During this inspection we inspected the regulated activities of diagnostic and screening procedures, treatment of disease, disorder and injury and surgical procedures.

When we inspected the service on 7 July 2013 we found the provider to be non compliant with Regulation 22 'Staffing'. We took enforcement action by way of a warning notice. In August 2013 the provider sent us an action plan telling us what they were going to do to achieve compliance by the end of September 2013.

On 9 October 2013 we carried out a follow up inspection to check whether improvements had been made. During this follow up inspection we visited the same three wards: Waterside, Chartridge and the Buckinghamshire Neurorehabilitation Unit (BNRU). We found the trust had introduced a new system to improve closer operational working across the three wards. This was to ensure at times of pressure at least minimal staffing levels were maintained. Senior staff told us recruitment was ongoing and some posts had been filled. Although the wards still relied heavily on bank or agency staff, particularly Waterside and BNRU. We were told the temporary staff were usually regular and this ensured a degree of continuity of care for patients. We noted incident reports were completed when staffing levels were found to be at the minimal accepted levels. This ensured the trust was able to accurately monitor staffing levels and the impact on patient care.

Patients on Chartridge and BNRU were complimentary about the care they received from the nursing staff. One person told us "Really good staff...always have time". On Waterside, patients also described the staff as good but "But always busy". Two people who needed assistance with toileting said staff did not always attend in time. Staff on Waterside felt they did not always have enough time to meet patients' needs in an appropriate manner, particularly when shifts were below optimal staffing levels.

On Waterside and Chartridge wards we found one third of shifts were below the optimal staffing levels for September 2013. There was also a high use of temporary staff, for example, 50% on the late shift on Waterside ward. Some shifts had no substantive nurse on duty. The trust had an action plan in place and had made progress to address the non-compliance identified in the warning notice. However, there were times when there was not always sufficient numbers of suitably qualified, skilled and experienced staff to meet the needs of people.

During this inspection we inspected the regulated activities of diagnostic and screening procedures, treatment of disease, disorder and injury and surgical procedures.

When we visited the service on 3 March 2013 we found the provider to be non compliant with Regulation 22 'Staffing'. A compliance action was set. In March 2013 the provider sent us an action plan telling us what they were going to do to achieve compliance by the end of June 2013. In July 2013 we carried out a follow up inspection to check whether improvements had been made.

During this follow up inspection we visited the same wards as in March 2013, Waterside and Chartridge plus the Buckinghamshire Neurorehabilitation Unit (BNRU).

On Waterside ward four out of five patients told us the ward was sometimes short staffed. We found one third of shifts were below optimal staffing levels and overall 45% of nursing staff on the early and late shifts were temporary staff. Agency staff were not authorised to carry out certain clinical procedures such as administration of intravenous medication. This meant a high use of agency staff placed a greater clinical burden on permanent staff.

On Chartridge ward, one patient out of four, told us they thought there was not enough staff on the ward. We found there were 24 shifts below optimal staffing levels and seven below minimal staffing levels. We found staff had not reported the subminimal shifts on the trust incident reporting system, contrary to what was expected.

On BNRU five out of six patients expressed an observation that they thought the ward was short staffed. One patient said they had to "Wait for call bells to be answered”, another patient told us of an occasion when they needed assistance from two staff and only one staff member was available to assist. This meant patients felt there was not always enough staff to provide care in a timely manner.

On BNRU The staffing levels for the month of June 2013 indicated 13 shifts were below optimal staffing levels and 18 below minimal. We found overall 67% of night shifts were staffed by temporary nursing staff and 11 night shifts had no substantive nurse on duty, that is only temporary nursing staff were available, although the HCA was usually a substantive staff member. Overall this meant there were not sufficient numbers of suitably skilled and experienced staff to meet people’s needs.

Waterside and Chartridge wards were community wards which provided rehabilitation for older people before discharge to the community. This inspection took place out of hours on a Sunday afternoon. We reviewed the regulatory activities of treatment of disease, disorder and injury, diagnostic and screening and surgical procedures

People said they were happy with the care they received. One person said “the nurses provided good care”. Some expressed concerns they were not given enough information about their treatment. One relative told us, “I would have appreciated it if someone would have told me what would happen next...I had to chase them.” Two people who were due to be discharged said they had been involved in the discharge process. One person said they felt they did not have enough physiotherapy support.

There was sufficient equipment and there were systems in place to ensure it was maintained.

We found staff were very busy and often shifts were not fully staffed in line with the trust’s own staffing matrix.

Staff said they were supported by their manager and colleagues to ensure "the work gets done". Staff received support through training, supervision and appraisal.

Amersham Hospital was part of Buckinghamshire Healthcare NHS Trust. This hospital was a community hospital and provided medical care and outpatients services. These were two of the core services always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection.

This hospital had a total of 75 beds and specifically provided care for older people. It also offered inpatient services in dermatology and the Buckinghamshire Neurorehabilitation Unit (BNRU) for people with neurological and rehabilitation needs. There were outpatient clinics and these saw more than 47,000 outpatients a year.

We carried out this inspection because the Buckinghamshire Healthcare NHS Trust had been flagged as a potential risk on CQC’s intelligent monitoring system. The announced inspection took place between 18 to 21 March 2014 and an unannounced inspection visit took place between 6pm and 10pm on Saturday 29 March 2014.

Overall we rated this hospital as ‘Requires improvement’. We rated it ‘Good’ for caring for patients but it required improvement in providing safe and effective care, being responsive to patients’ needs and being well led.

Our key findings were as follows:

• Staff were caring towards patients, and patients were treated with dignity and respect.
• Staff followed infection control practices and infection rates in the hospital were similar to those of other trusts.
• Patients were supported to eat and drink, where appropriate, and standards to ensure that patients were properly hydrated had improved.
• Patients whose condition was deteriorating were identified and escalated appropriately and mortality rates were now within expected range.
• Staffing levels were a concern because there were not always sufficient numbers of suitably qualified, skilled and experienced staff to meet the needs of older patients and medical emergencies out of hours were managed by 999 calls. Medical staffing for patients who required emergency care needed to improve. The trust was working to improve this situation.
• There were not enough bath and shower facilities for patients on the older people’s wards.
• There were security and safety concerns in the wards areas because fire cupboards and exits did not close properly.
• Patients were treated according to national guidelines but these were not always properly reviewed or monitored.
• Older patients living with dementia or a learning disability were not supported appropriately.
• Outpatients services were safe and changes were being made to speed treatment for patients and bring care closer to people’s homes.
• Outpatient clinic appointments were frequently cancelled at short notice and patients could wait a long time for consultations in busy clinic environments.

We saw areas of good practice including:

• There was a multidisciplinary team approach in the Buckinghamshire Neurorehabilitation Unit to coordinate care. This included involving patients in setting their own treatment goals and outcomes for their care and rehabilitation.

There were areas of poor practice where the trust needed to make significant improvements.

Importantly, the trust MUST take the following actions:

• Care plans need to be developed for all patients.

There were also areas of practice where the trust should take action which are identified in the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

- 12 June 2014