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Queen Alexandra Hospital Good

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

Good

Updated 29 January 2020

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.
Inspection areas

Safe

Requires improvement

Updated 29 January 2020

Effective

Good

Updated 29 January 2020

Caring

Good

Updated 29 January 2020

Responsive

Good

Updated 29 January 2020

Well-led

Good

Updated 29 January 2020

Checks on specific services

Medical care (including older people’s care)

Good

Updated 29 January 2020

Our rating of this service improved. We rated it as good because:

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However

  • The service did not always have staff with the correct skills available to them to care for patients and keep them safe.

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

Good

Updated 29 January 2020

Following improvements since the last inspection in record keeping, risk assessment, infection prevention and control, medicines management, theatre safety culture, leadership, Mental Capacity Act (2005) and Deprivation of Liberty Safeguards, our rating of this service improved. We rated it as good because:

  • The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service provided mandatory training in key skills to all staff. Nursing staff received and kept up-to-date with their mandatory training.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
  • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment and carried out daily safety checks of specialist equipment.
  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
  • The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
  • Staff kept records of patients’ care and treatment. Records were clear, up-to-date, and available to all staff providing care.
  • The service used systems and processes to safely prescribe, administer, record and store medicines. Staff stored and managed medicines and prescribing documents in line with the provider’s policy.
  • The service used monitoring results well to improve safety. Staff collected safety information and shared it with staff, patients and visitors.
  • The service provided care and treatment based on national guidance and best practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983.
  • Staff gave patients practical support and advice to lead healthier lives. The service had relevant information promoting healthy lifestyles and support on the wards. Staff assessed each patient’s health when admitted and provided support for any individual needs to live a healthier lifestyle.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary.
  • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Staff assessed patients’ pain using a recognised tool and gave pain relief in line with individual needs and best practice. Patients received pain relief soon after requesting it.
  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
  • The service made sure staff were competent for their roles. Managers appraised staff work performance and held supervision meetings with them to provide support and development.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
  • Key services were available seven days a week to support timely patient care. Staff could call for support from doctors and other disciplines, including mental health services and diagnostic tests, 24 hours a day, seven days a week.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Patients said staff treated them well and with kindness.
  • Staff provided emotional support to patients, families and carers to minimise their distress. Staff gave patients and those close to them help, emotional support and advice when they needed it. They supported patients who became distressed.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. The service actively involved patients’ relatives as partners in their care.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.
  • People could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were generally in line with national averages. Managers and staff worked to make sure that they started discharge planning as early as possible.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with staff.
  • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development.
  • Leaders operated effective governance processes. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. It used a systematic approach to continually improve the quality of the service. Managers we spoke with at all levels understood the risks to the service and could describe action to reduce risks.
  • The service collected reliable data and analysed it to understand performance, make decisions and improvements.
  • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.
  • Staff were committed to continually learning and improving services. Leaders encouraged innovation and participation in research.

However:

  • Medical staff received, but did not always keep up-to-date, with their mandatory training. Medical staff met the trust target of 85% for five out of 14 mandatory training modules.
  • Although policies included version control information, some forms used by staff did not include version numbers or review dates. This meant staff might not know whether they were using the most up-to-date version of the document.
  • Staff did not always fully complete fluid balance charts. This meant it was difficult for colleagues reviewing the chart to see a patient’s fluid balance at a glance.
  • Staff appraisal rates for the reporting period June 2018 to May 2019 were 81%, which did not meet the trust target of 85%.
  • The service did not meet the trust’s 30-day target for responding to complaints. In the reporting period June 2018 to May 2019, the service took an average of 45.5 days to respond and close complaints. This was not in line with the trust’s complaints policy. Complaints responses we reviewed sometimes included clinical language without explanations in plain English, which might have been difficult for some complainants to understand.
  • There were no side rooms for isolation of infectious patients on the Surgical High Care Unit.

