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Queen Alexandra Hospital Requires improvement

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

Inspection Summary


Overall summary & rating

Requires improvement

Updated 9 June 2016

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

Inspection areas

Safe

Requires improvement

Updated 19 June 2015

Effective

Good

Updated 19 June 2015

Caring

Outstanding

Updated 19 June 2015

Responsive

Requires improvement

Updated 19 June 2015

Well-led

Requires improvement

Updated 19 June 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 19 June 2015

Patients who used the maternity and gynaecology services were protected from avoidable harm.

The trust took action in response to reported incidents and feedback was provided to staff to ensure learning from previous incidents was achieved. When something went wrong there was an investigation, carried out by appropriate staff. Patients were included in discussions and feedback about their care.

Systems and processes were in place to promote the control of infection and ensure equipment in use was safe by servicing, maintenance and keeping it clean. Safeguarding women and babies was given high priority by the staff who were proactive in identifying and liaising with a multidisciplinary team to ensure the involvement of appropriate staff.

Systems were in place to review staffing levels to ensure they were safe. The staffing levels and skill mix on both the consultant-led obstetric unit and the gynaecology ward was discussed at handover and arrangements were made, if necessary, to risk assess and manage the staffing of each area. The consultant presence on the consultant-led obstetric unit had been measured against guidelines in Royal College of Obstetricians and Gynaecologists (RCOG) Safer Childbirth (2007). As the level of cover was lower than that recommended, this had been placed on the risk register and a business plan was being developed to obtain increased consultant cover. The safety of women was promoted by consultants attending the unit over the weekends in their on-call rota time.

The care and treatment provided to patients was effective in that patients experienced care, treatment and support that provided good outcomes for them.

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. However, the access and flow of women through the maternity unit had affected where staff were required to work and on rare occasions affected the choices women could make on where they delivered their baby. Because of pressures on medical beds, some medical patients were transferred to the gynaecology ward, which had increased the numbers of cancelled gynaecology operations. An action plan was in place to reduce the waiting time for women whose operation had previously been cancelled.

Patients’ care and treatment was provided in line with current evidenced-based guidance, national recommendations and legislation. Care and treatment was updated following changes in best practice guidance and legislation. The trust monitored the care and treatment provided to women; the data showed women received an effective service when compared with women in other parts of England.

Patients received an outstanding caring service because staff involved and treated patients with compassion, kindness, dignity and respect. Relationships between the staff and patients were strong, caring and trusting. Patients and their representatives were encouraged to make choices and were involved in their care and treatment. Staff took patients personal, cultural, social and religious needs into account when providing care and treatment.

Patients were actively encouraged to complete quality monitoring surveys and participated in the national NHS Friends and Family Test quality surveys, from which positive responses had been received.

Patients received a responsive service because the service provided was organised to meet the needs of women in their local areas. For example, antenatal and postnatal clinics and the midwife-led birthing units. Additional gynaecology clinics and appropriately trained staff had been put in place to meet the increased demand of newly referred patients. Women were informed on how to make a complaint and complaints were acted on and monitored effectively by the women’s and children governance and quality committee.

The service was well led because the leadership, management and governance of the organisation assured the delivery of high-quality person-centred care and promoted an open and fair culture.

Staff were positive about the management of their services and the accessibility to their line and senior managers. Innovative practice was encouraged and in evidence within the trust, including the development of an application to be used on smart phones and tablets enabling women to access information to make choices and decisions regarding their birth. Student midwives had support from experienced community midwives to run a postnatal clinic to increase their knowledge and competencies.

Medical care (including older people’s care)

Inadequate

Updated 24 August 2017

Medical care has been rated Inadequate overall. With safe, caring, effective and well led rated as inadequate and responsive rated as requires improvement.

Overall the care provided within this service was very poor. Staff did not always recognise and act appropriately in response to serious safeguarding concerns. Consent to care and 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/ or physical restraint.

Staff did not robustly assess, monitor or manage risks to patients. Risk assessments had not been completed or updated for all the escalation areas and additional beds in use. Vulnerable patients such as frail older persons and patients living with dementia did not have their needs appropriately assessed and risks for those patients were not sufficiently mitigated.

