Bradford Teaching Hospitals NHS Trust is an integrated trust, which provides acute and community health services. The trust serves a population of around 500,000 people in the Bradford and surrounding area. The trust operates acute services in Bradford Royal Infirmary and St Luke’s Hospital. The trust has three community hospitals; Eccleshill, Westbourne Green and Westwood Park. Eccleshill Hospital was closed at the time of the inspection. In total the trust has around 900 beds and employs approximately 5,500 members of staff.

We carried out a follow up inspection of the trust from 11-13 January 2016. This was in response to a previous inspection conducted as part of our comprehensive inspection programme in October 2014. In addition, an unannounced inspection was carried out on 26 January 2016.

Follow up inspections do not always look at every service the trust provides. They focus on the areas identified as requiring improvement in the previous inspection and any areas of concern identified in the time since the last inspection. In addition, not all of the five domains: safe, effective, caring, responsive and well led were reviewed for each of the core services we inspected.

At the comprehensive inspection in October 2014 we found the trust was in breach of regulations relating to care and welfare of people, assessing and monitoring the quality of the service, cleanliness and infection control, safety, availability and suitability of equipment and premises, respecting and involving service users and staffing. We issued a number of notices which required the trust to develop an action plan for how they would comply with the regulations where breaches had been found. We reviewed the trust’s progress against the action plan during this follow-up inspection.

Overall, we rated Bradford Royal Infirmary as requires improvement at this inspection.

Our key findings were as follows:

• We found that there had been improvements in some of the services and this had resulted in a positive change in the overall ratings from the previous CQC inspection, notably in critical care and outpatients and diagnostic imaging.
• However, the ratings remained the same in accident and emergency, surgery, medicine and children’s and young people’s services. This was because we either did not see significant improvement since our previous inspection or because we identified new areas of concern.
• In relation to outpatient services, the trust had taken the necessary steps to ensure that the backlog of over 250,000 non-referral to treatment patient pathways had been clinically reviewed and actions taken to reduce risks to patients, including prioritising appointments and the assessment of potential harm. An improvement plan had been developed and systems and processes had been changed. The trust had revised executive, clinical and managerial leadership arrangements for outpatients and invested in additional administrative staff and a rolling programme of staff training.
• However, the new systems and processes had not yet been embedded within the outpatient service and further work was required to establish the new centralised patient booking system. Staff did not feel engaged with the changes and expressed frustration at the new systems and processes. There were still a large number of patients waiting for outpatient appointments and there was a downward trend in referral to treatment times, which could delay access to treatment.
• The trust had taken action to address the staffing concerns identified in our previous inspection. The trust had introduced integrated patient acuity monitoring systems to assess patient acuity and staffing levels on a daily basis. Staffing levels were assessed in daily matron huddles that were led by the head of nursing and staffing levels were risk rated and monitored by the chief nurse. Nurse staffing levels had been reviewed across the trust and in December 2015 the Board of Directors had approved a £2.5millon spend on staffing.
• However, we found that there were significant nurse staffing shortages in urgent and emergency services, medicine, surgery, and services for children and young people.
• Governance and assurance arrangements had been reviewed since the last inspection. However, we found that they were not robust enough to identify issues relating to, for example, medicines storage and reconciliation, issues relating to the availability of portable oxygen cylinders on resuscitation trolleys and gaps in records in urgent and emergency services. This was of particular concern because we identified these issues in the comprehensive inspection in 2014 and the trust had an action plan in place to address them. We wrote to the trust to ask for information about how they would address our concerns. The trust has provided us with assurance that our concerns would be addressed promptly and we have seen evidence that medicines reconciliation rates are now above the trust’s target and that action has been taken to ensure that portable oxygen cylinders are available. The trust has a robust plan to improve the quality of records in the urgent and emergency service.

