Our rating of services stayed the same. We rated it them as requires improvement because:

• The rating requires improvement was given because although all of the services we inspected in March 2018 had shown significant improvements, the rating is aggregated with the ratings from previous inspections which continue to be considered where we have not re-inspected.
• Staffing continued to be a challenge. There were innovative roles created to mitigate some of the risks, there was ongoing recruitment and there was better use of in-house bank staff over agency staff. The only area where we saw an unacceptable impact was with the administrative and reception staff in the emergency department who felt unable to have any breaks during long shifts.
• The emergency care department was still rated as requires improvement because there was more work to be done to bring it to the same standard as the service on the Conquest Hospital site. This related particularly to the care of people with acute mental health needs and to the care of children and young people.
• Mandatory training completion rates needed further work to ensure that the trust met it’s own targets.

However,

• We were aware from our ongoing monitoring of wider improvement in core services which were not inspected in March 2018. These improvements cannot be reflected in the ratings as they have not been corroborated trough inspection.
• The ongoing monitoring and information we hold about Eastbourne District general Hospital, coupled with discussions with numerous staff, showed a cultural shift which resulted in a more motivated workforce and a commitment to improving the quality and safety of services. This was true across all areas of the hospital whether inspected at this inspection visit or not.
• Incident reporting and learning from incidents was embedded in everyday practice. Openness and transparency about safety was encouraged. Staff understood their responsibilities to raise concerns and report incidents and near misses. The number of incidents reported had increased steadily since our inspection in October 2015 but the number of incidents resulting in harm had fallen. This demonstrated a good reporting culture.
• There were robust safeguarding adults and children arrangements that were in line with current national guidance. Staff from Eastbourne Hospital were actively engaged in the local safeguarding arena and with other providers.
• Peoples care and treatment was planned and delivered in line with current national guidance and legislation. There was ongoing monitoring to ensure that practice and policy remained in line with best practice guidance.
• People had comprehensive assessments of their needs with consideration of their clinical needs, mental health and nutritional needs. Data provided showed improvements in assessing individual risks such as for venous thromboembolism (VTE). There was also a steady decrease in the incidence of falls with harm resulting from improved risk assessments.
• There was good multidisciplinary working across services. This was very evident in the care of patients who had suffered strokes. The trust had been recognised for particularly high performance by the Stroke Association.
• Consent was obtained in line with the current legislation and guidance. The trust had done much work on staff responsibilities in respect of the Mental Capacity Act 2005 and there generally good understood. All Deprivation of Liberty Safeguard applications were appropriate. Referrals to the Court of Protection were made when necessary.
• Infection prevention and control practice was much improved and there was data available to demonstrate that the hospital was routinely cleaned to an acceptable level in line with the National Specification for Cleanliness in the NHS.
• Staff were very positive about their work and spoke with pride about the relationships with patients. We observed and heard about numerous occasions where staff had gone beyond the usual expectations their role for patients. This was reflected in the results from the Friends and Family Test.
• On previous inspection visit in October 2015 some staff were unclear about their line management arrangements and felt unable to raise concerns. There were several complaints to the inspection team about bullying. This had now changed. Staff reported approachable and supportive managers, clear lines of accountability and an executive and senior management team who were visible and who listened to frontline staff.
• The governance processes were robust and understood by all. Work had been done to streamline the Risk and Quality Delivery Strategy that made explicit the lines of accountability and reporting systems. There was effective information sharing in both directions between the frontline operations and the board.

On the 7 May 2013 the East Sussex Healthcare NHS Trust (ESHT) completed the temporary reconfiguration of maternity and paediatric services. This had been undertaken as a result of an escalation in concerns regarding the overall safety of maternity provision within the acute hospitals.

The Care Quality Commission made plans to review the newly configured service, and allowed a month for the new service arrangements to embed. Prior to our planned visit we received information from a team of consultant paediatricians working at Eastbourne District General Hospital. They expressed concerns that the new arrangements for paediatrics across the Trust were now less safe than before. We met with the consultants on 18 June supported by a paediatric specialist. We listened to their concerns and said that we would give these due consideration in our planned inspection of these services.

When we visited the service at Eastbourne we were supported by a paediatric specialist, and a maternity specialist. We spoke with staff at all levels of the Trust to gain their views about the safety of the service. We looked at systems, and reviewed documentation. We spoke with parents, mothers and relatives of people using these services. From the feedback we received and records viewed we were satisfied that the Trust was providing a safe, effective, responsive, caring and well led maternity and paediatric service.