Medicines management policies were not always followed in the acute medical unit (AMU) and medical services. Patient confidential information was not stored securely. Staff did not always consistently follow infection control procedures.

Staff did not always respond to patients when they asked for assistance. On some occasions, the inspection team had to request that staff intervene to maintain patients’ safety. 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 in line with current guidelines. Not all incidents were reported, and some were categorised incorrectly. Care and service delivery failures were not always correctly identified during investigations of incidents. 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.

AMU had bed occupancy significantly higher than the England average and escalation areas were consistently in use. Patients were moved both during the day and night for non-clinical reasons to aid bed availability. Patients did not have timely access to discharge from hospital.

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.

Governance processes were not effective at identifying risks and improving the safety and quality of care and treatment. There was no clear or formal strategy to improve the urgent medical pathway and we could not evidence any significant improvements since our inspection in September 2016. The urgent medical pathway was still medically led and not all consultants were supporting necessary changes in the urgent medical pathway.

Not all staff had completed their mandatory training and the compliance for some staff groups was significantly lower than the hospital target. Not all staff completed safeguarding adults training to the appropriate level. Competency assessments for both permanent and agency nursing staff were not always in place.

However,

There was a standardised pain assessment tool was consistently in use which supported the management of pain in patients who could communicate verbally. Some patients and relatives praised the care they received on the renal day unit (RDU) and AMU.

Urgent and emergency services (A&E)

Requires improvement

Updated 24 August 2017

  

The emergency department has been rated requires improvement overall. With effective and caring rated as good, responsive and well led rated as requires improvement and safety rated as inadequate.

Incidents were not always thoroughly investigated which meant actions were not identified and lessons were not being learnt. Some daily checks on emergency equipment were not routinely carried out. Staff compliance with mandatory training requirements fell short of the hospitals target of 85%.

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 and meet the needs of all patients in this area. There were insufficient staff numbers in the Emergency Decision Unit (EDU) to care for patients with a mental health condition. Staff did not observe patients with a mental health condition often enough, which meant that patients had the opportunity to leave the department without challenge. Patients were assessed only for their risk of deliberate self-harm. This meant patients were experiencing other psychiatric disorders may not have their risks accurately identified. Vulnerable young people were admitted into the EDU with adult patients, many of which were in mental health crises.

We were not assured that the processes for safeguarding children were effective within the emergency department or that the bruising protocol for actual or suspected bruising was being followed.

Patients waiting in the corridor were not always observed by staff and had no means of summoning urgent help if required. Flow through the department was often compromised by a lack of available hospital beds. 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 trolley decision to admit breaches had risen rapidly with 226 recorded between January and March 2017. There were delays for patients referred to acute medical services to be seen by a senior medical doctor.

However,

Patients and their relatives told us they generally felt they were well cared for while in the department. Patients arriving at the department were seen and assessed quickly by a senior doctor or nurse.

Staff were aware of infection control procedures. Security staff were the only staff group who demonstrated excellent knowledge and understanding of the Mental Health Act, 1983 and the Mental Capacity Act, 2005.

TARN data showed better than national average outcomes for patients with severe or life threatening injuries.

There had been increased staff engagement via lunchtime drop-in sessions and multi-disciplinary staff engagement meetings.

The development of the new pitstop area had reduced the number of patients who had to wait in the corridor and helped to reduce the amount of time it took for patients to see a doctor.

Surgery

Requires improvement

Updated 19 June 2015

We found that while staff were compassionate and caring and outcomes for patients were generally above the England national average, improvements were required to ensure safe, responsive and well-led treatment and care for patients. Incidents were usually reported and learning from these was shared with staff. Overall standards of cleanliness were good, although there were exceptions in relation to hand hygiene practices on some of the wards we visited. Sufficient equipment was not always available to meet patients’ needs.

The five steps to safer surgery checklist was completed but its documentation needed to improve. Electronic monitoring was used on surgical wards to identify patients at risk of deteriorating. However, staff in theatres did not consistently use an early warning tool to identify deteriorating patients.