• Our previous concerns about the safety of children who were cared for in the stabilisation room pending transfer out of the hospital had largely been addressed. There were suitably qualified and trained staff to support critically ill children until the paediatric transfer team arrived. The service had been reviewed by the Royal College of Paediatrics and Child Health in August 2015 and an action plan had been developed to address the recommendations made in this report.
• Our previous concerns about the care of patients requiring non-invasive ventilation (NIV) had been addressed. Patients requiring NIV were now grouped together in the respiratory unit on ward 23 and the service was compliant with British Thoracic Society Standards.
• The trust had invested significantly in the estate and the environment. This included building a new hospital wing at the Bradford Royal Infirmary site, which was due to open around November 2016. Paediatric and critical care services would be relocated to the new wing, along with a new care of the elderly ward. The new wing would address many of the issues with the hospital environment identified in the previous inspection and the trust had commenced a full condition survey of the remaining estate. The trust was also in the process of redeveloping the accident and emergency department and gastroenterology.
• In the interim, the trust had taken action to address some of the issues with the environment, particularly in critical care. However, wards 7, 9 and 15 remained very cramped with limited space around beds. We were concerned that in an emergency situation this would present a challenge.
• There was a dedicated infection prevention and control team with arrangements in place to prevent the spread of infection. However, we observed staff not following infection prevention and control practices on a number of occasions. The MRSA, MSSA and C-difficile rates for the trust were above the England average for the period August 2014 to August 2015.
• Policies and procedures were not always up-to-date. We saw policies and procedures that were past their review date and in critical care some of the policies we looked at did not refer to current guidance and standards. Staff in urgent and emergency services were unable to provide us with records to support patient group directives (PGDs), which allowed nurses to administer certain drugs.
• The trust used the five steps to safer surgery process in the operating theatres to improve patient safety and reduce the risk of clinical incidents. The five steps included the use of the World Health Organisation surgical safety checklist. However, we observed patients receiving surgery when the surgical safety checklist process had not been followed fully. This meant there was a risk that safety issues might not be identified before a procedure took place.
• Confidential patient information was not always stored securely. In urgent and emergency services, we had concerns about the security of patient identifiable information relating to victims of domestic violence.

We saw several areas of outstanding practice including:

• The trust was collaborating with another local trust to work towards recruiting and retaining a workforce that reflected the 35% black, Asian and minority ethnic (BAME) population in the Bradford area. Between June 2014 and September 2015, the trust had improved the BAME representation on the trust Board of Directors from 0% to 29%.
• The trust was leading the “Well North” programme, which was a collaborative programme aimed at improving the health of some of the poorest communities in the most deprived areas in the North of England.
• The Bradford, Airedale, Wharfedale and Craven Managed Clinical Network for Specialist Palliative Care had won the British Medical Journal “Palliative Care Team of the Year” award in 2015.
• The trust had performed better than the England average for all indicators in the 2015 Hip Fracture Audit.

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

Importantly, the trust must:

• Ensure that infection control procedures are followed in relation to hand hygiene, the use of personal protective equipment and the cleaning of equipment.
• Review and risk assess the environment on ward 24 and put in place actions to mitigate the risk of the spread of infection.
• Ensure that the use of PGDs in accident and emergency is in-line with trust policy.
• Ensure that relevant staff working in surgery complies with the five steps to safer surgery process and that the WHO surgical safety checklist is consistently followed.
• Ensure there are improvements in referral to treatment times and action is taken to reduce the number of patients in the referral to treatment waiting list to ensure that patients are protected from the risks of delayed treatment and care.
• Ensure that robust arrangements are in place to ensure that policies and procedures (including local rules in diagnostics) are reviewed and updated.
• Ensure that patient information is held securely and patient confidentiality is maintained in relation to information about victims of domestic abuse in accident and emergency and the storage of property bags for deceased patients.
• Ensure that there are in operation effective governance, reporting and assurance mechanisms that provide timely information so that risks can be identified assessed and managed.
• Ensure that there are alert systems in place to identify when actions are not effective and need to be reviewed.
• Ensure that at all times there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance, taking into account patients’ dependency levels.
• Ensure that all staff have completed mandatory training, role specific training and had an annual appraisal.

