15 May 2023
We carried out this unannounced focused inspection of surgery, focusing on the neurosurgical service at Royal Sussex County Hospital, because we had received information of concern about the safety and quality of the service. We did not rate the service at this inspection. The previous rating of inadequate for surgery services at Royal Sussex County Hospital remains the same.
During the inspection we spoke with staff including managers, nursing staff, theatre staff, medical staff of all grades and senior leaders. We observed the environment and reviewed documents and information provided by the trust as part of the inspection process.
8 January 2019
Our rating of this service improved. We rated it as good because:
At our previous inspection in April 2017, we found several concerns such as;
- risk management strategies were not carried out in practice for the wards in the older buildings which were no longer fit for purpose
- no trust wide learning from incidents
- medical services operated in isolation
- culture of silo working and acceptance of poor behaviour amongst staff
At this inspection, we saw ample evidence of improvements made through the trust new strategy such as the “Patient First” programme. Despite significant lack of registered nurses and financial challenges, the service had embedded the programme and made great strides in a measured way not only to improve but ensured concerns found in the previous inspection were addressed. This resulted in us improving the ratings for all the key questions in medical care.
The service had also benefited from changes in the divisional structure and a new model of shared leadership between medical, nursing and operational managers called ‘triumvirates’. These changes had been implemented in August 2017 by the new trust leadership and staff we spoke with agreed that more improvements and innovations had been achieved in the last year. Staff reported the medical services no longer operated in isolation and now learnt and shared information across the services.
Although the medical wards were still located in the older Barry building, we saw risk management strategies put in place such as fire safety risk assessments and beds removed from overcrowded or unsuitable spaces. Meanwhile, the new purpose-built building works were well underway and on schedule for completion by end 2020.
We found a culture of openness and transparency about safety. Staff could raise concerns and report incidents, which were regularly reviewed to aid learning. Lessons learned were effectively shared and we saw changes implemented within the wards as the result of investigations.
There were sufficient numbers of staff with the right qualifications, training and experience to meet the needs of patients. Staffing was reviewed regularly to ensure the correct skill mix and numbers of staff on the wards and throughout the department.
Staff followed trust policies and best practice with regards to the department’s environment and equipment. Premises and facilities were visibly clean and suitable. Infection control and equipment management were regularly monitored.
The service undertook audits to ensure they regularly reviewed the effectiveness of care and treatment of patients. These showed that the care delivered was meeting national standards.
There was a good culture amongst staff. Staff described how they worked together across the medical services and were supported to challenge poor behaviour amongst themselves.
Patients received co-ordinated care from a range of different staff, teams and services. Staff worked collaboratively to meet patients’ individual needs, including their mental health and emotional wellbeing. Patients and relatives we spoke with gave positive feedback about the care they received.
10 August 2017
We did not inspect this service at this inspection as we rated it outstanding in April 2016.
8 January 2019
Our rating of this service improved. We rated it as good because:
- The service had addressed the significant backlog of incidents that had not been investigated. The number of outstanding investigations had stabilised and the number outstanding generally matched the number being reported.
- Incidents were thoroughly investigated and root causes were found. Where incidents were unavoidable, the service sought to try to take any learning that may have been available.
- The environment and equipment was clean and we observed all staff were bare below the elbow. There was a clear sense that infection prevention and control was now treated as a priority.
- Medicines management had improved significantly. Consequently, there were fewer medication errors. A system called the ‘five rights of medicine administration’ had been implemented. This required the staff to check the right patient, right drug, right dose, right route, right time. The five rights would then be checked three times.
- Multi-disciplinary team working was well co-ordinated and utilised the skills of all the staff. Medical, nursing, therapy and dietitian staff had an equal role to play in patient care.
- Staff appraisal rates had risen to 94.4% across all staff groups in the critical care units. Staff told us how their appraisals had real value.
- A programme to give general critical care nursing staff neuro competencies had been established. This had dramatically improved the skill mix across the units. There were now 56% of staff that had neuro competencies and could work with all patients admitted to critical care.
- We saw a significant number of plaudits from patients, relatives and loved ones describing how exceptional the care provided by the critical care team had been both for the physical wellbeing of the patient and the emotional wellbeing of the loved ones.
- Patients and visitors that we spoke with were unanimous in their praise of the care they or their loved ones received. One patient described how they had had frequent visits to the unit, that at no time had they ever been judged and were always treated with kindness.
- We observed many interactions between staff and patients, and staff and relatives. These demonstrated that all were given personalised care and privacy and dignity was always maintained.
- The service had improved the provision of information for patients and visitors that did not speak English as a first language.
- The critical care department carried out research with their interpreting provider to establish the three most common languages used. As a result, a full suite of information had been translated into the three most commonly used languages.
- A large picture that showed all the stages of the critical care pathway had been placed in the relatives’ room on level seven. The pictures displayed could be understood by adults and children alike as well as those who did not speak English as a first language. Included in the picture were links to a wide variety of support groups and information sources. These could be directly accessed by using a smartphone to link to the QR code
- The critical care directorate had a clear vision and strategy for the service.
- The vision and strategy were aligned to the trust’s true north objective where the patient is at the heart of everything that is done.
- There had been a significant culture shift where staff described critical care as a more cohesive unit. The differences between the neuro critical care staff and the general critical care staff had been overcome.
- Some pieces of equipment had not been serviced in accordance with their service due dates.
- Critical care staff did not carry out dementia assessments on patients directly, instead asking the dementia lead for the hospital to do so.
- Coverage from the critical care outreach team was not provided 24 hours a day, seven day a week. This was against the Guidelines for the Provision of Intensive Care Services, 2015.
