All inspections: Queen Alexandra Hospital

Pages 1 to 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at Queen Alexandra Hospital.

We inspected the maternity service at Queen Alexandra Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

The Queen Alexandra Hospital provides maternity services to the population of Portsmouth and surrounding areas.

Maternity services include an outpatient department, maternity day assessment unit, maternity triage, antenatal ward, labour ward, midwifery led birthing centre, two maternity theatres, postnatal ward, assessment observation unit, and ultrasound department. Between October 2022 and September 2023 4,874 babies were born at Queen Alexandra Hospital.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating of this hospital stayed the same. We rated it as Good because:

Our rating of Good for maternity services did not change ratings for the hospital overall. We rated safe as Good and well-led as Good.

We also inspected 2 other maternity services run by Portsmouth Hospitals University NHS Trust. Our reports are here:

Gosport War Memorial Hospital – https://www.cqc.org.uk/location/RHU10

St Mary's Hospital - https://www.cqc.org.uk/location/RHU02

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited the maternity day assessment unit, maternity triage, antenatal clinic, labour ward, birth centres, induction bay, maternity theatres, the antenatal and postnatal wards.

We spoke with 47 multidisciplinary staff, 3 women and birthing people and 1 birthing partner. We received 34 responses to our give feedback on care posters which were in place during the inspection.

We reviewed 10 patient care records, 8 observation and escalation charts and 10 medicines records.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Urgent and emergency services and medical care services at Queen Alexandra Hospital are provided by Portsmouth University Hospitals NHS Trust.

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

The emergency department is open 24 hours a day, seven days a week, with consultant-led emergency care and treatment provided to people across the city of Portsmouth and south east Hampshire. The trust was responsible for the delivery of care in the Urgent Treatment Centre (UTC) at Gosport War Memorial Hospital.

The emergency department is a recognised trauma unit. Major trauma patients are transported directly to the nearest major trauma unit. The department has a four-bay resuscitation area, with one bay designated for children. There is an additional resuscitation area, with two bays, for COVID patients – this is called the Star Suite.

There are two major treatment areas; majors A has 17 bays, majors B has 20 bays. In addition, there is a Fit-to-Sit area with 12 chairs in and an additional bay for clinical examinations.

There is a room designated for mental health practitioners to undertake mental health assessments.

The emergency department has a separate children’s treatment area with its own secure waiting room. This consists of an observed play area, a high dependency cubicle, an isolation room, five majors cubicles and four minors cubicles.

At the last inspection in July 2020, the medical care core service at Queen Alexandra Hospital was not rated because that inspection was a focused, responsive inspection. Previously, medical care at Queen Alexandra Hospital had been rated as requires improvement, in August 2018.

During our inspection we visited and inspected seven wards, including the acute medical unit (AMU), and the discharge lounge.

The maternity service at Queen Alexandra Hospital in Portsmouth is consultant led, providing care and treatment for women with high risk pregnancy or medical complications. The Mary Rose unit also known as (B5) is a co-located midwife led unit with two birthing pools offering midwife led maternity services to low risk women. The trust’s community team also offers a community and home birth service.

The maternity services provide care and treatment to women living in Portsmouth and the surrounding areas. There are approximately 5,000 babies born per year at Queen Alexandra Hospital.

The maternity services include hospital and community settings ensuring that women receive care across the antenatal, labour and post-natal periods. The service additionally includes the pre–natal diagnostic service such as fetal medicine, ante-natal screening facilities and the Ultrasound Sonography (USS) service.

The trust has three standalone maternity centres as well as a co-located maternity centre at Queen Alexandra Hospital;

• Blake maternity centre based at Gosport War Memorial Hospital

• Grange maternity centre based in Petersfield Community Hospital

• Portsmouth maternity centre based in St Mary’s Community health campus.

• Ward B5 co-located maternity unit.

The trust has a fetal medicine sub-specialty

We last inspected the maternity service between 15 and 17 October 2019. The report was published on 29 January 2020. The maternity service was rated requires improvement overall. Safe and effective were rated as requires improvement, caring and responsive were rated good and well led was rated requires improvement.

We carried out this unannounced focused inspection because we received information of concern about the safety and quality of the service.

We did not rate this service at this inspection. The previous rating of requires improvement remains.

How we carried out the inspection

As part of our inspection we visited the following areas within the maternity service: labour suite, midwifery led birthing unit, post-natal ward and the maternity day assessment unit.

We spoke with 30 members of staff including medical and midwifery staff, maternity care assistants, administrators and service leads. We observed care, handovers and meetings and reviewed four sets of maternity records.

We also looked at a wide range of documents including policies, standard operating procedures, meeting minutes, action plans, prescription charts, risk assessments and audit results. Before our inspection, we reviewed performance information about this service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

We carried out a short notice announced focused inspection of medicines management in response to increasing concerns highlighted by the incidents reported through national reporting systems and received by direct notification from the trust.

There had been two reported never events relating to wrong route administration of medicines and a series of medicines related discharge incidents had been reported.

Following the most recent inspection, published in January 2020, there was a should action relating to the adequate storage of medicines to avoid medicines errors in the medical care core service. We had found some inner locked controlled drug cupboards were untidy and controlled drugs were mixed with expired stocks and patients own medicines.

Following the inspection published in January 2020 we had not received evidence that showed clear action had been taken to address the concerns raised regarding medicines management in the report.

During this inspection we used our focused inspection methodology to look at medicines management across the hospital. We did not cover all key lines of enquiry and we have not rated this service.

We visited a selection of departments in order to review processes and confirm understanding of medicines management with staff.

We have reported our findings and evidence in relevant core service sections. Where evidence, for example trust governance processes, goes across core services we have reported these in the medical care section only.

During our inspection of 15 July 2020, we visited respiratory wards E7/E8, elderly care wards G1/G2/G3/G4 and C6, surgical ward E2, the acute medical unit and the emergency department (both adult and paediatric departments).

We spoke with 27 members of staff at all levels including nurses, ward managers, practice educators, matrons, pharmacists and pharmacy managers. We also looked at documentation including; patient medicine charts, incident records, quality audits and trust policies and procedures. During the inspection we also spoke with four patients.

After the onsite inspection we interviewed the chief pharmacist using remote video conference technology.

Due to risks associated with Covid-19, we did not visit any areas of the hospital where patients with Covid-19 were being treated.

During this inspection we found improvements regarding medicines management, safe storage of controlled drugs and patients own medicines.

We found:

Staff described the induction process which encompassed medicines management.
Pharmacy staff embedded within ward teams and wards.
Improved storage of medicines, including patients own medicines.
Improved availability of consumables to aid safe administration of medicines.
Improvements with the management and storage of discharge medications.
Patients told us drug rounds took place on time.
Incidents were reviewed and learning from recent medication incidents had been shared across the whole trust.
We saw an open culture with staff of different grades able to challenge each other and confirm medicine related queries.
Nursing and pharmacy leaders described improved and developing governance arrangements regarding medicines management, thematic reviews and safety.

