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Princess Royal University Hospital Requires improvement Also known as Farnborough Hospital

This service was previously managed by a different provider - see old profile

We are carrying out checks at Princess Royal University 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 30 September 2015

Princess Royal University Hospital (PRUH) is part of King's College Hospital NHS Foundation trust. The Trust provides local services primarily for the people living in the London boroughs of Lambeth, Southwark, Bromley and Lewisham. The PRUH serves a population of approximately 300,000 in the borough of Bromley.

King's College Hospital NHS Foundation Trust employs around 11,723 whole time equivalent staff with approximately 2,572 staff working at the PRUH.

We carried out an announced inspection of the PRUH between 13- 17 April 201. We also undertook an unannounced visit to the hospital on 22 April 2015.

Overall, this hospital requires improvement. We found the maternity and gynaecology services and services for children and young people were good. Urgent and emergency care, surgery, medical care, critical care, end of life care outpatients and diagnostics and imaging required improvement.

Patients received effective care and they were positive about their interactions with staff. Action needs to be taken to improve the responsiveness and some aspects of the safety and leadership in order to meet the needs of patients.

Our key findings were as follows:

Safe

  • Since our last inspection a lot work had been done to improve the reporting and investigating of incidents. Many staff we spoke with told us they were was an open culture and they were encouraged to report incidents. 
  • One of the key problems facing the hospital was the recruitment of substantive staff. Although the hospital was actively recruiting staff and there had been some improvement since our last inspection in December 2013, recruiting substantive staff was still a problem across most services.
  • Staff were aware of the policies for infection prevention and control and adhered to them. The clinical areas we visited were clean and tidy.
  • There was good pharmacy support for clinical areas. However on some areas, including medical wards and theatres medicines were not always stored safely. For example r was unlocked when theatre lists were running and on medical wards rooms storing medicines were not always locked and medicine trolleys were not always secured to the wall.
  • Access to and availability of equipment had improved since our last inspection. However equipment was not always cleaned and checked in line with trust policy.
  • In some services the environment needed to be improved. The environment in the surgical assessment unit was cramped and afforded patients little privacy. Confidential information could be heard when staff went through the theatre checklist with patients. A recent reconfiguration to the main waiting area of the imaging department meant that people with limited mobility had to negotiate two sets of manual doors. The amount of chairs in the waiting area of the imaging clinic had also been significantly reduced which had resulted in patients standing and waiting for their appointment most of the time.
  • The hospital used paper records and on some medical wards and critical care we found omissions in patients notes. For example there were omissions in risk assessments or assessments by a physiotherapist or occupational therapist. 
  • The availability of medical records in the outpatients department was a significant issue at our last inspection in December 2013. At this inspection, we found some improvements had been made, including a new medical records library at Orpington Hospital site which meant that records were delivered to the clinics more quickly. However, problems still remained in outpatients departments, day surgery unit and medical wards.
  • The introduction of a new IT system had caused significant problems. There were problems with how the new system interfaced with existing IT systems which resulted in some patients having five or six hospital numbers. Some clinic dates did not migrate accurately which meant that many people attended for an appointment on the wrong day. The hospital was working to resolve the issues
  • Attendance at mandatory training had improved along with the system for recording and monitoring attendance.

Effective

  • Most of the services we inspected provided effective care. National guidance was used to inform the care and treatment of patients and services participated in national and local audits.
  • There was good multidisciplinary working in many of the services except for some of the medical wards where staff felt the focus was on discharging patients quickly. They felt that  little attention was paid to concerns raised by other healthcare professionals. Some of the therapists felt their opinion was not always valued by certain members of the nursing and medical team.
  • Staff appraisal had been identified as an issue at our last inspection and there had been some improvement. In some areas all staff had had an appraisal whereas in others, they were still working towards this. In theatres, the number of staff who had had an appraisal was low, with at least ten staff who had not had an appraisal since 2012.
  • Patients received timely effective pain relief and the nutritional needs of patients were being met.
  • Understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards was variable: in some areas it was very good, but in others such as in medical care, more work was required. In surgery we found some of the consent forms did not include all the risks and benefits of a procedure.
  • Documenting of do not attempt cardio pulmonary resuscitation  (DNACPR) orders required more work  The trust policy was not embedded and there was a variation in completion of orders.
  • Average length of stay was higher than the England average for most of the elective and non-elective procedures at the Princess Royal University Hospital.

