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

Inspection Summary


Overall summary & rating

Inadequate

Updated 17 January 2018

  • Staff had not all received training in key skills to undertake their roles. This included resuscitation and safeguarding vulnerable adults and children.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. However, staff did not always have training on how to recognise and report abuse and how to apply the learning.
  • Medical staffing in the department was not always sufficient to maintain patient safety. Recommendations by the Royal College of Emergency Medicine (RCEM) were not met. Medical cover overnight consisted of one registrar who was responsible for all inpatient areas.
  • Learning from mortality, incidents and complaints was not always effectively identified, implemented, reviewed or shared.
  • Hand hygiene best practice was not always followed to prevent the spread of infection.
  • There was variable performance in a number of national audits relating to patient safety and treatment.
  • Departmental risks were recorded on the urgent care divisional risk register, which was not comprehensive and did not include control measures.
  • Patients’ views and experiences were not routinely gathered or acted upon to improve services.
  • We found progress had been made in assessments and responses to patient risk within each of the medical wards we visited. Initial venous thromboembolism assessments were completed on a patient’s admission to hospital. The assessments were not always repeated within 24 hours of admission.
  • Data showed that wards were regularly working with reduced numbers of qualified nursing staff.
  • Appraisal rates did not meet the trust target of 90%.
  • The service did not always treat complaints in line with trust policy.
  • There were a high number of patient bed moves out of hours (10pm to 7am).
  • The trust’s vision and strategy remained under development at the time of the inspection. There was no documented local strategy for the service however, and some staff were uncertain about the trust’s vision and strategy regarding the Alexandra Hospital.

However, we also found;

  • Patients had their needs assessed and their care was planned and delivered in line with evidence-based guidance, standards and best practice.
  • Staff provided care that was kind and compassionate. Patients’ individual needs were met.
  • Staff worked with the mental health liaison service to provide high quality care for patients with mental health conditions.
  • The trust planned and provided services in a way that met the needs of local people.
  • The ambulatory care and frailty pathways were operating effectively in the ED and contributing to improved patient flow. Patients spent less time waiting for hospital beds.
  • The trust recognised there were issues with leadership and governance arrangements in the ED. A new, smaller urgent care division had been set up and there were plans to provide executive support to improve governance and performance management.
  • The service prescribed, gave, recorded and stored medicines well.
  • Most patient safety incidents were managed well.
  • Medical notes contained comprehensive and detailed patient reviews, referrals to other clinicians, and clear treatment plans.
  • Staff from different disciplines worked together as a team to benefit patients.
  • Patients’ pain was assessed on admission to hospital and repeated at intervals throughout their stay.
Inspection areas

Safe

Inadequate

Updated 17 January 2018

Effective

Requires improvement

Updated 17 January 2018

Caring

Good

Updated 17 January 2018

Responsive

Requires improvement

Updated 17 January 2018

Well-led

Inadequate

Updated 17 January 2018

Checks on specific services

Outpatients and diagnostic imaging

Inadequate

Updated 20 June 2017

We rated outpatients and diagnostic imaging as inadequate because:

  • There were long waiting lists for the majority of specialities and the trust had not met all cancer targets for referral to treatment times. The trust was failing to meet a range of benchmarked standards with regards to the time with which patients could expect to access care.
  • Mandatory and safeguarding training levels did not always meet the trust’s target and not all staff had received an annual personal development review.
  • Incidents were not always categorised appropriately in terms of the level of harm caused. Incidents were not always reviewed in a timely manner and we were not assured that learning from incidents was cascaded to all staff.
  • Complaints were not always responded to in a timely manner.
  • There was a lack of radiation protection infrastructure.
  • Old and unsafe equipment across the trust was inadequately risk rated and there was a lack of capital set aside to fund replacement items.
  • There had been two patient safety incidents in the trust involving unsafe x-ray equipment and which had resulted in patient injury.
  • We were not assured the service had a robust, realistic strategy for achieving its priorities and delivering good quality care.
  • Governance arrangements and the management of risk was insufficiently robust and further improvements were needed.

However:

  • Patient records were stored securely and effective systems were in place to ensure clinicians had access to appropriate and up-to-date patient information.
  • Patients were treated with kindness, dignity and respect and spoke positively about the care they had received.
  • Care and treatment was delivered in line with national guidance.
  • Some departments had developed services, such as one-stop clinics, in order to better meet the needs of patients and improve service provision.
  • There was effective multidisciplinary working across the outpatient and diagnostic imaging service.
  • Local leadership was strong, supportive and approachable. However, staff did not feel directorate and divisional leads were visible.
  • Staff were proud to work at the hospital and were passionate about the care they provided.