However, there were some areas for improvement:

We saw variable adherence to trust policy regarding the security of keys for drug cabinets.
Staff reported the design and format of medicine charts made it challenging to sign and date the charts as required by trust policy.
We found there was an inconsistent approach across the trust relating to medicines and the discharge process.
We saw examples of poor compliance with prescribing and nurse record-keeping best practice on insulin charts.
We found a reactive approach to medicine related incidents and associated learning across the trust.
In one department we found a discrepancy with the recording of internal prescription forms.

We also saw examples of good practice:

Practice educators, employed by the trust, had developed and delivered both planned and ad hoc training to staff with regard to medicines management and administration. This included medicines management training for groups of patients that required specialist knowledge and skills to maintain good quality care.

Our rating of services improved. We rated them overall as good because:

Our rating of safe stayed the same. We rated it requires improvement because there were still significant concerns about safety in urgent and emergency care, medical care and maternity. However, there was improvement with regards to safety across the hospital.
Our rating of effective improved. We rated it as good because the hospital provided evidence based care, treatment and support to achieve good outcomes and promote a good quality of life. However, there were some inconsistencies between teams regarding information sharing, not all staff had appraisals and some services were outliers for some national audits.
Our rating of caring improved. We rated it as good because the hospital involved patients in their care and treated them with compassion kindness dignity and respect. We saw an improvement to caring treatment throughout much of the hospital including some examples of outstanding care. However, there were still some concerns about care provided and privacy and dignity in the urgent and emergency service.
Our rating of responsive improved. We rated it as good because the service provided care that met the needs of individual patients and the community. However, patients could not always access care and treatment in a timely way or in the right setting and there were delays to responding to more than 50% of complaints.
Our rating of well-led improved. We rated it as good because leadership, management and governance of the organisation had improved, enhancing the trust’s ability to deliver high-quality care, supporting learning and innovation, and promoting an open and fair culture. However, IT systems did not always support good care, not all risks were identified and there was a lack of pace regarding some improvements.
However, we have issued a warning notice to the trust regarding the urgent and emergency service's management of risk to self presenting patients, information about wait-times for self-presenting patients and ambulance waiting times.

This was a focussed, unannounced inspection of the emergency care service at Queen Alexandra Hospital. This inspection took place on 25 February 2019. We have not inspected all key lines of enquiry and so we have not issued any revised ratings of the urgent and emergency care service at this time.

Our key findings were:

We found there to be very limited clinical leadership of the emergency department, and in particular, the pit-stop area and ambulance reception area until the departmental Clinical Lead assumed control at approximately 16:00.

At times, we observed patients being handed between five different nurses with no clinical interventions occurring. These multiple handovers do introduce an element of risk for patients.

The nurse-in-charge was observed undertaking a range of task orientated activities including the physical movement of trolleys and patients; this distracted them from managing the emergency department and likely impacted on the poor flow across the emergency pathway.

Majors B lacked any noticeable senior clinical leadership; oversight of flow was by way of a band four associate practitioner (Nursing). Patients experienced delays in discharge because of a lack of suitably competent staff or the availability of equipment.

Flow through the pit-stop process was slow and at times became stagnated. There was confusion as to the purpose of the area with some patients receiving extended levels of care, again despite other patients waiting in the department for their treatment to commence. Again, there lacked any noticeable clinical leadership of the area which impacted on the smooth flow of patients through the emergency pathway.

The waiting room did not have sufficient seating to accommodate patients during peak times. Patients and visitors were observed standing for extended periods because of a lack of seats. We noted the streaming nurses to be competent at undertaking initial assessments. Patients did however experience delays in their care commencing, in part because of a congested emergency department. Patients also experienced delays in being initially assessed by the streaming nurse. There was a lack of robust assurance to support the effectiveness of the streaming pathway.

Hand hygiene practices and compliance remained poor with very limited hand decontamination taking place during the inspection.

There were occasions when the privacy and dignity of patients was not protected. During feedback we provided examples of occasions when nursing staff had failed to cover patients up; instead opting to half close cubicle curtains. Frail elderly patients were left for periods of time in Majors with no access to call bells, and left in unacceptable states of undress.

Patients were observed being moved through the department without being spoken to; staff routinely released the brakes on trolleys and started moving patients. Again, this was a common observation; it showed little in the way of positive communication between patients and staff.

However,

New bereavement facilities were a significant improvement on the facilities which had been found to be lacking at previous inspections.

The improvement board, located in the department, was observed to be well used with encouraging signs the views and voices of staff were being considered and heard respectively. There was a sense amongst staff we spoke with of improvements in relationships between the trust leadership team and staff working in the emergency department. Staff reported members of the executive team to be highly visible and supportive during times of surge.

The introduction of dedicated training time was welcomed by junior doctors across the department. The protected rostered non-clinical time for consultants to provide dedicated training on a weekly basis will be of great benefit to trainee doctors.

The use of the Hospital and Ambulance Liaison Officer (HALO) to oversee and co-ordinate the arrival of ambulances during times of surge, and the working relationships between the local NHS ambulance trust and Portsmouth Hospitals NHS Trust seemed robust. We observed good working relationships between ED staff and ambulance staff. There was clear prioritisation of patients who remained “On-board” ambulances due to limited capacity in the emergency department.

The service maintained a risk register which recorded known risks and rated them according to their potential impact. The risk register reflected the risks spoken about by staff in the department. The risk register further acknowledged the challenges inspectors identified during the inspection. There was a sense the leadership team were more aware of the challenges they faced than was the case in the previous inspection.

A range of staff including doctors, nurses, support workers, administrative staff and representatives from the local NHS ambulance trust reported they were able to raise concerns to local the management team without fear of retribution. Staff told us they felt supported and were encouraged to be open and transparent. There was an appetite among staff to improve the quality of care provided in the department.

Health professionals reported good multi-disciplinary working with positive relationships existing between doctors and nurses for example.

Many staff described their work colleagues as their second family and told us they would not want to work anywhere else. This continued to be the case at this inspection despite the department having experienced very busy periods over the preceding weeks.