In addition the trust should:

• Review use of the public address system in accident and emergency to ensure that patients are aware that they are being called and where they should go.
• Review the signage to the accident and emergency department within the hospital grounds to ensure that the department is clearly signposted.
• Improve assessment facilities for patients admitted into accident and emergency with mental health concerns.
• Review the arrival to initial assessment times in accident and emergency to ensure that patients are reviewed in a timely manner.
• Risk assess the isolation facilities in accident and emergency to ensure that they meet current infection control standards.
• Ensure cramped single rooms on wards 7, 9 and 15 are risk assessed to inform staff of the procedure in an emergency situation.
• Review and monitor the demand for the outreach service to ensure the needs of deteriorating patients out of hours are met.
• Review pharmacy cover against the Core Standards for Intensive Care Units (2013) (Pharmacy cover guidelines) which states that there should be at least 0.1 whole time equivalent specialist pharmacist for each single Level 3 bed and for every two Level 2 beds.
• Complete a review of unmet demand for beds which was identified as an action from the previous inspection and quality key indicators reports.
• Ensure that the amount of epidural waste destroyed is recorded, in-line with best practice.
• In maternity, the trust should ensure that PAT testing of electrical equipment takes place and is recorded.
• Consider having a policy regarding the use, monitoring and security of the baby milk refrigerators.
• Address the environmental issues on ward 2 to ensure patients and families have privacy and their dignity is respected.
• Review the practice of transferring patients from theatre to recovery with endotracheal tubes in place without any monitoring to ensure that any risks to patients are minimised.
• Ensure that staff in surgery and theatres understand the definition of a serious incident and a never event.
• Review ward 12 to ensure that patients are cared for by staff with appropriate skills and experience.
• Review the availability of play facilities for children.
• Review nurse staffing levels in services for children and young people to increase the availability of a senior staff member to provide clinical support and leadership to junior staff.
• Review the use of interpreters in outpatients and diagnostics to ensure that patients’ privacy is maintained.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We carried out this inspection to check on the progress made with the actions the Trust told us it was taking in order to be compliant with the management of medicines. We spoke with one patient about their self-administered medication and their medicine was being kept safely in-line with trust policy. However, in relation to the same patient, a nurse had signed the patient's drug chart to indicate they had taken two capsules of medication when they actually hadn't; the two capsules were still in a pot on top of the patient's locker.

We found a significant proportion of the prescription charts that we reviewed contained errors. We found recording errors or unresolved discrepancies on half of the eighteen charts we checked. We also found some evidence that the clinical service provided by the hospital pharmacy was limited and did not find all the errors on patients' medicine charts as they should. We also reviewed the trust's own recent pharmacy audit dated April 2013; the audit found that the dose of medicine was not included in the prescription in about a third of cases and just over a tenth of prescriptions had at least one prescribing error.

We found that the trust had made positive steps to address the issues raised at the previous inspection in relation to patients self-administration of medicines and we also found that controlled drugs were being safely managed.

At this inspection we found peoples consent was sought before treatment. The care and welfare of people who used the service was assessed and planned appropriately. The staff were supported to deliver care and records were accurate and fit for purpose. However there were some minor concern regarding the checking of medicines and prescribing by the pharmacy support and the safe self administration of medicines.

The expert by experience who joined us on this inspection spoke with 10 patients and 2 relatives, across 2 wards. Everyone they spoke with told them they or their relative had a good overall experience at Bradford Royal Infirmary. The people we spoke with told us they felt they or their relative had been treated with dignity and respect. Many of the people on the assessment unit had been admitted via the accident and emergency (A&E) department. They told us their experience in A&E was positive in that they were seen by a doctor and given an explanation regarding their condition and were kept fully informed. They all said they were looked after well and if necessary offered food/drink and toilet facilities. One person said although A&E was very busy he had “no complaints, they had seen the doctor during the night and again this morning”, they also said “I was given full information, what they have done and what they are going to do; I'm very impressed with it here”.

The patients we spoke to were generally positive about their experiences of care and treatment. Patients told us they were happy with the way staff cared for them, they said the staff are “lovely” and speak to them respectfully. Patients told us they had never felt embarrassed or uncomfortable during their stay in hospital. Overall patients felt staff responded quickly to their needs. Patients told us they understood the information they had been given and said when they asked for further explanation it was forthcoming.

