The Royal Bolton hospital is part of Bolton NHS Foundation Trust, which provides a range of hospital and community health services in the North West Sector of Greater Manchester, delivering services from the Royal Bolton Hospital (RBH) site in Farnworth, in the South West of Bolton, close to the boundaries of Salford, Wigan and Bury; and also providing a wide range of community services from locations within Bolton.

The Royal Bolton hospital site is situated in the town of Farnworth, near Bolton. For services, in particular patients requiring non-elective treatment, it is estimated to have a catchment population of 310-320,000, compared with a resident Bolton population of 270,000.

The Royal Bolton hospital provides a full range of acute and a number of specialist services including urgent and emergency care, general and specialist medicine, general and specialist surgery and full consultant led obstetric and paediatric service for women, children and babies,

including level three neonatal care and 24-hour paediatric and consultant-led obstetric services

.

Approximately 110,000 people

attend the trust for emergency treatment every year and 72,000 patients are admitted. Approximately 310,000 attend the outpatient departments for consultations. The Royal Bolton Hospital has approximately

740

beds and employs 5200 staff.

We visited the hospital on 21-24 March 2016. We also carried out an out-of-hours unannounced visit on 6 April 2016. During this inspection, the team inspected the following core services:

• Urgent and emergency services

• Medical care services

• Surgery

• Critical care

• Maternity and gynaecology

• Children and young people

• End of life

• Outpatients and diagnostic services

Overall, we rated Royal Bolton Hospital as good. We have judged the service as ‘good’ for effective, caring, responsive and well led. We found that compassionate, caring staff provided services and patients were treated with dignity and respect. However, improvements were needed to ensure that services were safe.

Our key findings were as follows:

Leadership and Management

• There was a positive culture and a sense of pride throughout teams in the hospital, and staff were committed to being part of the trusts vision and strategy going forward.

• There was effective teamwork and clear leadership and communication in services at a local level. Managers and leaders were visible and approachable. Staff felt supported by their managers and there was an open culture of transparency and communication in between teams.

• The hospital was led and managed by an executive team that were approachable and visible. Staff knew the team and felt that they were listened to and concerns were acted upon.

Access and Flow

• Access and flow remained a challenge, and the emergency department did not at times see, treat, admit or discharge patients within four hours. Between July 2014 and November 2015 the trust met the target to admit, transfer or discharge patients within four hours for six out of 17 months. However, the total average time spent in the emergency department between January 2013 and October 2015 was below the England average, ranging between 50 and 139 minutes.

• Plans were in place to expand the emergency department in order to accommodate the increase in patient attendances, of which notable there had been an increase in patients attending from outside of Bolton and patients being brought in by ambulance.

• There were some pressures with access and flow across the medical and surgical wards, including patients who were medically optimised for discharge, but awaiting further care arrangements to be agreed. Access and flow issues resulted in a number of patients being cared for on a ward outside of their speciality. Between August 2015 and November 2015, data showed there had been 208 medical outliers at the hospital. There were policies and procedures in place outlining the management of these patients to ensure that patients were seen by the appropriate medical teams at the right time.

• The trust had put a number of initiatives in place, including theatre productivity initiatives and opening additional beds to support access and flow through the hospital. There were also established escalation procedures in place, which were supported through regular bed planning meetings.

• The overall hospital-wide bed occupancy rate between

  July 2013 and December 2015

  ranged between

  80.8% and 88%, which rose to 91% on medical wards between January and March 2016.

• In spite of pressures, we observed that the average length of stay for elective medicine at the hospital was shorter (better) than the England average at 2.9 days. The England average was 3.8 days. For non-elective (not planned) medicine, it was shorter (better) than the England average at 5.8 days. The England average was 6.8 days.

• NHS England data showed the surgical and gynaecology services consistently performed better than the England average for 18-week referral to treatment standards for admitted (adjusted) patients between November 2014 and January 2016.

• Records between April 2015 and January 2016 showed the surgical services also achieved the historical 90% standard for 18-week referral to treatment standards for admitted (adjusted) patients for general surgery, ENT, ophthalmology, urology and oral surgery during this period. However, the trauma and orthopaedics specialty (84.5%) and oral surgery (77.65) did not perform as well other specialties during this period.