Dr. Nigel Acheson

Deputy Chief Inspector of Hospitals

Our rating of services stayed the same. We rated it them as requires improvement because:

Within medical care, surgery, maternity and urgent and emergency services records of patients care and treatment did not always contain updated risk assessments and appropriate individualised care plans. Up to date records were therefore not always available to all staff that provided care.
Medicines were not managed safely in many of the core services we inspected. Medicines were not always stored securely, and medicine fridges were not consistently monitored to ensure medication was kept at required temperatures.
There were insufficient numbers of staff with the right qualifications, skills, training and experience to keep people safe and provide the right care and treatment in the medical care, children and young peoples and urgent and emergency services.
The design and layout of the emergency department (ED) did not keep people safe. The emergency department was frequently crowded and patients were queued in a corridor which became congested, sometimes hampering the movement of patients and equipment. People waited too long for initial assessment in ED and the flow through the department often impacted on the movement of patients into the hospital.
Within ED and surgical services infection prevention and control was not robust in some areas and some equipment and premises were not sufficiently clean. Within the surgical high dependency unit there was no facility to isolate patients and therefore there was a risk of the spread of infection.
Mandatory training rates in some areas fell short of the trust’s target meaning staff did not have the minimum training deemed essential for their roles.
Staff who worked in the surgery, urgent and emergency and medical care services did not fully understand their roles and responsibilities with regards to the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards (DoLS). Where appropriate, people’s mental capacity and DoLS were not consistently assessed and recorded in line with legal requirements. This had been identified at previous inspections and the trust had not given sufficient priority to ensure staff were suitably trained, competent and fully understood their requirements under the legislation.
Within the maternity service, guidelines had not been reviewed and updated in line with current best practice or national guidance. There was no robust practice that ensured completed audits were acted upon to improve practices.
Staff did not always provide patients with compassionate or respectful care in the emergency department. We observed a number of nursing staff who did not behave in a way which was consistent with the trust’s stated values or desired practice. Staff did not always provide emotional support to patients and relatives to minimise their distress.
In both medical and urgent and emergency care staff did not always involve patients and those close to them in decisions about their care and treatment. Some patients and relatives told us there was little communication from staff and they were not kept well informed about what was happening
Within maternity, medical and urgent care, services were not consistently planned or delivered to meet the needs of the local population.
In urgent and emergency services patients were not always able to access care and treatment in a timely way and in the right setting. The trust was consistently failing to meet national standards in relation to the time patients spent in the emergency department, the time they waited for treatment to begin and the time they waited for an inpatient bed. Patients waited too long for their treatment to begin. Facilities and premises were not wholly appropriate for the services delivered and we observed patients queuing in non-clinical areas such as corridors where there was a lack of comfort and privacy. Patients sometimes waited on ambulances outside of the emergency department due to congestion.
Within maternity, services were not routinely planned to ensure women could always deliver their baby in the preferred place of birth.
There were shortfalls in how the needs and preferences of different patients were met in medical and urgent care. Staff did not fully consider the needs of individual patients living with dementia or who had a learning disability.
Although the medical service treated concerns and complaints seriously and investigated them, there was lack of process to ensure learning from complaints was communicated and shared across all staff groups.
During our inspection the trust was in the processes of re-designing both their risk and governance structures. While some new processes were in place these had not been fully embedded. There were systems in place to identify, manage and mitigate risks however risks had not been fully identified and risk registers had not been fully completed within the urgent and emergency, maternity, medical and surgery services.
Governance processes did not consistently provide an effective systematic approach which identified areas for improvements and there was no overarching governance structure in the outpatients service.
The trust had identified improvements were required to address some poor cultures across the hospital. On the whole staff told us managers promoted a positive culture that supported and valued staff creating a sense of common purpose. Managers had the skills and abilities to run a service which provided high quality sustainable care However we observed some poor behaviours exhibited by senior nurses within the urgent and emergency service. In the outpatients department there was a poor culture where staff concerns were not always taken seriously and there was low staff morale in some areas.
Information systems within urgent and emergency services, maternity and medical services did not support effective sharing of patient information or support comprehensive recording or analysis of data.

However

In critical care, diagnostic imaging, outpatients and children and young people staff kept clear, up to date, detailed records of patients care and treatment.
Overall in critical care, children’s and young people, end of life, outpatients and diagnostic imaging services people were protected from abuse and avoidable harm.
We identified comprehensive systems where in place to keep people safe and risks were regularly assessed and updated.

The services controlled infection risk well and staff kept themselves and equipment clean.
Within critical care, end of life, outpatients and diagnostic imaging there were sufficient numbers of suitably trained and competent staff available to care for patients safely.
Staff in urgent and emergency, services for children and young people, end of life care, diagnostic imaging and critical care provided care and treatment based on national guidance. Managers checked to make sure staff followed guidance and audits were undertaken and acted upon to improve services. Staff, teams and services worked well together to provide effective care for patients.
We observed exceptional care in both children’s and young people’s services and critical care. We observed staff going ‘above and beyond’ to ensure patients and their relatives were supported and involved in treatment plans.
Overall in the services other than patients were treated with care and compassion. Patients and their relatives were complimentary about the care and treatment they received.
Staff involved patients and those close to them in decisions about their care and treatment.
Staff offered emotional support to patients and their relatives.
In most services we inspected we found people were able to access the service when they needed them. The services had been planned and provided in a way that met the needs of local people.
The services mostly took account of people’s needs and were flexible to encompass individual needs and preferences.
In critical care there was a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way that met those needs, which was accessible and promoted equality.
Effective governance processes which monitored the quality of services provided were evident some services
Within critical care there was a fully embedded systematic approach to improvement. The service was forward looking, promoted training and clinical research and encouraged innovations. The service made effective use of internal and external reviews and learning was shared effectively and used to make improvements. There was a record of shared working locally, nationally and internationally.
Some services engaged well with patients, staff, and the public and local organisations to plan and manage appropriate services

We undertook this unannounced focussed inspection in response to concerns about the safety and quality of patient care during the winter months, when the trust has been under extreme pressure. Increased demand for services, a high incidence of flu, and poor outflow from the hospital had resulted in high bed occupancy and insufficient inpatient capacity in the hospital. This has led to crowding and extended waits for patients in the emergency department and has resulted in inpatients being cared for in outlying ‘escalation’ areas, not designed for inpatient care.

We did not rate this service due to the limited focus of our inspection. We looked at specific key lines of enquiry under three of our five key questions; Is the service safe, responsive and well led?

We found:

The trust’s escalation status during the months of December 2017, January and February 2018 indicated that they experienced significant and extreme operational pressures, due to insufficient capacity to meet demand for services, for much of this time. This put patients at risk.
The emergency department was frequently crowded; patients were cared for in corridors and in ambulances outside the emergency department. Patients experienced delays in their assessment, treatment and admission to a hospital bed. When there was insufficient inpatient capacity, patients were cared for in unsuitable outlying and escalation areas, some of which were not designed for inpatient care.

There were frequent delays in ambulance staff handing over care of patients to emergency department staff. This included a significant number of delays of over one hour, known as black breaches, and ambulance staff being unable to offload their patients. This not only delayed patients’ assessments in the emergency department, but also delayed ambulance staff who were not available to respond to further calls.

