Peninsula Postgraduate Medical Education

 

Postgraduate School of General Practice Quality Management Visit to Royal Cornwall Hospitals NHS Trust, including Cambourne and Redruth Community Hospital and West Cornwall Hospital

 

July 2015

  

Postgraduate School undertaking visit

GP School

Primary author of report (name and job title)

Dr Andrew Eynon-Lewis Associate GP Dean for Quality

Local Education Provider visited

Royal Cornwall Hospitals NHS Trust (embracing Cambourne and Redruth Hospital C&RH and West Cornwall Hospital WCH)

Date(s) of visit

14th May 2015 (C&RH informal visit 30th April 2015 and WCH 17th May 2015)

Visit team (names and educational job titles)

Cambourne and Redruth Hospital

Chair

Dr Andrew Eynon-Lewis

Panel member 1

Dr Chris Cuff

Royal Cornwall Hospitals NHS Trust

Chair

Dr Andrew Eynon-Lewis

Panel member 1

Dr Mike Waldron

Panel member 2

Dr Chris Cuff

Panel member 3

Dr Sarah Robbins

Panel member 4

Dr Paul Thomas

Panel member 5

Ms Amber Worley

Panel member 6

Ms Leanne Martin

Ley representative

Mr Martin Cooke

West Cornwall Hospitals NHS Trust

Chair

Andrew Eynon-Lewis

Panel member 1

Dr Mike Waldron

Panel member 2

Ms Jane Bunce

Lay representative

Ms Geraldine Lavery

 

Programme / Specialty

No. of trainees seen

No. of trainers seen

 

Not provided

Not provided

Evidence considered prior to review taking place

Trainee feedback; GMC Survey

Date visit report ratified by PPME

<<insert date>>

Date visit report made available to provider

<<insert date>>

Date provider ratifies visit report

<<insert date>>

Circulation of this report

Peninsula Postgraduate Medical Education Quality Team

Local Education provider, Director of Medical Education

Local Education Provider, Medical Education Manager

         

 

Executive Summary

 

This report summarises the visit to Royal Cornwall Hospitals NHS Trust (RCHT) by the School of General Practice. The report covers those hospital training posts included in the training programme of General Practice Cornwall and includes information gathered from independent visits to Cambourne and Redruth Hospital (CRH) and West Cornwall Hospital (WCH), details of which are to be found in the Appendix.

Overall trainees were very positive about RCHT and the training they received. The trainees’ perspective was reflected by the positive attitude from the senior staff which included the Medical Director of RCHT allocating time to meet with the Head of School and by the relatively large number of Consultants and Supervisors who made such a positive contribution to the visits. All Trainees we interviewed would recommend the provider to a colleague as a valuable placement for GP training.

The visitors did identify some variation in educational provision across posts which did not seem to be directly related to service pressures. Obstetrics & Gynaecology, Otolaryngology, Paediatrics, Sexual Health and Palliative Care Medicine, Rheumatology and Oncology at Treliske and Care of Elderly placements at WCH, were identified as providing valuable experience and teaching particularly relevant to GP training. Areas of potential patient safety issues include the current out of hour’s arrangements whereby GP ENT trainees are covering Orthopaedics and Trauma and the distant supervision of GP Trainees at CRH. Other areas requiring review included ‘hospital at night’, handover and on-call medical cover at Treliske. The Postgraduate Medical Education Centre (PGMEC) was recognised as a valuable resource for delivering GP teaching and training.

Dr Andrew Eynon-Lewis

Associate GP Dean for Quality

 

Contents

Key recommendations. 1

Areas of good practice. 2

Summary of the visit 3

Patient safety inc. handover and induction. 3

Supervision – clinical and educational (inc. career guidance, feedback) 3

Training environment (inc. access to educational resources. 3

Work load. 3

Adequate experience / achievement of curriculum competencies. 3

Teaching – local, regional and study leave. 4

Bullying and harassment 4

Additional comments / feedback. 4

Visit Panel Chair Declaration. 5

Health Education South West Peninsula Postgraduate Medical Education Declaration. 6

 

 

Key recommendations

These were shared with the Director of Medical Education Cate Powell, at the end of the visit.