• Most patients were admitted to the intensive care unit within four hours of making the decision to admit them and a consultant assessed 100% of patients within 12 hours of admission.

Cleanliness and Infection control

• Clinical areas at the point of care were visibly clean and trust had infection prevention and control policies in place, which were accessible to staff and staff were knowledgeable on preventing infection.

• There was enough personal protective equipment available, which was accessible for staff and staff used this appropriately.

• Staff followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures.

• Between April 2015 and December 2015, the trust reported 19 cases of Clostridium difficile, 4 cases of Methicillin-resistant staphylococcus aureus (MRSA) and 18 cases of Methicillin-susceptible staphylococcus aureus (MSSA).

• Lessons from all cases were disseminated to staff for learning across directorates

  .

• There were established audit programmes in place related to the prevention of cross infection, which included

  hand hygiene, infections within a central line (a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products) and

  methicillin-resistant Staphylococcus Aureus

  (MRSA).

Nurse staffing

• The trust undertook biannual nurse staffing establishment reviews as part of mandatory requirements. As part of this, key objectives were set though this work to support safer staffing.

• The trust was in the process of implementing a daily acuity tool to further support safer staffing levels based on patients acuity.

• There were processes in place to ensure ward staffing levels were monitored on a daily basis. Senior nurses and matrons met each week to discuss nurse staffing levels across services to ensure that that there were sufficient numbers of staff. Staffing on a day-to-day basis was reviewed as part of the trust bed management meetings.

• However, nurse staffing levels remained a challenge, particularly in emergency, medical and the paediatric department. Nursing staffing was identified on both operational and corporate risk registers. At the time of this inspection there were 50 nursing staff vacancies across the trust and additional posts had been made available in order to support the increased requirements across the across the hospital.

• Staffing levels were maintained by staff regularly working extra shifts and with the use of bank or agency staff. Inductions were in place for new staff in order to mitigate the risk of using staff that were not familiar with the hospital.

Medical staffing

• Whilst most areas had sufficient numbers of medical staff to meet patients needs, which included the use of agency staff, there were pressures within the emergency department due to increased demand.

• Increased activity in the emergency department had meant that emergency department consultants were regularly working in place of middle grade staff to ensure the department continued to function with safe medical staffing levels. We observed that medical staff were committed to maintaining patient safety and ensuring that rotas were covered.

• A recent review by the Royal College of Emergency Medicine had recommended an increase in establishment of consultants of 6.5 WTE, which was being considered at the time of this inspection. In addition, it had been recommended to increase medical middle grade staffing by five WTE. Whilst the shifts we reviewed showed that staffing levels were safe, we were concerned that the current use of consultants to fill middle grade shifts may not be sustainable in the long term.

• Locum doctors were also used to boost medical staffing levels, particularly in the emergency department. Between May 2014 and March 2015, the average rate of locum use in this area was high at 21.5%.

• The trust board had recently authorised recruitment for two middle grade doctors and relaxed the cap on locum use to assist with staffing. However, managers described difficulties recruiting due to the high volume of patients attending the ED compared with other EDs.

Mortality rates

• Mortality and morbidity reviews were held in accordance with trust policies and were underpinned by policies and procedures. All cases were reviewed and appropriate changes made to help to promote the safety of patients. Key learning Information was cascaded to staff appropriately. Monitoring arrangements were in place at board level to ensure that any findings were acted upon.

• The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators, which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to England. A score of over 100 means more adverse (worse) outcomes than expected and a score of less than 100 means less adverse (better) outcomes than expected. In November 2015, the trust score was 104.

• The sentinel stroke national audit programme (SSNAP) is a programme of work that aims to improve the quality of stroke care by auditing stroke services against evidence-based standards. The latest audit results rated the hospital overall as a grade ‘D’ which was an improvement from the previous audit results when the hospital was rated as the ‘E’. The trust had put in place actions to improve the audit results. These included a dedicated social worker on the stroke unit and further training for staff.

