Royal Manchester Eye Hospital

Transcription

1 Royal Manchester Eye Hospital Mini Quality Review September 2015 REVIEW TEAM LEAD Division Role Sue Ward Corporate Director of Nursing November

2 Introduction and Summary Review Findings Introduction The review process this year was scaled down due to the impending CQC visit to the Trust in November A small team of eight visited the Manchester Royal Eye Hospital on 23 rd September The Team was led by Sue Ward, Director of Nursing and Alistair Hutchinson, Clinical Head of Division, Division of Medical Specialties. Other team members included: Ann Parker Clements, Emma Whiteley, Tom Curtis, Sue Rothwell, Kayleigh Tomany and Christine Blakeley. Due to the scaled down approach the opportunity for in-depth review of all areas was more limited. Summary This was a very positive review in which the pride and passion of the highly skilled multi-disciplinary workforce stood out. There is a strong commitment to quality and delivering an excellent patient experience across all areas of the Eye Hospital, any many examples of staff demonstrating the Trust values in their interactions with patients, and with each other were seen. A strong team culture was evident and staff satisfaction was evidenced by low staff turnover. The most prominent area for improvement related to the secure storage of records. This issue had been recognised by the MREH management team. The findings of the review are summarised below against key themes that emerged during the review process. Safe Medicines: A training package developed with pharmacy in response to drug errors that had occurred. Secure medicines storage was observed on Wards 54 & 55 Infection control: The standard of cleanliness was good across most areas. Generally standards of hand hygiene and bare below the elbow were good and individuals are challenged if standards not adhered to Documentation: Secure records storage was noted in Emergency Eye Centre (EEC) and Acute Referral Centre. The Daycase Unit Manager audits 10 sets of records weekly (but this is not recorded). Skills and knowledge: Highly skilled staff from a range of disciplines were present across many areas providing care, support and supervision. Excellent training packages are available to staff along with development opportunities Harm free care: Effective falls management was evidenced by the data, which showed that the services are accessed by high risk patients but there is a low incidence of falls. Patient safety: Staff reported feeling confident to raise concerns/speak out. Staff were aware how to report incidents and managers demonstrated that they had implemented changes in response to incidents; in Ward 55 a thematic analysis of incidents had been undertaken and a letter sent to all staff to share learning. Team huddles were used to share experience and reflect on complex cases or situations to share learning. Outlier criteria are monitored daily and allocation of patients not meeting criteria is challenged. Workforce: Staff reported that staffing levels were much improved across all areas. Recent turnover of staff in the Daycase Unit had been managed successfully with effective succession planning. Safeguarding: OPD staff were trained in safeguarding children and staff inpatient areas were well informed regarding adult safeguarding and DoLS. 2