Ref

Department / Programme / Specialty

Key recommendation(s)

 

Healthcare of the Elderly

CRH

Contact with Supervisors is restricted by timetabling, which creates challenges in delivering teaching and performing WPBAs. There are also issues regarding handover; of patients transferred from Treliske; and of inpatients with the OOHs provider Serco. Trainees are isolated. The placement is the subject of a current educational review and this must be completed and actioned prior to the placement of further Trainees irrespective of programme.

 

ENT GPSTs covering Trauma & Orthopaedics (O&T) at night

The current arrangements are not supported by timely and meaningful induction to the O&T role, senior cover is described as variable and the handover of orthopaedic patients to the ENT GPST covering the nightshift is unreliable, as is the handover of ENT patients admitted by non-ENT on-call trainees. The situation presents a potential patient safety issue. We were made at the visit that another specialty trainee had written a formal letter to the trust concerning patient safety. The current  cross- cover arrangements need urgent review: Action plan within 3-months of report with intention to implement within 6-months

 

MAU

The current arrangements which have MAU and the junior trainee (who might be a GPST) supervised at night by a middle grade Medical trainee, who is also responsible for acute medical cover for the whole hospital, was reported as creating long waits for acutely ill patients to be seen and potential patient safety issue. The current supervision/staffing requires review:   Action plan within 3-months of report with intention to implement within 6-months

 

Cardiology

The requirement for trainees to cover those patients undergoing cardioversion was reported to us as generating minimal ward cover for cardiac ward patients and limiting trainee experiences. Furthermore, induction was judged poor and limited to reading a handbook. Teaching was reported as being limited and Trainees informed us that they experienced difficulties completing WPBAs. The delivery of educational opportunities/requirements requires strengthening:   Action plan within 3-months of report with intention to implement within 6-months

 

Hospital at Night

The current induction of trainees to the systems supporting hospital at night seems unreliable, resulting in trainee doctors not knowing of patients who are under their care. The situation presents a potential patient safety issue. The current induction of trainees requires review:   Action plan within 3-months of report with intention to implement within 6-months

 

Postgraduate Medical Education Centre PGMEC

During the visit we were made aware of the possibility that the PGMEC is under threat. The impact of any changes must take into account the need for an appropriate educational environment to support the successful GP half-day release scheme. From the information available to us, we were of the opinion that suitable options were not forthcoming and that retaining the PGMEC was important.  PPME ask that the trust keep HESW informed of any potential changes and any impact assessment which may be performed.

Areas of good practice

Department / Programme / Specialty

Area(s) of good practice

Otolaryngology

Good learning environment, excellent supervisors, good teaching and opportunities for clinic attendance. Supervisors actively encourage WPBAs.

Paediatrics

Recognised as a green outlier for Clinical Supervision in the GMC NTS 2014, trainees reported excellent formal teaching and experience and awareness by the supervisors for this to be targeted to the learning needs of GP trainees. There was an acknowledgement that the department was understaffed but that this did prevent delivery of education.

Obstetrics & Gynaecology

Previously highlighted as a red outlier for local teaching in the GMC NTS 2012, 2014, changes have been initiated and implemented and these have been recognised by the trainees. Teaching is held regularly and although possibly more secondary care focussed, was judged as good. The special interest days were valued. Induction was good. There was a sense that the department was educationally well led.

Sexual Health/ Palliative Care and Pain

A new split post this year which received universal positive feedback, offering valuable learning opportunities and good supervision.

Oncology/ Rheumatology

An established split post which also offers excellent experience for trainees with good supervision

Health Care of the Elderly

WCH

This post includes ward based care and work in the acute care unit and provides excellent experience for GP training. Induction is strong and timely, and Clinical Supervision excellent.

 

 

Summary of the visit

Patient safety inc. handover and induction

Wide variation was reported concerning handover and induction and these items form part of our key recommendations. The importance of adequate handover of patients being transferred to the community hospitals WCH and CRH from Treliske is crucial to secure patient safety, but this does not take place reliably. The importance of handover where there is OOHs cross specialty cover and when hospital at night is involved is clear and needs to be supported by effective induction to prepare trainees for systems and processes. Again this isn’t delivered reliably for ENT trainees cross covering Trauma and Orthopaedics and familiarity with the hospital at night patient record systems was reported as variable. There were some good examples of induction and handover in O&G and Paediatrics.