Patients were not always promptly assessed on arrival in the emergency department to identify or eliminate any serious or life threatening illness or injury. Processes to stream and triage patients on their arrival in the emergency department were not operating efficiently or effectively.

Staff in the emergency department did not consistently complete safety checklists so we could not be assured that patients were regularly monitored to ensure their on going safety and comfort.

Patients experienced lengthy delays in the emergency department. The trust was consistently failing to meet the national standard which requires that 95% of patients are admitted transferred or discharged within four hours. A significant number of patients waited up to12 hours in the emergency department from the time a decision was made to admit them to the time they were admitted. The trust’s performance was significantly worse than the England average.

The emergency department was not adequately staffed at night. The department had assessed that two middle grade doctors were required at night but currently night time cover was provided by only one. Junior medical staff felt unsupported and vulnerable at night and consultant staff were frequently working additional hours to support their junior colleagues. It was felt that this was not sustainable.

Patients were frequently accommodated in corridor areas of the emergency department, when all assessment and treatment areas were full. These areas were not suitably equipped and did not facilitate easy monitoring of patients held there. Queuing caused congestion, which hampered the movement of patients, staff and equipment in these areas. Despite the efforts of staff, patients’ comfort, privacy and dignity needs could not be met.

Inpatients were frequently cared for in unsuitable outlying areas of the hospital. This meant they were admitted to a ward in a speciality other than that which they were assigned to. We could not be assured that staff caring for these patients had the necessary skills and experience to meet these patients’ needs.

Patients were frequently cared for in departments (designated as escalation areas) which were not designed, equipped or staffed for inpatient care.

There was a lack of effective governance to provide assurance that escalation areas were being used in a safe and appropriate way.

The regular and frequent use of day case departments as escalation areas impacted on their ‘business as usual’ activity, their ability to function efficiently, and resulted in some elective day case procedures being cancelled.

Patients experienced frequent bed moves, often at night, which impacted on their comfort and wellbeing.
The trust did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The trust’s winter resilience plan had not been effective and had not yielded the required capacity and flow to manage the significant pressures the trust faced during the winter months. We questioned the effectiveness of the plan, the apparent lack of robust challenge and review in the face of failing systems, and whether planning for winter had begun soon enough.

Although the risks associated with poor flow and capacity were understood at a senior level in the trust, the corporate risk register did not accurately or fully reflect the serious risks to patient safety and quality.
Appropriate and accurate information was not always available or used effectively to monitor, manage and report on quality and safety. The trust was unable to provide us with key data, which could be used to provide assurance of quality and safety and inform and drive improvements.

There was a lack of assurance in regard to the effectiveness of safety systems in the emergency department.

However:

There was commitment to deliver improvement at a senior level in the trust. There were many streams of work on going to change internal processes to improve patient flow and operational performance. Alongside this there was a system-wide capacity and demand review led by commissioners to establish the level of capacity required to improve flow across the health and social care system.
There was evidence that staff in the emergency department consistently used a screening tool to identify suspected sepsis and followed guidance to ensure prompt treatment.
Patients attending the emergency department with acute mental illness were assessed using a recognised mental health risk assessment. The trust monitored compliance with this and had performed at above 90% since November 2017.
There was a dedicated discharge ambulance, which had been funded from December 2017 through to March 2018, which staff told us was very helpful in facilitating patient discharges and improving patient flow.

Importantly, the trust must:

Review the effectiveness of the winter resilience plan and its failure to yield sufficient capacity to improve patient flow and reduce crowding in the emergency department.
Review the corporate risk register to ensure the risks associated with capacity are fully captured and actions to mitigate risk are regularly reviewed by the board.
Set clear targets and milestones, review progress and challenge failure.
Improve monitoring systems; use timely and appropriate data to provide assurance of quality and safety and drive improvement.
Continue to drive initiatives to reduce length of inpatient stay and improve patient flow.
Fully embed new systems in the emergency department used to assess and monitor risks to patients, and audit their effectiveness.
Take steps to ensure the emergency department is adequately staffed at night.
Review the governance systems in relation to the use of escalation areas, to provide assurance that they are appropriately used, and appropriately staffed and equipped.

We have written to the trust outlining our concerns and asked that they respond to these urgently. We will follow up on these concerns at our scheduled comprehensive inspection of trust services in April 2018.

Professor Edward Baker

Chief Inspector of Hospitals

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;

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.
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.
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.
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

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

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

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

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

Portsmouth Hospital NHS Trust provides a full range of elective and emergency medical and surgical services to a local community of approximately 675,000 people who live in Portsmouth city centre and the surrounding areas of South East Hampshire. It provides some tertiary services to a wider catchment of approximately two million people. The trust also provides specialist renal and transplantation services and is host to the largest of five Ministry of Defence Hospital Units in England. Ministry of Defence staff work alongside NHS staff in the trust but have a separate leadership command structure. The trust employs over 7,000 staff.

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 and over 429,000 outpatient attendances each year. There are 6,000 staff employed by the Trust and approximately a further 1,000 are employed by a provide provider in portering, cleaning, maintenance and catering services under a PFI arrangements. The trust has not yet applied for foundation status.

The trust provides outpatients services in community hospitals at Gosport War Memorial Hospital, Petersfield Community Hospital and St Mary’s Hospital. Gosport War Memorial Hospital has a minor injuries unit, inpatient rehabilitation on Ark Royal Ward (16 beds) and the Blake Maternity Unit (six beds). Petersfield Community Hospital has inpatient rehabilitation on Cedar Ward (22 beds) and the Grange Maternity Unit (four beds). There are eight satellite renal dialysis services, with six across Hampshire, one in Salisbury (Wiltshire) and one in Bognor Regis (West Sussex).

We undertook this inspection of Portsmouth Hospital NHS Trust as part of our comprehensive inspection programme.

Services provided at Queen Alexandra Hospital include accident and emergency, medical care, surgery, critical care, maternity and gynaecological services, children and young people’s services, end of life care, and outpatient and diagnostic services. These eight core services are always inspected by the Care Quality Commission (CQC) as part of its new approach to the comprehensive inspection of hospitals. The services provided in community hospitals are integrated into the trust clinical and management structures; we have incorporated these within the core service areas.

The inspection took place between 10 and 13 February 2015, with additional unannounced visits on 25 and 26 February and 2 March 2015. The full inspection team included CQC managers, inspectors and analysts, doctors, nurses, allied healthcare professionals, ‘experts by experience’ and senior NHS managers.

Overall, we rated this trust as ‘requires improvement’. We rated it ‘outstanding’ for providing caring services and ‘good’ for effective services, but the trust ‘required improvement’ for providing safe, responsive and well-led services.