3 Communication: Good use of interpreters was seen in wards to support communication and consent processes; it would be even better if interpreters that had been booked were available at reception to support booking in on arrival. Caring Medicines: IV saline and Mannitol were stored in same drawer in Daycase Unit. Eye medications were left out unattended on desks and trollies in some clinics. Infection control: A small number of senior medical staff were not bare below the elbow. It was unclear who is responsible for cleaning toys in clinic H toys were grubby Documentation: Insecure records storage was seen throughout outpatient areas with records stored on window sills in patient areas, doors open to unmanned records stores/coding office and records left open on reception counters. A snap shot of medical records showed that 5/5 were dated, 0/5 were timed, 4/5 were legible, 4/5 were signed, 1/5 showed designation and 3/5 recorded GMC number. Correctly completed consent forms were present for 5/5 cases but the patient s copy was filed in the notes in 2/5 cases. Nursing documentation was inconsistent in compliance with professional standards e.g. risk assessments not always completed, patient s name not recorded on all sheets, VIP scores not always completed. Patient safety: Sign out element of the safe surgery checklist was not being completed routinely. The 15 minutes triage standard was not met or aspired to in EEC (triage time was approx. 1 hour). Frontline staff in some areas were unaware of themes and learning from incidents, complaints and patient experience feedback and were not aware of the risk register. One outlying patient had been placed in an inpatient beds that didn t meet outlier - despite the decision being challenged. The 15 minute triage standard not met or aspired to. Safeguarding: No staff on the Daycase Unit were trained in safeguarding children at level 3. Communication: A relative used to interpret for a patient in EEC. Medical devices: Medical devices in a number of areas were overdue servicing responsibility for monitoring equipment contracts and servicing was not clear within departments, particularly where there were a number of disciplines working with specialist equipment. However, the clinical effectiveness team were undertaking work to set up a spread sheet of all equipment to record competence. Oxygen masks behind beds in Daycase Unit should be replaced with rebreathe masks. Access: Some waiting areas were cramped with limited access for people with disabilities or limited mobility. Environment: Boxes fitted outside clinic rooms for records were often bumped into by staff and patients. Staff reported that many sets of records were too large to fit in the box these were balanced on top of the box. Clutter was seen on top of cupboards next to play area in paediatric clinic. The floor in one clinic needed cleaning. Values and behaviours: Staff feel very proud of their services and speak with passion and enthusiasm about developments to improve the patient experience. The large majority of staff demonstrated Trust values and appeared very caring, friendly and welcoming. The staff on the main reception in the Atrium were particularly responsive to patients needs and showed excellent customer service skills. Staff introduced themselves to patients appropriately. Patient experience: Many examples of individualised care and staff going the extra mile to 3

4 support the patient s needs were seen (this was overshadowed by reference to patients by bed number instead of name). Patients felt that they were receiving the best possible care and reported that staff were caring. Good practice was observed regarding support offered to patients with dementia and consideration was given to the needs of patients with learning disabilities. Patients were very impressed with the live music and entertainment in the atrium. Values and behaviours: A small number of reception staff didn t demonstrate compassion in their interactions and didn t acknowledge people standing at the reception desk. One patient who had entered the incorrect waiting was spoken to in an abrupt manner. Consultations were interrupted in a number of areas by staff seeking advice or equipment and by the telephone ringing in the consulting room, which is not conducive to maintaining privacy and confidentiality e.g. staff entering room to access records whilst patient having drops instilled; staff member sought advice about another patient during a consultation. Patient experience: The ffood was reported by patients on Ward 54 to be cold when it is served on some occasions; improvement work is ongoing to address meals delivery process. Waits: Long patient waits were reported with limited space in MTC, Emergency Eye Centre and ARC; some staff felt that patients should expect to wait. Environment: A number of patients reported that they found the lights to be too bright in the waiting rooms (ARC and OPD clinics). Effective Team working: Effective MDT working was observed in all areas. Best practice: Staff described that the MREH is leading best practice at a national level in many areas. Participating in national cataract audit. Discharge: Effective discharge processes were observed in the Daycase ward. Delays in obtaining TTO medicines had been identified and work was being undertaken using IQP methodology to make improvements Operational processes: The one stop shop approach in a number of areas allows patients to be assessed and treated in one attendance. Most patients waiting in the Atrium area reported that they had been seen within the timeframe set out in their letter. Coding: Coding sheets were not completed and there was some uncertainty regarding coding process when discussed with doctors. Systems: Paper appointment system in use in ARC Responsive Communication: A ggood range of patient information was available, which can be accessed in large print if required. Patients in ward areas reported that communication was good and that they had received clear information. The tell us today telephone line was available to patients. 4

