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Queen Alexandra Hospital Requires improvement

We are carrying out checks at Queen Alexandra Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Reports


Inspection carried out on 19 July 2017

During an inspection to make sure that the improvements required had been made

The Care Quality Commission (CQC) carried out an unannounced inspection at Queen Alexandra Hospital on 19 July 2017. The purpose was to look at specific aspects of the care provided by the diagnostic imaging department.

Concerns were initially raised by a member of the public, and the trust was given the opportunity to respond to these. When satisfactory assurances were not received from the trust, the local inspection team decided to conduct an unannounced inspection.

In particular we looked at the reporting of chest x-rays, and the governance processes in place to ensure that any backlog in reporting was managed, escalated and resolved.

We did not inspect other diagnostic imaging services or any outpatient services at the hospital on this occasion. Because of this we have not provided ratings for this inspection.

Our key findings in the diagnostic imaging department were:

  • An increasing problem with staffing capacity in radiology meant reporting of chest x-rays was not always undertaken by appropriately trained members of staff

  • There have been three serious incidents causing significant harm to patients which was caused by the failure of reporting of chest x-rays by radiologists.

  • At the time of inspection there had been no trust wide risk assessment or up to date audit of the potential harm caused by the failure to report chest and abdomen images

  • There was insufficient audit undertaken to ensure that every examination undertaken had sufficient clinical review.

  • During the junior doctor focus group, we were informed that staff that had been delegated responsibilities for reviewing chest and abdomen x-rays were not always appropriately trained and felt that they were not competent or confident to undertake such duties.

  • Reporting on some plain film and cross sectional diagnostic imaging tests were not completed in a timely manner.

  • Chest and abdomen x-rays from the emergency department did not always receive a formal report

  • There was no effective governance framework to support the delivery of good quality care around reporting times.

  • There was insufficient assurance that the risk was appropriately managed and mitigated to ensure that patients are protected from harm.

  • During the inspection we were told the risk was “being tolerated”.

However:

  • We saw good evidence of learning from radiation incidents which had meant that the department had good framework around radiation protection.

  • We saw some evidence that scope of practise had been and was continuing to be extended for radiographers.

  • The department did reach the department’s key performance indicator for turnaround times for reporting cancer waits.

  • Local leadership was good. The radiology service manager had kept oversight of the risk and had attempted to influence change as best to their ability.

  • The clinical director for radiology was new in post, and was highly regarded. They had already made several efforts to improve the service’s risk.

Based on the findings of this inspection CQC took urgent enforcement action and imposed conditions on the trust’s registration, as a service provider. CQC believed patients would be exposed to the risk of harm if these conditions were not urgently imposed. These conditions are;

  1. The Registered Provider must take evidenced based appropriate steps to resolve the backlog of radiology reporting using appropriately trained members of staff. This must include a clinical review, audit and prioritisation of the current backlog of unreported images, (including those taken before January 2017); assess impact of harm to patients, and apply Duty of Candour to any patient adversely affected.

  2. The Registered Provider must ensure that they have robust processes to ensure any images taken are reported and risk assessed in line with Trust policy.

  3. The Registered Provider must submit their evidenced based decision-making on how the backlog will be addressed to the Commission by the 21 August 2017.

  4. From 6 September 2017, and on the Wednesday of each week after, the Registered Provider must report to the Care Quality Commission, NHS Improvementand the NHS England Local Area Team:

  • The total number of images remaining in the backlog (including unreported images pre-January 2017) shown by year of image taken.

  • The current trajectory date of when the backlog (including unreported images pre-January 2017) will be cleared.

  • The proportion of patients waiting less than the trusts KPI for x-rays, CT and MRI.

  • The average waiting time (in days and hours) for a reported plain film (excluding GP requests).

  • The average waiting time (in days and hours) for chest and abdominal films (excluding GP requests).

  • Number of plain film requests (excluding GP requests).

  • Longest waiting time for a reported radiology plain film request.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 16, 17 and 28 February, 10 and 11 May 2017

During an inspection to make sure that the improvements required had been made

Portsmouth Hospital NHS Trust is located in Cosham, Portsmouth. The main site provided by this trust is the Queen Alexandra Hospital, which is a 975 bedded District General Hospital providing a comprehensive range of acute and specialist services to a local population of approximately 610,000 people. The trust provides specialist renal services to a population of 2.2 million people across Wessex.

We carried out an unannounced inspection of the Queen Alexandra Hospital on 16, 17 and 28 February 2017, where we inspected the medical care services and the emergency department. We returned on 10 and 11 May 2017 and inspected the key question of ‘well led’ for Portsmouth Hospital NHS Trust. As part of this later inspection in May 2017 we visited the emergency department, four medical care wards and the Acute Medical Unit (AMU) to review ward to board governance arrangements. During our May 2017 inspection we identified concerns in both the emergency department and medical care wards and AMU, which have been reported on in this February 2017 report. To view our findings and report from the inspection of ‘well led’ for the Portsmouth Hospital NHS Trust please refer to our website.

We inspected and rated urgent and emergency care and medical care. Urgent and emergency care has been rated as requires improvement overall, and medical care has been rated as inadequate overall.

Our key findings were as follows:

Urgent and emergency care:

  • The hospital was not performing well against the national four hour A&E standard, with 67-71% of all patients in the ED being seen within four hours.

  • Twelve hour Decision to Admit (DTA) trolley breaches had risen rapidly with 226 recorded between January and March 2017.

  • Not all incidents were reported within urgent and emergency care were graded correctly, or investigated thoroughly. Which meant opportunities to learn from incidents were missed.

  • The service did not consistently adhere to duty of candour legislation and ensure patients and their families were given open communication when incidents occurred.

  • Risk assessments had not been completed or updated for patients who had been in the department for more than 12 hours.

  • Patients with mental health conditions were only assessed for their risk of deliberate self-harm which meant other risks may not be identified.

  • Staff knowledge of mental health conditions and the Mental Health Act (MHA) 1983, was not sufficient to be able to safely care for patients in mental health crises.

  • Staff did not observe patients with a mental health problem often enough, meaning patients had the opportunity to leave the department without challenge.

  • There were insufficient staff numbers in the Emergency Decision Unit (EDU) to care for patients who attended the department with a mental health problem. Staffing was not always adjusted according to acuity and demand at any given time.

  • Young people (as young as 15 years old) were admitted to the EDU with patients with mental health conditions without additional safeguards being applied.

  • We were not assured that the processes for safeguarding children were effective, or that the bruising protocol for actual or suspected bruising was being followed.

  • There were missed opportunities to improve the service. Whilst some improvements with regards to the effectiveness of the area had been noted there were many risks within the department which had not been addressed, or had worsened. The governance system was not addressing these concerns in the emergency department.

  • There had been some improvement initiatives in the ED such as the navigator nurse and pitstop and some good areas of practice noted.However, ED performance was showing a downward trend for some areas of performance.

  • Staff did not always complete daily checks on emergency equipment within the ED.

  • Some specialty consultants were resistive to the medical take model which meant there were delays in patients receiving specialist assessment and/or treatment in the ED.

Medical Care:

  • Overall, the quality of care on the medical wards in relation to emergency medical care was very poor.

  • Not all incidents were categorised correctly. The quality of investigations was poor, and lessons to be learned or care and service deliver problems were not always identified.

  • The trust did not consistently adhere to duty of candour legislation and ensure patients and their families were given open and honest communication when incidents occurred.

  • Medicines management policies were not always followed in the acute medical unit and medical wards to protect the safety and wellbeing of patients.

  • Patient confidential information was not stored securely and documentation was not always accurate or updated in a timely manner.

  • Staff did not always consistently follow infection control procedures on medical wards.

  • Consent to treatment was not always obtained in line with the Mental Capacity Act (2005).

  • Staff administered medicines covertly and we did not find evidence that appropriate plans of care were in place for patients who required chemical and physical restraint.

  • The inspection team had significant concerns about the safety and care of vulnerable people such as frail older persons or patients living with dementia.

  • Staff caring for patients living with dementia did not always carry out a dementia assessment or use the dementia pathway.

  • Staff did not always recognise or act appropriately in response to serious safeguarding concerns. Staff did not have sufficient knowledge of essential legislation and procedures in order to safeguard patients.

  • Staff we spoke with did not have knowledge of the trust’s pain assessment tool for patients who could not verbalise their pain.

  • There were gaps in the care documentation for the most vulnerable patients who were at high risk of pressure sores.

  • Patients, some of which were deemed at risk of malnutrition were not assisted with their meals.

  • The trust did not always declare mixed sex breaches as they occurred in line with current guidelines.

  • There were significant concerns regarding the flow of patients throughout the urgent medical pathway. The acute medical unit (AMU) had bed occupancy significantly higher than the England average and escalation areas were consistently in use. This affected waits for cardiac and renal day case procedures.

  • Patients were moved both during the day and night for non-clinical reasons to aid bed availability.