We rated critical care services as ‘outstanding’; maternity and gynaecology, care of children and young people and Outpatients and diagnostic imaging as ‘good’. Urgent and emergency services, medical care, surgery, end of life care, as ‘requires improvement’.

Our key findings were as follows:

Are services safe?

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.
Patients were sometimes assessed according to the time that they arrived in the ED and not according to clinical need. Some patients with serious conditions waited over an hour to be clinically assessed, which meant that their condition was at risk of deteriorating. Many patients waited in corridors and in temporary bay areas. Patient in these areas and in the majors queue area were not adequately observed or monitored.
The trust had introduced an initial clinical assessment by a healthcare assistant to mitigate risks, but this was not in line with national clinical guidelines.
The environment in the ED did not enhance patient safety. The ED had been extended and its majors treatment area and children’s treatment area were now a considerable distance from the resuscitation room. Staff had to negotiate crowded public areas in order to gain access to the resuscitation room. Patients were in areas, some temporary, where there was no access to essential equipment or call bells, and there was no safe area to support patients with a mental health condition.
Nurse staffing levels were regularly reviewed using an appropriate and recognised management tool. There were high vacancy levels across the hospital, notably in the ED, the medical elderly care wards and the surgical assessment unit, where staffing levels were not always met and there were insufficient staff for the number of patients and the complexity of their care and treatment needs. Staffing levels were reviewed on a shift-by-shift basis and according to individual nursing requirements. Staff were transferred across units on a shift basis to try to reduce risk, but this affected the availability of expertise and continuity of care in other areas. There was high use of internal bank and agency staff, particularly on night shifts. Agency staff received an induction and safety briefing on wards before beginning their shift.
Midwifery staff ratio was an average of 1:29 which was in line with the England average. The maternity dashboard clinical scorecard showed that the ratio had varied from 1:27 to 1:33 over the past 10 months. This reflected the actual number of midwives to birth and did not include maternity support workers The recommendations of the Royal College of Obstetricians and Gynaecologists’ guidance (Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour, October 2007) that there should be an average midwife to birth ratio of 1:28. Midwives, however, were working flexibly and one to one care was being provided for women in labour and with additional staff or strategies were provided to ensure the safety of antenatal and postoperative care.
The trust had higher numbers than the England average of consultant medical staff in post, although it was not meeting national recommendations for consultant presence in maternity and for consultant staffing in end of life care. The trust had fewer middle-grade doctors and junior doctors compared with the England average and their workload was high in some specialties. For example, surgery and consultants in the ED were being stretched in an unsustainable way to cover posts and ensure safe services.
Medical patients who were in the ED overnight and those on non-medical wards (outliers) were not always reviewed by specialist doctors in a timely way.

Most services had a culture of openness and transparency. Staff understood the principles of duty of candour, and information, guidance and training were available to support staff to understand and implement the requirement of being open when things go wrong.

The NHS Safety Thermometer is a monthly snapshot audit of the prevalence of avoidable harms, including new pressure ulcers, venous thromboembolism (blood clots), catheter-related urinary tract infections and falls. The information was monitored throughout the hospital and the results were displayed for the public in clinical areas. The prevalence of catheter-related urinary tract infections was consistently low but the incidence of pressure ulcers and falls had not reduced but was increasing. Some pressure ulcer incidents were deemed unavoidable. However, the trust had not met its own targets for reduction in pressure ulcers and falls. There was evidence of actions taken in response but this varied; for example, the falls care bundle was used on medical wards but this was not used consistently on surgical wards.

Staff were reporting incidents and lessons were learnt and practice was changed as a result. On one surgical ward, however, staff were concerned that disciplinary action could be instigated unfairly for pressure ulcer incidents. The trust had said that staff may face disciplinary action if they failed to care for patients appropriately, but not if it was beyond their control. Recent hospital data, however, indicated a decrease in the reporting of pressure ulcers on this ward.
The wards were visibly clean, and infection control practices were followed. The trust infection rates for MRSA and Clostridium difficile were within an expected range and the trust had not had a norovirus outbreak for five years. However, infection control arrangements in the surgical high care unit did not meet professional guidelines.
Items of necessary equipment such as pressure-relieving mattresses, blood pressure monitors and medication pumps were not always readily available for patients when required. This meant that patient care and treatment could be delayed or adversely affected. The cardiac arrest call bell system in the E level theatres did not identify the location in which an emergency took place.
Medicines were stored safely. However, the staff on a unit designated as an escalation ward told us they sometimes ran out of essential medications and had to borrow them from another ward. As a result there were delays in the timely administration
Patients whose condition might deteriorate were being identified through the use of the early warning score. The trust had an electronic monitoring system for patients and this was used effectively, for example for the critical care outreach team to prioritise patients. However, early warning scores were not being used as part of bed management allocations.
Staff were not always aware of standardised protocols or agreed indicators for pre-assessment to support them in making decisions about the appropriateness of patients for day case surgery
Safeguarding processes to protect vulnerable adults, and children and young people were embedded across the hospital. There was a recent safeguarding policy and procedure, staff had attended appropriate training, and there was a culture of appropriate reporting.
Staff were undertaking mandatory training and progress towards trust targets was good for many staff disciplines with the exception of medical staff where attendance rates were low.
The completion of patient records varied in some areas it was very good and in some places information could be missing, and it was not clear if this was part of the electronic or paper record. New end of life care plans were being piloted in response to the national withdrawal of the Liverpool Care Pathway. However, where these care plans were not used, the documentation, of care was not appropriate to properly assess and make decisions about patient care and treatment. Do not attempt cardiopulmonary resuscitation forms were not always appropriately completed.

Are services effective?