The Care Quality Commission was notified by the trust of four serious untoward incidents that had occurred. We undertook a responsive review to ascertain any ongoing impact on people’s safety and to establish action taken by the trust in response to these incidents.

Five people who were using the service were spoken with and were asked for their views on their treatment, and the care provided in the maternity unit.

All feedback received was positive. People felt that they had been involved in any decisions made about their care, with options and consequences being fully explained. They were happy with all the care that they had received and felt that they had been well treated.

New mothers told us that staff were available, responded to any questions and provided support with their babies as necessary.

People told us that they had confidence in all the staff, who they said had the required skills to undertake their work effectively. This made them feel safe and that they could rely on the care and treatment that was provided to them

We spoke with people using the service (patients), relatives, and staff in all of the areas we visited. In total we spoke to 28 patients.

Patients told us that they felt their privacy and dignity was respected, that staff ensured curtains were closed during personal care and treatment.

We were told that patients were involved in their care and treatment. One patient told us “the doctor explained it to me”; another told us “staff come quickly when called”. The relatives of one patient told us “The consultant explained everything to us on dad’s behalf”.

Other patients spoken with confirmed that their condition, care and treatment had been discussed with them and without exception they were all satisfied with the care they had received since being admitted. One comment seemed to sum up the feeling of patients “I can’t fault the nurses here; they all do a wonderful job. It can’t be easy for them; they are so busy but seem so cheerful and always make time for you”.

Overall most patients told us they were happy with their admission process but two patients said there had been a delay in Accident and Emergency Department.

Another patient told us that they had been seen by a speech and language therapist who had provided them with advice about swallowing that they had found helpful.

We spoke with a total of 19 staff and they told us they had received training in privacy and dignity, equality and diversity, respecting patients’ choices, the Mental Capacity Act and Deprivation of Liberty Safeguards.

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.

We visited the Accident and Emergency Department (A&E), Jevington, Seaford 3, Cuckmere, Medical Assessment Unit, and Hailsham 3 wards and spoke with patients in all these areas.

The majority of patients we spoke with told us that they felt well informed about their care and treatment, and had been involved in decision making around this.

Patients said that all staff were actively maintaining their privacy and dignity; by pulling curtains around, and lowering their voices when sensitive information was being passed over.

Patients, who were able to make decisions for themselves, told us that consent was routinely verbally sought by staff for everyday care and treatment activities.

Overall patients told us that the care they had received had been good. They also thought that nursing staff had an understanding of their needs.

The majority of patients spoken with indicated that there was enough staff on duty, and thought call bells were generally answered in a reasonably short time.

However, some patients on Seaford 3, Jevington and Cuckmere wards did raise concerns about staff responses to call bells. Two patients spoken with expressed dissatisfaction with the lack of consultation with them in respect of their treatment or preferences.

In discussion, all the patients spoken with thought that the general standard of cleanliness was good. They said that cleaning was always happening, and that staff were always washing their hands, and using the alcohol based hand gels.

Some of the patients spoken with and three visiting relatives told us that they were in the main satisfied with the care and treatment they received at Eastbourne District General Hospital. They said they had been treated with courtesy and respect and that their privacy and dignity had been promoted and well-protected whilst receiving personal care.

Direct quotes include “Very helpful and kind” “Always lower their voice when giving me personal care” “Pretty good, staff are well meaning, I find it very hard to sleep because it is so noisy”.

Other patients spoken with were not so positive about their experience in hospital. One comment received from a patient indicated that her experience was mixed, “Can not complain, staff kind but meal times are a nightmare for me, last week they insisted on feeding me, this week they aren’t, if I could reach my meal I could feed myself. “

The feedback about the quality, range and availability of food was mixed. Breakfast was said to be the best meal of the day, and supper was the worst. The feedback taken from the medical ward was that patients indicated that the meals were very nice and appetising at lunchtime, although the vegetables were often overcooked.