  • Some staff were frustrated and demoralised. Levels of staff sickness and staff turnover on AMU were above the England average and showing an upward trend.

  • Staff did not feel listened to or connected to senior management. Allegations of bullying and harassment had been made directly to CQC and not all staff were aware of the process to raise concerns within the trust.

  • Department risk registers did not always reflect the current risks or demonstrate risks were effectively reviewed or managed.

  • Although some strategies were in place to improve the acute medical pathway, there was no evidence to show these had been embedded or had a significant impact on patients’ care. . We could not evidence any significant or sustained improvements in medical care since our previous inspections.

  • There were shortages of junior medical staff and consultants on AMU. Nursing shifts were not always filled which meant unwell or vulnerable patients did not receive the appropriate level of care and supervision. Staffing was not always adjusted according to acuity and demand at any given time.

We found the following areas of good practice:

  • Patients and their relatives told us they generally felt they were well cared for while in the ED.

  • Patients were given hot food and drinks if their transfer from the ED was delayed.

  • Patients arriving at the ED were seen and assessed quickly by a senior doctor or nurse.

  • Staff in the ED followed infection control procedures to reduce the risks cross-contamination.

  • ED staff felt more connected with senior managers than on previous inspections and were engaged with initiatives to drive improvements.

  • Staff in the ED treated patients and their relatives with dignity, respect and compassion.

  • TARN data showed better than national average outcomes for patients with severe or life threatening injuries.

  • Between November 2016 and March 2017 93% of patients said they would recommend the A&E service to family and friends, higher than the national average of 87%
  • The introduction of pitstop provided a rapid assessment and treatment to patients who attend the Emergency Department.

  • The trust had an identified pathway for patients living with dementia that included assessment, liaising with the older persons’ mental health team and discharge planning

For the areas of poor practice the trust needs to make the following improvements.

Importantly, the trust must:

  • Staff working with patients must have sufficient knowledge and skills to care for patients presenting with mental health condition.

  • Staff within the emergency and medical areas must have sufficient knowledge of the Mental Health Act (MHA), 1983, so they understand their responsibilities under the Act.

  • Ensure that all clinical staff have knowledge of the Mental Capacity Act and Deprivation of Liberty Safeguards, and implement them effectively.

  • Systems must be in place to ensure that the risks of detained patients, including the risk of absconding, are fully assessed and mitigated where possible.

  • Review the processes for the safeguarding of vulnerable adults and children to ensure that safeguarding processes work effectively across all services.

  • Safeguards must be put in place when children or young people are admitted into adult environments such as the EDU to ensure they are sufficiently safeguarded from avoidable harm.

  • Ensure the Local Safeguarding Children Board protocol for the management of actual or suspected bruising must be followed in all situations where an actual or suspected bruise is noted in an infant that is not independently mobile.

  • Staff mandatory training should be above the hospital’s own target of 85%.

  • Patients should not be transferred from ambulance trolleys in the corridor outside pit stop.Staff should move the patient to a more discreet area before attempting transfer, unless urgent transfer is required due to the patient’s clinical condition.

  • Patients waiting in the corridor for a space to become available in the ‘pit stop’ area should be either observed by staff at all times or have means of summonsing immediate help if required.

  • Staffing numbers and skill mix of staff working in all areas must reflect patient numbers and acuity which should be adjusted according to variations in need.

  • Staff in the medical services must follow the trust’s medicines management policy to ensure that medicines and prescribed, stored and administered appropriately.

  • Patients in the ED must be seen by a senior medical doctor in a timely way following referral to medical services.

  • The acute medical model must be immediately reviewed to ensure that patients are seen by a treating physician and treated at the earliest opportunity.

  • Equipment must be checked as per individual ward protocols to ensure it is safe and ready for use.

  • Risk assessments must be completed to assess the range of risks to patients being cared for in escalation areas. These must take account of environmental factors such restricted access to curtains, call bells and oxygen. These risks must be mitigated where possible.

  • Improve quality of incident grading and classification to ensure that they are escalated and investigated appropriately.

  • Improve the undertaking of duty of candour and being open following incidents.

  • Improve flow through the hospital to prevent patients being cared for in the ED for longer than necessary.

  • Patients must not wait on trolleys for more than 12 hour periods in line with national standards.

  • The hospital must declare mixed sex breaches as they occur in line with Department of Health guidance.

  • Improve processes to enable staff to safely speak up about concerns. All staff must know how to raise issues regarding bullying and harassment.

  • Protect patient’s confidentiality through safe storage of records.

In addition the trust SHOULD ensure:

  • Conversations between the navigator nurses should be held in a private area to preserve the patient’s dignity and respect.

Following the inspections of the Queen Alexandra Hospital in February and May 2017 we took immediate action to ensure the safety of patients. We have taken this urgent action as we believe a person will or may be exposed to the risk of harm if we did not do so. Details of this action are included at the end of the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 29 and 30 September 2016

During an inspection to make sure that the improvements required had been made

Queen Alexandra Hospital is the acute district general hospital of the Portsmouth Hospitals NHS Trust. It is the amalgamation of three previous district general hospitals, re-commissioned into a Private Finance Initiative (PFI) in 2009. The hospital currently has 1,053 inpatient beds, and has over 140,000 emergency attendances each year.

Prior to this inspection, we had undertaken an unannounced and focussed   inspection at the Queen Alexandra Hospital on 22 and 23 February and 3 and 4 March 2016. We inspected the Emergency Department (ED) and Medicine, specifically the urgent medical pathway. At that time we found some patients in the emergency department (ED) were at risk of unsafe care and treatment and there were areas of poor practice where the trust needed to make improvements.

We considered that people who used the emergency services at Queen Alexandra Hospital would, or may be, exposed to the risk of harm if we did not impose urgent conditions for the Trust to provide a safe service to patients. On 15 March 2016, we took urgent action and issued a notice of decision to impose conditions on their registration as a service provider.

We told the trust to take immediate action, under section 31 of the Health and Social Care Act (2008), and imposed four conditions on their registration. We told the trust to immediately ensure;

  • A clinical transformation lead had been appointed based on external advice and agreement, and ensure effective medical and nursing leadership in the emergency department.

  • Patients attending the Emergency Department at Queen Alexandra Hospital were triaged, assessed and streamlined by appropriate staff, and escalation procedures are followed.

  • The “Jumbulance” was not used on site at the Queen Alexandra Hospital, under any circumstances.The exception to this will be if a major incident is declared.

  • CQC received regular monitoring information from the trust.

At that time, we rated urgent and emergency services as inadequate and medical care as requires improvement.

On 29 and 30 September 2016 we undertook an unannounced focussed inspection of the emergency care pathway at the Queen Alexandra Hospital. The focus of our unannounced inspection was on the actions the trust had taken as a result of the urgent conditions imposed on them to improve the identified risks to patients through their emergency care pathway. We inspected two core services urgent and emergency care and medical services.

We rated Queen Alexandra Hospital as ‘requires improvement’ for both urgent and emergency services and medical care.

Our key findings were as follows:

  • Significant improvements had been made within the emergency department since our last inspection in February 2016,

  • A senior medical transformation lead had been appointed and was working with the trust to make necessary changes.

  • The vehicle known as the Jumbulance (a large multi patient use ambulance) vehicle had been removed

  • The department had submitted performance monitoring data to CQC and had started to use this in its own improvement reporting.

  • Incident reporting and figures about delays in treatment were now more accurately reflected emergency department activity.

  • There were effective clinical governance arrangements and reporting to the trust board.

  • National clinical audits showed that patient outcomes were better than many other hospitals within the Emergency Department.

  • Staff in the emergency department treated patients and their relatives with dignity, respect and compassion.

  • There was a proactive frailty intervention team, which worked with emergency department staff to coordinate care.

  • There had been improvements since our last inspection; however patients were still spending too long in the emergency department. There were occasions when patients had to wait outside in ambulances, although these were rare and for shorter periods of time than previously. During our last inspection we observed patients waiting for more than two hours before ED staff carried out a clinical assessment. Since then waiting times, monitored on a weekly basis, have seen a gradual improvement in recent months.Trust monitoring data demonstrated that no patients had waited for two hours or more for a clinical assessment since May 2016. By September 2016 90% of ambulance patients were assessed within 15 minutes.

  • There had been increased staff engagement via lunchtime drop-in sessions and multi-disciplinary staff engagement meetings. This had helped to reduce the culture of “learned helplessness” that we had found during the previous inspection. Staff were able to be more pro-active in effecting positive changes in patient care.

  • Ambulance patients were sometimes left in a corridor with no-one observing them and with no means of calling for help.

  • There were delays, caused by a lack of empty beds on wards, which sometimes resulted in a crowded department.

  • Emergency department staff expressed doubts regarding the sustainability of recent improvements. They felt that it was too early to say whether the latest changes would become embedded throughout the hospital.

