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Friday, January 09, 2015



The Care Quality Commission (CQC) carried out a comprehensive inspection which included an announced inspection visit between the 16 and 18 September 2014 and subsequent unannounced inspection visits on 21 and 28 September. We carried out this comprehensive inspection of the acute core services provided by the trust as part of Care Quality Commission’s (CQC) new approach to hospital inspection.
Hinchingbrooke Hospital is an established 304 bed general hospital, which provides healthcare services to North Cambridge and Peterborough. The trust provides a comprehensive range of acute and obstetrics services, but does not provide inpatient paediatric care, as this is provided within the location by a different trust. The trust is the only privately-managed NHS trust in the country, being managed by Circle since 2012.The Trust's governance is derived from the Franchise Agreement and Intervention Order approved by the Secretary of State for Health. This approach empowers all members of staff to take accountability and responsibility for the planning and implementing of a high quality service.

Prior to undertaking this inspection we spoke with stakeholders and reviewed the information we held about the trust. Hinchingbrooke Health Care NHS Trust had been identified as low risk on the Care Quality Commission’s (CQC) Intelligent Monitoring system. The trust was in band 6, which is the lowest band.
The hospital was first built in the 1980s. It was the first trust in the country to be managed by an independent healthcare company, Circle, which occurred in February 2012. It is led by a multidisciplinary team of clinical and non-clinical executives partnered with a non-executive Trust Board. However we found that the trust was predominantly medically led but a new director of nursing had been appointed four months prior to our visit and was beginning to address the input of nursing within the hospital.
We found significant areas of concern during our inspection visit which we raised with the chief executive, director of nursing, head of midwifery and the chief operating officer of the trust and the next day with the NHS Trust Development Authority.

We were concerned about patients safety and referred a number of patients to the Local Authority safeguarding team. Since the inspection the Trust Development Authority have given the trust significant support to address the issues raised in this report.

CQC served a letter which informed the trust of the nature of our concerns in order that action could be taken in a timely manner. CQC also requested further information from the trust as we considered taking urgent action to reduce the number of beds available on Apple Tree Ward.