Maternity and gynaecology

Updated 8 August 2017

We carried out a focused inspection to review concerns found during our previous comprehensive inspection on 22 to 25 November 2016. We inspected parts of four of the five key questions but did not rate them. We found significant improvements had not been made in these areas:

  • Despite assurances from the trust, we saw no evidence that obstetrics and gynaecology mortality and morbidity reviews were held. Furthermore, whilst perinatal mortality and morbidity meetings were minuted, we were not assured that action was taken to address any learning identified from case reviews.
  • The trust had monitoring systems in place to ensure medicines were stored within recommended temperature ranges. However, these were not consistently followed across the service.

We also found other areas of concern:

  • Surgical nursing staff, who cared for gynaecology patients on the designated wards, had not received any specific gynaecology training, such as management of surgical miscarriage and bereavement care. However, the gynaecology medical team were available for advice as needed.

However, we found improvements in some areas:

  • All clinical areas we visited were clean and there was good adherence to infection control policies and the use of personal protective equipment.
  • There had been an improvement in compliance with safeguarding children level three training. Staff demonstrated awareness of safeguarding guidance, including female genital mutilation. Staff understood their responsibilities and were confident to raise concerns. However, training compliance was still below the trust target.
  • Equipment was clean, maintained and serviced to ensure it was safe for patient use.
  • Compliance with Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training had improved. Staff demonstrated awareness of relevant consent and decision making requirements relating to MCA and DoLS, and understood their responsibilities to ensure patients were protected.

Medical care (including older people’s care)

Requires improvement

Updated 17 January 2018

  • During this inspection we found that mandatory training compliance had improved, however, did not meet the trust target level of 90%.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. However, staff did not always have training on how to recognise and report abuse and how to apply the learning.
  • The service mostly controlled infection risk well, however not all staff we observed followed the trust infection control and prevention policy.
  • We found progress had been made in assessments and responses to patient risk within each of the medical wards we visited. Initial venous thromboembolism assessments were completed on a patient’s admission to hospital. The assessments were not always repeated within 24 hours of admission.
  • Data showed that wards were regularly working with reduced numbers of qualified nursing staff. There was a high number of qualified nurse vacancies within the medical division however, in mitigation the trust filled vacant shifts with bank and agency staff when possible.
  • Medical cover overnight consisted of one registrar who was responsible for all inpatient areas.
  • There was variable performance in a number of national audits relating to patient safety and treatment.
  • The endoscopy department had their Joint Advisory Group accreditation deferred following a recent inspection.
  • Appraisal rates did not meet the trust target of 90%.
  • Mental Capacity Act 2005 and Deprivation of Liberty training compliance was poor.
  • The service did not always treat complaints in line with trust policy.
  • From October 2016 to September 2017, the service reported a high number of patient bed moves out of hours (10pm to 7am).
  • Managers had the right skills and abilities to run a service providing high-quality sustainable care. A stable leadership team had been in place for a period of six months only however, at the time of our inspection and there had been significant instability during the previous two years.
  • The trust’s vision and strategy remained under development at the time of the inspection. There was no documented local strategy for the service, and some staff were uncertain about the trust’s vision and strategy regarding the Alexandra Hospital.
  • Not all data across the trust was managed effectively to ensure it was accurate and reliable.

However, we also found;

  • The service prescribed, gave, recorded and stored medicines well.
  • The service mostly managed patient safety incidents well.
  • Medical notes contained comprehensive and detailed patient reviews, referrals to other clinicians, and clear treatment plans.
  • The service had introduced a safer staffing application (app) which was completed locally on wards daily. The app recorded the number and type of staff on duty each day and compared this to the ward planned establishment.
  • Patients had their needs assessed and their care was planned and delivered in line with evidence-based guidance, standards and best practice.
  • Staff from different disciplines worked together as a team to benefit patients.
  • Patients’ pain was assessed on admission to hospital and repeated at intervals throughout their stay.
  • Staff cared for patients with compassion.
  • The trust planned and aimed to provide services in a way that met the needs of local people.
  • Within the medical division, the capacity review had resulted in changes in the allocation of patient beds to improve patient flow.
  • The medicine divisional dashboard clearly demonstrated performance measure against key indicators, such as NHS Safety Thermometer data, infection control rates, complaints performance, bed occupancy, length of stay and readmission rates. The dashboards were discussed at divisional meetings and at board level.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

Urgent and emergency services (A&E)