  • The culture of the consultant body and the hospital did not support effective change with the urgent medical pathway Strategies designed to improve the urgent medical pathway were not yet fully embedded and meeting their planned expectations.. Lack of medical staff allocated to escalation areas and the winter pressures ward, had a detrimental effect on patient flow through the hospital.

  • Leadership on AMU was medically driven, with minimal input from the nursing team. Staff in some wards and clinical areas felt the senior management team was disengaged from them, their views were not listening to and they felt they were just left to “get on with things.” Staff felt demoralised by continued lack of improvements in the urgent care pathway. However, we did see there was good local leadership in some clinical areas.

  • Governance processes throughout the medical pathway were not effective at identifying risks and improving safety and quality of services provided.

  • Systems, processes and standard operating procedures were not always reliable, consistent or appropriate to keep people safe. In AMU, and on the medical wards, infection control procedures were not consistently followed. Medicines management in AMU and on the wards did not always follow the trust procedures and did not protect the wellbeing of patients. On AMU confidentiality of patient records was not always maintained and some patient records across all areas were difficult to read.

  • Care and treatment was inconsistent within the AMU. Some patients did not receive care based on assessment of risk or plans were not developed to support identified risks. Patients and their representatives were not routinely involved in planning and decision making processes about their care and treatment. We witnessed some care practices that showed empathetic and compassionate care was not always provided to patients.

  • Most patients had assessments for pain throughout their hospital stay, but staff did not consistently monitor the effectiveness of pain relief. In AMU patients did not always receive the support they needed at meal times because assessments had failed to identify the support they needed.

  • The trust was failing to meet its target for completion annual appraisals and mandatory training targets were not consistently met for staff working in the emergency clinical services centre and medicine clinical services centre.. When some escalation areas were open, staff felt they did not always have the necessary skills to care for some patients.

  • We noted breaches of mixed sex accommodation on day units where medical outliers were. The trust had not considered these as mixed sex breaches.

  • Patients were frequently moved which affected the timeliness of discharge. Some patients had multiple bed moves and were moved at night. Data showed there had been no improvements in the frequency of patient bed moves since the last inspection. However, systems were in place, which ensured medical outliers were tracked and reviewed on a daily basis.

  • Patients did not have access to timely discharge from hospital. The number of patients experiencing a delayed discharge had increased since the last inspection. Consultants and senior managers did not demonstrate any drive or innovation to promote the access and flow of patients through the hospital. Strategies designed to improve the urgent medical pathway were not yet fully embedded and meeting their planned expectations. The lack of medical staff allocated to escalation areas and the winter pressures ward, was having a detrimental effect on patient flow through the hospital because patients experienced delays in medical assessments.

We considered that the trust had made significant improvements to reduce the risk of harm to patients in the emergency department. On 13 October 2016 we issued a notice of proposal to remove the conditions imposed on their registration as a service provider made on 15 March 2016.

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

During our inspection of the medical service we identified failings to comply with some requirements of the Health and Social Care Act 2008 and its associated regulations. These were:

  • Regulation 10(1) (2) (a) Dignity and respect, Health and Social Care Act 2008 (Regulated  Activities) Regulations 2014. During our inspection we saw and identified practices that did not ensure that patient’s privacy and dignity was always protected.

  • Regulation 12(1) (2) (a)(b)(e)(g)(h)(I) Safe care and treatment, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We observed and found that patients were not always prevented from receiving unsafe care and treatment or prevented from avoidable harm or risk of harm.
  • Regulation 17 (2) (a)(c) Good Governance, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.During our inspection of the AMU we observed and found that the trust did not have effective assessing or monitoring systems to improve the safety or quality of the services provided. Providers must continually evaluate and seek to improve their governance and auditing practice. In addition we observed and found patient records were not consistently legible, timed dated or had the designation of the member of staff.

We asked the trust to address the failings we identified during our inspection and issued them with a Requirement Notice letter issued under Regulation 17 (3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. As part of the notice the trust were required to send us an action plan which detailed how the trust planned to address the failings and improve the standard of services provided to patients. We received the Action plan from the trust within 28 days as requested.

Importantly, the trust must ensure:

  • All incidents and near misses are reported using the trust’s incident reporting processes, and all staff receive feedback from reported incidents.

  •    All staff follow the trust’s infection prevention and control procedures.
  • Staff follow the trust’s medicines’ management procedures.

  • All equipment is maintained and is ready and safe to use.

  • All emergency equipment is checked, following trust procedures, to ensure all equipment is present, in date and in working order.

  • Patient details and information are not accessible to unauthorised personnel.

  • All patients have an individualised care plan to enable staff to provide the appropriate care and treatment.

  • There is adequate medical cover at all times, including cover in escalation areas and the winter pressures ward.

  • Completion of patient documents follows national guidelines, including accurate completion of food and fluid charts.

  • Patients receive the assistance they need at meal times to reduce risks of malnutrition.

  • Appraisals and supervision meets the trust’s targets.

  • Staffing at weekends does not have a detrimental effect on patients flow through the hospital and discharge planning.

  • Staff are aware of their responsibilities towards the Mental Capacity Act 2005.

  • Planning and delivery of care is in accordance with the Mental Capacity Act 2005.

  • Needs of patients living with dementia are met.

  • Mixed sex accommodation breaches are identified and reported and take action to reduce their occurrence

  • Patients and their representatives are involved in planning and making decisions about their care and treatment.

In addition the trust should ensure:

  • Mortality and morbidity meetings include learning from reviews of care and treatment.

  • Safety thermometer information is displayed in all clinical areas.

  • Planned and actual staffing levels are displayed in all clinical areas.

  • Serious incidents are investigated in a detailed and comprehensive manner.

  • There is sufficient flow of patients through the emergency department so that patients do not have to wait outside in ambulances.

  • Ligature risk assessments are undertaken in all rooms that may be used by people with mental health problems

  • Length of stay on AMU meets the trust target of less than 24 hours.

  • Length of stay on the short stay ward meets the trust target of less than 72 hours

  • The urgent medical care pathway is fully established and embedded into the management of the hospital.

  • There is an action plan for, and a demonstrable reduction in patients being moved overnight.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 22 and 23 February 2016, and 3 and 4 March 2016.

During an inspection to make sure that the improvements required had been made

Queen Alexandra Hospital is the acute district general hospital of the Portsmouth Hospitals NHS Trust. It is the amalgamation of three previous district general hospitals, re-commissioned into a Private Finance Initiative (PFI) in 2009. The hospital has approximately 1,250 inpatient beds, and has over 137,000 emergency attendances each year.

We undertook a comprehensive inspection of Portsmouth Hospital NHS Trust last year, in February and March 2015. At that time we found some patients in the emergency department (ED) were at risk of unsafe care and treatment. We rated the safety of urgent and emergency care services as ‘inadequate'. We served two warning notices on 4 March 2015, under safety for “care and welfare of patients” and “assessing and monitoring the quality of service provision” in the emergency department. These required the trust to make immediate action to improve the initial assessment of patients, the safe delivery of care and treatment, and the management of emergency care in the ED. A subsequent re-inspection of the emergency department in April 2015 saw improvements, and the service was then rated overall as ‘requires improvement’.

Prior to this inspection, we had received information of concern about the trust’s performance with its emergency pathway from the trust, NHS England, the Trust Development Authority and the Emergency Care Improvement Programme (ECIP). There had been two risk summits held on 14 December 2015 and 28 January 2016, which had identified the following significant areas of risk.

  • The trust performance against the four hour national emergency access target was one of the lowest in the county (in January 2016 it was 68.8%; national average was 83%).
  • The emergency department (ED) was overcrowded and patients were not being assessed and treated in a timely way. Significant areas of risk identified delays in initial 15 minute assessments and patients for Medical Assessment Unit (MAU) were being held in a queue instead of immediate access
  • Escalation procedures had not been appropriately followed and sometimes the trust had reacted too late to pressures.
  • A ‘Jumbulance’ was being used to assess and treat patients because of ongoing over-capacity in the ED.

