in Hampshire and West Berkshire. It provides services from Andover War Memorial Hospital, Basingstoke and North Hampshire Hospital and the Royal Hampshire County Hospital. Outpatient and assessment services are provided from Alton, Bordon and Romsey Community hospitals, and the Velmore Centre in Eastleigh.

Andover War Memorial Hospital (AWMH) was opened in 1926. The hospital provides inpatient rehabilitation, day hospital services and a minor injuries unit, and a new outpatient unit opened in 2010. The site also houses the Countess of Brecknock Hospice, which provides six inpatient beds, day care, and a base for Macmillan Nurses.

We inspected the hospital as part of our comprehensive inspection programme. We inspected six core services at this hospital: Urgent care services, medical (including older people) services, surgical services, maternity and gynaecology, end of life care and outpatient services. The hospital did not have critical care or services for children and young people.

There were 60 staff employed at the hospital.

The inspection of AWMH took place on 28 and 30 July 2015. The full inspection team included CQC senior managers county managers, inspectors and analysts. Doctors, nurses, allied healthcare professionals, ’experts by experience’ and senior NHS managers also joined this team.

We rated AWMH as overall as ‘requires improvement’. We rated it as good for providing safe, caring, responsive services. However, MIU was rated as requires improvement for effective and well led services.

We rated the hospital’s services for end of life care as ‘outstanding’; for medical care, maternity and outpatients and diagnostics as ‘good’ and for the minor injuries unit and surgery as ‘requires improvement’.

Our key findings were as follows:

Are services safe?

• Staff were encouraged to report incidents and learning from incidents to improve the safety of services locally and across the trust. However, in the Minor Injuries Unit (MIU) and in surgery, learning was not being effectively shared across the trust’s services.
• In diagnostic imaging, staff were confident in reporting ionised radiation medical exposure (IR(ME)R) incidents and followed procedures to report incidents to the radiation protection team and the Care Quality Commission.
• Patient clinical areas were visibly clean and staff followed good infection control procedures.
• Staffing levels were appropriate in all areas.
• Overall, staff had a good understanding of safeguarding adults and children. In the MIU there were pathways for children with non-accidental injury. However, safeguarding checks had not been consistently recorded in patient notes.
• Medicines were appropriately managed and stored. Action was being taken in areas where there were some concerns. The Patient Group Directions, which allows trained nurses to prescribe and administer drugs, were out of date in the MIU.
• Equipment was checked and stored appropriately in most areas but this needed to improve in the MIU, specifically for resuscitation equipment.
• More staff needed to complete mandatory training.
• Patients’ were assessed and monitored appropriately. However, the early warning score needed to be used in surgery, and a scoring tool was required for outpatients, for patients whose condition might deteriorate. There also needed to be a clear hospital protocol for responding to a collapsed patient.
• The trust did not employ site security for the hospital. MIU staff were concerned about the number of recorded incidents of abuse from patients attending the MIU towards staff.
• The new regulation, Duty of Candour, states that providers should be open and transparent with people who use services. It sets out specific requirements when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, giving truthful information and an apology. The trust monitored duty of candour through their online incident reporting system. Senior staff we spoke with were aware of duty of candour and talked about the importance of being open and transparent with patients and their families

Are services effective?

• Staff were providing care and treatment to patients based on national and best practice guidelines. In some areas guidelines had been unified across the trust for consistency of care. However, the MIU did not have clear guidelines or protocols for the management of common conditions. Staff in surgery did not all know how to access the trust’s guidelines and protocols and some policies they were using were out of date.
• Most services were not monitoring the standards of care and treatment. Patient outcomes, where available, were similar to the England average or within expected range.
• Patients received good pain relief in the MIU, after surgery and in end of life care. The Maternity Centre used hypnotherapy-birthing techniques to support women in pain during labour.
• Patients, particularly older patients, were supported to ensure their hydration and nutrition needs were met.
• Staff were supported to access training and there was evidence of staff appraisal and supervision. Nursing and midwifery staff were autonomous, experienced and competent practitioners. However, staff in the MIU were not supported to keep their clinical skills up to date through supervision or developmental training, and day surgery staff did not have regular and up to date competency assessments. Midwifery staff told us they did have opportunities for professional development.
• Staff worked effectively in multidisciplinary teams to centre care around patients. There were innovations in electronic records and the use of video conferencing in end of life care that enabled information to be shared about patient’s clinical needs and preferences across the trust, and with community and GP services.
• Seven-day services varied. These were developed in the MIU, the Maternity Centre and the hospice. However, day surgery occurred Monday to Friday and medical patients did not receive therapy input for rehabilitation over the weekends. There were a high number of repeat attenders to the MIU because there was no radiology at the weekend.
• Staff had appropriate knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards to ensure that patients’ best interests were protected. Guidance was available for staff to follow on the action they should take if they considered that a person lacked mental capacity. Notification of Deprivation of Liberty Safeguards applications were correctly submitted to the Commission. However, the capacity assessments were not always documented or regularly reviewed in patient care records.
• ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) forms had been fully completed.