“Its fine” “Breakfast is my favourite” “The vegetables are always overcooked and tasteless”

“Not bad, but I am not here just for the food” The same standard was not described as acceptable at suppertime. The patients commented on the lack of choice, pasta dishes overcooked and often unpalatable, “The supper is terrible” “I’ve put on weight, because I am eating so many biscuits and cakes”. The surgical ward patients said

“Too heavy and stodgy” “I can not eat that” “Good food, but not always the hottest”

We inspected Eastbourne Hospital as part of the East Sussex Healthcare NHS Trust inspection on 4,5 and 6 October 2016. The trust had been previously inspected in September 2014 and March 2015. On both inspections we identified serious concerns and gave the hospital an overall rating of inadequate. The trust was rated inadequate overall because the two location reports and the concerns that we identified across the trust relating to culture and governance. A Quality Summit which included all key stakeholder organisations was held in September 2015 and, following that meeting, I recommended that the trust be placed into ‘Special Measures’. This meant that the trust was subject to additional scrutiny and support from the local clinical commissioning groups and NHSI who provided an improvement director to advise and to monitor the implementation of action plans to address the shortcomings identified. The commission also maintained a heightened programme of engagement and monitoring of data and concerns raised directly with us.

This inspection was specifically designed to test the requirement for the continued application of special measures at the trust. Prior to inspection we risk assessed all services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment led us to include six acute hospital services (emergency care, surgery, maternity and gynaecology, children and young people, end of life care and outpatients) in our inspection. The two other acute hospital services (medicine and critical care) and community services were not inspected as they had indicated good performance at previous inspections and our information review suggested that this had been sustained.

We did consider how medical services and the high number of medical patients impacted on patient flow and whether this affected other core services. We also visited medical wards as part of the review of end of life care.

We did not inspect community services as part of this inspection as they were currently rated ‘good’ overall. We did consider where new initiatives developed by the community services impacted upon the work of the two acute hospitals.

Following this inspection we have re-rated the services inspected. For other services we have maintained ratings from previous inspections. We have aggregated the ratings to provide an overall rating for the trust of requires improvement. Caring was rated as good, whilst safe, effective, responsive and well-led are all rated as requires improvement. This constitutes a significant improvement from the previous rating of inadequate.

.Our key findings were as follows: -

SAFE

• The incident reporting culture had been significantly improved.

• We saw clear evidence of learning from a Never Event with robust investigation and embedded changes to practice across the hospital.

• Staff understanding of duty of candour had improved.

• Infection control oversight had been significantly strengthened and hand hygiene practice was largely compliant.

• We were able to see fledgling improvements in the provision of services trustwide with clear indicators of positive changes from data provided by the trust and from national data we hold at CQC about the trust.

• Daily ‘Safety Huddles’ were being rolled out across the hospital. These encouraged the wider multidisciplinary team to share concerns and consider ways to improve the care of patients.

• Where compliance with VTE risk assessment and prevention had been a concern in our previous inspection report, there was now evidence of high rates of compliance with 95% of patients having a properly completed VTE risk assessment in July 2016.

• Safeguarding vulnerable adults and children was given sufficient priority.

• Medicines management processes had been significantly improved.

• The transfer of patients from ambulance to the emergency department was subject to delay and not being monitored.

• There was a significant backlog in the reporting of x-ray examinations.

• Record keeping was not consistent across the trust notably in the documentation of risk assessments within the emergency department and full completion of risk assessments in paediatric services. 

• Where electronic recording and escalation of observations had been introduced this had demonstrably improved the outcomes for patients.

• Staff recruitment continued to be problematic with high levels of bank and agency use in some areas. There were departments such as the emergency department where the staffing arrangements were not in line with the national recommendations.

EFFECTIVE

• Pain was managed well with new initiatives in the care of children and young people and better recording of pain scores across the hospital.
• Stroke services had been consolidated at the Eastbourne site. A recent report issued by the Stroke Association in  November 2016 showed that the hospital was providing good access to stroke services.

• End of life care and emergency departments were not meeting national audit standards in some areas.

• The assessment of mental capacity by staff remained inconsistent across the trust.

• The wishes of patients about the upper limit of treatment when on an end of life care pathway was not always recorded. Staff had not always discussed the 'ceiling of care with patients or their families.

• There were no services now rated as inadequate

• Policies were  largely up to date and referenced by best practice, with the exception of maternity services.

• Surgery services were no longer an outlier for clinical outcomes.

• Auditing programmes were more developed than on previous inspection visits but further work was needed to ensure that the full cycle of data collation being used to drive improvements needed further embedding.

CARING

• All services inspected were rated as good for caring.

• Data and our observations confirmed the very positive feedback received from patients with respect to the caring nature of staff.

• Staff treated patients with dignity, respect and kindness. Patients felt supported and said staff cared about them. Patients and staff worked together to plan care and there was shared decision-making about care and treatment

• The trust’s Friends and Family Test performance (% recommended) was generally better than the England average between July 2015 and June 2016. In the latest period, July 2016 trust performance was 97.9 % compared to an England average of 95.4%. This was an improvement on the performance in the FFT in August 2014, when the score was 67% trust wide.