  • Medical teams did not have general medical beds for admission. Whilst there is a named physician within AMU, it was not always clear who was the admitting consultant  responsible for the patient

  • The hospital reported between 90 to 150 medically fit patients awaiting discharge. This number reduced to 50 patients when delays over 24 hours were removed. Some were simple discharge delays and some were delayed transfer of care.
  • The trust’s failure to manage emergency admissions was impacting on partners. South Central Ambulance Service had queuing ambulances. Their reduced fleet had meant they were not meeting response times. There had been two serious incidents where response times for life threatening conditions had not been met, this included a road traffic accident on the M27 where a tent had to be erected whilst waiting for an ambulance.
  • Solent NHS Trust was using escalation beds and community, GP and local authority teams have said that some patients were being discharged inappropriately.
  • Southampton General Hospital had to take patients diverted from Portsmouth when the hospital itself was under pressure with emergency admissions.
  • The trust had experience an increased number of emergency attendances in 2015/16 (month 10) when compared to the previous year (2014/15). There had been an increase of 4.6% attendances which equated to an extra 11 patients per day. This was higher than the national average at 1% increase. Overall, when GP heralded and urgent care centre patients were included the increase was 7.3% which equated to an extra 20 patients per day. This presented significant pressure on the ED. However, the trust had yet to ensure appropriate use of the Urgent Care Centre. GP heralded patients went direct to ED rather than directly to MAU and this was added to the overcrowding in the emergency department.
  • The conversion rate of patient attendance to admission was 35.5%. Delayed transfers of care were at 1.9% which was significantly lower than national levels (2.5%). Comparatively, the trust was admitting more patients for assessment, although the case mix of patients needed further review. There was however, a delay in introducing admission avoidance models of care and in ensuring coordinated hospital action to improve patient flow.

Following the first risk summit, the trust was given a number of actions. These were reiterated at the second risk summit due to a lack of initial progress, to: introduce Safer Start, a system to accelerate discharge, develop a short stay patient model of care, ensure that expected GP patients went directly to the medical assessment unit, change the medical model for emergency admissions, introduce a frailty interface team, focus on reducing the variation with simple discharge and complex discharges and introduce ‘discharge to assess’. The trust was also required to work with the Emergency Care improvement Programme (ECIP) and ensure their recommendations were implemented

On 22 and 23 February 

and 

3 and 4 

March, 2016, we undertook an unannounced and focused inspections of the emergency care pathway at Queen Alexandra Hospital. The focus of our unannounced inspection was on the actions taken by the trust in response to the identified risks to patients through their emergency care pathway. We inspected two core services: urgent and emergency care and medical services.

We reviewed the service based on our five key questions: is the service safe, effective, caring, responsive and well-led?

Our key findings were as follows:

  • The trust was failing to ensure emergency patients received safe care and treatment and the emergency service was struggling to respond to the needs of patients. The trust leadership had failed to make significant, urgent and necessary changes to improve the flow of emergency patients through the hospital. The risks to patients was unacceptable; the pressure and environment under which staff were working was unacceptable.

  • Patients were not being triaged, assessed and treated within the emergency department in a timely manner. The 15 minute standard to assess patients was not being met. During the inspection time period, we observed only some patients, including patients with serious conditions, being assessed with 15 minute.  Trust data was in averages but additional data available from the Trust covering the four days of the inspection demonstrated that only 65% of ambulance patients were assessed within 15 minutes and approximately 87% were assessed within 30 minutes. For patients with a serious condition, such as sepsis, chest pain or fractured neck of femur, trust data demonstrated that only 57% were triaged with 15 minutes (11% waited over 30 minutes).  35% were treated within 1 and 34% waited over two hours for treatment.
  • Due to poor flow through the department, there were often several ambulances queuing outside the department. On 22 February there had been 16 vehicles queuing at 19:00. On 23 February, there had been 16 ambulances queuing outside of the trust by 16:00 and overnight. The Jumbulance was re-opened and was being used to manage the ambulance waits.

  • On 22 February, South Central Ambulance Service (SCAS) recorded there was a total of 93 hours of excess handover time, and a further 84 hours the following day. The average handover time across those two days was 61.5 minutes. The 16 ambulances represented one third of the South East Hampshire ambulance fleet were being held at Queen Alexandra Hospital. The ambulance stacking had meant there have been capacity issues for the ambulance service, that have had to hold eleven 999 emergency calls due to no emergency ambulances being available locally for dispatch.

  • There was a significant risk of harm to patients being held, assessed or treated outside the ED, within an ambulance or “Jumbulance”. There was no single accountable lead for the decision about which patients should be brought into the department, when there were ambulances held. There was not always a senior decision maker evident. The decision making process was often arbitrary between nurses and ambulance staff. Although there was a process, as agreed by ECIP for the triage of patients.  However, as the department became overcrowded we observed that clinical staff did not adopt a standard process to triage and we observed the process to be “chaotic”. Some patients had two clinical staff go to assess them – a consultant and a nurse from the majors areas - and some patients had none.

  • We identified patients with serious conditions, such as chest pain, suspected sepsis, fractured neck of femur, and stroke that had not been triaged, assessed and treated in a timely manner. For example, patients with suspected sepsis patients were not always seen or treated within an hour of presentation. Patients with suspected stroke symptoms were not always triaged quickly enough to allow for timely administration of thrombolysis.

  • Patients with non-life threatening conditions were waiting long periods of time in an ambulance. Many of these were vulnerable patients. Elderly frail patients were waiting in ambulances for over two hours. One patient with a learning disability had waited in an ambulance for over 2.5 hours. Whilst there is no formal policy describing the accountability arrangements for patients whilst in the back of an ambulance on site, at all times a trained paramedic is with the patient; However, the responsibility to notify Trust staff of any patient deterioration was not clear. There was not a consistent mechanism for ensuring that any deterioration would be detected by staff. During the wait in the vehicle, observations were not consistently recorded. Sometimes, the first observations recorded in the triage process had been recorded by the ambulance staff and were not up to date information.

  • There was regular, significant and substantial overcrowding in the emergency department. Patients were waiting on trolleys in the corridors. On 22 and 23 February, the corridor outside the ambulance handover area was being used for up to nine patients. There were instances where initial assessments and minor procedures (such as venesection) occurred in the corridor.

  • On 22 and 23 February, the patients in the corridor were being observed and monitored by one nurse. The nurse was also allocated to assess the incoming ambulance patients. She did not have capacity to look after the patients in the corridor queue and in ambulances. The assessment and ongoing care and treatment of patients in the corridor was inconsistent. The privacy and dignity of the patients waiting in the corridor was could not be guaranteed. There were frequent and lengthy period where patients were not being observed by a healthcare professional in the corridor. One agency paramedic was observed in the department at approximately 16.00 on the 23 February. Agency paramedic staff had not been observed in the department from between 8am and 4pm that day when the department had been equally as busy.
  • Mental health patients remain in the department in an unsuitable environment for excessive amount of time, for example, one patient waited 23 hours in the majors area.
  • On 4 and 5 March the corridor was again being use for up to nine patients by one nurse. There patients in the corridor who were not being observed or monitored and patients waiting in ambulances who had not been assessed after one to two hours. One agency ambulance healthcare support worker and one agency healthcare technician arrived to support at 12.25am on the 5 March. These agency staff had not been observed beforehand. After patients were assessed patients were waiting a long time for treatment. For example, a patient who required oxygen had not been given this for several hours. A diabetic patient with acute kidney injury had a referral letter handed to the receptionist. The letter was scanned on to the computer system by the receptionist and the triage from was ticked to indicate documentation was received from the GP. The patient had not received immediate treatment and we asked the nurse about the patient. The nurse told us that she was not aware of the contents of the letter. The nurse had not looked at the computer system and the letter had not been given to the nurse until three hours after their triage assessment.
  • Patients waiting in ambulances and those queuing in the corridor did not always receive compassionate care. For example, there was no means for patients to call for help and staff were not always able to check on the wellbeing of patients. We observed many patients who were confused and in distress.

  • We found that escalation process were not consistently followed. Staff did not respond appropriately to peaks and surges in demand. There was no evidence that patients were being effectively streamed through the department or that beds were being used flexibly, for example, in ‘majors’, to respond to the care and treatment needs for patients. The standard operating procedure for Full Capacity in the Emergency Department (November 2015) or the Management of Majors during Full Capacity (draft 22 February 2016)’ was not being used to allow flexibility in the way beds and cubicles were used in the emergency department. In February and March, we often observed empty beds in majors and the observation wards when patient had been in an ambulance, in corridors, and in areas without curtains.

  • The capacity and flow issues meant that simple processes became very inefficient. For example, blood samples and ECGs test results went missing and were being repeated, this presented delays to patient treatment. There were multiple moves of patients around the department and through the Medical Assessment Unit (MAU), resulting in multiple handovers of care.

  • The handover of patients was not sufficiently detailed and there were important and clinically significant details missed. Handover information within the ED and between ED and MAU was either absent or too brief. For example, we observed risk assessments about patient’s condition or a patient risk of absconding, was not provided. Patients were not being effectively streamed through the emergency department. We identified that staff had “lost” patients within the system. For example, on three occasions, on 23 February staff were unable to say where their patient was in the emergency department, or what treatment they required next.

  • During our inspection, CQC staff had to intervene to keep patients safe on several occasions, including asking staff to assess patients in the ambulance and the corridor, and to prevent a patient from leaving the department when there was not a member of staff present.