Are services caring?

• Staff were caring and compassionate and treated patients with dignity and respect. Patient feedback was positive across all services. The Countess of Brecknock Hospice provided outstanding care with patients and relatives providing examples where staff had gone “above and beyond” and developed trusting relationships to provide personalised care and support to patients and their families.
• Staff maintained patient’s confidentiality, privacy and dignity in all areas.
• Patients and their relatives felt involved in their care and treatment, staff provided explanations in the way patients could understand. Patients felt that their views and considerations were listened to and acted upon.
• Patients and their families were supported emotionally to reduce anxiety and concern, particularly for example, in preparation for surgery, or for women during labour. There was support for carers, family and friends from the chaplaincy and bereavement services for patients having end of life care.
• Data from the NHS Friends and Family Test demonstrated that patients were very satisfied and would recommend the care they received.

Are services responsive?

• The MIU service saw and treated patients within the national emergency access target of four hours.
• Medical patients did not have to wait for access to the Kingfisher ward and there was active therapy input to commenced rehabilitation immediately. Discharge planning was supported but there were delayed transfers of care.
• The trust was achieving the 18-week referral-to-treatment time target for medical patients. The target had been met in surgery between April to December 2014 but was not being met between January to March 2015. The target was not being achieved in orthopaedics and ophthalmology.
• The majority of patient who had cancelled surgical procedures for non-clinical reasons were rebooked for surgery within 28 days. Some operations and procedures were being cancelled because of absent medical records.
• Patients did not have staggered admission times for all procedures as recommended, to limit fasting and waiting times on the day of surgery.
• Women were able to make choices about where they would like to deliver their babies. They had access to their preferred ante-natal clinics and women in the early stages of labour had access to telephone support.
• There were one stop gynaecology, cataract and orthopaedic clinics.
• The trust was meeting national waiting times for diagnostic imaging within six week, outpatient appointments within 18 weeks and cancer waiting times for urgent referral appointments within 2 weeks and diagnosis at one month and treatment within two months.
• The trust cancellation rate for appointments was 13%; the England average was 7%. Many of these clinic cancellations were at short notice. The reasons for this varied and included cancellation for staff sickness, training and annual leave. There was a plan to address this but this was in development. Patients were not appropriately monitored to ensure the timeliness of re-appointments.
• Some patients had long waiting times whilst waiting in clinic for diagnostic imaging, and there could be delays of up to an hour.

• Support for patients living with dementia or a learning disability was well developed for medical care, but was not consistent for patients undergoing surgery.

• There was access to the breast unit at Winchester, which offered access to one stop clinics. Appointments were offered to patients within two weeks following GP referral. The referrals were initially received into the central booking office and prioritised by consultants. Patients who attended the one stop clinics would see a clinician, have a biopsy taken and see a radiologist if required. If a cancer diagnosis was suspected, patients were told before leaving the clinic and an appointment given to discuss the outcome and treatment options. This unit provided a responsive service for patients who were anxious about a potential cancer diagnosis.
• There was a hospital at home service to deliver care to those patients identified as being in the last days or hours of life. The service was 24 hours and seven days a week. Multidisciplinary team working, and innovations in electronic records and the use of video conferencing in end of life care, also facilitated rapid assessment and access to equipment.
• Patients having end of life care had multi-disciplinary care focused on their physical, mental, emotional and social needs. Patients could have a rapid discharge to home arranged within 24 hours. However, there were delays to the rapid and fast track discharge processes (within 48 hours) and processes were being improved to meet national standards.
• Complaints were handled appropriately and there was evidence of improvements to services as a result.

Are services well-led?