Department / Programme / Specialty

Area(s) of development

 

Healthcare of the Elderly sited at CRH and WCH

 

 

 

 

ENT cover for O+T OOHs

 

There is a need for clear verbal and written handover of patients transferred from Treliske. This should include a management plan to support trainees, who at CRH have only once weekly timetabled supervision. It is also important that the transferring doctor is made aware of the limited resources and expertise of the GP trainees at CRH and WCH and acknowledges this when patients are being assessed remotely through discussion with the GPST by the admitting doctor at Treliske  (see Key Recommendations)

Induction at WCH has been referred to in highlights

 

 

 

The current arrangements need review ( see Key Recommendations)

 

Supervision – clinical and educational (inc. career guidance, feedback)

Overall Supervision was reported as good, with most trainees not experiencing any difficulties meeting with their Clinical Supervisors nor achieving WPBAs. It has been mentioned previously that the visit was well supported and usefully informed by supervisors. However, we do have concerns about supervision in Cardiology and also in the department of elderly care at CRH, where it would seem that this has been generated by timetabling issues.

Department / Programme / Specialty

Area(s) of development

Cardiology

Healthcare of the Elderly

There is a need to review current systems of supervision ( see Key Recommendations)

Training environment (inc. access to educational resources

These were reported as being accessible in all sites

Department / Programme / Specialty

Area(s) of development

 

N/a

Work load

Workload is regularly highlighted by trainees but RCH did not seem to be different than any other acute hospital trust as witnessed by our trainees. However, concerns were expressed about MAU and current arrangements of middle grade cover, resulting in ill patients experiencing inappropriate waiting times to be reviewed by a more senior doctor.

Rota issues at WCH have resulted in trainees working for exceptionally large number of days without a break. These work patterns are not sustainable. Details are described in the appendix

Department / Programme / Specialty

Area(s) of development

MAU

 

Rota

WCH

 

There is a need to review current rota arrangements (see Key Recommendations)

 

Whilst acknowledging that the current arrangements are a consequence of under recruitment, the rota is of concern. It does raise potential issues of patient safety and also continuity of care. We understand this is currently being addressed.

 

Adequate experience / achievement of curriculum competencies

Trainees generally reported good opportunities to gain experience within the programme and gain the curriculum competencies. Trainee experience at WCH provides exceptional broad-based experience particularly relevant to general practice.  Cardiology was highlighted as struggling in this area with workload  limited for GPSTs.

Department / Programme / Specialty

Area(s) of development

Cardiology

The educational opportunities for the post are in need of review with the aim of enabling GP Trainees to cover relevant competencies and curriculum statements

Teaching – local, regional and study leave

Nine consultants joined us during the visit to Treliske (far more than we have experienced at other LEP visits) and the two Clinical Supervisors were met with at WCH and one at CRH. All expressed a clear desire to develop teaching and training at RCHT. Overall teaching was reported by trainees as good, with Paediatrics and ENT being recognised as being particularly good. Rota problems were reported as an issue in ED making attendance difficult and teaching was described as ‘poor’ in Cardiology.

Department / Programme / Specialty

Area(s) of development

Emergency Medicine

 

Cardiology

Teaching recognised as good but not supported by rota. Suggest options are explored.

Teaching is reported as falling below what might be reasonably expected. GP focussed teaching is to be encouraged

Undermining, bullying and harassment

There was no reporting of these activities in all sites

Department / Programme / Specialty

Area(s) of development

 

N/a

Additional comments / feedback

The two formal visits to Treliske and WCH were well organised by the local PGME department for which we are grateful. Trainee attendance was good with over twenty trainees being met with in a ‘coffee house’ style setting at Treliske, four at WCH and two at CRH. The process was successful. The contribution of the consultants and supervisors attending all visits has previously been referred to positively.

We are grateful to Dr Cate Powell DME for finding time to meet with us immediately following the two formal visits to Treliske and WCH and receiving verbal feedback.

Visit Reports on CRH and WCH are appended.

 

 

Visit Panel Chair Declaration

This completed report is a true and accurate account of the discussion that I participated in or were reported to me from this visit.

The key recommendations have been identified within this report have been identified with good faith.

I can confirm that any areas of significant concern and that have a direct impact upon patient safety has been brought to the attention of the relevant Director of Medical Education (or equivalent), responsible Medical Director and Executive Lead for Quality at Health Education South West Peninsula Postgraduate Medical Education.