Services provided care and treatment in line with national best practice guidelines, and outcomes for patients were often better than average or improving. However, operating procedures in theatres needed updating and end of life care guidance needed to be further developed across the trust. The trust needed to improve the management of stroke patients and it was not meeting the target for 90% of stroke patients to be cared for in a stroke unit.
There was good participation in national and local audit programmes, although the trust did not fully participate in the National Care of the Dying Audit – Hospitals 2013/14.
Patient outcomes, as measured by national audits, were either better than or similar to the England average; where they were below the average they were improving. Each clinical service centre had a quality dashboard to monitor patient safety outcomes although these needed further development to focus on clinical outcomes.
The trust’s mortality rates were within the expected range.
Patients received good pain relief, in particular after surgery, in critical care and in end of life care. There were some delays, however, for patients who had arrived by ambulance in the ED.
Patients, particularly older patients, were supported to ensure their hydration and nutrition needs were met. Although there were areas of concern identified on ward E3 for all patients and in end of life care on the acute medical unit.
Staff were supported to access training and there was evidence of staff appraisal, although clinical supervision for nursing staff was under developed.
Staff worked in multidisciplinary teams to centre care around patients. Physiotherapists on medical wards told us that although they did see medical patients, they could not always provide sufficient therapy sessions for their individual requirements.
Discharge summaries giving GPs information on patient care were delayed. The trust was not meeting Department of Health standards for letters to be sent within 48 hours and there could be delays of up to two weeks. Renal outpatient letters were taking 35 days to be typed and sent to the patients’ GP because the renal department had a separate IT system from the rest of the trust. This had caused significant delay in GPs receiving updated information regarding their patients’ treatment.
Seven-day consultant-led services were developed in all areas, with the exception of outpatient services. Support services such as imaging, pharmacy, physiotherapy and occupational therapy were also available seven days a week.
Staff had appropriate knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards to ensure that patients’ best interests were protected. Guidance was available for staff to follow on the action they should take if they considered that a person lacked mental capacity. Notification of Deprivation of Liberty Safeguards applications were correctly submitted to the Commission.
Critical care services demonstrated outstanding innovations in delivery of effective care, ensuring there were robust systems to deliver and monitor care to high standards by highly skilled staff.

Are services caring?

The trust had a culture of compassionate care. Staff were caring and compassionate, and treated patients with dignity and respect. Many patients and relatives told us that although staff were very busy, they were supported with compassion, patience, dignity and respect, with time being given to the delivery of personalised care.
Staff were responsive to patients’ emotional care needs. Emotional care was also provided by the chaplaincy department and patients and relatives told us show much they valued this service, which had supported them at difficult times.
We observed outstanding care and compassion in critical care, maternity and gynaecology and children and young people’s services. Staff were person-centred and supportive, and worked to ensure that patients and their relatives were actively involved in their care.
Data from the NHS Friends and Family Test demonstrated that patients were satisfied with the care they received. Overall results were above the England average and the trust was in the top quarter of all trusts. Results were clearly displayed in ward areas.
Patients’ experiences of care was variable, however. There were concerns, particularly for patients on the surgical ward E3 where staff were busy and essential and timely personal care was not delivered and patient dignity and confidentiality was not always maintained. Some patients with end of life care needs on wards E3 and the acute medical unit did not always get the timely care the families thought necessary or appropriate, and care was sometimes given by relatives instead.

Are services responsive?

The trust was not meeting national targets for the timely handover of patients from ambulances. The trust had not met the emergency access target for 95% of patients to be admitted, discharged or transferred from A&E within four hours since November 2013. There was no hospital-wide escalation response to overcrowding in the ED to improve flow in the hospital.
Specialty teams were often delayed in seeing patients who had been in the ED overnight.
Bed occupancy across the hospital was 92% (January 2014 to March 2015). This was consistently above both the England average of 88%, and the 85% level at which it is generally accepted that bed occupancy can start to affect the quality of care provided to patients and the orderly running of the hospital.
Patients were not always admitted to wards according to their clinical needs and were being placed where beds became available. This meant that the necessary level of specialist expertise and experience may not always have been available to them.
Patients could be moved several times during their admission. This happened at night and for non-clinical reasons. The trust identified that older patients, patients with high dependency and acuity needs and end of life care patients should not be moved. However, older patients, including patients who were confused, or living with dementia and who may have had complex conditions, were being moved.
Patient moves were tracked but the information was not used effectively at ward level. Some medical staff told us they did not always know where to find them and this could lead to a delay in treatment. Patients’ relatives also told us that they had difficulty finding patients.
The critical care unit experienced discharge delays out of hours and delays to admission because of pressure on beds in the hospital. The unit had taken action to mitigate risks and this included comprehensive discharge summaries and a retrieval team who care for patients on the ward while they waited for admission.
The national referral to treatment time target for 90% of patients to have surgery within 18 weeks was not met overall, although this was a planned fail in agreement with commissioners to address patients on the waiting list. Targets were not achieved in general surgery, trauma and orthopaedics, urology and ENT. In relation to urology, the trust attributed delays to limited staffing capacity, which had led to the cancellation of over 200 elective surgeries and a reduction in the number of elective patients admitted.
Capacity issues within the hospital resulted in elective procedures being cancelled. Some patients told us their operations had been cancelled several times; although the majority did go on to have their surgery within 28 days.
The trust was meeting the cancer waiting time target for 93% of patients to have referral from a GP to see a specialist within two weeks. The trust was also meeting the target for 96% of patients to have diagnosis to definitive treatment within one month (31 days). The trust had also met the target for 85% of patients to be waiting less than two months (62 days) from referral to start of treatment from April 2014 to December 2014. However, the target had not been met in January 2015 to March 2015.
The trust was meeting referral-to-treatment time targets for most outpatient specialities but there were long waiting times for patients attending colorectal clinics, back pain clinics and the gastroenterology clinic. There was evidence of action being taken to address the long waits.
Patient had timely follow up outpatient appointments although there were patients waiting beyond their due date in colorectal surgery, orthopaedic and gastro specialities. Ophthalmology had a high number of patients with significant delays to follow-up and who were on an outpatients waiting list. This had been on the service risk register since 2009, but as a result of a serious incident requiring investigation that occurred as a result of this backlog, it was escalated to the trust risk register In April 2013. The waiting list had been reduced but the number of patients waiting was still significant
The trust was now meeting the diagnostic waiting time target after extending the service times.
Discharge plans were expected to commence on admission but this varied across wards, as did planning around simple and complex discharges. There were some delays in discharging patients and patients told us they had to wait a considerable time (hours) for their medications to take home. A discharge lounge was available and was used appropriately. Patients were able to have food and drink while waiting for discharge.
The trust had delayed transfers of care and national data showed the main causes of delayed transfers of care at this trust (which could prevent a patient from being discharged) included waiting for nursing home places, waiting for social care arrangements, and patient/family choice. The trust was working with its partners to alleviate this problem and data published by NHS England (December 2014 to January 2015) demonstrated that the trust had a comparatively smaller number of delayed discharges compared with other similar trusts.
The integrated model which the trust maternity service runs (Nurture programme) allowed flexible use of staff to maintain 1:1 care in labour. This had kept women’s denied choice of place of birth to a minimum.
There was a rapid access discharge service within 24 hours and the number of patients discharged to their preferred place and who were able to die at home was higher than the national average.
In most clinical areas there was adequate provision to protect a patient’s privacy and dignity. However, this was not the case for ambulance patients waiting in corridors in the emergency department and also for patients in the dialysis unit on the Isle of Wight. Patients attending for outpatient appointments had to walk through the dialysis unit where patients were receiving treatment in their beds to attend their consultations. In ophthalmology department at Queen Alexandra Hospital, patients receiving treatment (pupil dilation) were being treated in a room that was glass walled, enabling any person walking by to observe a patient being treated.
Staff across the hospital demonstrated a good understanding of how to make reasonable adjustments for patients with a learning disability. However, care for patients living with dementia varied. Training, assessment, the use of the dementia care bundle and making reasonable adjustments to reduce stress and anxiety, we being used but not consistently. In some areas the care needs of people living with dementia were not always met. Some areas demonstrated excellent examples of the care such the ‘memory lane’ service on the elderly care wards. This was held once a week and included engaging patients in remembering their past times by means of music, games, reading material and communication.
An interpreting service was available for people whose first language was not English and the service was used. All information for patients was only available in English. In radiology, easy-to-read leaflets were available for patients with a learning disability, where language style had been adjusted and pictures used to explain procedures. We did not see any other information in an easy-to-read format.
Information from complaints was reviewed and acted on; although some patients told us they were not always given information about how to make a complaint.

