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Queen Alexandra Hospital Requires improvement

We are carrying out a review of quality at Queen Alexandra Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 October 2018

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
Inspection areas

Safe

Requires improvement

Updated 5 October 2018

Effective

Requires improvement

Updated 5 October 2018

Caring

Requires improvement

Updated 5 October 2018

Responsive

Requires improvement

Updated 5 October 2018

Well-led

Requires improvement

Updated 5 October 2018

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 5 October 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service did not consistently provide safe or effective care and treatment. Staff did not always identify risks to patients, and where staff identified risks there was often lack of guidance about how to lessen the risk. Patient records were not held securely and often had missing information. The records did not demonstrate staff always followed evidence based care pathways.
  • Nursing and allied health care professional shortages increased the risk of patients receiving unsafe or inadequate care and treatment. There was a lack of assurance that staff had the necessary skill set to carry out their roles. There was a low rate of medical staff compliance with mandatory training and annual appraisals were below the trust target.
  • Across staff groups there was a lack of understanding and application of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards.
  • The service was not fully developed to meet the needs of the local population. The individual needs of patients with dementia were not fully considered. Some staff did not consider involving people, carers and their families as an important part of care.
  • Staff did not consistently monitor and manage risks to patient safety and governance arrangements to identify shortfalls in performance and areas for improvement were not fully effective.
  • Staff and managers had not developed and implemented a strong vision and strategy for the service.

However:

  • The medical services used national audits to monitor and improve their services.
  • Staff understanding about safeguarding vulnerable people had improved.
  • There were some good examples of multidisciplinary working, on many of the medical wards.
  • Staff commented that the new trust leadership team were visible. There was increased confidence in the trust leadership team.

Services for children & young people

Good

Updated 5 October 2018

Our rating of this service stayed the same. We rated it as good because:

  • Staff were clear about their safeguarding responsibilities and if there was a concern about a child’s wellbeing staff understood and followed safeguarding procedures. All staff we spoke with had completed the appropriate level of training in safeguarding, apart from the medical and dental staff who had not yet achieved above 85% training in levels two and three.
  • There was openness and transparency about safety, and continual learning was encouraged. Staff were supported to report incidents, including near misses. Both units were secured both day and night.
  • The service controlled infection control well.
  • Staff used a paediatric early warning system for the early detection of any deterioration in a child’s condition, and we observed children and young people’s pain effectively assessed and treated.
  • Services were provided seven days a week by medical and nursing staff. There was good multidisciplinary working evident across both units.
  • Inpatient services were tailored to meet the needs of individual children and young people. Access and flow through all departments was very good and complaints were dealt with in a timely manner. Staff listened to feedback and complaints and responded to them in a timely manner.
  • Staff planned and delivered care in line with evidence-based guidance, standards and best practice and met the individual needs of the child and family through the careful care planning. Staff followed care pathways on electronic, multidisciplinary patient records to support practice.
  • Staff received annual appraisals and new staff were supported when completing their competency assessments, helping to maintain and further develop their skills and experience.
  • Parents and children gave feedback about the care and kindness received from staff, which was positive. All children and their carers we spoke with were happy with the care and support provided by staff. We observed staff treated children, young people and their families with compassion, kindness, dignity and respect. Staff worked in partnership with children, young people and families in their care.
  • Play staff ensured that children and their families were supported during their hospital stay and their interventions during procedures reduced the anxiety and worry for the children for example during blood tests.
  • The children’s unit had its own radiology department which provided specific ‘child friendly’ environments for children to wait and undergo investigations and worked closely with the play therapist team to reduce stress and anxiety during those procedures.

However:

  • There was not enough nursing staff on the neonatal unit and medical staff on the children’s unit with the right skill mix to provide safe care. The trust had reviewed staffing levels, and identified a shortage of medical and nursing staff. Recruitment to vacant posts was ongoing at the time of inspection. Nursing levels on the neonatal unit did not conform to the British Association of Perinatal Medicine (BAPM) standards and the medical staffing on the children’s unit did not conform to the Royal College of Children’s and Child Health (RCPCH).
  • There was a risk children would be distressed in the maxillo facial (Max Fax) outpatient’s clinics as they were treated alongside adult patients Mandatory training rates for both medical and nursing staff were below the trusts target of 85% for nine mandatory training modules.

  • The Children and Adolescent mental health service (CAMHS) did not cover weekend and evenings, therefore children requiring a review before discharge would have extended stays in hospital.
  • Adult trained nurses who had not completed child specific competencies worked with children and young people in the children’s fracture clinic and ophthalmology clinic.

Critical care

Outstanding

Updated 5 October 2018

Our rating of this service stayed the same. We rated it it as outstanding because:

  • People were protected from abuse and avoidable harm by a strong comprehensive safety system, with a focus on openness, transparency and learning from when things went wrong.
  • People received excellent care, treatment and support which achieved good outcomes when compared with similar services, promoted a good quality of life based on the best evidence-based care and treatment.
  • People were treated with compassion, kindness, dignity and respect. They were truly respected and valued as individuals and were empowered as partners in care received, practically and emotionally, by an exceptional and distinctive service.
  • Services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care.
  • The leadership, management and governance of the critical care unit assured the delivery of high-quality and person-centred care, supported learning and innovation and promoted an open and transparent culture.
  • The critical care unit had been rated as outstanding following our last inspection in 2015. However improvements had been made to the service since our last inspection. This included but not limited to: safety briefings increased to twice daily; a dedicated dietitian; increased physiotherapist staffing levels; new systems for improving patient flow; an improved and extended critical care outreach team that was now 24 hours a day seven days a week; an updated computer information system; introduced a relatives bleep system; and looked at ways to humanise the critical care environment to aid patient treatment and recovery.