Staff were not 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. There was a high uptake of mandatory and statutory training by nursing staff but trust records showed poor take up of this training by surgical and dental staff. Risks to patient care were identified and escalated but were not always resolved in a timely manner, particularly in relation to theatre facilities. There was a shortage of nursing staff across the service as well as a shortage of anaesthetic staff.

Emergency surgery was managed in line with national professional requirements. Clinical audit was used to monitor compliance with evidence-based national guidelines and best practice. Patients’ needs were assessed, monitored and addressed. Patient outcomes against a number of indicators were better than the England national average. Mental capacity assessments were undertaken by surgical staff. However, ward staff did not always understand their roles and responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

There were sometimes not enough beds for the number of patients requiring them. Patients were not always put on wards best suited to meeting their requirements for specialist treatment and care. 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. Capacity issues within the hospital resulted in elective procedures being cancelled.

The trust was achieving the 31-day cancer waiting time diagnosis-to-treatment target. The trust was not meeting the 62-day referral-to-treatment target overall. The target was not being met in head and neck, lower GI and urology surgical specialties.

There were clear clinical governance arrangements. Performance against operational and quality targets was monitored and action was taken when performance fell below expectations. Key risks were identified and escalated to the trust’s risk register. However, staff across a number of wards raised concerns about not being able to escalate risks beyond ward level. Risk registers did not always identify how risks were being managed and many interventions were out of date. Staff were also concerned that disciplinary action was sometimes being instigated unfairly.

Intensive/critical care

Outstanding

Updated 19 June 2015

There were many areas of outstanding and innovative practices in the critical care service. Innovative daily safety briefings and the use of secure social media informed staff about risk to patients, the running of the service and learning from incidents. The environment and equipment were well maintained. There were innovative and imaginative ways of storing equipment, which meant emergency equipment and information, could be accessed promptly when required. This included airway equipment and information for staff about what to do in the event of major incidents.

Electronic records supported the effective assessment and monitoring of patients. Electronic recording of patients’ vital signs in the general hospital allowed the outreach team to remotely monitor deteriorating patients and prioritise which patients they attended to.

Staffing levels met patients’ needs. Innovative practices and team working meant vacancies within the medical staff did not have an adverse impact on the wellbeing and safety of patients. This included consultants working in a registrar role to fill middle-grade vacancies.

There was a strong and effective education programme for nursing, medical and allied health professional staff. When possible, there was a multidisciplinary approach to education. In partnership with the University of Portsmouth, the unit was developing an Advanced Critical Care Practitioner course, the first in the UK. However, for trust-required mandatory and essential training, medical staff had not complied with the target set by the trust.

Feedback from patients and their relatives strongly indicated that there was a caring and supportive culture in the critical care unit.

The trust had the foresight to plan for the expansion of the service when designing and building the unit in 2009. There was capacity to expand the unit to 36 beds. National data showed that the unit performed worse than similar units for discharging patients to wards out of hours (between 10pm and 7am). The unit had taken action to mitigate any risk this posed, with the use of detailed discharge summaries, verbal handovers and ensuring all medicines had been administered before the patient is discharged.

Information for relatives and patients about the unit was available in leaflets and on the unit’s own website. However, the information on the website was not easily accessible to people with a disability that made it difficult to read or understand written words.

To reduce the risks for patients requiring critical care who were located elsewhere in the hospital, the unit 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 retrieval team in the ED, before admission to the unit. This also happened for patients requiring admission to the unit from the general wards.

There was strong, supportive and effective leadership of the service. Staff were supported to develop leadership skills. The culture of leadership resulted in a no blame culture, where lessons were learnt from incidents and mistakes without blame being apportioned to staff.

Innovative ideas and approaches to care were encouraged and supported, many of which were enhancing patient safety and experience on the unit. This included the use of information technology and social media to enhance patient safety, the practice of daily safety briefings, the continued development of the electronic patient recording system, and the use of grab packs to give staff instant guidance about what to do in the event of utility failure, emergency telephone breakdown and major incidents.