Requires improvement

Updated 17 January 2018

Our overall rating of this service improved. We rated it as requires improvement because:

  • Staff had not all received training in key skills to undertake their roles. This included resuscitation and safeguarding vulnerable adults and children.
  • Medical staffing in the department was not always sufficient to maintain patient safety. Recommendations by the Royal College of Emergency Medicine (RCEM) were not met.
  • Learning from mortality, incidents and complaints was not always effectively identified, implemented, reviewed or shared.
  • Hand hygiene best practice was not always followed to prevent the spread of infection.
  • Performance was variable against the national quality indicators used to monitor emergency departments (ED).
  • Monitoring performance occurred at divisional level and did not always feed into departmental service delivery. The divisional structure had recently changed and performance management arrangements were not finalised at the time of inspection.
  • There was limited evidence to show audit results were used to improve services. The ED participated in national RCEM audits, which showed they were not meeting national standards in the majority of areas. Robust actions to improve had not been implemented.
  • There was lack of emphasis on improving quality and sustainability at departmental level. Clinical leaders in the department were responsible for all local governance, quality and risk management, which meant they did not always have capacity to fulfil these duties to a sufficient level.
  • Departmental risks were recorded on the urgent care divisional risk register, which was not comprehensive and did not include control measures.
  • Information was not always effectively disseminated from divisional and senior leaders. Staff in the ED were not always aware of recent learning or improvement plans.
  • Patients’ views and experiences were not routinely gathered or acted upon to improve services. There was limited patient engagement and the response rate for the NHS Friends and Family Test was consistently below 1%, compared to an England average of 13%.

However:

  • Data showed that no patients spent time in the corridor after ambulance handover, including those who were waiting for an available hospital bed after a decision to admit. This was a significant improvement since the November 2016 inspection when patients frequently waited in the corridor due to poor patient flow and lack of bed capacity across the hospital.
  • Care pathways and protocols based on National Institute for Health and Care Excellence guidelines had been introduced.
  • Staff provided care that was kind and compassionate. Patients’ individual needs were met.
  • Staff worked with the mental health liaison service to provide high quality care for patients with mental health conditions.
  • The trust planned and provided services in a way that met the needs of local people. For example, through collaborative working with the frailty team, ambulance service and local prisons.
  • The ambulatory care and frailty pathways were operating effectively in the ED and contributing to improved patient flow. Patients spent less time waiting for hospital beds.
  • The trust recognised there were issues with leadership and governance arrangements in the ED. A new, smaller urgent care division had been set up and there were plans to provide executive support to improve governance and performance management.
  • The culture in the ED had improved since previous inspections. In November 2016, there was trust-wide acceptance of long waits for patients and corridor care. At this inspection, the culture was now focused on teamwork and putting patients first.

Surgery

Updated 8 August 2017

We carried out this focused inspection to inspect three of the five key questions but we did not rate them. This was a focused inspection to review concerns found during our previous comprehensive inspection in November 2016 and therefore we did not inspect every aspect of each key question. We found significant improvements had not been made in these areas:

  • Venous thromboembolism risk assessments were not completed in line with national guidance.
  • Medications were not administered as prescribed.
  • Medications were stored in temperatures above manufactures recommended guidelines.
  • Some staff were not compliant with infection control precautions including hand hygiene and appropriate use of personal protective equipment.

We also found other areas of concern:

  • Patient details were visible to all staff and visitors on the ward.
  • All wards displayed the actual number of staff on duty. However, some surgical wards did not display the planned number of staff and therefore patients and visitors could not identify any staff shortages.
  • Less than 20% of nursing and medical staff had received training in Mental Capacity Act 2005 and Deprivation of Liberty.
  • Senior leaders were aware of the trust’s failure to follow national guidance in relation to venous thromboembolism risk assessments and compliance with hand hygiene. However, we saw examples throughout surgery where national guidance had not been followed.
  • When risks had been escalated, there was a lack of follow up and resolution. For example, medications were stored in fridges at higher temperatures than recommended by medicine manufactures and clinical staff had escalated this to managers. However, clinical staff were unable to identify any action taken to reduce the risks of patients receiving medication stored in these fridges.

However, we found improvements in some areas:

  • All staff had ‘arms bare below the elbows’ in clinical areas.
  • Adequate staffing levels were observed on all wards during our inspection. Staff explained their new staffing application (an electronic tool which measured how many staff were on duty against how many should have been on duty), which helped escalate any shortages rapidly.
  • We saw fewer medical outliers on most surgical wards. However, one surgical ward had nine medical outliers at the time of our inspection.
  • Patients undergoing surgery had the correct consent form.
  • Patients who lacked capacity had evidence of a mental capacity assessment.
  • The trust had implemented a new quality dashboard. The dashboard provided monthly quality data for all wards and clinical areas.