5 Environment: Signage was in colours recognized as best practice for people with visual impairment Capacity: Clinic capacity has been increased through the utilisation of satellite clinics. Skills and knowledge: A Children s Nurse provides expertise in the paediatric clinic. Patient experience: Very successful Feed our PET initiative in Daycase unit to encourage staff to seek patient feedback. Staff showed genuine interest in patient experience and many examples were seen of actions taken by staff to improve patient experience. Post discharge questionnaires are provided to patients admitted to Ward 54; evidence of changes made in response to feedback. Patients and staff welcomed the patient listening event. Patients liked the pager system; patients attending the detached retina clinic in clinic C asked if they could use the pagers. Operational processes: Emergency Eye Clinic staff demonstrated flexibility to respond to increased demand and reported that staffing was being reviewed to match staffing to pressure points during the day. Communication: Patients in clinic areas reported that they are not always kept informed of delays to scheduled appointments. Information about delays on the TV screens is in small text and not visible by all patients. Patients attending OPD appointments reported that when contacting the department they received a voice mail message to say the department opened at 8.30am but they found that the telephone wasn t answered until 9am. A number of people found the voice mail message too quiet to understand clearly. Patients in some clinics reported having limited information about their pathway through services or their diagnosis and treatment plan. One patient had returned to EEC with Iritis and explained that he had stopped his treatment as the condition appeared better; it hadn t been made explicit that the treatment must be continued. Some patients found the appointment letter confusing re: which hospital they should attend as it lists all CMFT hospitals. Patient experience: Children s survey cards are on display but the box to post them in is above child height; staff were unaware of the themes identified through this survey. The children s clinic was also seeing adult patients, the environment was not child-friendly with limited toys for small children and no play equipment for older children; the Starlight Unit and TV were broken. A teenage patient suggested access to music, fashion magazines and a craft area would improve the experience for older children. Play staff are accessed from RMCH on occasions but none were present in the clinic. Staff in the emergency eye clinic and ARC reported that toys were available but none were visible. There were no cover arrangements for the Registered Children s Nurse s leave. Operational processes: In the Daycase Unit and some clinics, patients were all booked to attend at same time or given time slots that didn t match the reason for attendance (e.g. a patient was given a 5 minute slot for a 45 minute appointment). Clinicians reported that pressure points in pathways cause a knock on effect and sometimes leaves clinicians waiting. 4 hour breaches are unusual in Emergency Eye Clinic but no clear escalation process was in place to prevent/report breaches (4 on previous day). Discharge: Delays in getting TTO medicines had been identified and work was being undertaken using IQP methodology to make improvements Access: Heavy double doors to 1 st floor services impede access for people with disabilities; a patient with a walking frame was unable to open the doors. 5

6 Well Led Operational processes: All areas were well organised and felt calm. Leadership: Leadership was very clear on wards and the Daycase unit with clear role modeling by ward manager/senior nurses; staff across all areas reported feeling well led with a good team culture. Management drop in clinics were well received by staff who reported feeling valued. Matron presence was visible across outpatient areas. An effective DMB meeting was observed. Recruitment and retention: Staff turnover is low; many staff have been in post for many years, successful recruitment has taken place resulting in the workforce being close to establishment. Good recruitment and retention initiatives were described by staff, such as open days and rotation. Education and training: New and junior nursing and medical staff reported very effective induction and felt well supported by senior staff. Staff reported being up to date with appraisals and mandatory training; mandatory training records viewed and showed 93% compliance with corporate and 87% compliance with clinical mandatory training. Appraisal rates were 91%. Work was being conducted to ensure accurate capture of medical staff mandatory training. Junior doctors reported being well supported by senior staff (though there was no visible supervisory consultant presence in the EEC). Staff engagement: Staff were aware of, and involved in, planned changes within services Operational processes: Ward 54 is very well led by a Band 6 sister but felt disconnected from other areas; all other staff rotate into this area. Discharges can be delayed until late evening/night as ward 55 staff provide cover overnight. Leadership: No-one in individual clinics was able to articulate who was in-charge and therefore accountable for activity within the clinic that shift Education and training: A poor result had recently been received from the GMC trainee survey. The Divisional Management Team was responding to this issue. Administrative staff reported lack of induction. General Findings Excellent staff commitment. Nurses are exploring nursing research in relation to pain management. 6