Urgent and emergency services

Requires improvement

Updated 29 January 2020

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

  • Staff did not assess risks to patients in a timely manner. Arrangements for patients self-presenting at the department increased the risk of delays to assessment of their conditions and risk of deteriorating patients not being identified. Staff did not always carry out clinical observation of patients in line with the hourly requirement set by the department. There was no assurance that staff completed patient records fully and accurately. It was not clear that staff recognised and reported all incidents and near misses. The service did not consistently control infection risk well.
  • There were significant numbers of patients waiting in ambulances over an hour before being handed over the emergency department staff and delays with the timeliness of assessments and start of treatment.
  • Staff did not have assurance that patients had enough food and drink to meet their needs and improve their health, as staff did not record whether patients had eaten or drunk the food and drink provided. Annual appraisal rates still did not meet the trust’s target.
  • Staff did not always respect the privacy and dignity of patients.
  • Facilities and premises did not meet the needs of the number of patients attending the department. Demand for services frequently outstripped the availability of appropriate clinical spaces to assess, treat and care for patients. Patients were frequently cared for in non-clinical spaces and there were regular occurrences of patients being held in ambulances outside the department due to lack of capacity to accommodate them. Patients were not always able to access care and treatment in a timely way and in the right setting.
  • Not all service risks were identified and included in the risk management process.

However,

  • The service had enough staff to care for patients and keep them safe. Most staff had training in key skills and understood how to protect patients from abuse. They managed medicines well. The service managed safety incidents and learned lessons from them.
  • Staff provided patients pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives and supported them to make decisions about their care. Key services were available seven days a week.
  • Staff helped patients to understand their conditions. They provided emotional support to patients, families and carers.
  • Staff took account of patients’ individual needs, and treated concerns and complaints seriously. The service was making changes to try to improve patient flow. Although not meeting most of the national targets for patient flow, there were some improvements with performance against some of the targets.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged with patients and the community to plan and manage services and all staff were committed to improving services continually.

Maternity

Requires improvement

Updated 29 January 2020

We undertook an announced inspection of the maternity services between 15 and 17 October 2019.

We last inspected Portsmouth Hospital NHS Foundation Trust maternity services in April 2018 as part of a joint maternity and gynaecology inspection. The purpose of this inspection was to see if maternity services performance had been maintained or if any improvements had been made by the service in the interim.

We spoke with 13 patients, relatives and carers. We spoke with approximately 18 members of staff including midwives, managers, maternity support workers, doctors, reception and medical records staff, and healthcare assistants. We observed care in outpatient clinics and looked at 16 sets of patients’ records. We received comments from the staff and from patients and the public directly.

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated maternity as requires improvement because:

  • Women were not assessed in a timely way when they were referred to the maternity assessment unit.
  • Infection control practices for the birthing pool may pose safety risks to women and babies.
  • Emergency evacuation of women from the pool and the use of the hoist was not effectively managed.
  • There was a backlog of incidents which had not been reviewed in a timely way in order to mitigate risks.
  • The facilities in the bereavement suite was not homely and clinical in appearance which did not meet the needs of women and their families.
  • Although some women’s records were fully completed, there were some inconsistencies in the recording of assessments of women.
  • The maternity IT system did not support comprehensive recording and analysis of data.
  • There was a lack of oversight and monitoring of mandatory training for medical staff including safeguarding.
  • Women’s personal information was not managed effectively and could be viewed by visitors and other people in the unit.
  • The trust’s data submission to the maternity services dataset was inconsistent and they could not be assured that outcome data was used to effectively improve the service provision.
  • Although there were some plans to reduce risks these were not fully developed and embedded in practice.
  • There was no vision and strategy specific for maternity services and the trust had recognised this needed to be developed.

However;

  • The maternity unit was well maintained, and the accommodation was spacious and well equipped to meet the needs of women.
  • Emergency equipment was checked regularly in line with the trust policy, well maintained and available to the staff.
  • Maternity services had a clearly defined accountability structure. The midwifery matron and community matron were accountable to the head of midwifery.

  • Medical staff and midwives received practical obstetric multi-professional (PROMPT) emergency training

  • There were a range of structured governance meetings to provide oversight of risks and quality assurance.

  • The maternity unit employed infant feeding specialists and provided breastfeeding clinics and drop-in sessions.
  • The trust had developed a multi birth facility which offered women one stop clinic and continuity in their care.
  • The trust had developed the role of midwives’ sonographers which impacted positively on care women were receiving.
  • Maternity staff understood how to protect women and babies from abuse and the service worked well with other agencies to do so. Midwives had completed 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-based practice. Managers checked to make sure staff followed guidance.
  • Doctors, midwives and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.

Outpatients

Good

Updated 29 January 2020

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

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.

  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.

  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it.

  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services.

    However

  • Patients in some departments were waiting for lengthy periods before they were given a follow-up appointment.

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