    length of stay was higher than the England average for most of the elective and non

    -elective procedures at the Princess Royal University Hospital

  • The risk of readmission for elective general medicine was noticeably worse

     

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    than the England average at the Princess Royal University Hospital In surgery the relative risk of re-admission to the PRUH following surgery was reported to be less than the England average for the top three elective and non-elective surgical specialities.  

Caring

  • Patients we spoke with were positive about how staff cared for and engaged with them. They told us staff treated them with dignity and respect and maintained their privacy.
  • We observed  staff

    being friendly towards patients and treating them and visitors with understanding and patience.

  • Patients felt they were listened to and were involved in discussions about their care and treatment.
  • Parents felt involved in the care of their child and participated in the decisions regarding their child’s treatment.

Responsive

  • The hospital continued to experience severe difficulties managing patient movement ("flow")  around the hospital. There were difficulties in managing bed capacity. Both of these issues impacted on several core services. Bed capacity had consistently been above 90% since April 2013. This had been identified at the previous inspections and although some action had been taken, particularly in the emergency department (ED), the problem persisted.
  • The ED was not achieving the four hour standard to see, treat and discharge patients within four hours and once a decision to admit a patient was made they often had to wait more than 12 hours for a bed to become available.   
  • In surgery, operations were cancelled, and not always rescheduled and undertaken within 28 days.  Critical care had experienced over 100% capacity in the four months preceding the inspection with over 40% of discharges being delayed by more than four hours between January and March 2015.  
  • The hospital referral-to-treatment times had been deteriorating since October 2013. It was below the England average but above the 90% standard.
  • There were regular delays in outpatient clinics, with patients waiting from a few minutes to over an hour. Staff were aware of the delays along with over booking of appointments but no systematic action had been taken to address the situation.
  • In medical care the pressures on beds meant that that medical patients were sometimes admitted to non- medical wards and moved several times during their stay.
  • Services, such as translation services, were available to meet the needs of individual patients. Specialist nurses were available and patients were referred to the falls team or tissue visibility nurses if they sustained a fall or developed a pressure ulcer. There was a learning disability nurse attached to the safeguarding team.
  • There was good staff awareness about caring for patients who were living with dementia and how to meet their needs.
  • Staff were aware of the complaints process and received feedback through governance meetings and newsletters.

Well-led

  • At the last inspection we found significant problems with clinical governance at all levels in the hospital. Since our last inspection the leadership, governance and culture of the hospital has improved.
  • Most of the services either had or were developing a local or trust wide strategy.
  • Unlike the End of Life service at Denmark Hill site the service at the Princess Royal University Hospital was not commissioned which impacted on resources and long term planning.  A business case had been submitted to the local clinical commissioning group but it had not been approved. 
  • Systems for clinical governance had been developed and were being embedded across services. Compared with the last inspection staff were able to tell us about how they monitored the quality of care they provided.
  • Leadership had been strengthened and improved since our last inspection with additional staff being appointed clear management structures. The improvement was evident in improvements in service delivery, training for staff and monitoring the quality and safety of care provided. Many staff were positive about the local leadership and felt supported by their immediate line managers.  
  • There was an open culture and staff were encouraged to report incidents and concerns. Staff told us they were encouraged to share their ideas and felt they were listened to and treated with respect. They also commented on the good teamwork.
  • Many services and staff had embraced the changes being part of Kings College Hospital NHS Foundation Trust had brought. A small number of staff felt the good work being done at the PRUH did not always get the recognition it deserved and that it was the "Kings way or no way".
  • Work had been undertaken to improve engagement with staff and this was evident in discussions with staff, although more work was required with some senior medical staff. .
  • Staff surveys had been undertaken to examine the cultural differences across the trust and a three year plan developed to address the differences identified. The most recent survey had found some improvements at the Princess Royal University Hospital.
  • At the last inspection we commented on the commitment and motivation of staff and although not all of the problems had been resolved staff remained positive and motivated about working at the hospital.  