  • Patients received inconsistent care and treatment on the MAU. Some patients had risks assessments of their needs but their plans for care were either absent or were not being followed. For example the Sepsis pathway was not followed for one patient. No written care plans for six patients with indwelling urinary catheters were identified, however it is noted that this was recorded on the electronic Vitalpac system. Two patients had grade 2 pressure ulcers without care plans or body maps and for one patient the nursing staff did not know the appropriate dressing to use. The early warning score was not consistently being used to responded to and escalate patients appropriately. Nursing staff were sometimes not competent to care for patients.  We observed poor care for a patient with cognitive impairment. We raised our concerns with the senior nurse in charge. Infection control practices were not being followed and there was not always appropriate availability of equipment, for example, cardiac monitors.

  • Patient flow was not being managed effectively. There were multiple Patient Flow Nurses from different clinical service centres. The nurses were not communicating effectively with each other to enable effective patient flow through the MAU and the wards. We observed three bed meetings. There was not a collective or cohesive process to identify capacity across the hospital. There was no challenge on individual bed states in the clinical service centres despite evidence of protecting their own bed states, for example, not declaring beds or discharges. Patients had multiple bed moves and were being moved overnight. Vulnerable people (people assessed as not being suitable to move) were being moved. Discharge was being delayed by the poor flow through MAU. Patients suitable for discharge were not routinely identified or plans put in place to move them to other areas to improve flow during the day. The discharge lounge moved on a regular basis, and had varying capacity. There was currently no capacity to take patients in beds, and therefore patients had to wait on wards if they required a bed. This was further congesting an already busy hospital and reducing patient flow options.

  • The staff we spoke with described an executive leadership team who demonstrated a “hands on” rather than strategic mechanism of support. They were involved and physically helped in the department at periods of high pressure. These good intentions were acknowledged by almost all staff. However, these interventions were identified as having little impact. That is, they had been a response to crises rather than the intended leadership to improve the situation. Staff did not feel empowered to make decisions and make changes in their own department.

  • Some of the executive team were identified as barriers to the leadership of effective change.

  • Senior medical leadership in the emergency department had tried unsuccessfully for a considerable length of time to engage productively with some members of the executive team to produce effective and necessary change. Staff described a culture of “learned helplessness” within the organisation and the level of increased risk had become normalised within the trust. Staff had now accepted a standard of care that was unacceptable.

  • Staff we spoke with identified “change fatigue” based on the trust introducing many “solutions” to the ongoing problem. There had been many changes to the emergency pathway which were not followed through. Staff described an environment lacking in grip and pace. When the emergency department became extremely busy or under considerable internal and external pressure, the hospital improvement plan was not always followed. Interim “quick fixes” were put in place but discarded after insufficient time to assess their ongoing efficacy. Staff further described a level of “solution inertia” where the imposition of the short term “quick fixes” had resulted in weary staff who could not see a way forward. It was now accepted, for example, that the 4 hour emergency access target was unachievable.

  • The trust improvement plan was not being adhered to. A short stay medical model should have been implemented by the week beginning 29 February. However, staff told us this had not been properly costed and would not now start until April. GP heralded patients were meant to be admitted straight to MAU for assessment and treatment on 15 February. This had changed to 2 March 2016. When we inspected, this service change was not in operation on the evening and night of 4 and 5 March. We had observed on the evening of 3 March that the process had been in place and had worked well. However, when pressure had increased in the department, this practice had been discarded and many staff did not know about the decision. We had not seen any senior leaders supporting the change.

  • Data was not being recorded appropriately. Staff told us they were not reporting incidents that had occurred or near misses because of the clinical workload. The number of incidents recorded was low compared to the incidents identified on inspection and identified by staff we spoke with. Figures provided by the trust were being based on averages and did not effectively represent the proportion, or the extremes of patients, having long waiting times for assessment and treatment. Staff were recording information in a way that could not be validated. We observed many patients waiting on a trolley in the ED for over 12 hours and up to 18 hours. We observed that the decision to admit time was recorded in electronic patient record. A 12 hour trolley breach is recorded from the decision to admit for non-clinical reasons. . Assessment and treatment were being delayed and the decision to admit was being delayed based on the medical specialty agreeing to admit the patient. We did not receive assurance that this breach was being measured according to guidance. The trust had only recorded seven 12 hour trolley breaches over 2 December 2015 to 23 February 2016. The time in ED was not being measured in terms of the impact on patients. There were only five vulnerable patients (red patients) recorded as having patient bed moves including overnight from 1 September 2015 to 3 March. However, staff consistently told us there was pressure to move patients and vulnerable patients were being moved.

  • We observed an inconsistency of care on the medical assessment unit (MAU). On yellow unit, risks were appropriately recorded on patient care plans and care and treatment was appropriate and timely. However, on the Orange and Lilac units, some patients did not have risks appropriately recorded and observations were not done in a timely way. This was despite some patients having a high risk (for example, at risk of Sepsis) condition.

  • Infection control procedures and practices were not consistently adhered to throughout the MAU.

  • The safe storage of medicines was inconsistent in MAU.

  • Patients were not always cared for in single sex facilities in the escalation areas.

  • There were a high number of patients’ moves because of capacity issues.

  • Discharge of medical and frail elderly patients from hospital was inconsistent and did not always happen in a timely way.

  • There were delays in the development of strategies designed to improve the urgent medical pathway.

There were areas of poor practice where the trust needs to make improvements.

We considered that people who used the emergency services at Queen Alexandra Hospital would, or may be, exposed to the risk of harm if we did not impose urgent conditions for the Trust to provide a safe service to patients. On 15 March 2016, we took urgent action and issued a notice of decision to impose conditions on their registration as a service provider.

We asked the trust to take immediate action, under section 31 of the Health and Social Care Act (2008), and imposed four conditions on their registration. We told the trust to immediately ensure:

  • A clinical transformation lead is appointed based on external advice and agreement, and ensure effective medical and nursing leadership in the emergency department.
  • Patients attending the Emergency Department at Queen Alexandra Hospital are triaged, assessed and streamlined by appropriate staff ,and escalation procedures are followed.
  • The “Jumbulance” is not used on site at the Queen Alexandra Hospital, under any circumstances. The exception to this will be if a major incident is declared.
  • CQC receive daily monitoring information that is to be provided on a weekly basis

The trust must also ensure:

  • Patients waiting in the corridor, or in ambulance vehicles, must be adequately observed and monitored by appropriately trained staff.

  • The hospital must accept full clinical responsibility for patients waiting on the ambulance apron.
  • The safe storage of medicines in the MAU.
  • Patients are cared for in single sex facilities in the escalation areas.
  • Patient notes are stored securely across the hospital to prevent unauthorised access.
  • All patients in MAU have care based on plans developed to support identified risks.
  • Patients receive timely discharge from hospital.
  • Plans to change the urgent medical pathway are implemented in a timely manner.
  • Staff in the MAU adhere to infection control policies and procedures.
  • There is better and more accurate monitoring information to reflect patient safety and the quality of care.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 25 April 2015

During an inspection to make sure that the improvements required had been made

Queen Alexandra Hospital is the acute district general hospital of the Portsmouth Hospitals NHS Trust. It is the amalgamation of three previous district general hospitals, re-commissioned into a Private Finance Initiative (PFI) in 2009. The hospital has approximately 1,255 inpatient beds, and has over 137,000 emergency attendances.

We undertook a comprehensive inspection of Portsmouth Hospital NHS Trust in February and March 2015. At this time we found patients who arrived by ambulance at the emergency department (ED) were at risk of unsafe care and treatment. We served two warning notices under safety for “care and welfare of patients” and “assessing and monitoring the quality of service provision” in the emergency department. These required the trust to make immediate action to improve the initial assessment of patients, the safe delivery of care and treatment, and the management of emergency care in the ED. We rated the safety urgent and emergency care services as ‘inadequate’

We undertook this unannounced focused inspection of Portsmouth Hospital NHS Trust to follow up on the warning notices served.

The inspection took place on 25 April 2015. The inspection team of four included a CQC inspector, and specialist advisors who were, an executive director from an acute hospital trust with an ED background, a consultant in emergency medicine, and a nurse consultant in paediatric emergency medicine

Overall, we rated safety in the urgent and emergency care services as ‘requires improvement’. This was an improvement from the previous rating of ‘inadequate’.

Our key findings were as follows:

  • In February 2015, patients who arrived by ambulance at the emergency department (ED) were at risk of unsafe care and treatment. We served two warning notices to the trust requiring immediate improvement to be made to the initial assessment of patients, the safe delivery of care and treatment, and the management of emergency care in the ED.
  • During this inspection we found that the trust had made improvements but that there were still areas where safety needed to be improved further.

