“It would have to be the recognition of improvement,” reflects Sarah Cullen when asked what she found most pleasing about initial feedback from regulators following an inspection of the Royal Preston and Chorley and South Ribble hospitals last month.
As the new director of nursing and midwifery at the trust which runs the two sites, one of Sarah’s first tasks was to assess the contents of a letter from the Care Quality Commission (CQC). That correspondence outlined the regulator’s early conclusions after inspectors spent four days - two announced, two unannounced - observing how Lancashire Teaching Hospitals (LTH) operates.
For a trust which has been found to require improvement on three consecutive occasions in the last five years, it is hardly surprising that any acknowledgement that it was heading in the right direction would be welcomed by senior managers. But Sarah says she cannot predict whether the CQC’s initial findings will translate into the trust being moved into the category of “good” when its full report is published in the autumn.
“It’s so difficult to tell, but overall the quality and safety feedback was really positive, so I’m delighted about that.
“It’s really important to us that we do get to ‘good’, because we know that in hospitals [with] higher ratings, patients are more satisfied and seen in a timely way, staff are happier and there is less sickness absence and the finances of the organisation are better.
“So there is every single indication in the land to say that it’s good to get good for our local population – it’s not just a reputational tick the box,” says Sarah, who has spent several years in the deputy nursing director role at the trust.
That means she has witnessed first hand the challenges laid down by the CQC about how the organisation needs to improve. Last year, regulators criticised unsafe staffing levels in certain areas, the way in which medicines were sometimes managed and – that focal point of any hospital inspection – the performance of its Accident and Emergency department.
Since then, the triage process at the Royal Preston has been overhauled with a new dedicated area in which patients are assessed by lead clinicians. Inspectors observed that the system was “working well” and had improved ambulance handover times – although they noted that the trust was not meeting a locally-agreed target for it to treat, admit or discharge 87 percent of A&E patients within four hours.
“Patients are still waiting too long, but the new rapid assessment and treatment area at the Royal Preston means people can be seen in a more appropriate environment – whereas historically they would have been on the corridor,” Sarah recalls.
"The whole hospital response to A&E performance is important - because it’s not an A&E problem, it’s a system problem and every part of the system from the assessment units to the wards to community services has a responsibility. It’s pleasing we have seen some response and improvement, although we are not quite where we need to be.
“But the A&E teams have delivered fantastic improvements in triage.”
Walk-in patients at A&E in Preston are now assessed and directed either into the department itself or to the separately-run urgent care centre – rather than making the decision for themselves.
The trust is poised to introduce the same system at Chorley A&E later this month, which regulators noted was performing better than its sister site in Preston – in spite of experiencing delays caused by its existing triage process.
The CQC also acknowledged improvements in medicines management – a new electronic prescribing system will see patient safety considerations “built-in”, Sarah explains.
Meanwhile, after clarification from the trust, the regulator’s main concern about staffing levels this time round was restricted to the number of paediatric nurses available at the Royal Preston, where one nurse is on duty during the day, compared to the expected standard of two. Sarah says that the money is available to recruit extra positions as part of a multi-million pound investment in staffing made over the last twelve months and she hopes that the creation of dedicated paediatric area in Preston should make it a more inviting place to work for nurses specialising in children.
Concerns highlighted in the inspector’s initial feedback include some problems with the quality of the environment in critical care at Preston and issues with infection control, for which action plans have been put in place.
As in previous inspections, staff were praised for the care offered to patients and a “good culture” was recognised within the organisation.
That is something which Sarah hopes to build upon once the whirlwind of her first few weeks in the job is over.
“We’re hoping to follow a programme which uses the power of storytelling to create a compassionate environment. A mix of staff would sit in front of a room full of others and talk about a scenario – but less about the facts and more about their feelings.
“There is so much work being done by so many people in lots of areas and that is testament to the individuals who work really hard to make sure the services they deliver improve all of the time. So our focus should be on them as well.”
MENTAL CAPACITY CONCERNS
The single biggest criticism in the CQC’s initial feedback following its latest inspection of Lancashire Teaching Hospitals is one which is repeated from last year’s visit – the safeguarding process at the Royal Preston for patients not deemed to have “mental capacity” and who are deprived of their liberty. That can be via methods as simple as putting side rails on a bed, but the CQC said it witnessed “restraint being used without evidence of consideration that it was the least restrictive form of restraint”.
Nursing director Sarah Cullen says that the issues stem from a lack of written evidence of the process which has been undertaken before such decisions are made.
“We reviewed eight cases highlighted by the CQC and identified six where documentation would have explained why a particular option had been put in place for a patient. In the other two cases, our safeguarding team determined that the decisions were reasonable.
“The judgements can be quite subjective – one clinical practitioner could determine one thing and another could determine something else.
“But we’ve got a really good appetite amongst staff for understanding this – they want to uphold people’s human rights,” Sarah says.
The process of depriving somebody of their liberty is governed by the Mental Capacity Act and Chorley Hospital was highlighted as demonstrating “best practice” in that regard. Inspectors also noted good interaction with a patient who had been deprived of their liberty on a surgical ward at the Royal Preston.
The trust appointed a matron for mental health and learning disability earlier this year and five hundred staff over and above the minimum number required have now undertaken mental capacity training.
"We‘re better at picking up mental health issues now - historically, physical health environments have been focused on physical health only and it's genuinely positive that there is now a much more holistic view of the patient," Sarah adds.