We saw several areas of outstanding practice including:

  • Recent data from the Royal College of Physicians' Sentinel Stroke National Audit Programme (SSNAP) had given the PRUH stroke service a Level A ranking. This is the highest possible rank and only eight per cent of stroke units in the country currently achieve it. This is a significant improvement as the hospital was previously rated as Level D and has risen to Level A in 18 months, making it one of the most improved stroke services in the country.

    Recent data from the Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP), had given the Princess Royal University Hospital stroke service a Level A ranking. This is the highest possible rank and only eight per cent of stroke units in the country currently achieve it.  This is a significant achievement as the hospital was previously rated as Level D and has risen to level A in just 18 months, making it one of the most improved stroke services in the country.

  • Pets As Therapy (PAT) dogs is an initiative to help patients who may be feeling low after suffering a disability following a stroke, or who may have been in hospital for a long period of time. The stroke ward had introduced pet therapy and a dog and their owner visited the ward weekly. They visited patients who were unable to communicate and found they often made huge efforts to communicate with the dog.  

    The stroke ward had introduced pet therapy and a dog and their owner visited the ward weekly. They  visited patients who were unable to communicate and found they often made huge efforts to communicate with the dog.

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

Importantly, the trust must:

  • Continue to work to improve the availability of medical records in the outpatients department and medical care wards.
  • Work with key stakeholders to improve patient flow throughout the hospital to reduce waiting times in the ED, cancellation of operations and delayed discharges.
  • Improve the system for booking and managing waiting times in outpatient clinics to reduce delays for patients and clinics running over time.
  • Improve the environment in the surgical assessment unit.
  • Review and improve record documentation to ensure it is fully completed and in line with national guidance including DNACPR orders.

In addition the trust should:

  • Continue to recruit to substantive posts and ensure that there is always an appropriate skill mix of staff on duty
  • Continue to embed the processes for monitoring and improving the quality and safety of care provided including incident reporting and learning from incidents
  • Continue to improve the rate of staff appraisal and attendance at mandatory training
  • Ensure all medicines are stored and secured in line with trust policy
  • Improve the monitoring of hand hygiene in services for children and young people
  • Ensure all equipment (including resuscitation trolleys) is cleaned, maintained, checked and secured in line with trust and national policies
  • Continue to work to resolve the problems with IT system to ensure patient information is managed effectively and safely.
  • Improve multidisciplinary working in medical care and services for children and young people.
  • Improve staff awareness and understanding of their role and responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards
  • Continue to work with commissioners to ensure there is adequate funding and resources for the End of Life service

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 30 September 2015

Effective

Requires improvement

Updated 30 September 2015

Caring

Good

Updated 30 September 2015

Responsive

Requires improvement

Updated 30 September 2015

Well-led

Requires improvement

Updated 30 September 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 30 September 2015

Women and their families received good care in the maternity and gynaecology services. They told us they received good care and felt staff listened and involved them in decisions about their care.

The hospital had effective systems to respond and minimise risks to women. Since our last inspection more midwives had been recruited and support and leadership has been strengthened with the appointment of two senior midwives. Consultant cover over the weekend had improved and more consultants had been recruited.

Women received evidence based care and clinical audits were carried out in both maternity and gynaecology. The number of women having caesarean sections had been reduced; information at the time of the inspection showed that the rate was 23% compared with the England average of 26%.

The number of births had decreased and the unit had not had to close or cap the number of deliveries since December 2013.

The gynaecology service was not meeting the referral to treatment time for 12% of women. A one stop clinic had recently been introduced where women could receive diagnosis and treatment of common gynaecological conditions.