Nutrition and Hydration

• Patients and people close to them attending departments had access to food and drink whilst visiting this hospital, including a café that was open out of hours and vending machines in areas such as the emergency department.

• Patients were able to choose from a wide range of meals, which took account of their individual preferences, including religious and cultural requirements. Most patients felt that the quality of food offered was of a good quality.

• We found that there were policies and procedures in place to support patients nutritional and hydration needs and staff across the hospital knew how to access them.

• The hospital used part of the malnutrition universal screening tool (MUST) to assess patient’s nutritional needs. An audit of the completion of the tool was undertaken as part of the food standards assessment and the trust scored an amber rating. Nutrition champions are now in place who undertake regular audits of nutrition and hydration standards.

• We found that patients nutritional needs were risk assessed and results were acted upon appropriately, however on some medical wards, fluid balance charts and nutrition charts had not been completed promptly.

• There was a system in place to identify patient in needs of assistance with eating and drinking. We found that most patients received assistance with eating and drinking as needed.

• Staff and patients had access to specialist nutritional advice from the dietician team who responded promptly to patient referrals.

• Breast feeding support was available for mothers after discharge. Post-natal support for breast-feeding was provided by peer support workers.

We saw several areas of outstanding practice including:

• The emergency department had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.

• The emergency department offered bereavement meetings were offered to those who had lost a loved one, to help them understand what had happened.

• Emergency department Consultants were regularly working in place of middle grade staff to ensure the department continued to function with safe medical staffing levels.

• The radiology department had a managed equipment programme in place. This meant that equipment was serviced, repaired and replaced as part of the contract in a timely way, minimising disruption to services and reducing the need for costly and time consuming business cases when equipment needed replacing. This was an innovative way of managing high cost equipment.

• The trust were early adopters of the neonatal behaviour evaluation scale (NBES). The scale represents a guide that helps parents, health care providers and researchers understand the newborn’s language.

• The neonatal unit were early adopters of volume ventilation.

• The neonatal unit introduced ‘Matching Michigan’, a two-year programme designed to reduce infections in central lines, before it was rolled out as best practice. The service was nominated for an award from the Health Service Journal (HSJ) for this.

• The neonatal unit introduced the ‘fresh eyes initiative’, which is where nursing staff look at other nurses’ patients at 1am and 1pm to promote things not being missed.

• There was a visible person-centred culture with caring, compassionate staff who considered the needs of patients nearing their final days or hours and their families. There were systems in place to support this, including the butterfly logo. This was embedded throughout the organisation so that any staff coming into contact with bereaved families could offer care and support where this may be needed.

• The trust had adopted the ‘butterfly symbol’, which made staff aware of a family in need (identified by the symbol). This ensured that during difficult times families were supported (for example by staff offering drinks etc.). The scheme also ensured that the deceased’s property was put into a special bag (with the butterfly symbol on). Relatives were offered a fingerprint, lock of hair and photo (from medical illustration) of the deceased patient.

• We observed nurse interaction with patients living with dementia on the bluebell ward, using a variety of dementia friendly strategies. Staff used aids, for example dolls, computers, karaoke and a piano. Interaction was approached in a caring way, and tailored to support each patients individual needs.

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

Importantly, the trust must:

• Complete mental health assessment forms in the emergency department as soon as practicable and ensure these are distributed and used where appropriate.

• Improve appraisal rates in the emergency department.

• In the emergency department, Improve the focus on audits, ensuring clear action plans are formulated and progress regularly tracked to improve outcomes

• Ensure that robust information is collected, analysed, and recorded to support clinical and operational practice in medical services.

• Must ensure that there are sufficient staff with the appropriate skills on wards.

• Must ensure that records are kept secure at all times so that they are only accessed and amended by staff.

• The trust must ensure that staff are up to date with appraisals and mandatory training in medical wards.

• The trust must ensure that paper and electronic records are stored securely and are complete in outpatients areas.

• The trust must ensure that essential safety checks are completed and records of checks are maintained to provide assurance that all steps are being taken to maintain patient safety in outpatients.

In addition the trust should:

In urgent and emergency care services :

• Ensure building work continues at a suitable pace.

