A summary of services at this hospital appears in the Overall summary section at the start of this report.

As part of the inspection we visited the Accident and Emergency department, the Medical Assessment Unit and three inpatient wards. We spoke with 27 staff who worked across these departments and wards, two relatives of patients with dementia, 10 patients with dementia and pathway tracked the care of five patients with dementia. We also provided the wards with comments cards to help gain patient’s view on the service. Unfortunately we received no responses to these comment cards.

We spent time in the Accident and Emergency department to see what arrangements were in place in relation to patients with dementia. We found staff had limited knowledge and training in relation to dementia care and were not aware of the National Institute for Clinical Excellence NICE guidelines regarding standards of dementia care.

We found that the wards were well led. The senior staff were able to identify who was on the ward with dementia, and what support they needed. In most cases, staff were motivated to provide a high standard of dementia care. Most of the staff we spoke with told us they had received training in relation to dementia care. They were able to give examples of how they used it in their daily roles.

There was good evidence in patient’s notes, and through discussion with staff, that there was regular effective working with other departments for a Multidisciplinary Team (MDT) approach.

There was information throughout the wards about ways to improve the quality of dementia care and systems for gaining feedback about the patient’s experiences.

We saw and we were told that there were systems in place to share good practice and lessons learned. Staff told us, and we saw from records, that there were quality assurance audits and checks carried out by the dementia lead and dementia/elderly care matron. This included skill sharing on the job, observing staff, spot checking records and dealing with any issues that had arisen.

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.

The people we spoke to on the day of the visit told us that they were happy with the services offered by the QE II. They said that the staff treated them with respect and in a manner that promoted their dignity. People using the service felt that their privacy and confidentiality was maintained at all times.

They told us that the staff were professional and caring and that they had confidence in the treatment they received. They also told us that they were happy with the environment they were treated in.

Queen Elizabeth II (QEII) hospital is part of East and North Hertfordshire NHS Trust and it provides outpatient and diagnostic imaging services for a wide range of medical and surgical specialities. The hospital opened fully for patients in June 2015. Outpatient appointments are available from 8:30am to 5:30pm, Monday to Friday. The diagnostic imaging department is open for appointments from 8:30am to 5:30pm and offers plain film radiography, computerised tomography (CT), magnetic resonance imaging (MRI), ultrasound, fluoroscopy and breast imaging. This department is open between 8.30am and 4.30pm Monday to Friday for routine appointments.

During January to December 2014, the hospital facilitated 16,2278 outpatient appointments of which 40% were new appointments and 60% were follow up appointments (8% of appointments were not attended by patients).

The hospital also provides an urgent care centre (UCC) which is open 24 hours a day seven days per week. The UCC comprises a nurse led minor injuries unit and a GP led minor illness service. Since opening the unit has had 18,867 attendances, with 5,904 of these being patients under the age of 16. The UCC is designed to treat adults and children with minor illness and injuries and does not admit patients.

We carried out an announced inspection from 20 to 23 October 2015 and inspected a number of the outpatient clinics and diagnostic services and the urgent care centre at QEII. We spoke with 22 patients and 25 staff including nursing, medical, allied health professionals and support staff. We also reviewed the trust’s performance data and looked at twelve individual care records.

We inspected two core services, urgent and emergency care and outpatients, and rated the UCC as requiring improvement and outpatients as good. Both services were rated as good for caring.

We rated QEII as good for two of the five key questions which we always rate, which were whether the service was caring and responsive. We rated the hospital as requiring improvement for safety, effectiveness and for being well led. Overall, we rated the hospital as requiring improvement.

Our key findings were as follows:

• Staff interactions with patients were positive and showed compassion and empathy.

• Feedback from patients was generally very positive.

• The service consistently met the four hour target for referral, discharge or admission of patients in the UCC.

• The environments we observed were visibly clean and staff followed infection control procedures.

• Nurse staffing levels were generally appropriate with minimal vacancies.

• Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.

• Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice.

• We found that both services were generally responsive to the needs of patients who used the services.

• Waiting times were within acceptable timescales.

• Clinic cancellations were around 2%.

• There were effective systems for identifying and managing the risks associated with Outpatient appointments at the team, directorate or organisation levels.

• There was a strong culture of local team working across the areas we visited.

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

• Staff in the UCC did not always report incidents appropriately, and learning from incidents was not always shared effectively.

• During the inspection, staff told us that leaders in UCC were not always visible in the department and it was the perception of staff that they did not feel adequately supported as a result of this.

• Mandatory training attendance in the UCC was not sufficient to meet the trust’s target, and did not ensure that all staff were trained appropriately.

• Medicines were not always stored and handled safely in the UCC.

• Reassessments of patients’ pain levels were not always completed following treatment in the UCC.

• There was not a robust system of clinical audits in the UCC to drive improvements in service delivery.

• Most nursing staff we spoke with in the UCC lacked an understanding of the Mental Capacity Act (MCA) and how to assess whether a patient had capacity to consent to or decline treatment.

• Whilst the majority of equipment was fit for use and had been maintained well, the ocular computed tomography (OCT) imaging systems across the trust were not compatible. This meant that the images could not be compared to monitor disease progression as they were on different systems.

• Medical records were stored centrally off-site and were not always available for outpatient clinics.

The trust should therefore:

• ensure robust systems are in place to learn lessons from incidents and embed learning throughout the UCC.

• ensure staff receive mandatory training in accordance with trust procedures in the UCC.

• should ensure effective procedures are in place for the storage and management of medicines in the UCC.

• ensure effective arrangements are in place when patients are transferred or advised to attend other accident and emergency locations to ensure the other service is aware.

• ensure participation in appropriate clinical audits in order to enhance performance and service delivery in the UCC.

• ensure patients are reassessed following pain relief.

• ensure that leadership within the UCC facilitates effective staff engagement.

• The trust should ensure all equipment in Outpatients is suitable for use.

• The trust should ensure that patient records are available for all clinic appointments in Outpatients.

Professor Sir Mike Richards

Chief Inspector of Hospitals