On this inspection we inspected the Accident and Emergency (A&E) service and the orthopaedic services only. We visited the A&E department, the children's unit, Broadwater and Becket Wards. We looked at the care that patients received following a fractured hip and other orthopaedic injuries. We spoke with nine patients, one relative of a patient, and 16 members of staff.

All of the patients that we spoke with were complimentary about the care that they had received at the hospital and the staff that cared for them. One patient said, "The nurses are fantastic, they are gentle as you would expect them to be. They are very caring". Another patient said, "They are marvellous here, I couldn't ask for better".

We found that records were very well completed and provided comprehensive evidence that patients had care delivered according to their preferences and needs. They showed that the multidisciplinary team worked together to meet the needs of patients.

The individual care pathways seen had been completed appropriately and individual risk assessments were updated as necessary. Rehabilitation pathways ensured that patients were encouraged and supported to regain their levels of independence, as far as was possible. This meant that patients experienced care, treatment and support that met their needs and protected their rights.

We found that the wards had sufficient numbers of staff. Patients told us that there were enough staff to meet with their care needs in a timely way.

We found that the hospital was clean and that infection control was taken seriously. We also found that the hospital had systems in place to monitor the quality of the service that they provided to patients.

People spoke very highly of the care they received at Worthing Hospital. Very few people made any negative comments at all. One person said “This hospital is a shining example of the NHS at its best.” Another told us that they had been anxious about being admitted to an NHS hospital as the media carried such worrying stories. They went on to say that they had been pleasantly surprised about how good it all was and how kind the staff were.

People were positive about the medical, nursing and housekeeping staff and said that they were kind and attentive. They told us that staff took the time to explain things properly and answered their questions fully. One patient told us “I have had better treatment than Prince Phillip”. Another told us “I was very frightened to have a scan and they explained everything and reassured me”

The few negative remarks we heard were around the hospital food. Nine patients told us they were happy with the food and three told us that they were not.

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.

People told us that they were very happy with the care they were receiving at Worthing Hospital. They told us the staff were wonderful and that they were hardworking, kind and caring. People told us they felt involved in decision making and that staff always asked them for their consent before they provided any care. People told us that the staff were very supportive and that they trusted them.

Overall people told us they were being very well looked after and that they were happy with the care they received. On the majority of wards we visited people were entirely positive about their experiences at Worthing hospital and said staff could not be nicer or do more for them. Most people told us they were involved in decisions about their care and always asked for their permission before anyone provided care or treatment.

There were instances where people were less happy with the care or where they were not able to communicate fully the level of involvement in decision making. One ward stood out as providing care below the standard of the rest of the hospital and this was reflected in what people told us.

We carried out an announced inspection visit from 9 to 11 December 2015. We held focus groups with a range of hospital staff including; nurses of all grades, junior doctors, consultants, midwives, student nurses, administrative and clerical staff, physiotherapists, occupational therapists, pharmacists, domestic staff, porters and volunteers. We also spoke with staff individually.

We talked with patients and staff from all ward areas and outpatient services. We observed how people were being cared for, talked with carers and/or family members and reviewed patient records of personal care and treatment.

We carried out an unannounced inspection on 21 December 2015 at Worthing Hospital.

Overall we found that Western Sussex Hospitals Foundation NHS Trust was providing outstanding care and treatment from Worthing Hospital. We saw many examples of very good practice across all areas of the hospital. Where we identified shortcomings, the trust was aware of them and was already addressing the issues. The trust is one of the 16 members of NHS Quest, a member-convened network for Foundation Trusts who wish to focus on improving quality and safety within their organisations and across the wider NHS. NHS Quest members work together, share challenges and design innovative solutions to provide the best care possible for patients. The trust was also a winner of a Dr Foster Better Safer Care at Weekends award.

Our key findings were –

• The executive team provided an exemplar of good team working and leadership. They had a real grasp of how their hospital was performing and knew their strengths and areas for improvement. They were able to motivate and enthuse the overwhelming majority of staff to ‘buy in’ to their vision and strategy for service development. Middle managers adopted the senior manager’s example in creating a culture of respect and enthusiasm for continuous improvement.

• Innovation was encouraged and supported. We saw examples that when raised directly with the Chief Executive and her team, had been allowed to flourish and spread across the services.

• We saw respectful and warm relationships internally amongst staff teams, the wider hospital team and outwards to external stakeholders and the local community.

• Across the hospital there was an embedded culture of learning from incidents. Staff were encouraged to have an open and honest attitude towards reporting mistakes and incidents that were then thoroughly investigated. There was strong evidence of learning from incidents both locally and across the organisation.

• The hospital was performing better, and sometimes much better than comparable trusts across England on many measures. Where this was not the case, the trust had clear action plans and investigations on-going to bring about improvements.

• An example of this was the 4 hour Emergency Department target, where new and innovative approaches coupled with strong monitoring systems had resulted in the trust meeting the target over 95% of the time. They were amongst only a handful of trusts to meet the quarter four target.