 However the trust took the decision to reduce the number of beds as part of their action plan and so this regulatory action was therefore not necessary. The matter has been kept under review and the CQC has undertaken two unannounced inspections, attended the Annual Public Meeting [i.e. the Annual General Meeting] on 25 September 2014 and held two follow up meetings with the trust to ensure that action have been taken.
The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each core service receives an individual rating, which, in turn, informs an overall trust rating. The inspection found that overall; the trust has a rating of 'inadequate'.
Our key findings were as follows:
  • We found many instances of staff wishing to care for patients in the best way, but unable to raise concerns or prevent service demands from severely impinging on the quality and kindness of care for patients. In both maternity and critical care we noted good care, focused on patients’ needs, meeting national standards.
  • The provision of care on Apple Tree Ward, a medical ward, was inadequate and there were risks to patient safety. This required urgent action to address the concerns of the inspection team.
  • There was a lack of paediatric cover within the A&E department and theatres that meant that the care of children in these departments was, at times,increasing potential risks to patient safety.
  • The senior management team of the trust are well known within the hospital; however, the values and beliefs of the trust were not embedded, nor were staff engaged or empowered to raise concerns by taking responsibility to 'Stop the Line'. Stop the line is a process which empowers all members of staff to raise immediate concerns when they believe that patient safety is being compromised. Initiating a "Stop the Line" facilitates management support to the area identified and action to address the issue.
  • There was a lack of knowledge around Adult Safeguarding procedures, Mental Capacity Act and Deprivation of Liberty processes.
  • A response to call bells in a number of areas, in Juniper Ward, Apple Tree ward and the Reablement Unit for example, was so poor that two patients of the 53 we spoke to in the medical and surgical areas stated that they had been told to soil themselves. A further one patient advised that they had soiled themselves whilst awaiting assistance. We brought this to the attention of the trust and they investigated. However neither CQC nor the trust could corroborate these claims.
  • Risk assessments were not always reflective of the needs of patients in surgery and medical wards. This was evidenced by review of 46 sets of notes of which 19 were found to have incomplete information or review.
  • Infection control practices were not always complied with in A&E Apple Tree ward, Cherry Tree ward, Walnut ward and in the Treatment Centre.
  • Medicines, including controlled drugs, were not always stored or administered appropriately in A&E, Juniper ward, Apple Tree ward or Cherry Tree ward.
We saw several areas of good practice including:
  • In both maternity and critical care we noted good care, focused on patients’ needs, meeting national standards.
  • The paediatric specialist nurse in the emergency department was dynamic and motivated in supporting children and parents. This was seen through the engagement of children in the local community, in a project to develop an understanding of the hospital from a child’s perspective, through the '999 club'.
  • The support that the chaplaincy staff gave to patients and hospital staff was outstanding. The chaplain had a good relationship with the staff, and was considered one of the team. The number of initiatives set up by the chaplain to support patients was outstanding.
However, there were also areas of poor practice, where the trust needs to make improvements.
Importantly, the trust must:
  • Ensure all patients health and safety is safeguarded, including ensuring that call bells are answered in order to meet patients’ needs in respect of dignity, and patient’s nutrition and hydration needs are adequately monitored and responded to.
  • Ensure that staffing levels and skill mix on wards is reviewed and the high usage of agency and bank staff to ensure that numbers and competencies are appropriate to deliver the level of care Hinchingbrooke Hospital requires.
  • Ensure that the arrangements for the provision of services to children in A&E, operating theatres and outpatients areas provided by the trust, is reviewed to ensure that it meets their needs, and that staff have the appropriate support to raise issues on the service provision.
  • Ensure records, including risk assessments, are completed, updated and reflective of the needs of patients.
  • Ensure the care pathways, including peadiatric pathways, in place are consistently followed by staff.
  • Ensure an adequate skill mix in the emergency department and theatres to ensure that paediatric patients receive a service that meets their needs in a timely manner.
  • Ensure that there are sufficient appropriately skilled nursing staff on medical and surgical wards to meet patients’ needs in a timely manner.
  • Ensure medicines are stored securely and administered correctly.
  • Improve infection control measures in the Emergency department and medical wards to protect patients from infection through cross contamination.
  • Ensure staff are trained in, and have knowledge of their responsibilities under the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS).
  • Ensure that patients are treated with dignity and respect.
  • Ensure that all staff are adequately supported through appraisal, supervision and training to deliver care to patients.
  • Ensure pressure ulcer care is consistently provided in accordance with National Institute for Health and Care Excellence (NICE) guideline CG:179.
  • Ensure that catheter and intravenous (IV) care is undertaken in accordance with best practice guidelines.
  • Ensure patients are treated in accordance with the Mental Capacity Act 2005.
  • Ensure that the staff to patient ratio is adjusted to reflect changing patient dependency.
  • Review the ‘Stop the Line’ procedures and whistle blowing procedures, to improve and drive an open culture within the trust.
  • Standardise and improve the dissemination of lessons learnt from incidents to support the improvement of the provision of high quality care for all patients.
  • Ensure that all appropriate patients receive timely referral to the palliative care service.
  • Ensure action is taken to improve the communication with patients, to ensure that they are involved in decision-making in relation to, their care treatment, and that these discussions are reflected in care plans.
  • Review mechanisms for using feedback from patients, so that the quality of service improves.
In addition, the trust should:
  • Review the checking of resuscitation equipment in the A&E department, and across the trust, to ensure that it occurs as per policy.
  • Take action to reduce the overburdensome administration processes when admitting patients into the acute assessment unit (AAU).
  • Review intentional rounding checks to ensure that they cover requirements for meeting patient’s nutrition and hydration needs.
  • Involve patients in making decisions about their care in the A&E department.
  • Review the training given to staff, and the environment provided, for having difficult discussions with patients.
  • Review translation usage in A&E, to ensure that patients receive information appropriate to their needs.
  • Provide adequate training on caring for patients living with dementia, to improve the service to patients living with dementia.
  • Discontinue the practice of adapting day rooms in rehabilitation wards to use as additional inpatient bed spaces.
  • Review the clinical pathways for termination of pregnancies in the acute medical area.
  • Review the policy on moving patients late at night.
  • Review the out-of-hours arrangements for diagnostic services, such as radiology and pathology, to ensure that patients receive a timely service.
  • Review mechanisms for fast track discharge, so that terminally ill patients die in a place of their choice.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Last inspection report