Patients told us the meal times are not rushed and said they are given a choice of meals from the menu. Generally patients were satisfied with the quality of the food, one person described it as “adequate”, and another said the salads were the best. The patients we spoke to said they had not been asked about their dietary needs and preferences. Some patients told us staff checked if they had enough to eat, others said they did not. Patients told us they always have jug of water and said staff would get them iced water if they asked. Generally patients were not sure whether they could get snacks between meals if they wanted them but one patient said they felt staff would get them something if they asked.

• The medical services were rated as requires improvement in safe and effective but good in caring, responsive and well-led. The service did not always have appropriate numbers of staff to ensure patients received safe care and treatment. However, despite the 18% overall nursing vacancy rate for medicine, the service did manage staffing well and reviewed staffing throughout the day. There is concern regarding the sustainability of the current situation as there is also a 15% nursing turnover rate and a 5% sickness rate. The service was not meeting trust targets for mandatory training completion. The service did not always have suitable premises. The trust had been identified as an outlier for stroke mortality data and they were Band D in the Sentinel Stroke National Audit Programme (SSNAP). Results for the 2015 Heart Failure Audit were worse than the England and Wales average for all of the four of the standards relating to in-hospital care and

  for all of the seven standards relating to discharge.

  The Myocardial Ischaemia National Audit Project (MINAP) from April 2015 to March 2016 was noted to be below the national average for being admitted to a cardiac ward and better than average for being seen by a cardiologist. Also a lower proportion of patients were referred for angiography than the England average. Training that staff needed to undertake for their job roles was not consistently up to date. However, staff cared for patients with compassion and treated them with dignity and respect and we saw areas of outstanding practice. The service had an outstanding approach to multidisciplinary working. Staff described effective working relationships between consultants, doctors, nurses, health care assistants and allied health professional staff.

• The maternity services were rated as requires improvement in the safe, effective and well led domain; caring and responsive were rated as good. We found some of the areas of concern had not changed from the last inspection. Mandatory training rates and compliance with the World Health Organisation (WHO) safety checklist was variable. Infection prevention and control audit data was not being consistently collected each month. We also found some concerns in relation to medicines management and midwifery staffing. Care and treatment was evidence based however we found a number of guidelines past their review date. Some patient outcome data was worse than regional averages. We were concerned over the identification of some risks to the service and the slow pace in implementing actions from audits and reviews. However, we also found that care was patient centred and compassionate and we received positive feedback from the patients and relatives we spoke with.

• In surgical services we rated all domains as good. We found that relevant staff working complied with the five steps to safer surgery process and that the WHO surgical safety checklist was consistently followed and audited. Policies and pathways were based on guidance from the Royal College of Surgeons and the National Institute for Health and Care Excellence (NICE). Staff worked together as a team for the benefit of patients. Doctors, nurses and other healthcare professionals supported each other to provide care. The trust’s performance for elective and non-elective admissions relating to overall length of stay was better than the England average. Staff told us the division had strong leadership and senior managers were visible and engaged with staff.
• The urgent and emergency care services had improved overall and was rated good in all domains. The new emergency department met our previous concerns about the limitations of the previous department’s facilities; the department worked closely in liaison with the acute assessment area, the medical admissions unit and the ambulatory care unit to support the efficient flow of patients. Leadership and governance of the emergency department was stable with elements of good practice and staff spoke positively about the clinical leadership of the department; medical and nursing staff at all levels were clear about their roles; the culture was positive, friendly and open with high staff morale. The vision and strategy for the emergency department was supported by the clinical services strategy for 2017 to 2022 and the department embraced the overall mission of the trust to provide the highest quality healthcare. Information was used to monitor and manage the operational performance of the department, and to measure improvement. However, the sepsis audit figure, for antibiotic administration within 1 hour, was only 16% against national average of 44%; there were staffing concerns and the introduction of the electronic patient record in September 2017 adversely affected the completion of mandatory training.
• Overall we found that care was patient centred and compassionate and we received positive feedback from the patients and relatives we spoke with.
• This demonstrates positive improvement since the last inspection but as two of the services that were not inspected on this visit had elements of requires improvement this has not allowed the hospital to raise its rating overall. The concerns in those services will continue to be monitored through our engagement programme.