• In 2014/15 the trust improved their infection control ratings for the sixth successive year.

• There was good management of deteriorating patients and systems in place to allow early identification and additional support when a patient’s condition became unexpectedly worse.

• Monitoring by the Care Quality Commission had not identified any areas where medical care would be considered a statistical outlier when compared with other hospitals. The trust reported data for mortality indicators, the summary hospital-level mortality indicator (SHMI) and hospital standardised mortality ratio (HSMR). These indicate if more patients were dying than would be expected given the characteristics of the patients treated there. The figures for the trust were as expected and the figures for HSMR places the trust in the top 20% of hospitals.

• Information regarding patient outcomes was monitored. The trust participated in all national audits it was eligible for. Where improvements were identified, the trust was responding and was making progress implementing its action plans in order to improve the quality of care they were providing.

• Across all disciplines and in all core services we found a good knowledge and understanding of the policies and guidance relating to safeguarding vulnerable adults and children. Trust staff were involved in local initiatives, working with other key agencies to improve outcomes for babies and children from challenging or vulnerable families.

• Staff of all grades and from all disciplines at Worthing Hospital contacted us to tell us about their belief that Worthing Hospital was a very good hospital. They talked with great pride about the services they provided and all agreed they would be happy for their family members to be treated there. They talked of their commitment to making sure they did their very best to provide optimal care for patients. They talked about initiatives to improve patient care they had been involved in.

• Medical, nursing and midwifery staffing levels were safe and allowed staff to provide good care. Staffing acuity tools were in routine use and staffing was reviewed frequently – in some areas such as ED this was done four hourly. However, there were areas where the trust did not meet the recommendations of professional bodies such as the royal colleges. This included medical staffing in the critical care unit and the number of Supervisor of Midwives. In both these cases the trust was already taking action.

• An overwhelming majority of consultants from Worthing Hospital contacted us and were very positive about how the trust provided service from this site. The majority of consultants employed at Worthing responded to our invitation to submit written comments or to meet with us. They told us the executive team and medical director in particular were supportive, encouraging of new ideas and approachable. They told us about the work that had been done to improve the mortality figures overall and in specific areas. This included the changes to the pathways for patients who suffered a fractured neck of femur where changes to the care and treatment of this condition had reduced the number of elderly patients who died as a result of this.

• One small group of consultants from one speciality were less favourable about their engagement with the trust. They were led by a doctor who did not work at the trust and who had spread their allegations widely outside the organisation, without using the trust incident reporting and governance structures. We interviewed the protagonist prior to the inspection and also spent a whole day interviewing consultants regarding potential bullying and harassment. We found no indication of corporate bullying – in fact quite the opposite. Consultants told us the executive team were open and approachable and they felt valued and listened to. The main issues of concern appeared to stem from two things – the appointment of an external rather than a favoured internal candidate and some issues of standardising practice across the two sites.

• The trust has had an external review of the service where concerns had been raised. The report of the review gave no indication that patient safety issues were hidden or ignored. Patient safety had a very high focus amongst trust staff and outcomes were generally very favourable compared to other trusts.

• Volunteers from across the hospital were also keen to tell us about how much they enjoyed working at the hospital. They told us they were supported and accepted as a part of the hospital team. Those working in clinical areas described a sense of belonging and felt their work helping people to eat and drink or occupying elderly patients was valued.

• We received an unprecedented number of letters and emails from people who used the service prior to, during and after the inspection visit. The overwhelming majority of these were very positive and told stories of staff going above and beyond the expected level of care. Staff we spoke with were exceptionally compassionate when talking about patients and we observed kindness not only towards patients but towards each other whilst on site.

• The results of the Friends and Family Test supported the view of the many patients who contacted us. In most areas the hospital consistently scored above the national average.

• The commitment of staff to providing good care coupled with good strategic and operational planning led to a service that was responsive to the needs of individuals. We saw flexibility and a willingness to make local changes to improve how people were cared for. There were numerous initiatives that improved patient experiences and allowed them equal access to care. These included Learning Disability nurses visiting the ED, interagency joint working in the hospital and community and the 'Harvey’s Gang' project.

• The trust has introduced a ward accreditation scheme that was being rolled out to all wards. This scheme focussed on promotion of the trust Vision and Values through monthly monitoring of key metrics.

Outstanding practice

We saw much that impressed us but of particular note was –

The level of 'buy in' from all staff to the trust vision and value base was exceptional. We were flooded with requests from staff wanting to tell us about specific pieces of work they were doing, how much they liked working for the trust and how supportive the trust executive team were of innovative ideas and further learning as a tool for improvements in patient care. The trust ambassadors worked to promote the positive work that the trust was doing to other staff and visitors. Specific areas and staff groups of particular note included the whole neonatal team and children’s services team, the emergency floor team, the Specialist Palliative Care Team, the volunteers across the hospital and the cleaning team.