• Improve staffing levels in the emergency department with an aim to reducing agency and locum rates.

• Review the security arrangements for both paediatric entrances to ensure the trust is satisfied the risk is mitigated as far as possible.

• Consider the addition of facilities appropriate for adolescents in the paediatric area

• Review the number of computer terminals in the clinical areas to ensure this meets the needs of staff during peak periods.

• Continue to work to improve figures in relation to Department of Health targets.

In medical care services :

• The trust should ensure that hazardous chemicals are stored appropriately in a locked cupboard when not in use.

• The trust should ensure that patient is discharged as soon as they are fit to do so.

• The trust should wherever possible ensure that patients are cared for on a ward suited to meet their needs.

• The trust should ensure that patients’ privacy and dignity is maintained at all times

• The trust should ensure that equipment and facilities in the endoscopy mobile unit are fit for purpose

• The trust should ensure that procedures and assessments in place to provide safe care are completed correctly. Especially comfort round and fluid and nutrition charts and assessments.

In surgical services :

• Take appropriate actions to minimise the occurrence of never events.

• Take appropriate actions to improve staff appraisal rates.

In Maternity and Gynaecology

:

• Consider improving the electronic patient management systems.

Children and young people’s services

:

• Review the door exit systems on the paediatric and neonatal unit to improve security.
• Ensure all staff working with children and young people have level three safeguarding training.
• Ensure that there is a trained Advanced Paediatric Life Support or European Paediatric Life Support nurse on each shift.
• Ensure there is sufficient staff to match patient acuity on the paediatric unit,
• Ensure that all paediatric staff have a good working understanding of the Mental Capacity Act and how it works in practice.
• Ensure the risk register highlight all risks and controls that are in place and is periodically reviewed.
• Ensure that neonatal practitioners all have current NLS training certification

In end of life services:

In relation to DNA CPR:

• In all cases assess and record patients’ mental capacity as part of the DNA CPR assessment.
• Document a summary of communication with the patient, welfare attorney and/or next of kin (NOK).
• Document consent.
• Ensure private rooms are available to break bad news to bereaved family and friends of a deceased patient

In outpatients and diagnostic imaging services :

• The trust should ensure that medical gases are stored safely and securely.

• The trust should ensure that letters are provided to GPs in a timely way.

• The trust should ensure that patients are kept informed about any delays in outpatient and diagnostic imaging services and should monitor how long patients wait to be seen.

• The trust should ensure that the recovery plan for breast screening is completed within agreed timeframes.

• The trust should consider participating in the Imaging Services Accreditation Scheme (ISAS) and the Improving Quality in Physiological Services (IQIPS) accreditation scheme.

• The trust should consider how to meet the need to see patients in the TIA clinic with 24 hours over weekend and bank holiday periods.

• The trust should consider how the privacy and dignity of inpatients can be maintained in the main radiology department.

• The trust should consider how to manage environmental capacity in the eye unit and breast unit.

Professor Sir Mike Richards

Chief Inspector of Hospitals

During the inspection we visited C2, C3, D2, F3, Maternity Theatre and the Clinical Decisions Unit (CDU). We spoke with a total of 15 staff, including medical, nursing and support staff, 10 patients and four visitors.

We observed the general environment on the wards and departments visited was clean and well organised. Public corridor areas were free from clutter and were clean. Infection control links from ward and department staff had been identified and when we spoke with them we were told: “I take this very seriously and the rest of the staff do as well” and “I think the whole hospital is tackling this problem much better, we can get guidance from the infection control team but then it’s about making sure that guidance if put into practice”.

We spoke with patients who said: “I think this ward is very clean, you see staff washing their hands, even the doctors use that spray”, “The ward is clean, I have been here for three days and the ward is cleaned every day”, “The staff work hard to keep it clean” and “I am very happy with the standard of cleanliness, the whole place is much cleaner”.

The trust had, since the last inspection, committed to invest in a significant increase in nursing and support staff, with a view to reducing the use of bank staff and was on track to fill vacant posts.

We found the trust had improved systems to identify, assess and manage the risks to the health and safety and welfare of the patients using the service.