9 January 2015
Inspection areas



Last inspection report

9 January 2015


Requires improvement

Last inspection report

9 January 2015



Last inspection report

9 January 2015


Requires improvement

Last inspection report

9 January 2015



Last inspection report

9 January 2015
Checks on specific services

Urgent and emergency services (A&E)

The emergency department at Hinchingbrooke Hospital was inadequate in respect of the safe and well-led domains. We could not be assured that there were sufficient assurance processes in place to demonstrate that patients were not at high risk of harm when we inspected.There was minimal incident reporting and recording within the emergency department. We could not see that completed incident reports had a clear ‘lessons learnt’ approach. We looked at equipment which was visibly clean, but found that some equipment was not maintained to the manufacturer’s recommendations with service labels highlighting that a service was due. Medication was not securely stored appropriately, and daily checks on emergency resuscitation trollies were not carried out by staff. Staff vacancies were covered with bank and agency staff which accounted for over a quarter of the staff numbers. Paediatric cover for children in this department was not sufficient to cover 24 hours, and staff did not have the competency to care for children when paediatric nurses were not on duty. Since our visit the trust has employed peadiatric agency and bank staff to cover 24 hours.
Clinical outcomes and monitoring of the service showed that the trust was not outliers when compared to others however we found that the provision of care was not assured by the leadership, governance or culture in place during our inspection. Patients were routinely triaged within the waiting room area with no consideration for their privacy or dignity. This practice was not in line with departmental expectations; the trust does provide a private room suitable for triage and expects staff to offer patients a choice. There was a senior member of nursing staff who was designated as a shift co-ordinator, and we found that the priorities and management of the department were weak. When busy, two staff told inspectors that they accepted that they could not give the care that they would wish to do so. We heard one patient request assistance and a member of staff told them that they did not have time but would return. However after 30 minutes the patient stated that no one had returned. We raised this issue to a member of staff who assisted the patient.
The department was not responsive to the needs of all of the people who used it. Children had no seperate waiting area and treatment rooms designed for children were not always used for them. There were higher than the England average number of people who left the department before being seen due to long waiting times and those who were to be admitted also spent considerable lengths of time in the department. The escalation protocol was not used effectively to reduce patients waiting times
Mental capacity assessments were being undertaken appropriately, and staff demonstrated knowledge around most of the trust’s policy and procedures. We saw that staff were rushed with their workload, but took the time to listen to patients, and explain to them what was wrong and any treatment required. The staff we spoke with were proud to work in the emergency department.

Last inspection report

9 January 2015

Medical care (including older people’s care)

Medical services were inadequate because we found poor emotional and physical care which was not safe or caring. This was not reported by leaders of the service to the trust management therefore we judged the leadership to be inadequate. Services were not caring because people were not treated with dignity or respect. We were also concerned that people were not being treated in an emotionally supportive manner. Hand hygiene and infection control techniques were poor. Staffing numbers were not always reflective of patient dependency. Examples of treatment without consent were identified on one patient who lacked mental capacity but we found an under recognition of patients who may lack capacity throughout the medical wards. Services were not effective because pressure ulcer prevention and treatment was not always provided in line with NICE guidelines. There were no seven day services provided by the hospital. The service was not responsive; we found that medical patients were not always classed as outliers despite requiring specialised care. This meant that the frequency of review by their own consultant might be reduced. The Medical Short Stay Unit and the Reablement Centre were not utilised for their intended purpose.
The service was not well-led. We found that the culture of identifying, reporting and escalating concerns was not open. We found that teams were not engaged or felt enabled to raise concerns. We wrote to the trust to express our concerns and with the support of the Trust Development Authority action underway to address these.