Multidisciplinary working was a very strong feature across the hospital that resulted in better patient care and outcomes. There was clear professional respect between all levels and disciplines of staff. We saw real warmth amongst teams and an open and trusting culture. Exceptional examples of this included how 'Harvey's Gang' was growing and developing as more staff became involved a local initiatives such as the joint working 'Five to Thrive' protect and Family Nurse Partnership which improved outcomes for the children of young and vulnerable parents.

The trust had won a Dr Foster Better, Safer Care at Weekends award.

The level of feedback from patients and their families was exceptional. We received many letters and emails before, during and after the inspection visit. It was overwhelmingly and almost exclusively positive. Amongst the hundreds of people who contacted us to say how good the hospital was, there were just a few who felt unhappy with the care they had received.

The staff knowledge of safeguarding vulnerable adults and children and how they should proceed if concerns arose was a significant strength. There was very good joint and interagency working. The transfer of responsibility for the management of ‘at risk’ babies from maternity (during the antenatal period) to paediatrics (following delivery) was seamless.

The culture of safety and learning from incidents and complaints was well embedded. All staff felt responsibility for reporting mistakes and incidents and there was good dissemination of learning following investigation or review.

Worthing Hospital was the first hospital in the country to provide visitors with the opportunity to use a hand scanner that detected abnormal heart rhythms and offer immediate clinical assessment. The 'Scan Station' in outpatients gave directions of how to get to the cardiac department when an abnormality was detected where the result was discussed and an ECG performed to exclude or identify Atrial Fibrillation, if necessary. Staff told us the idea of widening the self-testing was being considered with potential for early identification and management advice for conditions such as hypertension.

Worthing Hospital had won three catering awards. These included an 'Eat Out Well Award' (Gold) issued by West Sussex Environmental Health Service. The 'Eat Out Eat Well Award' had been developed to reward caterers who make it easier for their customers to make healthy choices when eating out. A 'Food for Thought Award' was won by both the main kitchen (Silver) and the Education Centre (Gold).

The  trust wide work on the care of people living with dementia was notable. The trust maintained a dashboard that was used as a tool for monitoring the implementation of the dementia strategy. Direct feedback from relatives and observation showed people with dementia received very good care. A hospital administration manager talked to us about the initiative to get staff/visitors and other people to make and donate 'Twiddle muffs' to occupy and calm patients with dementia. The really outstanding part of this was not the activities but the 'whole hospital' approach that involved non-clinical staff, volunteers, executive team members as well as clinical staff from all settings including the operating theatres and outpatients department.

The introduction of a ward accreditation scheme based on values, the trust vision and a safety focus was beginning to demonstrate how the monitoring of key performance indicators at local level and comparing these to similar wards could be used as an effective tool for improving the quality of services.

The hospital was involved in the trust wide NHS Quest initiative which focused on improving quality and safety. This involved the trust taking part in collaborative improvement projects for sepsis and cardiac arrest. Work was in progress on these initiatives at the time of our inspection.

The local leadership of services was very good. Staff told us they were approachable and open and they valued staff input. We saw particularly good examples in the ED where the hospital had continued to meet the four hour target despite a threefold increase in demand. Local leaders had worked with staff in the department and across the hospital to ensure flow through the department was maintained.

The chaplains were repeatedly mentioned as 'going the extra mile'. Staff and patients told us about the level of kindness and support shown by the team.

The improvements in the stroke service had resulted in significant and demonstrable improved outcomes for patients. In the preceding two years the SSNAP rating had moved up from a 'D' to a 'B'. This was particularly impressive given the scores were benchmarked nationally and were not adjusted to take account of the high admission rate from a population of greater age and complexity than the national average.

Welcome home packs were a really nice idea. The hospital worked with local supermarkets to provide frail and isolated patients with hampers that meant they did not have to worry about food for the first 24 hours. Packs included basics such as milk, bread, fruit and cheese.

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

The most notable issue was the referral to treatment times where the trust was not meeting the 18 week target in some specialities.

The trust should continue develop strategies to recruit and retain sufficient medical and nursing staff to meet the needs of the service.

The trust should ensure all staff have completed mandatory training and they receive an annual appraisal to ensure their continuous professional development needs are met.

The trust should ensure all staff are aware of the duty of candour requirements.

Senior staff should establish active processes for compliance with the European Waste Frame Directive (2008/98/EC) and the HSE Health and Safety (Sharp Instruments in Healthcare) Regulations 2013 with regards to the storage and disposal of sharps bins and chemical storage on the critical care unit.

Senior staff must establish active processes to ensure compliance with the trust medicines policy in relation to stock rotation and the disposal of expired products.

The trust should consider ways of ensuring they meet the RTT admitted pathway targets.

The trust should review the discharge arrangements from the critical care unit to ensure patients are cared for in an appropriate environment.

The trust must ensure they have sufficient Supervisor of Midwives.

Professor Sir Mike Richards

Chief Inspector of Hospitals