End of life care

Good

Updated 5 October 2018

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.

  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.

  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • The service mostly took account of patients’ individual needs.
  • People could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice.

  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
  • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

However,

  • Not all staff had received an annual appraisal of their work, although the trust had plans to address this.
  • The trust was not able to provide a seven day service. This was due to some long term sickness within the nursing team. Actions had been taken to mitigate the impact of this, freeing up nurses for clinical time on the ward. Cover arrangements had been put in place for out of hours. Patients received consistent end of life care because care was provided on the wards by staff across the trust.

Surgery

Requires improvement

Updated 5 October 2018

  • Safe was rated as “requires improvement” as there were areas of poor practice in respect of infection prevention, assessing and responding to patient risk, records and medicines management.
  • Effective was rated as “requires improvement” which is down one rating from that given in 2015. This is largely due to poor practice in respect of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and Mental Capacity Assessment (MCA) assessments and recording which still required improvement in decision making and in recording as required from the 2015 report.
  • Caring was rated as “good” which was an improvement on its previous rating of “requires improvement”. This was because the service was meeting the standards expected.
  • Responsive was rated as “good” which was an improvement on its previous rating of “requires improvement”. This was because the service was meeting the standards expected.
  • For Well-led, while there were good systems observed, the fact remained that many of the policies, processes and procedures were in the course of being revised and introduced hence its rating as “requires improvement”.

Urgent and emergency services

Not sufficient evidence to rate

Updated 16 April 2019

Diagnostic imaging

Good

Updated 5 October 2018

  • Staff had completed training which allowed them to undertake their role effectively. Further training opportunities were provided by the trust to allow staff to expand their skills and professional knowledge.
  • Staff took appropriate action to minimise the risk of cross infection between patients.
  • Staff followed professional guidance and working practices during investigation to keep patients safe.
  • Risk to patient safety due to the type of investigation being undertaken were identified and managed appropriately
  • Patients received care from staff who treated them as individuals and ensured their physical and emotional wellbeing needs were met
  • Waiting times for investigation were similar or better than the national average identifying patients received the right investigation at the right time.
  • Staff felt valued and supported in their role enabling them to provide high quality care. Patient feedback confirmed this was happening.
  • Innovative practice was supported and promoted by staff who took responsibility to explore options to increase the quality of patient care

However

  • The trust did not consistently meet the national and trust target of 48% of patients entering the emergency department with a suspected stroke receiving a CT scan within an hour of arrival.
  • The Queen Alexandra Hospital environment did not fully support patients to move around the hospital independently. Environmental design did not always support those with a sensory loss such as vision impairments to negotiate the hospital whilst transferring between departments.
  • Steps taken by staff to ensure a patient’s individual needs could be met appropriately were not always followed consistently. Information about particular additional needs or patient support was not always passed between teams to ensure these needs could be met prior to investigation.
  • The investigation of complaints did not take place in a timely way leading to delays in responding to the complainant. The service did not complete investigation of, respond to, and close complaints within agreed timescales

Maternity

Requires improvement

Updated 5 October 2018

Our rating of this service went down. We rated it it as requires improvement because:

  • There were gaps in the service’s safety systems, such as monitoring training for obstetric medical staff, monitoring infection control, monitoring competency using equipment and monitoring medicines management.
  • Staff created records which were not consistently person-centred and with some omissions
  • Staff did not always receive feedback when reporting incidents and some felt discouraged from reporting.
  • In theatres, staff did not consistently follow the World Health Organisation (WHO) guidelines and the five steps to safer surgery.
  • Some of the protocols and guidelines for the service had not been reviewed and updated against best practice and national guidance.
  • The service did not use audit effectively to ensure the service delivered care in line with practices and implemented improvements where necessary.
  • The leadership structures and processes were relatively new and there was not an embedded culture of effective teamwork across different disciplines.
  • Women could not always give birth in the place of their choosing.
  • The maternity IT system did not support comprehensive recording and analysis of data.

However

  • Staff demonstrated care and compassion when caring for women.
  • There was effective engagement with the local community and the wider health economy in developing services
  • Women could access maternity services when they needed it, with access to 24/7 telephone guidance and prompt responses.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results.
  • The service had good systems for training staff and was working towards providing improved arrangements for sharing learning.

Outpatients

Good

Updated 5 October 2018

Our rating of this service stayed the same. We rated it as good because:

  • People were protected from avoidable harm and abuse.
  • People had good outcomes because they received effective care and treatment.
  • People were supported, treated with dignity and respect and involved in their care.
  • People’s needs were met through the way the service was organised and delivered.

However:

  • The governance and culture did not always support the delivery of high-quality person centred care