Services for children & young people

Good

Updated 19 June 2015

Children, young people and their families were very positive about the care and support they received. They told us they were kept informed and involved in making decisions and were partners in their care. There was a strong family- and child-focused culture in the service.

The paediatric unit was purpose built and provided a bright and ‘child-friendly’ environment. Original plans included a ward for teenagers and adolescents, but this ward was now used by another service. We found facilities for teenagers on the unit were limited and they were sometimes cared for in bays with children and babies of all ages. There was no designated high dependency area; due to a shortage of cubicles the original space allocated for the high dependency unit was converted to accommodate small babies, and so these patients were spread across the medical ward.

There was no single point of access for emergency care; the children’s emergency department and children’s assessment unit (CAU) had different roles in the pathway, which were not always clear or efficient. But children and young people known to the service, with long-term conditions, had direct access to the CAU.

The service had identified these issues as part of their strategic ambitions, but detailed plans were still in development.

There were effective procedures to support safe care for children and young people and to keep them safe from avoidable harm. Staff were aware of how to report incidents and this information was monitored and reviewed, and learning was shared with the staff. There was sufficient medical staffing, team working, protocols, robust records and communication, to support safe care and manage risk. Nursing staffing levels and skill mix were planned using national guidance, with contingencies for to staff work flexibly across the service as required. But a formal acuity tool was not used for assessing staffing levels to meet patient needs.

Care and treatment was provided in line with best practice guidance and outcomes were positive. The outcomes for babies on the neonatal unit were good when benchmarked against other services. Staff were well trained and supported in their role and were provided with development opportunities. There was good multidisciplinary team working and a seven-day service was established.

The service had strong and visible leadership. There was a culture of continual learning and improvement, which was supported by strong leadership and multidisciplinary team working. Risks and quality were monitored at all levels, with action taken and changes made when needed.

There was good communication and engagement with staff and innovation was encouraged. Children and young people and their parents were encouraged to provide feedback and ideas for improving the service.

End of life care

Requires improvement

Updated 19 June 2015

Nurse staffing levels in some ward areas meant that the personal care needs of patients receiving end of life care were not being met. The trust also needed to improve the medical staffing levels, in particular consultant staffing for palliative and end of life care in line with national recommendations. Nursing staff were not doing appropriate safety checks on syringe drivers when these were being used by patients. Pressure relieving air mattress were not available for patients when required and therefore increased the risk of patients developing pressure ulcers.

The trust had one standard form for do not attempt cardio pulmonary resuscitation (DNACPR) decision which was introduced in 2014. However, some ward areas still retained and used old forms and these did not include any guidance for completion. The trust DNACPR audits demonstrated gaps in completion but there had been improvements. During our inspection, however, we found some forms were not completed according to national guidelines.

Staff reported incidents on the trust-wide electronic reporting system. They also received feedback from concerns and incidents reported. Staff had a good understanding of safeguarding. Medicines were appropriately managed and staff followed infection control procedures.

Following the withdrawal of the Liverpool Care Pathway in July 2014, the trust was piloting new care plans for end of life care on four wards. These were completed to an acceptable standard. However, where these care plans were not used, the documentation, of care was not appropriate to properly assess and make decisions about patient care. We found some staff were not aware of end of life care principles and there was a reluctance to make end of life care decisions.

The AMBER care bundle was an approach used in hospital when doctors were uncertain whether a patient may recover. Generally, it was initiated when patients had a few months to live. The roll out of the AMBER care bundle had been kept to a limited number of wards to ensure its effectiveness due to the sensitivity of the removal of the Liverpool Care Pathway, and to avoid confusion during the introduction of the Wessex wide Achieving Priorities of Care (APoC). Most patients received appropriate pain relief and had appropriate nutrition and hydration.

The trust only partially participated in the National Care of the Dying Audit – Hospitals (NCDAH) 2013/14 and was not able to compare its performance with other trusts. For the organisational key performance indicators the trust scored better or the same for five out of seven indicators. Local audits demonstrated some progress with clinical and organisational performance indicators.