Last inspection report

9 January 2015


Requires improvement
The surgical services require improvement because there were significant risks and deficiencies evident across four areas of our inspection domains. The safety of patients was at risk due to delays in nurses attending when patients call for help. In Juniper Ward there was a clear consensus from many patients that they were not cared for safely because it took too long for nurses to respond, in particular at night time.However the trust produced data which demonstrated that the average response time in the week prior to our visit was on average four minutes, this meant that this may have been an emerging issue. We found that there were continuing problems of medication not being administered as prescribed. Nursing care records and plans did not always reflect the current needs of the patient, or have clear guidance of the care to be provided.
Patient outcomes were good in certain respects, such as low incidence of pressure ulcers, and low readmission rates indicating successful overall treatment. Many issues were evident and had been identified by the trust, but action had not been taken to improve the issues or actions taken had not been effective. It was not evident that staff could easily raise issues they were concerned about, either in their own teams or across professional boundaries.

Last inspection report

9 January 2015

Intensive/critical care

Critical care services were good overall. We found that services were safe, as competent medical, nursing and other professionals worked effectively together to ensure safety. The environment was cramped and old, which meant that staff had to work flexibly and efficiently to ensure cleanliness, safety, and privacy and dignity for patients. The service is effective as staff followed clinical guidance and locally agreed protocols. Performance data showed that there were few incidents of harm.
The service was caring as patients and relatives told us that staff were very supportive. There were systems available to provide follow-up emotional support if required. Critical care services were responsive because a range of detailed assessment records were used to prompt staff to meet patients' individual needs. Children were cared for in the Critical Care Centre, but this was a temporary measure to provide urgent support until specialist care was arranged. The service was well-led, as staff worked well as an integrated team to provide very specialist care within the unit, and also to patients requiring aspects of intensive care in other ward areas. Audit work was established by the outreach staff to monitor the overall management of deteriorating patients in all wards.

Last inspection report

9 January 2015

Maternity and gynaecology

The current level of maternity services provided to women and babies by Hinchingbrooke Hospital were good. The maternity unit provided safe staffing levels and skill mix, and encouraged proactive teamwork to support a safe environment. We saw that there were arrangements in place to implement good practice, learning from any untoward incidents, and an open culture to encourage a focus on patient safety and risk management practices.The trust is working towards achievement of Level 2 Unicef's Baby Friendly Initiative
All permanent staff were appropriately qualified and competent to carry out their roles safely and effectively in line with best practice. There were detailed and timely multidisciplinary team discussions and handovers, to ensure women and babies care and treatment was co-ordinated and the expected outcomes were achieved. Staff in all roles put effort into treating women with dignity, and most women felt well-cared for as a result. Staff in the hospital and community were flexible in working practices and responding to the needs of women and babies. We found the midwifery leadership model encouraged co-operative, supportive relationships among staff. Staff reported that the managers and supervisors ensured that they felt respected, valued, supported and cared for. Staff contributions and performance were recognised and celebrated.

Last inspection report

9 January 2015

End of life care

Requires improvement
End of life care service require improvements as patients are at risk of not receiving safe or effective treatment that meets their needs. Do not resuscitate forms were not completed correctly, the palliative care team were over stretched which meant that staff were not effectively trained and patients did not receive the levels of care they could expect. These risks were not recorded on a risk register as there was not one specific to end of life care. We were told that there were no associated end of life care risks.
'Do not attempt cardio-pulmonary resuscitation' (DNA CPR) forms were completed, but a high percentage had not been appropriately signed by a consultant. In many instances, we found that DNA CPR decisions had not been discussed with the patient or their representatives. Assessments had not been completed when the reason given for not discussing decisions with patients was recorded as the patient lacking capacity. Documentation was found to be poor throughout the service. Ward staff training in end of life care was lacking, and no one we spoke to on the wards had advanced communication training, however the palliative care team did have this training.
The specialist palliative care team was well-led, and had worked hard to improve end of life care throughout the hospital. The team had put together a business case to increase staffing within the team, in order to ensure that they could provide an equitable, effective and safe end of life care service, that was available 24 hours every day. The chaplaincy service provided outstanding care to patients and support to the nursing staff on wards.
Most of the hospital wards were providing end of life care and therefore this report should be read in conjunction with the medical care report.