RESPONSIVE

• The emergency department indicated a deteriorating performance against access standards.

• The trust was not maintaining the delivery of treatment to patients within 18 weeks of referral from GP's or within 62 days for patients referred onto a cancer pathway.

• Patient flow through the hospital was challenged leading to patients being cared for in suboptimal clinical areas.

• A Frailty Nurse Specialist team had been set up to work across the acute hospitals and community services to reduce the number of unnecessary admission (particularly from care homes) and to support patients who were best cared for in the community.

• Patients on an end of life care pathway did not have access to a rapid discharge service.

• The outpatients service was no longer rated as inadequate with significant improvements to the call centre.

• The hospital staff tried to ensure that the individual needs and preferences of patients were met. Our previous report from September 2014 talked about staffing shortages and a culture that led to task focussed nursing care and a lack of consideration of individual needs. This was not something we observed on this inspection visit.

• The trust was very responsive to meeting the complex needs of patients notably those living with dementia or learning disabilities.

• .Appropriately trained staff were not available to support children who were particularly anxious or in pain through play

• Response times to complaints had improved significantly since April 2016. We saw evidence of appropriate responses to complaints, and learning from complaints and concerns. The trust had improved the way they responded to complaints as well as the response times.

WELL LED

• No services were rated as inadequate for leadership.

• The senior leadership was now sighted on operational and strategic issues and had clear and well considered plans for service improvement.

• Staff told us that the executive team were much more visible around the hospital than they had been prior to the appointment of the new chair in January 2016 and new chief executive in April 2016.

• Nursing staff also talked to us about the Director of Nursing (DoN) who was felt to be a consistent and steadying influence as the trust went through a period of significant change. Nurses said they trusted the DoN and felt she was ever present, approachable and understood the challenges at ward level.

• The organisational culture had transformed since our last inspection. Staff were largely positive, well engaged and felt valued by the organisation. However, there were areas where staff were still feeling daunted by the changes and where morale was low. This was particularly the case with medical records and some administrative staff where the systems they worked with and, in some cases, their place of work had changed.

• Governance had been significantly strengthened in terms of structure and the quality of board papers and data. This had led to a strong sense of accountability within the trust.

• The senior team remains relatively new in constitution and some elements of governance and performance management have only recently been introduced

• The trust was yet to complete the transition to a new operational structure.

• At service levels our inspection identified some weaknesses in the management of risk and mortality.

• Innovation was now encouraged and we saw several areas where staff had been encouraged and supported to introduce changes to bring about improvements in quality and safety. Staff felt more engaged in developing the service and were allowed more involvement in how services were provided.

We saw several areas of outstanding practice including:

• Following the project lead midwife’s maternity review, the trust had introduced a programme of project groups related to maternity. These included the pilot scheme of a new homebirth and triage role for community midwives, and a perinatal mental health specialist midwife role.

• A consultant orthopaedic surgeon had written a national guide for the Royal College of Surgeons on avoiding unconscious bias which was published in August. The guide focused on overcoming the unconscious opinions that everyone forms about people when they first meet them and offered advice to get beyond this. This national guidance referenced the trust’s Anti-bullying Policy in the Doctors’ Clinical Handbook and highlighted the progress and work made within the trust to address perceptions of bullying and harassment.

• We saw an example of best practice for care provided to dental patients with special needs or learning disabilities. A multidisciplinary planning meeting was conducted in advance of the attendance. The appointment was used to provide one stop care including taking bloods, scans and giving the patient a haircut to minimise distress to the patient. There were a variety of options provided for location; aspects of care could be initiated in different locations such as properly supported sedation in the patient’s home and anaesthesia in the car park or in the hospital depending on the need.

• A dedicated multidisciplinary team had established a five-year plan to establish an innovative rehabilitation care plan as part of an out of hospitals services transformation programme. This programme included staff from multiple specialties and enabled ED staff to work with colleagues from across the trust and in the community to develop future services, including an ambulatory rehabilitation unit and a rapid access care service. The programme planned to introduce nurse practitioner roles for frailty, crisis response and proactive care who would provide an integrated rehabilitation service alongside hospital and community-based specialists. This programme would significantly improve working links between the trust’s hospitals and local authority social care services and enable rehabilitation services to be provided more responsively to avoid the need for hospital admissions. There was significant support and infrastructure for staff to develop this programme and they had been invited to present their plans and work so far at a national Health and Social Care Awards ceremony.