Both the hospital palliative care team staff and end of life care team were supported to develop their knowledge and competencies. The hospital had strong links with the local hospice. Whilst the organisation was not part of the trust, it worked closely with the palliative care physician. The end of life care support team provided a 7 day service during specific hours. The hospital had access to 24 hour palliative medicine consultant advice 365 days a year

During our inspection we observed staff were compassionate and caring and treated patients with dignity and respect. Families told us they were well informed about the condition of their relatives.

Services were being planned to meet and delivered in a way that met the needs of the local population. For example, the trust had introduce a seven day service on the ward by the end of life care team and was planning to merge the palliative care and end of life care teams to provide a more seamless service. Information was being used to improve awareness of the service across the trust so that patients were appropriately referred to the teams.

Most patients were being seen within 24 hours of referral to the teams. Many patient requiring end of life care were treated in side rooms. There was a rapid access discharge service within 24 hours and the number of patient discharged to their preferred place and who were able to die at home was higher than national average.

The leadership team had developed a draft revised strategy for end of life care that took into account national guidance and reports on improving end of life care. The strategy outlined initiatives to improve and monitor the quality of care, care coordination and the culture of care in the trust and working with community teams. The leadership was knowledgeable about quality issues and priorities. Senior staff members took appropriate action to address these issues. There was a culture of responsibility between the end of life care team and the palliative care team. However, risks needed to be better identified, assessed and managed.

The trust had a Listening into Action initiative enabled staff to provide solutions to common challenges for end of life care in the trust. Patients and their relatives were to be consulted on the strategy and the relatives of bereaved patients had been surveyed to improve the service. There were innovations in practice, which included integrated care and trained volunteers to support patients.

Outpatients

Good

Updated 19 June 2015

All outpatient and diagnostic imaging departments demonstrated good knowledge of reporting incidents and of learning from incidents. These were often shared with other outpatient specialities, but real learning only occurred within the speciality reporting the incident. All mandatory training, including safeguarding and infection control, was completed by all staff. Compliance for mandatory training was well monitored by senior staff members.

National Institute for Health and Care Excellence guidelines were followed in many departments and some excellent examples of practice was demonstrated. Staff were encouraged to develop professionally and regularly update their clinical skills. Rheumatology, dialysis and respiratory outpatient departments demonstrated outstanding practice and accomplishments.

Patients were positive about their experiences of care, including care that had been extended to relatives.

In ENT, patients were given access to a private room when they were being given difficult news or were distressed. A symbol on the door indicated to other staff not to enter the room. The privacy and dignity of patients was mostly adhered to. There were, however, some concerns about the building design affecting the privacy of patients in the dialysis unit on the Isle of Wight and in the ophthalmology department at Queen Alexandra Hospital. There were risks relating to infection control at the dialysis unit on the Isle of Wight.

Staff across outpatients and diagnostic imaging demonstrated a good understanding of how to make reasonable adjustments for patients living with dementia or those with a learning disability.

The waiting times for diagnostic imaging have historically been significantly higher than the national average up until July 2014. The Trust had met the waiting times for diagnostic imaging from September 2014, having extended the working day in the service to achieve this. In rheumatology, a rapid access clinic operated. Patients may receive an appointment that suits their existing commitments; often same-day appointments are available. It also provided innovative patient education and support conferences that are well attended by patients and have been nominated for awards.

The referral-to-treatment targets for most outpatient specialities were being met, although colorectal, back pain and the gastroenterology clinics had longer waits. The trust taking action to addressing this issue. Cancer urgent referral times for patients to be seen within two weeks were being met.

Ophthalmology had a high number of patients awaiting follow-up who were significantly delayed in receiving their follow-up appointment and were on the outpatients waiting list. This had been on the service risk register since 2009, 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. This number had been reduced, but the number of patients waiting was still significant. The learning from this had improved how risks were escalated. Risks were being managed and waiting lists and service quality was monitored.

Renal outpatient letters were taking 35 days to be typed and sent to the patients’ GP. This was because the renal department had a separate IT system from the rest of the trust. It had caused significant delay in GPs receiving updated information regarding their patients’ treatment. An outpatients administration review was underway to improve services within the department.