  • We observed patients who arrived by ambulance were now being clinically assessed within 15 minutes by a trained nurse and their condition was monitored. Trust data confirmed that the majority of patients (94%) were now being assessed within 15 minutes.
  • The ambulance streaming area was still being used for four patients when it was designed for two. This meant that there was not enough essential equipment such as medical suction and two patients had no means of calling for help. There had not been a formal risk assessment of this area.
  • The trust had introduced a new system for the referral and admission of medical patients. The decision to admit would now be done by the on call medical team instead of the ED consultants. This had improved access to a specialist doctor and fewer patients now waited for long periods in the ED for admission. However, there were still delays in patients waiting to see on call medical teams even at times when beds were available in the hospital. These delays in admissions meant that the department was often full and posed a risk to patients. Ambulance patients continued to wait in a corridor, some for over an hour.
  • A nurse was now allocated to the corridor areas in the ED. The nurse was organising activity to avoid the disorder that we observed during the previous inspection. We did not, for example, observe any collisions between patient trolleys that had happened previously.
  • Medical and nurse staffing levels had improved to take account of the increase in the number of patients, and the need for skilled and experienced staff to be present in the department overnight. Patients in corridors were being observed and monitored; however, this did not happen appropriately when staff were on breaks. The appropriateness of nurse staffing levels had not been assessed for the ambulance streaming area.
  • There had not been any serious incidents requiring investigation (SIRIs) related to queuing or capacity issues in the department since our inspection in February 2015.

Importantly, the trust must ensure :

  • Patients are appropriately monitored at all times by sufficient numbers of staff in the ED to ensure they receive appropriate care and treatment.
  • Patients in the ambulance streaming area have access to sufficient essential equipment and have a means of calling for help when necessary.
  • There is a risk assessment of the ambulance streaming area.
  • The new referral and admission process works effectively for the timely assessment and admission of patients and to prevent overcrowding in the ED.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 10–13 February 2015 Unannounced visits 25, 26 February and 2 March 2015

During a routine inspection

Queen Alexandra Hospital is the acute district general hospital of the Portsmouth Hospitals NHS Trust. It is the amalgamation of three previous district general hospitals, re-commissioned into a Private Finance Initiative (PFI) in 2009. The hospital has approximately 1,250 inpatient beds, and has over 137,000 emergency attendances each year.

We undertook a comprehensive inspection of Portsmouth Hospital NHS Trust last year, in February and March 2015. At that time we found some patients in the emergency department (ED) were at risk of unsafe care and treatment. We rated the safety of urgent and emergency care services as ‘inadequate'. We served two warning notices on 4 March 2015, under safety for “care and welfare of patients” and “assessing and monitoring the quality of service provision” in the emergency department. These required the trust to make immediate action to improve the initial assessment of patients, the safe delivery of care and treatment, and the management of emergency care in the ED. A subsequent re-inspection of the emergency department in April 2015 saw improvements, and the service was then rated overall as ‘requires improvement’.

Prior to this inspection, we had received information of concern about the trust’s performance with its emergency pathway from the trust, NHS England, the Trust Development Authority and the Emergency Care Improvement Programme (ECIP). There had been two risk summits held on 14 December 2015 and 28 January 2016, which had identified the following significant areas of risk.

  • The trust performance against the four hour national emergency access target was one of the lowest in the county (in January 2016 it was 68.8%; national average was 83%).
  • The emergency department (ED) was overcrowded and patients were not being assessed and treated in a timely way. Significant areas of risk identified delays in initial 15 minute assessments and patients for Medical Assessment Unit (MAU) were being held in a queue instead of immediate access
  • Escalation procedures had not been appropriately followed and sometimes the trust had reacted too late to pressures.
  • A ‘Jumbulance’ was being used to assess and treat patients because of ongoing over-capacity in the ED.

  • Medical teams did not have general medical beds for admission. Whilst there is a named physician within AMU, it was not always clear who was the admitting consultant  responsible for the patient

  • The hospital reported between 90 to 150 medically fit patients awaiting discharge. This number reduced to 50 patients when delays over 24 hours were removed. Some were simple discharge delays and some were delayed transfer of care.
  • The trust’s failure to manage emergency admissions was impacting on partners. South Central Ambulance Service had queuing ambulances. Their reduced fleet had meant they were not meeting response times. There had been two serious incidents where response times for life threatening conditions had not been met, this included a road traffic accident on the M27 where a tent had to be erected whilst waiting for an ambulance.
  • Solent NHS Trust was using escalation beds and community, GP and local authority teams have said that some patients were being discharged inappropriately.
  • Southampton General Hospital had to take patients diverted from Portsmouth when the hospital itself was under pressure with emergency admissions.
  • The trust had experience an increased number of emergency attendances in 2015/16 (month 10) when compared to the previous year (2014/15). There had been an increase of 4.6% attendances which equated to an extra 11 patients per day. This was higher than the national average at 1% increase. Overall, when GP heralded and urgent care centre patients were included the increase was 7.3% which equated to an extra 20 patients per day. This presented significant pressure on the ED. However, the trust had yet to ensure appropriate use of the Urgent Care Centre. GP heralded patients went direct to ED rather than directly to MAU and this was added to the overcrowding in the emergency department.
  • The conversion rate of patient attendance to admission was 35.5%. Delayed transfers of care were at 1.9% which was significantly lower than national levels (2.5%). Comparatively, the trust was admitting more patients for assessment, although the case mix of patients needed further review. There was however, a delay in introducing admission avoidance models of care and in ensuring coordinated hospital action to improve patient flow.

Following the first risk summit, the trust was given a number of actions. These were reiterated at the second risk summit due to a lack of initial progress, to: introduce Safer Start, a system to accelerate discharge, develop a short stay patient model of care, ensure that expected GP patients went directly to the medical assessment unit, change the medical model for emergency admissions, introduce a frailty interface team, focus on reducing the variation with simple discharge and complex discharges and introduce ‘discharge to assess’. The trust was also required to work with the Emergency Care improvement Programme (ECIP) and ensure their recommendations were implemented

On 22 and 23 February 

and 

3 and 4 

March, 2016, we undertook an unannounced and focused inspections of the emergency care pathway at Queen Alexandra Hospital. The focus of our unannounced inspection was on the actions taken by the trust in response to the identified risks to patients through their emergency care pathway. We inspected two core services: urgent and emergency care and medical services.

We reviewed the service based on our five key questions: is the service safe, effective, caring, responsive and well-led?

Our key findings were as follows:

  • The trust was failing to ensure emergency patients received safe care and treatment and the emergency service was struggling to respond to the needs of patients. The trust leadership had failed to make significant, urgent and necessary changes to improve the flow of emergency patients through the hospital. The risks to patients was unacceptable; the pressure and environment under which staff were working was unacceptable.

  • Patients were not being triaged, assessed and treated within the emergency department in a timely manner. The 15 minute standard to assess patients was not being met. During the inspection time period, we observed only some patients, including patients with serious conditions, being assessed with 15 minute.  Trust data was in averages but additional data available from the Trust covering the four days of the inspection demonstrated that only 65% of ambulance patients were assessed within 15 minutes and approximately 87% were assessed within 30 minutes. For patients with a serious condition, such as sepsis, chest pain or fractured neck of femur, trust data demonstrated that only 57% were triaged with 15 minutes (11% waited over 30 minutes).  35% were treated within 1 and 34% waited over two hours for treatment.
  • Due to poor flow through the department, there were often several ambulances queuing outside the department. On 22 February there had been 16 vehicles queuing at 19:00. On 23 February, there had been 16 ambulances queuing outside of the trust by 16:00 and overnight. The Jumbulance was re-opened and was being used to manage the ambulance waits.

  • On 22 February, South Central Ambulance Service (SCAS) recorded there was a total of 93 hours of excess handover time, and a further 84 hours the following day. The average handover time across those two days was 61.5 minutes. The 16 ambulances represented one third of the South East Hampshire ambulance fleet were being held at Queen Alexandra Hospital. The ambulance stacking had meant there have been capacity issues for the ambulance service, that have had to hold eleven 999 emergency calls due to no emergency ambulances being available locally for dispatch.

  • There was a significant risk of harm to patients being held, assessed or treated outside the ED, within an ambulance or “Jumbulance”. There was no single accountable lead for the decision about which patients should be brought into the department, when there were ambulances held. There was not always a senior decision maker evident. The decision making process was often arbitrary between nurses and ambulance staff. Although there was a process, as agreed by ECIP for the triage of patients.  However, as the department became overcrowded we observed that clinical staff did not adopt a standard process to triage and we observed the process to be “chaotic”. Some patients had two clinical staff go to assess them – a consultant and a nurse from the majors areas - and some patients had none.

  • We identified patients with serious conditions, such as chest pain, suspected sepsis, fractured neck of femur, and stroke that had not been triaged, assessed and treated in a timely manner. For example, patients with suspected sepsis patients were not always seen or treated within an hour of presentation. Patients with suspected stroke symptoms were not always triaged quickly enough to allow for timely administration of thrombolysis.