 

Chair name:

 

Chair educational role:

 

Date of signature:

 

 

 

Informal GP School visit to Camborne and Redruth Hospital

30 April 2015

Visiting team: Dr Chris Cuff Dr Andrew Eynon-Lewis Associate GP Deans HESW

Background

This informal visit was undertaken to review progress against the action plan created by Dr Pollard in response to Dr Cuff’s report of November 2014. The findings of this review will be used to inform the LEP visit to RCHT scheduled for 14th May 2015. The action plan responded to the following areas of concern: 

a)      ‘Paucity of adequate training/education’

b)      ‘Poor handover arrangements and admissions procedures’

c)       ‘Poor continuity of care’

d)      ‘Poor availability of senior medical advice’

CRH is part of Peninsula Community Health C.I.C.  Medical care is provided by the elderly care department of the RCHT and consists of three GP STs providing in-hours care, who are supervised by the visiting consultants. A formal ward round on Lamorna and Lanyon are held weekly (both on a Monday) with senior support provided the remaining time via telephone and ward visits after clinics, if requested by junior staff. Out of hours care is provided by Serco and middle grade medical trainees who visit at weekends.The last CQC inspection report is dated July 2013 with all markers being met with at that time.

The Visit

We are grateful to Dr Purchase and the trainees for finding time in their busy schedules to meet with us. Apologises were received from Dr Pollard.

  1. Meeting with Dr Purchase:
  2. Meeting with trainees ( two)

Summary

This summary commences with addressing the areas of concern and then includes other items raised at the visit. The summary includes some suggestions for development.

a)      Paucity of adequate training/education: The case-mix at CRH clearly provides educational opportunities relevant for GPSTs and these are supported by the varied clinics held. The lack of close supervision encourages trainees to work independently and for many (but not necessarily all) this promotes their confidence and competence.  To protect patient safety however, trainees need to be aware of their limitations and be clear when and how to call for assistance. Holding one weekly ward round restricts ‘bed-side’ teaching and crucially WPBAs and may result in exclusively patient -problem- based teaching. A move towards a twice weekly ward round might broaden the educational agenda and enable the consultant to assess the competence/confidence levels of the trainees informally and through planned WPBAs, which is important given the lack of any middle grades and that the majority of supervision is remote.  As an aside twice weekly ward rounds might lead to more active patient management (which educationally might be valuable) and reduce length of stay times. The clinic opportunities are varied and trainees need to be aware of these opportunities and positively seek time to attend where possible.  We were not aware of any progress being made on completing the action stated at the time of the visit.

b)      ‘Poor handover arrangements and admission procedures’:  The lack of consistent Dr-Dr handover for patients being admitted to CRH presents a potential patient safety issue. Such potential risks are of increased importance given that the trainees might have little medical experience, that consultant ward rounds only take place on one day of the week (Monday) and that facilities for patient testing is limited. There is a sense that discharging medical staff at RCH are not aware of these limitations. The experience of the trainees was one of patients being transferred without management plans and on one occasion a patient was transferred ‘post-take’ without medical review.  There seemed a lack of clarity concerning the clinical governance of patient transfers and it would be of interest to know if the contractual arrangements between the RCHT and Peninsula Community Health included this activity and who would be responsible if a SUI took place. The trainees were aware that medical cover was the responsibility of Serco from 7pm, but stated that communicating with Serco about patients was difficult. We were not aware of any progress being made on completing the action plan stated at the time of the visit.

c)       ‘Poor continuity of care’:  Acknowledged as an issue, especially given that only one weekly ward round is held on each ward.

d)      ‘Poor availability of senior staff’: None of the trainees questioned stated that they had experienced difficulties obtaining senior support. Clarity concerning the system of contacting seniors was thought important.

e)      Communication within Elderly Care Department: we were surprised that the Action Plan written by Dr Pollard had not been shared with Dr Purchase given her involvement at RCH and in GPST supervision. We were concerned that this might reflection communication issues within the department.

f)       Nursing issues: whilst the quality of care given to patients especially on Lanyon was thought to be good, the trainees did raise instances where abnormal results were not shared in a timely fashion thereby exposing the trainee and patient to unnecessary risk. There was a sense that overall quality of nursing needed improvement. Interestingly reference to supervision of nursing staff was made in the last CQC report 2013.

g)      Clarity of purpose of CRH: CRH is different from other community hospital in that it has no GP cover, rather it is staffed by GPSTs who are exclusively supervised by consultants from Elderly Care Department RCH.  Although recognised as being consultant beds, direct consultant-patient contact time is limited to one ward round per week. Given the lack of clarity around transfers we think it possible that those Drs transferring patients to CRH are not aware of the limitations of care at CRH and that this might result in inappropriate transfers. This is an area which requires clarification and communication.