Intensive/critical care

Good

Updated 20 June 2017

We rated critical care as good because:

  • There was a positive safety culture. Staff recorded incidents, investigations were completed and staff received feedback. The service had a robust safety briefing in place, which was attended by all staff.
  • Staff maintained and monitored patient safety through local audits which included infection control, patient harms and risks. Action plans were developed to address any issues.
  • Patient records were contemporaneous, legible and stored safely. Evidence based assessment tools were used to monitor risk.
  • Mandatory training was generally in line with trust targets.
  • Medications were stored, prescribed and administered safely. There were systems in place to monitor safe storage and staff took appropriate actions in line with local protocol to address any concerns or anomalies.
  • The service used evidence-based guidelines, policies and protocols to monitor patient outcomes. Results were used to compile service dashboards, which were used to present audit results and monitor trends. Clinical leads reviewed these for compliance and trends and discussed results as part of the divisional and trust wide service meetings.
  • The service had a flexible approach to delivering patient care across both critical care units (Alexandra Hospital and Worcestershire Royal Hospital) to maintain patient safety.
  • Patient outcomes were used to benchmark the service against similar organisations to identify areas for improvement.
  • The service had access to additional specialists such as a pain specialist nurse, dietetics, microbiologists and pharmacy.
  • Staff competence was monitored and maintained through annual appraisal and competency reviews. External training was available for staff.
  • There was evidence that the multidisciplinary team was inclusive and well organised.
  • Patients were treated with dignity and respect, and in line with their individual beliefs and were involved with the care and treatment planning. Patients spoke positively about the care they received.
  • Relatives had access to facilities to enhance their stay on the unit, this included overnight accommodation, refreshments and information leaflets.
  • Patients were assessed appropriately for admission to critical care and received a full review by a consultant within 12 hours of admission to the unit.
  • There were no formal complaints regarding the service.
  • The service was well-led with strong local leadership, a service vision and robust governance systems in place.
  • All staff were positive about their roles, enjoyed working for the service and were dedicated to improving the standards of patient care.

However:

  • There were a small number of delayed discharges from critical care, which affected patient flow and experience.

Services for children & young people

Requires improvement

Updated 20 June 2017

We rated services for children and young people as requiring improvement because:

  • Staff were not aware of any guidance to support them in identifying what incidents should be reported. This created a risk that some incidents might not be recorded and therefore any learning from these would be missed.
  • Incidents were not always graded. In addition, learning from incidents was not identified. This meant there was a risk in the service that staff would not learn from incidents.
  • Recording templates for patient information were not always clear and did not contain columns on documents that clearly identified where height and weight should be recorded. This meant they were difficult to read and information could be lost.
  • Staff were unaware of female genital mutilation (FGM) and child sexual abuse (CSE). There was a risk that staff would not recognise when a child was being abused or exploited.
  • Level 3 safeguarding children’s training was not always face to face and was not updated annually; this was not compliant with the guidance on safeguarding training.
  • There were some policies relating to safeguarding children that were not available on the trust intranet. This included the ‘no allegations’ policy, and the ‘managing celebrity visits’ policy. The ‘safeguarding supervision’ policy also stated that it was in development on the intranet safeguarding pages.
  • There was no clinical audit plan for the children’s clinic. There was little evidence that continual improvement of the service and compliance with best practice was identified or actions taken to address any shortfalls.
  • The women and children’s division had introduced a performance dashboard to monitor patient outcomes. There was little evidence that performance in the children’s clinic was discussed.
  • There was no formal clinical supervision for nursing staff. Supervision was provided by the outpatient’s manager over the telephone. However, the manager also worked in WRH as an advanced nurse practitioner and could only offer staff telephone support when there were quiet periods at WRH.
  • Multidisciplinary working between all the trust’s hospital sites was not effective at all times.
  • The ‘did not attend’ appointment rate for new children and young people’s services appointments was regularly above the trust’s target of 7%.
  • From September 2015 to August 2016 there had been three complaints about children’s services at Alexandra Hospital. The hospital took an average of 31 days to investigate and close complaints. This was more than their complaints policy, which requires complaints to be closed within 25 days.
  • As a result of the emergency service reconfiguration, the children’s service did not have a clear vision and did not have a long-term strategy for children’s services. Staff were unaware of the vision and values in the children’s outpatient service as these had not been defined.
  • The governance framework was not effective. There was no evidence that information flowed between the directorate and divisional governance or quality meetings.
  • Monthly divisional governance meetings were not consistently adhering to their terms of reference. This included, not focusing on themes and trends from incidents and safeguarding training performance. Compliance to level 3 safeguarding training was not recorded separately and therefore the service was unaware which staff had completed level 3 safeguarding training.
  • The divisional risk register, focused on the number of risks recorded, rather than how they were being managed. The hospital had recently closed to paediatric inpatients and there had been little discussion around how the transitional period was managed.
  • The outpatients manager had not been allocated any contracted hours for service leadership, which they had to fit around their other role at WRH. This meant it was unlikely that staff would receive timely supervision and advice.
  • Some staff did not feel fully consulted about the service reconfiguration.

