Queen Victoria Hospital NHS Foundation Trust

Updated 23 May 2019

Queen Victoria Hospital NHS Foundation Trust is a leading specialist centre for reconstructive surgery and rehabilitation, helping people who have been damaged or disfigured through accidents or disease. Queen Victoria Hospital NHS Foundation Trust provides a specialist burns and plastic surgery service to both adults and children. Patients are admitted from the south east of England including south and east London. The trust also provides ‘hub and spoke’ specialist services at other hospitals in the south east of England, bringing Queen Victoria Hospital NHS Foundation Trust staff with specialist skills to remote hospital locations. The hospital provides a minor injuries unit and community services for people living in and around East Grinstead and is situated on the outskirts of the town.

Queen Victoria Hospital NHS Foundation Trust holds contracts with 21 Clinical Commissioning Groups (CCGs); the co-ordinating commissioner is Horsham and Mid-Sussex CCG with associates including West Kent, High Weald Lewes Havens and Coastal West Sussex CCGs. The trust also holds a contract with NHS England for the provision of specialised head and neck surgery, ophthalmic (eyes), burns services and other specialist dental services.

The trust was last inspected in 2016 and was rated as good overall.

Updated 23 May 2019

We did not inspect all core services during this inspection, we inspected surgery (burns and plastics), outpatients and critical care. Overall, we rated the trust as good for safe, effective, responsive, well-led and outstanding in caring. All three core services we inspected were rated as good overall.

We rated safe, effective, responsive and well-led as good, and caring as outstanding. We rated all three of services as good. In rating the trust, we took into account the current ratings of the two services not inspected this time.

We rated the trust overall as good.

• The trust had responded to concerns raised in our last inspection in critical care and improvements had been made. These included, for example, dedicated medical cover out of hours.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises visibly clean. They used control measures to prevent the spread of infection.
• The service followed best practice when prescribing, administering, recording and storing medicines. Patients received the right medication at the right dose at the right time.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.
• There was a strong, visible person-centred culture and the service truly respected and valued patients as individuals. Staff were highly motivated and inspired to offer care that was exceptionally kind and promoted people’s dignity.
• Feedback from patients, those close to them and stakeholders was continually positive about the way staff treated people. The trust performed ‘much better than expected’ compared with other trusts in CQC’s 2017 Adult Inpatient Survey. NHS Friends and Family Test data displayed on the wards showed almost all patients would recommend the service to family and friends. There were consistently high recommendation rates, which reached 100% in nine out of 12 months in 2018 on the Burns Unit, and eight out of 12 months on Margaret Duncombe Ward.
• Staff saw patients emotional and social needs as being as important as their physical needs. Staff provided emotional support to patients and those close to them to minimise their distress and help them in their recovery from traumatic events or major surgery.
• Patient safety and the patient experience were the focus of the trust’s strategy and service delivery.
• Staff were fully committed to working in partnership with people and making this a reality for each patient. The service always reflected patients’ individual preferences and needs in the delivery of care.
• Advice and guidance for non-urgent GPs referrals were in place, this allowed GPs access to consultant advice prior to referring patients into specialist clinics.
• Safety huddles were held every morning in each outpatient department. All staff working in the outpatient clinics met at the same time every day to discuss current safety issues relating to the premises, patient care and other relevant issues that could impact on patient safety.
• The trust’s leadership team had the skills, knowledge, experience and integrity that they needed to lead the trust. Executives were given the support they needed. Where an individual board member was lacking in experience, they were supported to gain relevant expertise.
• The trust’s existing strategy and projected ‘strategic direction’ were aligned to local plans in the wider health and social care economy and were planned to meet the needs of the relevant population. The trust worked closely with other trusts, clinical commissioning groups and sustainability and transformation partnerships to identify and meet regional patient’s needs.
• The trust monitored their progress against delivery of the strategy and local plans. The strategic objectives, were outlined in the unique and exemplar Board Assurance Framework (BAF). The trusts BAF brought together the strategic objectives and used them to evaluate board work and risk. This ensured objectives were reviewed and acted against, in terms of current risks and long-term strategy.
• The different levels of governance and management functioned effectively to provide assurance. The board had a structure of committees which were chaired by non-executive members and reported directly to the board. Each committee reviewed evidence to gain information and assurances and escalated to the board in line with their terms of reference.
• The trust had arrangements for identifying, recording and managing risks, issues and had identified actions to reduce the impact of them. The trust used a risk register system to manage risks of all levels. Core service level risks were held on a departmental risk register. Risks that were strategic or affected multiple core services were held on the trust risk register. The board reviewed and managed the trust risk register.
• The trust had positive and collaborative relationships with external partners. It worked closely with other trusts in the region, clinical commissioning groups and the regional sustainability and transformation partnership to build a shared understanding of systemic challenges and identify and meet patient’s needs.
• The two highest rated risks on the risk register were both rated 20. One was referral to treatment time delivery and performance and one was financial performance.
• The trust had a referral to treatment time recovery action plan to eliminate 52 week waits across the three affected areas of the trust, and reach performance compliance by September 2019. The trust was on trajectory to meet this target.
• The trust was beginning its journey to address financial performance. The board recognised that system-wide working and collaboration could be key to its financial sustainability and that they needed to utilise support within the system and determine their position and the corresponding financial strategy aligning to this.
• The trust used secure electronic systems with security safeguards. It had a clear technology infrastructure plan for the hospital hub (main) site and had implemented current cyber security systems.
• The trust had a focus on learning. They supported research internally and as part of external research projects. Learning from and participation in internal and external reviews was used to lead improvement and innovation. The trust was able to identify numerous research-based initiatives it had adopted over the past 12 months to improve patient care.