An inspection was undertaken in August 2012 were the trust were found to be non compliant with outcome 6 and outcome 9. Compliance actions were made and the trust submitted an action plan in order to achieve compliance.

We followed up the actions undertaken and visited four wards, we spoke with 6 patients and 9 staff members. We also sampled 12 patients care records and 12 patients medication records.

We found in care plans and daily entries, discharge planning had been initiated at the point of admission. We saw timely referrals made to other health or social care providers.

We found social services or other health agencies had been contacted in a timely manner to contribute to the effective discharge of patients. Multidisciplinary meetings were arranged to ensure that all parties participated in and were informed of the continued needs of the patient.

We found the trust were in the final stages of disseminating the reviewed medicines policy across the trust. There had been some delay as the policy had been through various governance, quality and risk assurance groups, where amendments had been requested.

The trust ensured that wards had received an appendix to the policy, in regard to self administration of medicines, whilst in hospital. This ensured that patients who chose, could continue to administer medication themselves for long term medical conditions such as respiratory conditions and diabetes.

Due to the current financial posiition of the trust concerns were raised in relation to the impact on patient care and welfare and quality of services. We visited 10 wards, the Community Unit, ICU, 2 Out patient’s clinics and Theatres. We spoke with 20 patients across the wards and departments we visited and also with 8 visitors.We spoke with relatives and other agencies. We were told :

“They (the staff) close the curtains and I get as much privacy as possible.”

“Staff are quick to respond if asked for help, they close the curtains and I get as much privacy as possible.”

"I can't fault it", "The service they provided is to the highest standard”, “My relative always seems to be cared for when I visit.

“I have no concerns about the care up to now", “The staff have been fantastic, their approach and care is very good.”

“Its lovely on here always tidy and clean.”

“My friend was in hospital six months ago and this is so much cleaner now than then.”

“The matron is on this ward is brilliant, nothing is too much trouble and the nurses are very efficient.”

We spoke to patients on the majority of the wards that we visited. We heard comments such as “I think the staff do a good job, they always make sure I understand what the doctor has said” and “Sometimes the doctor in charge doesn’t speak to me directly, but then the junior doctor or the nurses explain”. One patient told us that he had asked a nurse for more information about his condition. He said that the nurse showed him pictures in a book to explain his condition in more detail, and he commented “She was very thorough. I’m really pleased”.

Patients spoke positively about the staff they had seen. Comments included “I have no complaints about the attitude of the staff, they are fine”, ”I’ve always found them extremely nice and nothing is too much trouble for them” and “[The staff] are cracking. I’d always come here in the future”.

When we asked patients and their visitors about the care they had received in hospital we heard comments such as “I can’t fault it”, “The service they provided was to the highest standard”, and “[My relative] always seems to be cared for when I visit. I have no concerns about the care up to now”. On one ward we spoke with five patients who all said staff asked them on a regular basis if they needed anything.

When asked about the food provided in hospital we were told “I have no complaints about the food, it’s fine”, and “I have been off my food for a while but the nurses try to encourage you to eat. They do give you something different, like a sandwich or toast”.

Some patients told us that they could help themselves to food from a kitchen on their ward, and they said that fresh fruit and fruit juice was always available.

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.

During our visit patients told us “I can’t fault the staff, they do their best for you” and “I can’t complain about any of the nurses”. We heard that people were not kept waiting when they needed assistance, with one person saying “I press the buzzer if I need a nurse and they come quickly”. People thought that enough food was provided, but that this was not always the type of diet they preferred.

We spoke with patients who said that they were kept informed about their illnesses and treatments and we heard “The physiotherapist has explained what she is doing with me” and "The doctor has explained what will happen when I am discharged to another unit”.

Most people thought they had been treated in a dignified manner, but one patient who used a wheelchair did not like having to be assisted to use an able bodied toilet because the disabled toilet was not in use.

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

• We rated safe, effective, caring and well led as good.
• All services were rated as good overall.
• The only rating of requires improvement is in children and young people’s services for safe which we did not inspect at this inspection.
• The caring domain in medicine was rated as outstanding.