  • Patients with non-life threatening conditions were waiting long periods of time in an ambulance. Many of these were vulnerable patients. Elderly frail patients were waiting in ambulances for over two hours. One patient with a learning disability had waited in an ambulance for over 2.5 hours. Whilst there is no formal policy describing the accountability arrangements for patients whilst in the back of an ambulance on site, at all times a trained paramedic is with the patient; However, the responsibility to notify Trust staff of any patient deterioration was not clear. There was not a consistent mechanism for ensuring that any deterioration would be detected by staff. During the wait in the vehicle, observations were not consistently recorded. Sometimes, the first observations recorded in the triage process had been recorded by the ambulance staff and were not up to date information.

  • There was regular, significant and substantial overcrowding in the emergency department. Patients were waiting on trolleys in the corridors. On 22 and 23 February, the corridor outside the ambulance handover area was being used for up to nine patients. There were instances where initial assessments and minor procedures (such as venesection) occurred in the corridor.

  • On 22 and 23 February, the patients in the corridor were being observed and monitored by one nurse. The nurse was also allocated to assess the incoming ambulance patients. She did not have capacity to look after the patients in the corridor queue and in ambulances. The assessment and ongoing care and treatment of patients in the corridor was inconsistent. The privacy and dignity of the patients waiting in the corridor was could not be guaranteed. There were frequent and lengthy period where patients were not being observed by a healthcare professional in the corridor. One agency paramedic was observed in the department at approximately 16.00 on the 23 February. Agency paramedic staff had not been observed in the department from between 8am and 4pm that day when the department had been equally as busy.
  • Mental health patients remain in the department in an unsuitable environment for excessive amount of time, for example, one patient waited 23 hours in the majors area.
  • On 4 and 5 March the corridor was again being use for up to nine patients by one nurse. There patients in the corridor who were not being observed or monitored and patients waiting in ambulances who had not been assessed after one to two hours. One agency ambulance healthcare support worker and one agency healthcare technician arrived to support at 12.25am on the 5 March. These agency staff had not been observed beforehand. After patients were assessed patients were waiting a long time for treatment. For example, a patient who required oxygen had not been given this for several hours. A diabetic patient with acute kidney injury had a referral letter handed to the receptionist. The letter was scanned on to the computer system by the receptionist and the triage from was ticked to indicate documentation was received from the GP. The patient had not received immediate treatment and we asked the nurse about the patient. The nurse told us that she was not aware of the contents of the letter. The nurse had not looked at the computer system and the letter had not been given to the nurse until three hours after their triage assessment.
  • Patients waiting in ambulances and those queuing in the corridor did not always receive compassionate care. For example, there was no means for patients to call for help and staff were not always able to check on the wellbeing of patients. We observed many patients who were confused and in distress.

  • We found that escalation process were not consistently followed. Staff did not respond appropriately to peaks and surges in demand. There was no evidence that patients were being effectively streamed through the department or that beds were being used flexibly, for example, in ‘majors’, to respond to the care and treatment needs for patients. The standard operating procedure for Full Capacity in the Emergency Department (November 2015) or the Management of Majors during Full Capacity (draft 22 February 2016)’ was not being used to allow flexibility in the way beds and cubicles were used in the emergency department. In February and March, we often observed empty beds in majors and the observation wards when patient had been in an ambulance, in corridors, and in areas without curtains.

  • The capacity and flow issues meant that simple processes became very inefficient. For example, blood samples and ECGs test results went missing and were being repeated, this presented delays to patient treatment. There were multiple moves of patients around the department and through the Medical Assessment Unit (MAU), resulting in multiple handovers of care.

  • The handover of patients was not sufficiently detailed and there were important and clinically significant details missed. Handover information within the ED and between ED and MAU was either absent or too brief. For example, we observed risk assessments about patient’s condition or a patient risk of absconding, was not provided. Patients were not being effectively streamed through the emergency department. We identified that staff had “lost” patients within the system. For example, on three occasions, on 23 February staff were unable to say where their patient was in the emergency department, or what treatment they required next.

  • During our inspection, CQC staff had to intervene to keep patients safe on several occasions, including asking staff to assess patients in the ambulance and the corridor, and to prevent a patient from leaving the department when there was not a member of staff present.

  • Patients received inconsistent care and treatment on the MAU. Some patients had risks assessments of their needs but their plans for care were either absent or were not being followed. For example the Sepsis pathway was not followed for one patient. No written care plans for six patients with indwelling urinary catheters were identified, however it is noted that this was recorded on the electronic Vitalpac system. Two patients had grade 2 pressure ulcers without care plans or body maps and for one patient the nursing staff did not know the appropriate dressing to use. The early warning score was not consistently being used to responded to and escalate patients appropriately. Nursing staff were sometimes not competent to care for patients.  We observed poor care for a patient with cognitive impairment. We raised our concerns with the senior nurse in charge. Infection control practices were not being followed and there was not always appropriate availability of equipment, for example, cardiac monitors.

  • Patient flow was not being managed effectively. There were multiple Patient Flow Nurses from different clinical service centres. The nurses were not communicating effectively with each other to enable effective patient flow through the MAU and the wards. We observed three bed meetings. There was not a collective or cohesive process to identify capacity across the hospital. There was no challenge on individual bed states in the clinical service centres despite evidence of protecting their own bed states, for example, not declaring beds or discharges. Patients had multiple bed moves and were being moved overnight. Vulnerable people (people assessed as not being suitable to move) were being moved. Discharge was being delayed by the poor flow through MAU. Patients suitable for discharge were not routinely identified or plans put in place to move them to other areas to improve flow during the day. The discharge lounge moved on a regular basis, and had varying capacity. There was currently no capacity to take patients in beds, and therefore patients had to wait on wards if they required a bed. This was further congesting an already busy hospital and reducing patient flow options.

  • The staff we spoke with described an executive leadership team who demonstrated a “hands on” rather than strategic mechanism of support. They were involved and physically helped in the department at periods of high pressure. These good intentions were acknowledged by almost all staff. However, these interventions were identified as having little impact. That is, they had been a response to crises rather than the intended leadership to improve the situation. Staff did not feel empowered to make decisions and make changes in their own department.

  • Some of the executive team were identified as barriers to the leadership of effective change.

  • Senior medical leadership in the emergency department had tried unsuccessfully for a considerable length of time to engage productively with some members of the executive team to produce effective and necessary change. Staff described a culture of “learned helplessness” within the organisation and the level of increased risk had become normalised within the trust. Staff had now accepted a standard of care that was unacceptable.

  • Staff we spoke with identified “change fatigue” based on the trust introducing many “solutions” to the ongoing problem. There had been many changes to the emergency pathway which were not followed through. Staff described an environment lacking in grip and pace. When the emergency department became extremely busy or under considerable internal and external pressure, the hospital improvement plan was not always followed. Interim “quick fixes” were put in place but discarded after insufficient time to assess their ongoing efficacy. Staff further described a level of “solution inertia” where the imposition of the short term “quick fixes” had resulted in weary staff who could not see a way forward. It was now accepted, for example, that the 4 hour emergency access target was unachievable.

  • The trust improvement plan was not being adhered to. A short stay medical model should have been implemented by the week beginning 29 February. However, staff told us this had not been properly costed and would not now start until April. GP heralded patients were meant to be admitted straight to MAU for assessment and treatment on 15 February. This had changed to 2 March 2016. When we inspected, this service change was not in operation on the evening and night of 4 and 5 March. We had observed on the evening of 3 March that the process had been in place and had worked well. However, when pressure had increased in the department, this practice had been discarded and many staff did not know about the decision. We had not seen any senior leaders supporting the change.

  • Data was not being recorded appropriately. Staff told us they were not reporting incidents that had occurred or near misses because of the clinical workload. The number of incidents recorded was low compared to the incidents identified on inspection and identified by staff we spoke with. Figures provided by the trust were being based on averages and did not effectively represent the proportion, or the extremes of patients, having long waiting times for assessment and treatment. Staff were recording information in a way that could not be validated. We observed many patients waiting on a trolley in the ED for over 12 hours and up to 18 hours. We observed that the decision to admit time was recorded in electronic patient record. A 12 hour trolley breach is recorded from the decision to admit for non-clinical reasons. . Assessment and treatment were being delayed and the decision to admit was being delayed based on the medical specialty agreeing to admit the patient. We did not receive assurance that this breach was being measured according to guidance. The trust had only recorded seven 12 hour trolley breaches over 2 December 2015 to 23 February 2016. The time in ED was not being measured in terms of the impact on patients. There were only five vulnerable patients (red patients) recorded as having patient bed moves including overnight from 1 September 2015 to 3 March. However, staff consistently told us there was pressure to move patients and vulnerable patients were being moved.

  • We observed an inconsistency of care on the medical assessment unit (MAU). On yellow unit, risks were appropriately recorded on patient care plans and care and treatment was appropriate and timely. However, on the Orange and Lilac units, some patients did not have risks appropriately recorded and observations were not done in a timely way. This was despite some patients having a high risk (for example, at risk of Sepsis) condition.

  • Infection control procedures and practices were not consistently adhered to throughout the MAU.