Are services well-led?

Many staff were committed to the values of the trust: ‘best hospital, best people, best care’.
Most services did not have a formal written strategy, although aspects of future plans could be verbalised by staff. Staff in the ED were not aware or confident that there were clear plans and strategies to address significant concerns in a timely way.
Departmental strategies and vision were generally well understood, except in medicine where no discernible long-term strategy could be described by staff.
Clinical governance arrangements were well developed to assess and manage the quality of service provision. However, better management of risks was needed. Not all risks were appropriately identified, escalated and mitigated across service areas. The pressures in the ED were long-term and significant risks to patients had not been appropriately managed.
Many staff told us overall they had good support from the local clinical leaders, for example ward managers and consultant staff. However, there were concerns, including: the support from managers at senior levels, the capacity of managers in the ED, of some ward managers and the fragmentation of management in end of life care.
Many staff commented on the visible and approachable presence of the chief executive officer.
Staff were positive and proud to work for the trust; many staff had worked in the trust for their entire career. There was an open and honest culture and a strong sense of teamwork across most areas. However, there were a few areas of concern and these were identified as the lack of hospital support and clinical engagement for the pressures in ED, the lack of integrated working across clinical service centres, the concern by staff on one ward of being unfairly disciplined for pressure ulcer incidents in surgery and the dysfunction team working in the colorectal team.
There were innovative approaches to patient and public engagement across services, which included survey, focus groups, consultation, committee representation and the use of social media.
Staff engagement was good, and the latest staff survey showed significant improvement in key areas. The trust was in the top 20% of trusts for staff engagement. The Listening in Action programme was cited as a particular example of involving staff in improving the quality of their services.
There was a strong and visible commitment to research and development.
Innovative ideas and approaches to care were encouraged and supported, and the trust was the recipient of many awards, both national and international, for the excellence of some of its services.
The leadership in the critical care unit was outstanding.

.

We saw many areas of outstanding practice including:

A ‘Coffee and conversation’ group was held for patients in the stroke wards. This gave patients an opportunity to share their experiences, provide peer support and education. Patients were also given information about support available in the community.
There were good arrangements for meeting the needs of patients with a learning disability, particularly in theatres. The staff showed good awareness of the specialist support that patients with complex needs sometimes require. Staff used a specialist pain management tool for assessing pain levels in patients who could not verbally communicate their experiences of pain.
The trust had developed bespoke safeguarding training modules to meet the specific needs of staff and their working environments. For example, there was safeguarding training specific to the issues identified for staff working in theatres and specific types of wards.
The practice of daily safety briefings on the intensive care unit (ICU) ensured the whole multidisciplinary team was aware of potential risks to patients and the running of the unit.
In the ICU there were innovative approaches to the development and use of IT systems and social media. Secure Facebook and Twitter accounts enabled staff to be updated about events affecting the running of the service. This included information about risks, potential risks and incidents. Electronic ‘Watch out’ screens in the unit displayed information about incidents and the unit’s risk register. The education team advertised information about training opportunities on the education Twitter account.
In the ICU, innovative electronic recording systems supported the effective assessment and monitoring of patients.
The electronic monitoring system used in the hospital for monitoring patients’ vital signs enabled staff to review patient information in real time and the outreach team to monitor patients on all wards and prioritise which patients they needed to attend to. This early warning system was developed in response to delayed care in deteriorating patients. Its adoption has saved over 400 deaths, and overall has reduced our mortality levels by 15%.
Innovative and practical planning of emergency trolleys meant that all equipment needed to manage a patient’s airway, including equipment to manage difficult airways and surgical equipment, was stored in a logical order and was immediately accessible.
In most critical care services, beds are positioned to face into the ward. On some units beds were positioned so that conscious patients could look out of the window. Queen Alexandra Hospital’s critical care unit had learnt that some patients were frightened when they could not see the ward and wanted to be able to see into the unit for reassurance. In response, the unit had equipment that could position beds at an angle so patients could see out of window as well as into the unit.
In response to difficulties in recruiting middle-grade (registrar) doctors, the ICU in partnership with the University of Portsmouth was developing a two-year course in Advanced Critical Care Practice (ACCP). The planned outcome from this course was that Advanced Critical Care Practitioners would be employed in the unit to fulfil some of the medical tasks and release medical staff to do more complicated work. This was the first initiative of this kind in the UK.
To reduce the risks for patients requiring critical care who were located elsewhere in the hospital, the ICU had an innovative practice of retrieving the patient from elsewhere in the hospital. Patients admitted into the emergency department (ED) requiring critical care were treated by the critical care team in the ED, before admission to the unit. The same practice was followed for patients requiring admission to the unit from the general wards.
The innovative use of grab packs meant staff had instant guidance about what to do in the event of utility failure, emergency telephone breakdown and major incidents.
The critical care unit had developed their own innovative website that included educational information and guidance documents. There was guidance, tutorials and podcasts from recognised intensive care organisations, Portsmouth intensive care staff and other intensive care staff about the use of intensive care equipment and procedures. This was accessible to staff, staff from other trusts and the general public.
A perineal clinic had been designed and implemented to provide outpatients care and treatment to women who had sustained third- and fourth-degree tears following delivery. This service enabled women to access treatment sooner than under previous systems. Staff also provided treatment, support, information and education to women who had experienced female genital mutilation.
There was a telephone scheme for women who had experienced complex or traumatic deliveries to talk about, and have a debrief conversation, with a midwife following their discharge. The outcomes from the conversations were used as part of the governance processes and this had demonstrated a reduction in the number of complaints.
A mobile telephone application (app) had been developed by the trust and the Chair of the Midwife Liaison Committee together with women who used the services. The app provided information on choices of place of birth and was being developed to include additional information. The app won an award from NHS England in the excellence in people category and the service had also been recognised with an innovation award from Portsmouth Hospitals NHS Trust.
The multidisciplinary team in the children’s and young people’s services had made a commitment to creating an open culture of learning, reflection and improvement. This included listening to and empowering and involving staff, children, young people and their families. We found all staff, at all levels, were involved in working towards this goal and this was having a positive impact on improving the safety and quality of services for children, young people and their families.
There was a new initiative called a ‘talent panel’, which was a mechanism to discover and develop staff, both for individual career development and the future sustainability of the service. Staff of all grades were encouraged to submit their career aspirations to a panel so that steps to support them could be identified.
The trust had introduced a volunteer programme for people who wanted to work as a chaplain’s assistant. Volunteers were trained on how to support patients through visiting them. Through this training programme, the trust had over 50 volunteers coming to help and support patients.
The trust received a national award for clinical research impact. The award recognised the trust “Research in Residence Model” and its ability to harness clinical research to improve services and treatments for its patients. The trust identified the development of the early warning system, mobile application for pregnant mothers (cited above), and developing methodologies to reduced respiratory exacerbations and admissions and detect upper and lower gastrointestinal cancer more effectively.