However:

  • The environment in the children’s clinic was visibly clean and staff followed correct cleaning protocols.
  • Overall, care records were generally written and managed well.
  • Staff had achieved the trust’s mandatory training target of 90%.
  • There was no paediatric resuscitation ‘bleep’ in use at Alexandra Hospital. However, there were clear protocols describing how children should be transferred to WRH if they needed to be treated by a specialist paediatric doctor.
  • Medical and nursing staffing levels were planned and reviewed in advance based on an agreed number of staff per shift.
  • The trust had a major incident plan in place although some staff were unaware of the business continuity plan to deal with adverse weather.
  • Staff who worked in the children’s clinic took time to interact with patients and their parents in a manner which was respectful and supportive.
  • The patients and parents we spoke with told us that staff were kind and caring and that they felt well looked after.
  • Feedback from the CQC’s children and young people’s survey 2014 was largely similar to other trusts including privacy, care and treatment and staff friendliness.
  • Staff communicated with children and young people and their families in a way that they could understand.
  • Children and young people and their families said they could be involved in their own care and treatment if they wished.
  • There was a range of patient information available in the children’s clinic.
  • Staff understood the impact that a patient’s care, treatment and condition had on them and those close to them.
  • Services in the children’s clinic took into account the needs of different children and young people. Consideration had been given their age, gender and any disability.
  • Transition arrangements were in place for patients approaching adulthood to ensure children and young people had access to the appropriate support.
  • The trust regularly met its 95% target for referral to treatment time for non-admitted children and young people and most received an appointment within 18 weeks.
  • Managers told us service reconfiguration was made with the objective of making improvements for patients and staff. However, at the time of our visit it was too early in the reconfiguration process to measure whether this would result in sustainable improvements to children and young people’s care.

End of life care

Good

Updated 20 June 2017

We rated the end of life care service as good because:

  • Staff understood their responsibilities to raise concerns and to record safety incidents. Incidents relating to end of life care were reviewed by the lead nurse for specialist palliative care. DNACPR (do not attempt cardiopulmonary resuscitation) records were generally completed well and the trust were making use of audits and learning from incidents to drive improvements.
  • There was good identification of patients at risk of deterioration and those in the last days of life. There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. There was consistent promotion of the delivery of high quality person centred care. Several audits had been undertaken to evaluate the service with associated action plans to address improvements identified.
  • A comprehensive programme of end of life care training was available for the full range of staff within the trust. However, we were not able to establish compliance with mandatory training (including safeguarding adults training) for specialist palliative care staff, including their annual appraisals rates. Evidence for this was requested but not provided by the trust.
  • There was good evidence of multidisciplinary working and involvement of the specialist palliative care team throughout the hospital including allied healthcare professionals as well as medical and nursing members. The specialist palliative care team provided a seven day face to face assessment service across the trust.
  • The trust had taken action to improve the service since the previous inspection. This included the replacement of fridges, flooring and improving the hot water facilities within the mortuary. Issues relating to obtaining syringe drivers had been addressed and appropriate anticipatory prescribing was used at the end of life.
  • There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. The trust had begun to record and audit preferred place of care and there were clear systems in place to make improvements in this area.
  • The specialist palliative care team responded quickly to referrals and would see patients within a few hours if the need was urgent. The majority (92%) of patients were seen within 24 hours and there was a good balance between cancer patient and non-cancer patient referrals.
  • Patients and relatives told us that the staff were caring, kind and respected their wishes. We observed staff communicating with patients and relatives in a manner than demonstrated compassion, dignity and respect.
  • There was a clear vision for the service and a draft strategy was in place, highlighting the key areas the trust were focusing on in relation to end of life care.