  • The safe storage of medicines was inconsistent in MAU.

  • Patients were not always cared for in single sex facilities in the escalation areas.

  • There were a high number of patients’ moves because of capacity issues.

  • Discharge of medical and frail elderly patients from hospital was inconsistent and did not always happen in a timely way.

  • There were delays in the development of strategies designed to improve the urgent medical pathway.

There were areas of poor practice where the trust needs to make improvements.

We considered that people who used the emergency services at Queen Alexandra Hospital would, or may be, exposed to the risk of harm if we did not impose urgent conditions for the Trust to provide a safe service to patients. On 15 March 2016, we took urgent action and issued a notice of decision to impose conditions on their registration as a service provider.

We asked the trust to take immediate action, under section 31 of the Health and Social Care Act (2008), and imposed four conditions on their registration. We told the trust to immediately ensure:

  • A clinical transformation lead is appointed based on external advice and agreement, and ensure effective medical and nursing leadership in the emergency department.
  • Patients attending the Emergency Department at Queen Alexandra Hospital are triaged, assessed and streamlined by appropriate staff ,and escalation procedures are followed.
  • The “Jumbulance” is not used on site at the Queen Alexandra Hospital, under any circumstances. The exception to this will be if a major incident is declared.
  • CQC receive daily monitoring information that is to be provided on a weekly basis

The trust must also ensure:

  • Patients waiting in the corridor, or in ambulance vehicles, must be adequately observed and monitored by appropriately trained staff.

  • The hospital must accept full clinical responsibility for patients waiting on the ambulance apron.
  • The safe storage of medicines in the MAU.
  • Patients are cared for in single sex facilities in the escalation areas.
  • Patient notes are stored securely across the hospital to prevent unauthorised access.
  • All patients in MAU have care based on plans developed to support identified risks.
  • Patients receive timely discharge from hospital.
  • Plans to change the urgent medical pathway are implemented in a timely manner.
  • Staff in the MAU adhere to infection control policies and procedures.
  • There is better and more accurate monitoring information to reflect patient safety and the quality of care.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 13 March 2014

During a themed inspection looking at Dementia Services

During this inspection we visited 15 wards and other areas where patient's received care within the hospital.

We looked at the quality of care provided to support patients who were living with a diagnosis of dementia. We looked at the support they received to maintain their physical and mental well-being as part of a themed inspection programme. This programme looked at how providers worked together to provide care to patients with dementia, how the needs of patients in relation to their dementia were assessed, planned and delivered and how the trust monitored the quality of the care, treatment and support provided to patients with dementia during their hospital stay.

We spoke with 13 patients with dementia during this inspection. We also spoke with five relatives and approximately 40 staff, including the chief executive officer, acting director of nursing and deputy director of nursing.

For all the patients we saw and records we reviewed dementia was the secondary diagnosis and not the main reason for admission to hospital.

We were provided with information from the trust that told us that all areas within the hospital had an appointed, "dementia champion". We were told that these staff had undertaken additional training about dementia and were responsible for cascading any new developments through to their teams. We were told this was working well in some areas although others had only just received the training. We saw that in all the areas we visited a member of staff had been designated as a dementia champion.

Nursing staff we spoke with told us that they are required to undertake annual essential skills days and that these have included sessions about dementia. They also told us that they are required to undertake a competency assessment, which included questions about dementia and the care people would require.

Inspection carried out on 16 May 2013

During an inspection in response to concerns

This inspection focused on the discharge process because the public had raised concerns to us. In order to assess the discharge process we spent time in the discharge lounge, on ward F4, the pharmacy and the various wards within the Medical Assessment Unit (MAU). One member of the inspection team spent the day with the hospital's lead in Discharge Liaison. This included spending time with other professional's from external organisations and attending a multidisciplinary meeting where discharges were discussed and arranged. Over the course of the day we spoke to 33 patients, five relatives/friends of patients, three doctors, twenty two nurses, eleven support workers, three pharmacists, a pharmacy technician, a ward clerk and at least nine professionals from other organisations.

We met and observed a variety of other staff such as porters and physiotherapists. On the wards and units we observed that people were spoken to in a friendly manner and their wishes were respected. The majority of people we spoke to were happy with their treatment and their plans for discharge. Records showed they were consulted on the decision making and their relatives and other professionals were also consulted if necessary. We found that the provider had robust systems for discharge and worked well with other providers to ensure safe and successful discharges took place. Sometimes those systems fell short of ensuring this for every patient in particular those admitted for short periods.

Inspection carried out on 5, 6 March 2013

During a routine inspection

During our two day inspection we spoke to 51 patients and nine relatives or representatives. We also spoke to 57 staff including consultants, senior nurses, ward managers, support workers and domestic staff. The majority of patients we spoke to were positive about their care and treatment including those that had been treated in the Accident and Emergency Department (ED). A minority of people commented on waiting a long time in the ED, although those people had been offered food and drink and where necessary were being treated.

During this inspection we spent a day and half in the ED, we observed care and treatment, spoke to patients, spoke to staff, observed shift handovers and looked at patient records and other documentation, such as the hospital’s “Queue management system policy” and staff rotas. We also spent time on the Medical Assessment Unit (MAU) and its various wards. Also, G2, G3, E1, the oncology day ward and the oncology inpatient wards F5, F6 and F7 were visited. We also visited other wards to track the care of specific patients, for example, people who had been admitted through the ED and patients with a learning disability.

Overall people were satisfied with their care and treatment saying things like “They are very respectful”, “They are brilliant” and “I feel safe in here”. Our observations confirmed that in the main people were well looked after, treated with respect and involved in the decisions about their care and treatment.

During a check to make sure that the improvements required had been made

At a previous inspection of Queen Alexandra Hospital we found that improvements were needed to their record keeping.

We reviewed all the documentation provided to us by the provider and found the improvements made to the assessment and care planning process are more detailed and offer greater consistency across the hospital.

Inspection carried out on 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

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.

Inspection carried out on 30 December 2011

During an inspection to make sure that the improvements required had been made

The patients we spoke with were generally happy with the care provided at the hospital. They said that staff were kind and helpful and responded to calls for assistance, although they were very busy. They told us that staff maintained their dignity and privacy at all times by ensuring that the screens were always pulled around the bed when care and treatment was provided. Patients told us that staff provided them with sufficient information about their care.

The patients who were admitted for elective surgery told us that the system worked very well and they were provided with information prior to admission. One patient said that they also received the information in writing on admission which made it easier to remember what was happening.

Four relatives told us that information was very good on the current ward, but this had not been their experience in the medical assessment unit (MAU). Two patients told us that both they and their families had been involved in discussion about them going home.

Some people said that they were advised when their relative had moved to another part of the ward into a side room. Three people said that they were not kept informed when their relative had moved to another ward following deterioration in their conditions. They only found out when they arrived on the ward and found that their relative had been moved during the night. One person said that they ‘nearly pulled open the curtain’ to another patient as they thought it was their relative.

Inspection carried out on 23, 26 May 2011

During an inspection in response to concerns

Patients said “staff always had a kind word”. Some of them said that the staff did not have “a lot of time for chit chat.” They said that they were happy with the care given.

People told us that staff understood their needs and were generally very caring.

People also said that the wards were clean, and that staff washed their hands or used antibacterial gel before and after providing care.

Some people we spoke to said they were “moved around a lot” and not told what was happening until staff came to move them to another ward. People said that they were not always told that they would be moving and sometimes they were moved “in the middle of the night.”

Patients on some wards told us that the staff “did their best” but there was not always enough staff and that this was particularly in the mornings and evenings, when they often had to wait for assistance.

Some people told us that they had to wait for hours for their medicines on discharge and that the transport was “very bad” where it was provided for them on leaving hospital. Comments from some of the patients were that “they want to clear the beds as quickly as possible.”

Inspection carried out on 12 April 2011

During a themed inspection looking at Dignity and Nutrition

The patients we spoke to were mainly positive about the care and treatment that they were receiving. People told us that they were treated with respect and their privacy and dignity had been respected when receiving personal care. Patients were asked if the staff used their preferred names when speaking to them. Most of them said that the staff had asked how they liked to be called.

Patients told us that they were asked about medical procedures that needed to be carried out and said the staff had kept them informed about investigations such as taking a blood sample from them. We asked the patients whether they had been asked how they would like to be treated and some said they had been.

Patients we spoke to said that they received an adequate amount of food. A visitor also commented that their relative received adequate amounts of food. They said that the staff always provided them with water jugs and ensured they had enough water. People we spoke to told us that they were supported by the staff to eat.

Patients commented that the staff had not asked them about what they liked to eat and whether they needed support, but they said that they received a menu card to complete. One patient said they were helped with the menu as they had poor eyesight and staff were aware that they required a special diet. People told us that meal times were nice and quiet but they said that they were not always offered the opportunity to wash their hands before or after eating.