Last inspection report

9 January 2015


We found outpatients to be safe. Medicines and prescription pads were securely stored, although we found a small amount of medicines within the trauma and orthopaedic outpatient clinic, which were being stored along with cleaning fluids and other items. The outpatient areas we visited were clean, and equipment was well maintained. Staff vacancies were being managed appropriately. Patients were appropriately asked for their consent to procedures. On most occasions records were available for patient clinic appointments.
The service in outpatients was caring. Patients received compassionate care, and were treated with dignity and respect. The outpatient service was responsive to people’s individual needs. Patients were seen within national waiting times. Staff told us that clinics were rarely cancelled. Translation services were available for people who did not speak English, and all the staff we asked about this were able to tell us how to access these services. Complaints were handled appropriately, and action was taken to improve the service. Outpatient services were well-led and there was good local leadership of clinics. Patient feedback was used to improve the service, and there was innovation in some service areas, such as one-stop clinics in gynaecology.

Last inspection report

9 January 2015

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Assignment and Licence
PBROTRIB believes that Material We Request From You should be PBROTRIB ’s property as PBROTRIB has requested the Rights Holder’s services and instructed them to create the Contribution on its behalf. However, PBROTRIB acknowledges that the Right Holder may need a licence from PBROTRIB to
use the Contribution for limited purposes. Therefore, in submitting Material We Request From You to PBROTRIB , the Rights Holder assigns to PBROTRIB with full title, right and interest all existing and future intellectual property rights in the Contribution. In return, PBROTRIB will endeavour to give a Credit to the Rights Holder and PBROTRIB grants the Rights Holder a non-exclusive, non-transferable licence to use the Contribution in its own online and offline portfolio, provided that the following copyright notice is applied to the Contribution “©Peterborough
Tribune, used under limited licence”.
General notes about Rights: Any rights granted to PBROTRIB or the Rights Holder under this Charter shall survive termination of the Contract for any reason. Rights Holder Promises The Rights Holder promises: that it owns the Contribution and / or is (and will continue to be) authorised to grant the rights to PBROTRIB; nothing in the Contribution is blasphemous, discriminatory, defamatory, untrue, misleading or unlawful; that the Contribution complies with the NUJ Code of Professional Conduct and the Independent
Press Standards Organisations Editors’ regulations and Code of Practice; the Contribution does not contain any virus, Trojan horse, hidden computer software or similar; the Contribution does not infringe the intellectual property rights of any third party; where the Contribution contains Personal Data, all
the necessary consents in compliance with the Data Protection Act 1998 have been obtained; where the Contribution contains images of children under the age of 16, written parental consent has been obtained and can be provided on request; and maintain and comply with, at all times, the highest ethical standards in the preparation, creation and delivery of the Contribution.
Complaints In the event that a complaint is raised in relation to a Contribution, the Rights Holder agrees to co-operate fully with any internal or external investigation or process. Status. The Rights Holder is an independent contractor and nothing in the Charter shall render the Rights Holder an employee, worker,
agent or partner of PBROTRIB. The Rights Holder is responsible for any taxes/national insurance payable in relation to any services provided under the Charter.
Indemnity The Rights Holder shall keep PBROTRIB indemnified in full against all loss incurred or paid by PBROTRIB as a result of or in connection with any claim made against PBROTRIB by a third party:
arising out of, or in connection with the Contribution, to the extent that such claim arises out of the breach of this or any terms of this Charter (including any Special Terms); and for actual or alleged infringement of a third party's intellectual property rights arising out of, or in connection with the use of the Contribution except in so far as the claim arises as a result of changes made by PBROTRIB or a breach of the Licence by PBROTRIB.
Variation of the Charter No variation of any term of this Charter will be effective, unless it is set out in writing (letter, fax or email) and signed by
a relevant authorised representative of PBROTRIB. If you wish to submit a Contribution and are unable to agree with the terms of this Charter or if you
have any questions regarding this Charter, please contact a relevant authorised representative of the PBROTRIB publication.
Problems & Disputes In the event of a problem or dispute in relation to a Licence and/or in connection with this Charter, in the first instance the Rights Holder and the Editor will look to resolve the dispute amicably. Application of the Charter Unless otherwise agreed, this Charter shall be interpreted in accordance with the laws of England and Wales and English courts will have exclusive jurisdiction