- There was not a critical care pharmacist. This was against the Guidelines for the Provision of Intensive Care Services, 2015.
- There had been occasions when patients’ diaries had gone missing when being discharged from critical care. This meant that some patients could have missed a key component to their continued recovery.
- Patient flow remained a significant problem for the service.
- The service had not met its target of admitting all patients to the critical care unit within four hours of the decision to admit. There were significant delays discharging patients to the general ward environment
- Out-of-hours discharges were well above the 6.3% target in all five months from April 2018.
- The critical care team did not have a wide range of service level agreements with organisations that could assist with patients leaving the critical care environment.
- The critical care team did not have a designated lead for mental health.
10 August 2017
We did not inspect this service at this inspection as we rated it good in April 2016.
8 January 2019
Our rating of this service stayed the same, although we saw that improvement had been made. We rated it as requires improvement because:
- Some items of clinical equipment in the ophthalmology clinic were seen to be overdue for maintenance.
- The service did not monitor or audit the quality of patient records.
- Although there was a trust wide programme for providing training to staff regarding the Mental Health Act 1983, no staff in outpatients had received Mental Health Act training.
- Patients could not always access the service when they needed it. Overall waiting times from referral to treatment were worse than the national average.
- Patients referred on a cancer pathway were not always treated within 62 days of referral from their GP. The trust was performing worse than the England average in this area.
- The patient led assessment of the care environment audits for dementia and disability scored significantly worse than the national average across four outpatients areas that were assessed. The trust wide dementia strategy did not have any outpatient related actions.
- Department waiting times for individual clinics were not recorded or collected by the services.
- The service treated concerns and complaints seriously, investigated them and learned lessons from the results. However, trust wide, not all complaints were responded to within the timeframe set in the trust guidelines.
- The leadership and governance structures did not provide consistent and visible support to staff working in outpatients, although arrangements were in place to appoint to key management vacancies and address this moving forward.
- There were some discussions of governance at the team meetings within the outpatient department, however the interface between local and divisional governance was in its infancy. This meant that governance issues may not be consistently communicated between operational and divisional teams.
- The service had a vision for what it wanted to achieve. A new clinical strategy had been created since our last inspection and we were told that this had involved in depth discussions with divisions and services and had been aligned to the trust strategic objectives. However, we were unable to see the strategy due to it not being approved or ratified, and staff we spoke with had not been involved or engaged with this process.
- There were improvement projects being run within the department, however key staff from the departments were not always included as part of this, such as outpatient improvement meetings where performance information was reviewed.
- Action plans were not in place following poor performance in three areas of the Patient Led Assessment of the Care Environment audits.
- The trust did not always collect, analyse and use information well to support it activities.
- Staff recognised incidents and reported them appropriately. Lessons were learned and improvements made when things went wrong. Staff understood their responsibilities to raise concerns, to report safety incidents, concerns and near misses, and to report them internally and externally.
- Outpatient services were provided from premises where risks were assessed and mitigated, particularly where these had been identified because of the age and design of the buildings.
- The service had enough staff with the right skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
- The service controlled infection risk well. Staff kept themselves, equipment and the premises clean.
- The service provided mandatory training and key skills to all staff and made sure everyone completed it.
- Emergency equipment in all outpatient clinics was accessible and checked in line with trust policy.
- Medicines and medicines-related stationary were managed in a way that kept people safe; prescriptions were tracked and medicines were stored securely.
- The service had systems which promoted patient safety and we saw staff following these. For example, staff were completing the World Health Organisation safety checklist prior to dental extractions which ensured all patient safety checks had been completed.
- Patient’s physical, mental health and social needs were holistically assessed and staff delivered patient care in line with evidence based care and best practice guidelines.
- Staff had the skills, knowledge and experience to deliver effective care, support and treatment. Staff had access to appraisals, ongoing training and assessments of competency.
- All necessary staff, including those in different teams, services and organisations, were involved in assessing, planning and delivering care and treatment.
- Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.
- Staff gave patients enough food and drink, where appropriate, to meet their needs whilst in the outpatient department
- People were treated with compassion, kindness, dignity and respect, when receiving care. Feedback from people who used the service and those who are close to them was positive about the way staff treated people.
- Patients were given timely support and information to cope emotionally with their care, treatment or condition.
- Staff communicated with people so that they understood their care, treatment and condition. At the end of their appointment patients were informed of the next steps, such as when they would receive test results or when their next appointment would be and with whom.
- The service had taken action to address some issues around privacy and dignity since our last inspection. This included the creation of a patient assessment room so that patients no longer had to be weighed in corridors.
- Patients referred on a two week wait pathway for suspected cancer could expect to see a specialist within two weeks of referral from their GP and the trust was performing better than the England average in this area.
- Once a decision to treat had been made for a patient with a cancer diagnosis, they could expect to be treated within the operational standard of 31 days, and the trust was performing better than the England average in this area.
- The service took account of patients’ individual needs. The main outpatient departments were signposted, and the service had addressed issues identified in previous inspections relating to patient needs including the provision of a disabled access toilet in main outpatients.
- Since our last inspection, the central administrative service and outpatients had been merged as a standalone directorate. This meant that the majority of outpatient services were under one directorate, which would enable better governance of key performance figures such as mandatory training.
- Staff felt well supported at a local level by the department manager and individual line managers.
- The culture of the staff in the department was positive and open. Staff put patients at the centre of their work.
- The service demonstrated a commitment to improvement and innovation. There had been a significant improvement in the friends and family response rates and the successful roll out of the e-referral system.
- The Royal Sussex County Hospital outpatient department was piloting the Patient First Improvement Project for outpatient services across the trust. Staff we spoke with were enthusiastic and engaged with this process.