• Patients on a cancer pathway had a dedicated booking team in the booking centre. All referrals were received electronically and an email was sent to the GP to indicate it had been received. The booking team escalated concerns about appointments to service managers. Weekly cancer patient tracking list meetings provided clinical oversight of patients on cancer pathways.

• The paediatric team had introduced a ‘consultant of the week’ system whereby a designated consultant answered enquiries from local GPs about sick children in their care. This recent initiative had reduced the number of admissions because GPs had a specific point of contact and could be supported to care for the child in the community, where practical.

• An entrepreneur programme was being established that focused on the reduction of ambulance handover delays.

• There were good initiatives being developed and encouraged to meet people’s individual needs. The hospital’s League of Friends team had knitted comfort bands for patients, which helped them stop picking at intravenous lines. A ‘distraction box’ was also available to help provide stimulation for patients with dementia and reduce their anxiety in an unfamiliar environment. A nurse had developed a number of resources to help provide emotional support to parents who lost a child to sudden infant death syndrome.

• A member of the maintenance team had given up his own time to paint a mural on the wall of the recently decorated ultrasound unit to soften the environment for young patients.

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

Importantly,  the trust must :

• Ensure that consultant cover meets the minimum requirements of 16 hours per day, as established by the Royal College of Emergency Medicine.

• Ensure that play specialist staff are employed to lead and develop play services in all areas where children are cared for.

In addition the trust should:

• Review all maternity policies and procedures that are outside their review date and take action to ensure all policies reflect current national and evidence-based guidance.

• The hospital should discuss and record ceilings of care for patients who have a DNACPR.

• The trust should have a defined regular audit programme for the end of life care service.

• The trust should provide for the specialist palliative care team at Eastbourne District general Hospital weekly multidisciplinary meetings to discuss all aspects of patient’s medical and palliative care needs.

• The trust should record evidence of discussion of an end of life care patient’s spiritual needs.

• The trust should implement a formal feedback process to capture bereaved relatives views of delivery of care.

• The trust should ensure that all staff received regular mandatory training for end of life care.

• The trust should provide a formal referral criterion for the specialist care team for staff to follow.

• The trust should define and streamline their end of life care service to ensure staff are clear of their roles and who to contact.

• Develop a rapid discharge process for end of life care patients to be discharged to their preferred place of death.

• Extend the Palliative care team service to provide support and advice over the full seven days. As the hospital did not currently have this provision, some patients did not have access to specialist palliative support, for care in the last days of life in all cases.

• Work towards meeting the requirements of the key performance indicators of the National Care of the Dying Audit (NCDAH) 2016.

• Develop and implement a programme of regular audits for end of life care.

• The trust should ensure audits of infection control practices in ED including hand hygiene are used to improve practice.

• Investigate and reduce the mixed sex breaches on surgical wards at EDGH. The reason for these should be documented in all cases.

• Continue to consider ways to improve staff recruitment and retention such that it meets the national recommended levels.

• Work with local stakeholders to address the delays to patient pathways and continue to progress towards meeting their referral to treatment time targets.

• The diagnostic imaging department should ensure they have a recent audit from their Radiation Protection Advisor.

• Play services should be developed and a play specialist employed.

• The trust should ensure hazardous waste management and disposal practices in the ED meet national control of substances hazardous to health guidance.

• The trust should ensure nurse to patient ratios in the ED are managed in relation to the individual needs of patients based on acuity.

• The trust should ensure that RTT is met in accordance with national standards.

• The trust should ensure that standard for a patient receiving their first treatment within 62 days of an urgent GP referral is met.

• The diagnostic imaging department should ensure they are reporting incidents in line with legislation and demonstrate following their own policy.

• The diagnostic department should ensure all policies and procedures are up to date.

• The diagnostic imaging department should ensure they have a recent audit from their Radiation Protection Advisor.

• The diagnostic imaging department should monitor their waiting and reporting times.

• The diagnostic imaging department should ensure staff attend mandatory training in line with the trusts target.

• The children's service should develop clear criteria for the transfer of patients by private car between sites.

• The children's service should ensure that children are not transferred to the Conquest Hospital late at night, through timely decision making and effective planning of the transfer.

• The children's service should ensure that outpatients appointments are not subject to cancellation and delays,.

Professor Sir Mike Richards

Chief Inspector of Hospitals