• All services identified the plans to build a new Critical Treatment Hospital as the overall strategy for the trust, and there were in-depth plans towards this across services. However, the individual services did not have specific strategies and plans in the short and medium term for their development. Priorities were identified to increase capacity and staffing.
• Clinical governance arrangements varied across the hospital. The Kingfisher Ward (medical care), Maternity Centre and Countess of Brecknock Hospice had effective arrangements to assess and manage the quality of service provision. However, the MIU, day care unit for surgery and outpatient department required more robust arrangements to effectively monitor the quality of the service, clinical standards and to mitigate risks.
• Many staff told us overall they had good support from the local clinical leaders, for example ward managers and clinical leads.
• Staff engagement also varied and was good in some areas, but there was a disconnect with the trust’s working arrangements in the MIU, Day Care Unit and outpatient department, and staff did not feel part of the wider trust.
• Many staff identified the visibility, approachability and support of the chief executive of the trust.
• The leadership for end of life care was outstanding. There were robust governance arrangements and an engaged staff culture, all of which contributed to driving and improving the delivery of high quality person-centred care. This was an innovative service with a clear vision and supportive leadership and board structure.
• Patient engagement was mainly through survey feedback, although the Maternity Centre also used social media.
• Innovative ideas and approaches to care varied. This was being encouraged and supported on the Kingfisher Ward (medical care), in maternity and end of life care, and there were good examples of innovations in care. This was less evident in the MIU, the day care unit for surgery, and outpatient and diagnostic imaging services.
• The non-clinical site manager was a highly-valued member of staff.

We saw several areas of outstanding practice including:

• Kingfisher ward had activity coordinators who planned and conducted different activities for patients after consulting them. There was a range of activities offered, including arts and crafts, music, dance, group lunches and movie time.

• Pregnant women were able to call Labour Line which was the first of its kind introduced in the country. This services involved midwives based at the local ambulance operations centre. Women who called 999 could discuss their birth plan, make arrangements for their birth and ongoing care. The labour line midwives had information about the availability of midwives at each location and were able to discuss options with women and their partners. Labour Line midwives were able to prioritise ambulances to women in labour if they were considered an emergency. The continuity of care and the rapid discharge of ambulances when they are really needed, have been two of the main benefits to women in labour. The Labour line had recently won the Royal College of Midwives Excellence in Maternity Care award for 2015, and they were also awarded second place in the Midwifery Service of the Year Award.
• The specialist palliative care team provided a comprehensive training programme for all staff involved in delivering end of life care.
• The cardiac palliative care clinic identified and supported those patients with a non-cancer diagnosis who had been recognised as requiring end of life care.
• The hospice at home service was proactive in supporting patients in their own home.
• The use of the butterfly initiative promoted dignity and respect for the deceased and their relatives.
• There was strong clinical leadership for the end of life service with an obvious commitment to improving and sustaining care delivery for those patients at the end of their lives. All staff throughout the Countess of Brecknock Hospice were dedicated to providing compassionate end of life care.

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

Importantly, the trust must ensure:

• MIU staff have access to up- to-date approved Patient Group Directions (PGDs).
• MIU staff must all have received update mandatory training in basic life support and infection control
• Safeguarding checks are consistently completed and recorded.
• Resuscitation equipment is appropriately checked and equipment is sealed and tagged.
• There is a clear hospital protocol for responding to a collapsed patient in an emergency.
• There is appropriate security on site for the protection of staff and patients in the MIU.
• The lead consultant for ED should regularly monitor and maintain clinical standards in the MIU
• There are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.
• There is an effective system to identify, assess, monitor and improve the quality and safety of the MIU, the day care unit and outpatient services

In addition, the trust should ensure:

• Staff receive appropriate training, and there is a formal process in place for staff to follow to meet requirements of the Duty of Candour.
• The availability of medical notes for outpatient clinics continues to improve and this should be audited.
• There is a formal method to identify patients whose condition might deteriorate in the outpatient clinic.
• Patients receive better access to therapy services to continue rehabilitation over weekends.
• Clean equipment is clearly identified for use and is appropriately separated from dirty equipment.
• Bariatric equipment is available when required.
• Continue to recruit to support radiographers, and assess the impact of vacancies on staff.
• All staff have appropriate clinical supervision.
• The Maternity Centre has better access to defibrillator equipment.
• Medicines are appropriately stored in the Maternity Centre.
• Clinical audit programmes are developed in all services.
• Information is being measured, monitored and recorded regarding outcomes for women.
• Theatre capacity is reviewed and patients are not waiting longer than 18 weeks for surgery.
• Patient have staggered admissions for day surgery.
• Patient operations are not cancelled on the day of surgery for non-clinical reasons.
• Patient’s privacy and dignity is maintained on the day care unit by reviewing same sex arrangements.
• There is service continuity with local funeral directors to collect deceased bodies from the Countess of Brecknock Hospice, to reduce the risk of any services being withdrawn.
• The process for ‘fast-track’ discharge for end of life care is reviewed so that the standard is met.
• Improve staff engagement in the MIU, day surgery unit and outpatients.
• There are formal methods to feedback complaints to staff.

Professor Sir Mike Richards

Chief Inspector of Hospitals