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

Importantly, the trust must ensure that:

Patients are appropriately assessed and monitored in the ED to ensure they receive appropriate care and treatment.
Ambulance patients are received and triaged in the ED by a qualified healthcare professional.
There are effective system to identify, assess and manage the risks in the ED.
There is an adequate supply of basic equipment and timely provision of pressure-relieving mattresses.
The cardiac arrest call bell system in E level theatres is able to identify the location of the emergency.
Medication is prescribed appropriately in surgery and is administered as prescribed in gynaecology
The emergency resuscitation trolley on the gynaecology ward is appropriately checked.
Appropriate standards of care are maintained on ward E3 and the acute medical unit.
There is a hospital wide approach to address patient flow and patient care pathways across clinical service centres.
Patients’ bed moves are appropriately monitored and there is guidance around the frequency and timeliness of bed moves so that patients are not moved late at night, several times and for non-clinical reasons.
Patients are allocated to specialist wards, when clinical need requires this, and medical outliers are regularly reviewed by medical consultants.
Nurse staffing levels comply with safer staffing levels guidance.
There are adequate numbers of medical staff on shifts at all times.
All wards have the required skill mix to ensure patients are adequately supported by competent staff.
Patients are risk-assessed before providing treatment for deep vein thrombosis.
The falls action plans are followed in a consistent way across the medical services.
There is compliance with the WHO Surgical Safety Checklist.
Staff awareness of standard protocols or agreed indicators for pre-assessment improves to support them in making decisions about the appropriateness of patients for day case surgery.
Staff on all wards are able to raise concerns above ward level, particularly when this impacts on patient care, and there is a response to these concerns.
Discharge summaries are sent out in a timely manner and include all relevant information in line with Department of Health (2009) guidelines.
Staff observe recognised professional hand hygiene standards at all times.
The surgical high care unit is risk-assessed for infection control risks.
Medical and dental staff complete mandatory and statutory training.
Nursing staff receive formal clinical supervision in line with professional standards.
Nursing handovers provide sufficient information to identify changes in patients’ care and treatment and to ensure existing care needs are met.
Nursing staff are appropriately trained in the safe use of syringe drivers.
All pharmacists have an appropriate understanding of insulin sliding scales and where such information should be recorded.
Patient confidentiality is protected so that patients and visitors cannot overhear confidential discussions about patients’ care and treatment.
Records are kept relating to the assessment and monitoring of deteriorating patients in recovery.
Patient records and drug charts are complete and contain all required information relating to a patient’s care and treatment.
Do not attempt cardiopulmonary resuscitation forms are completed appropriately and mental capacity assessments, where relevant, are always performed.
Patient records are stored so that confidentiality is maintained.
The trust fully participates in all national audits for which it is eligible on end of life care.
Action is taken to improve the leadership where there are services and ward areas of concern.

In addition the trust should ensure that:

Drugs trolleys are not left open or unsupervised in patient bay areas.
Medicines reconciliation is based on one or more sources of information to determine which medicines an individual patient has been prescribed outside the hospital and still requires while in hospital.
The ‘This is me’ booklet for patients living with dementia is used appropriately by staff.
There is a ‘flagging’ system for identifying patients with a learning disability.
Patients are able to take the medicines they are given and do not have problems opening medication packaging.
Staff are aware of protocols for recording opening or expiry dates on part-used medicines.
Pharmacists initial all changes to patient prescriptions.
Staff in surgery understand their roles and responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
Clinical governance arrangements include Ministry of Defence staff so these staff are aware of quality and safety issues when working on wards.
The need for a dedicated dietician is reviewed on the ICU.
Patient clinical details are recorded in a clear and consistent manner so that there is no risk of information being missed.
Documentation regarding fluid intake and output, and intentional rounding, is appropriately completed to demonstrate that care is delivered.
The trust continues to review consultant cover on the obstetric consultant-led unit so that this is in line with Royal College of Obstetricians and Gynaecologists Safer Childbirth (2007) recommendations.
Physiotherapy services to patients on the consultant-led obstetric unit are reviewed so that patients do not experience delays in accessing physiotherapy care and treatment.
An accredited acuity tool is used to accurately assess nurse staffing levels required to care for medical and high dependency patients on the wards.
Security arrangements are sufficiently robust to avoid visitors ‘tailgating’ into the paediatric unit out of hours, or to gain access to the children’s assessment unit.
Protocols for the treatment of diabetic ketoacidosis for young people are standardised across the hospital.
There are appropriate facilities for teenagers admitted to the wards, and accommodation is provided in bays with patients of a similar age.
Access arrangements to the neonatal unit are sufficiently responsive out of hours when nursing staff are busy caring for neonates.
Arrangements for psychological and emotional support for children and young people with non-acute mental health needs is reviewed.
The bleep holder’s folder contains current information that is clear to read and easy to find.
Services have detailed strategic plans for service developments, for example, for the single point of access and appropriate provision of high dependency services.
Action is taken on the workload of the bereavement support service in response to the external assessment undertaken by the local clinical commissioning group.
Patient information is available in an easy-to-read format.
Patients are given information about how to make a complaint and what responses they should expect to receive.
There are end of life care link nurses on wards and the link nurses are given time and support to be the champions of end of life care.
The layout of the ophthalmology outpatient department and location of visual acuity tests is reviewed so that patients’ privacy and dignity is maintained during treatment.
Patients attending for renal outpatient appointments on the Isle of Wight do not walk through the dialysis unit where patients are receiving treatment.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.

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.

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.

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.

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.

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.

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.'

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.

All Inspections

Professor Edward Baker

Chief Inspector of Hospitals

Professor Sir Mike Richards

Professor Sir Mike Richards

Professor Sir Mike Richards

Professor Sir Mike Richards