 

AEL CC 5/15

 

 LEP Visit to West Cornwall Hospital (WCH)

(Part of Royal Cornwall Hospital Trust RCHT)

Date: 17.6.15

Visiting Team: Jane Bunce (Quality Team Manager), Dr Mike Waldron & Dr Chris Cuff (Associate GP Deans Cornwall), Dr Andrew Eynon-Lewis (Associate GP Dean for Quality)

Background

West Cornwall Hospital forms part of the RCHT and provides c 50 inpatient medical (predominantly elderly care) beds, which take ‘step down’ transfers from Treliske and direct admissions via the acute care service. The acute care service provides GP Triage of patients referred by their named GP. Patients may also be directly admitted via the hospital’s acute care centre. The hospital has eight GP approved training posts but only seven of these were filled at the time of the visit. Consultants in Elderly Care from Treliske visit daily to perform ward rounds and clinics. The urgent care centre is staffed by experienced GPs on a rota basis from 8am-10pm. Treliske is twenty-seven miles or forty-five minutes ambulance drive away.

The Visit

  1. Meeting with Trainees: The visiting team met with four trainees (three GPST2s and one GPST1) all currently in post.
  2. Meeting with Supervisors: and then separately with Dr Neil Davidson and Dr Agashi who are supervisors covering the acute care centre.

None of the Elderly Care consultants were available.

Summary

This was a very positive visit with both the trainees and supervisors expressing an enthusiastic approach to learning and teaching. The placement presents excellent learning opportunities for GP trainees, with a broad case-mix and good supervision and all the trainees interviewed strongly recommended it. Interestingly, supervisors indicated that the clinic opportunities however were not taken up by trainees. The current under staffing and resulting rota does undermine some of the positives, as does the not unexpected issues concerning transfer of patients from the main DGH (Treliske). 

Highlights

  1. Acute care centre: the centre provides an excellent case-mix relevant to GP training. Supervision is excellent (see below). Trainees are provided with a comprehensive induction, are well supported and where possible exposure is directed by the supervisors to meet trainees learning needs. One trainee informed us of a patient death from a cardiac arrest, which she was involved with in her first couple of weeks. She reported that she felt equipped to handle this because she had received ALS training in the induction and knew where all the equipment was. She was subsequently given a one-to-one debrief post event by an experienced supervisor.
  2. Clinical supervision: this was generally reported as very good. Mention has already been made of the acute care centre, where the supervisors actively promote and deliver WPBAs. The visiting Consultants are supportive and are always willing to address clinical problems on the daily ward round. At weekends the urgent care GPs offer support.
  3. Daily consultant input: this seemed crucial to the success of the placement: trainees knew that a senior would be available every day and that patient problems would be addressed.

Areas of development

  1. Review of Rota: under-recruitment has impacted on the rota and trainees were reporting regularly working excessive days without a break because of need to cover. One trainee reported working twenty-five days without a break and all trainees reported working four out of seven weekends. The rota was reported as undermining continuity of patient care. We understand moves are afoot to address this issue.
  2. Patient transfers: Trainees reported variable information sharing about patients being transferred from Treliske to WCH; often there was no management plan which might be especially relevant with late night transfers. This contrasted with acute care transfers where communication was reliable. Transferring patients to Treliske- generally to the on-call medical take was reported as being difficult at times. There was a sense that the medical registrars didn’t appreciate the level of experience of trainees at WCH and that the pressures on beds on occasions resulted in a negatively bias discussion concerning transfer which potentially might present a patient safety issue. Trainees reported that they felt the decision to transfer was theirs’s, which might not be appropriate given their experience. No actual patient safety events were offered. There would seem to be a need to inform those Drs making decisions concerning transfers from WCH to be made aware of the expected level of experience of GP trainees at the hospital and also the resources available at WCH.
  3. Work Place Based Assessment: this is largely delivered in the acute care setting, which although effective, might be enhanced for the benefit of learners by having some delivery by consultants on the ward based patients.

 

 AEL 6/15