Becoming part of King’s College Hospital NHS Foundation Trust had resulted in significant change and improvements. Governance and risk processes had improved and matrons and managers were more visible. The clinical director for maternity and gynaecology had spent much of the working week at the hospital leading the changes.

While most staff were positive about the changes some administrative staff felt their job had become more difficult due to the incompatibility of some of the IT systems and difficulties in sometimes obtaining notes.

 

Medical care

Requires improvement

Updated 30 September 2015

Medical care (including older people’s care)

Updated 30 September 2015

Patients receiving medical care were treated with dignity and respect. They told us they were treated with kindness and compassion, and most were involved in decisions about their care.

Many improvements had been made since our last inspection in December 2013 but some aspects of safety required further work; patient records we reviewed did not always include information about the risks and treatment that patients had received and

 and were not always available.

Wards generally had sufficient staff, but were sometimes staffed by newly qualified nurses and less experienced nurses. There were not always enough competent staff to undertake tasks such as phlebotomy and administer chemotherapy.  This  caused delays with admissions and impacted on patient care and treatment.

Stroke care for patients had improved and the performance in the Sentinel Stroke Audit Programme (SSNAP) was particularly praised as the hospital had significantly improved its rating over the past year.

The hospital was able to meet the needs of individual patients including those living with dementia but there were some delays with discharges.

 

performance in the Sentinel Stroke National Audit Programme (SSNAP) was particularly praised as the hospital had significantly improved its rating over the past year and was now rated twelfth nationally.

The hospital was able to meet the needs of individual patients including those living with dementia.  However, s

ome patients experienced a delay with their discharge.

 

Urgent and emergency services (A&E)

Requires improvement

Updated 30 September 2015

The Emergency Department provided effective  care and patients were positive about the care they received. However, some aspects of the service required improvement.

Staffing levels, both medical and nursing, need to be improved. The children's ED did not comply with the Royal College Paediatrics Child Health (RCPCH) guideline’s as they did not always have two paediatric trained nurses on duty twenty four hours seven days per week.

The ED was not meeting the national standard to see, treat and discharge 95% patients within four hours. Between January and December 2014 the weekly performance ranged between 45% and 91%. Patients waiting to be admitted to the wards frequently waited longer than 12 hours for a bed to become available.  

Care was evidence based and the ED participated in national audits. Despite the long waiting times patients spoke positively about the care they received and said their dignity and privacy was maintained.

Leadership in the ED had improved and there was good teamwork and an open culture. It did not have a written strategy and the problems with long waiting times remained even though senior management arrangements had improved since the merger with Kings College Hospital NHS Foundation Trust. This was mainly due to difficulties in admitting patients to wards leading to slow patient flow and a crowded department

Surgery

Requires improvement

Updated 30 September 2015

Surgical services were well led and patients received effective care. Staff reported incidents and there were processes in place to monitor the quality of care provided.

Surgical procedures were sometimes cancelled and not rescheduled within 28 days; some cancellations were due to the lack of available medical records.  Some patients had to wait too long from when they were referred to when they received treatment. Due to a lack of beds on the wards some patients were nursed in recovery areas overnight.

Patient records were not always complete and medical equipment had not always been checked to ensure it was fit for use. Space in the admissions unit was limited and did not provide privacy and dignity for patients.

Anaesthetic medicines were stored in unlocked rooms and an audit of controlled drugs had found areas which required improvement.

Patients had their nutritional needs assessed and met and effective management of their pain. They told us that they were involved in discussions about their treatment and relatives were informed of their progress.

Intensive/critical care

Requires improvement

Updated 30 September 2015

Critical care services provided effective evidence based care and patient mortality outcomes were within the expected range.

Staff were caring and feedback from patient surveys was positive about staff. They were described as  “friendly, kind, thoughtful and so attentive”.  People  felt that their friend/family member had been treated with dignity and respect.