However:

• Mandatory training rates including safeguarding and Mental Capacity Act 2005 modules for all staff groups did not always meet the trust target of 95%. However, at the time of inspection compliance had improved. For example, the critical care unit had an aggregated compliance rate of 90%.
• The service’s admissions policy for surgical and critical care patients relied heavily on the individual judgement of the on-call consultant as to whether a patient met the criteria for admission to the hospital. For example, there was no specific criteria for burns patients around the total body surface area affected by the burns. There were also no specific criteria for significant co-morbidities. However, the service had service-level agreements with a nearby large NHS acute teaching hospital trust for the provision of services such as general surgeons and geriatricians (specialist elderly medicine consultants) to support patients with existing co-morbidities.
• There were high numbers of registered nurse vacancies predominantly in theatres and critical care and heavy reliance on temporary staff. However, the trust had systems and processes to mitigate the risk, for example, a limit to how many agency staff could be allocated to each theatre. These services used regular agency staff to provide consistency and continuity.
• Nursing agency usage was higher than was recommended for a critical care unit. The Guidelines for the Provision of Intensive Care Services, 2015 recommended level was a maximum of 20% agency staff usage. There was a departmental policy of not having more than 50% agency on any one shift. This was an improvement which had been discussed and approved by senior clinical leads and the managers within the trust. Senior staff explained that due to the number of nurses, this would mean not more than two agency nurses per shift.
• The critical care unit was not fully meeting the Guidelines for the Provision of Intensive Care Services 2015 but there had been an improvement since the last inspection. At the time of our last inspection critical care had no intensive care consultants but now had intensive care consultant cover Monday to Friday. However, the unit still lacked this cover out of hours and at weekends.
• The trust had struggled to meet both the 18-week referral to treatment and cancer targets. Five specialties were below the England average for non-admitted pathways for referral to treatment times. The trust was acting to address this and was on a trajectory to meet the targets by April 2020.
• The trust was not meeting its targets for cancellations of outpatient appointments in the seven days prior to the appointment. These rates varied within the reporting period, but neither the plastic surgery department, sleep disorder unit and ophthalmology met their target during the reporting period. On the day cancellations by the hospital had stayed the same for a period but also failed to reach their target.
• The hospital did not meet the British Burn Association National Burn Care Standards. This was because, as a specialist trust, the hospital did not provide the usual range of hospital services such as general surgery, mental health liaison and paediatric medicine. To reduce these risks, the trust had service level agreements with a nearby acute NHS trust to provide these services in a timely way, 24 hours a day, seven days a week.
• The trust was not expected to meet its financial plan in this year and the trust was projected to have a deficit of £5.9 million in 2018 to 2019. The trust was not used to operating within such a financially challenging environment. They were in the process of developing systems to manage the trust under these pressures.