The service experienced problems with receiving and transferring patients due to capacity issues and a lack of available beds on wards for patients once they were well enough to leave critical care. The hospital had taken some action and was using two ‘satellite’ critical care beds but his had not resolved the problem.  .

Information in some patient records was incomplete and some notes lacked sufficient detail. There were also problems with ventilators and the blood gas analyser, although steps were in progress to address these concerns.

Learning from incidents was variable despite staff having a proactive approach to reporting.

Senior staff, nurses, managers and consultants, told us they envisaged the service would be expanded but there was no plan or strategy to support this.

Staff were positive about the support they received from their line managers and were engaged in clinical governance activities.

 

Services for children & young people

Good

Updated 30 September 2015

There had been significant progress in how the trust delivered services to neonates, children and young people since our last inspection. Some improvements were still required to ensure that nursing levels were aligned to national standards and  that all staff complied with trust-wide policies regarding infection prevention and control practices including the screening of patients for MRSA.

The majority of care and treatment was provided in line with evidence based practice but some improvements were required in areas such as the management of children presenting with asthma. Clinical outcomes for children with diabetes was better than the national average in a number of areas.

Staff had fully embraced the concept of family centred care. All members of the family played pivotal roles in the care and treatment of neonates and children. Children and parents spoke positively about the care they received.

Access into children’s services was generally good. There had been a reduction in the number of surgical cases being cancelled and children and young people who presented to the hospital requiring surgical intervention were appropriately managed in a safe and effective way.

Local leadership at ward level was considered to be good. Staff were complimentary about their direct ward leaders who were seen to be working at ward level, supporting staff.

The service had a specific child health strategy that was aligned with the trust-wide strategy. The strategy was driven by quality and safety, and took into account the requirement for the service to be fiscally responsible.

Governance arrangements were in place for which a range of healthcare professionals assumed ownership. There was evidence that risks were managed and escalated accordingly. However, there were a small number of examples where risks that might have an impact on the clinical effectiveness of the service were not recorded on the divisional risk register.

Since our previous inspection in December 2013, the service had introduced a quality measurement scorecard; however, there was a lack of information for some metrics, which meant that the scorecard was not being used to its optimum.

End of life care

Requires improvement

Updated 30 September 2015

The end of life care service was underfunded and under resourced. The service was not commissioned and although the trust had submitted a business case to the clinical commissioning groups it had not been approved.  However, despite this the end of life care team, where possible, provided an effective service and were caring and compassionate.

There was no consultant cover on Fridays and staff worked long hours to meet the needs of patients. They were just below their targets for responding to routine and urgent referrals.

The clinical nurse specialist  met with bereaved relatives and offered support by referring them to community services.

Outpatients

Requires improvement

Updated 30 September 2015

The outpatients and diagnostic and imaging departments were caring and well led.

Some aspects of safety including learning from incidents, IT problems availability of medical records needed to be improved.

Staff were reporting incidents but learning from never events that had happened at the Denmark Hill site had not been shared with staff at the PRUH.  

Problems with the compatibility of some IT systems meant that some patients attended  their outpatient appointment on the wrong day.  Availability of medical records was an on going problem although some improvements had been made including a medical records library at Orpington Hospital. The department had introduced an on-going programme of audit and root cause analysis for when notes were missing. This resulted in additional medical records staff been recruited and standard operating procedures being implemented.

Staff told us that patients were experiencing longer waiting times in most clinics. There was no system to ensure there were sufficient nurses and doctors to see patients. This resulted in longer waits for initial appointments and over-booking of clinics, leading to longer waiting times.

The radiology department was able to provide reports electronically within the trust reporting protocol of 24 - 48 hours for most of the time.

Patients were positive about how the staff communicated with them and the care they received. They were involved in discussions about their care and their privacy and dignity was maintained.

Staff were proud of their services and felt supported by their managers. The told us they were able to raise concerns and there was good communication between staff.  Both departments held were monthly governance meetings and team meetings where information about incidents and complaints were shared with staff, although some staff told us they did not receive this information.