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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. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 31 January 2018

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

A number of ratings had improved at the PRUH. Of particular note was the work done in the urgent and emergency department care to bring the rating from inadequate to good for responsive. This service also improved the rating from requires improvement up to good for effective. All other domains remained unchanged, with requires improvement for safety and well-led and good for caring.

With respect to medicine services, ratings went up to good from requires improvement for safety, effective and responsive. Caring remained unchanged at good. However, there was a fall from good to requires improvement for well-led.

Surgery services increased the ratings in two domains previously found to require improvement to good. This included effective and well-led. Caring remained unchanged at good, and safe and responsive remained as requires improvement.

The critical care unit improved its ratings from requires improvement to good in safety and well-led. All other domains remained unchanged, with good ratings for effective and caring, and requires improvement for responsive.

The majority of domains in the outpatients remained unchanged with requires improvement for responsive and well-led, and good for caring. Safety improved from inadequate to requires improvement. We do not currently rate the effectiveness domain in this service.

Inspection areas

Safe

Requires improvement

Updated 31 January 2018

Effective

Good

Updated 31 January 2018

Caring

Good

Updated 31 January 2018

Responsive

Requires improvement

Updated 31 January 2018

Well-led

Requires improvement

Updated 31 January 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 31 January 2018

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

  • Prescription pads (FP10) were not stored securely and their appropriate use was not monitored. As a result we were not assured staff knew if prescriptions were being accessed and used by unauthorised people.

  • The ‘Medicines Management Policy, version 5’, did not include a section on the storage of prescription pads (FP10) or detail whose responsibility it was to ensure secure storage of prescription pads.

  • We found patients’ paper based notes stored on corridors outside clinical rooms in the outpatients department. This meant unauthorised people could have gained access to confidential information.

  • The trust reported a vacancy rate of 20% in May 2017 in medical and dental staff at Princess Royal University Hospital (PRUH). This exceeded the trust’s target vacancy rate of 8%.

  • The fracture clinic had been relocated as a result of the ambulatory care unit being relocated to the fracture clinic’s former location at PRUH. The plaster room was not wholly suitable with regard to the environment, and did not protect people’s privacy and dignity.

  • Between 1 July 2016 and 30 June 2017 the trust’s referral-to-treatment time (RTT) for non-admitted pathways was worse than the England overall performance.

  • The patient experience dashboard found that between September 2016 and August 2017 on average only 47% of patients who responded said they had been seen on time. This was worse than the trust’s benchmark of 70%.

  • There were delays of 40 minutes and over in the phlebotomy clinic and fracture clinic.

  • Lack of visibility of the executive team and clinical director was reported by some staff.

  • Senior level managers were not aware of performance in their areas of responsibility in terms of referral-to-treatment (RTT) and did not attend rates (DNA). A lack of communication from the Business Intelligence Unit was reported to us as a factor.

  • A lack of available performance information reduced the ability of staff to plan and monitor improvements.

  • Some staff reported they had not been informed about the transformation agenda and did not know what this would mean for their service.

  • The outpatients matron covered clinical shifts over four sites; occasionally this included staff sickness absence. There was a risk that the matron would not have sufficient time to complete managerial tasks.

However:

  • Clinicians had told us in our last inspection in April 2015 that there had been extensive use of temporary medical records for some patients. However, when we visited in 2017 staff reported that these issues had been resolved and patients that did not have their medical records available for clinics were rare.

  • There were robust systems in use by staff to ensure that incidents were reported and investigated appropriately. All staff we spoke with confirmed they were encouraged to report incidents via the electronic incident data management system.

  • Medical device inventories were kept up to date by the trust’s estates team. Safety testing for equipment was in use across outpatients.

  • Clinics were usually well organised and delivered effective assessment and treatment. Staff delivered evidence based care and followed National Institute for Health and Clinical Excellence (NICE) guidelines.

  • Patient’s pain was assessed and monitored.

  • Between 01 April 2016 and 31 March 2017 the follow-up to new rate for the Princess Royal University Hospital was better than the England average.

  • The outpatients department provided clinical support for nursing staff. This included: clinical nurse facilitators, clinical peers, and buddies.

  • The trust had an up-to-date policy and procedure relating to consent to care and treatment. Mental Capacity training was accessible to staff and was on course to have met the required target by the end of the financial year.

  • Staff in outpatients provided compassionate care to patients and their families. Patients and families were positive about the care they received, and felt involved in decisions about their care and treatment. Patients and relatives told us they were fully informed about the processes in the department and received regular updates on their care and treatment.

  • Staff understood their role in providing emotional support to patients and their families.

  • The director of delivery and improvement had a working group for the transformation of outpatient services across the trust, and work was in progress to conduct a demand and capacity analysis to develop an outpatients’ model whereby the hospital could assess and effectively manage the demands on the department.

  • The trust had a call centre based at PRUH.

  • The trust was performing better than the operational standards for cancer waiting times.

  • Delays in clinics were announced and explained to patients.

  • Complaints were investigated and relevant findings were passed on via staff meetings, although responses were not always within the required timeframe. Information on how to make a complaint was available to patients in the outpatients’ patients waiting areas.

  • Managers understood the risks and challenges to the service. Local leaders were visible and approachable.

  • Monthly outpatients’ team meetings took place to ensure staff received information and feedback regarding incidents and complaints.

  • The outpatients and imaging services were in transition, and a strategy was in development.

  • The hospital had introduced a range of governance processes, but these were relatively recent and not fully embedded.

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)

Good

Updated 31 January 2018

  • There was a shortage of permanent employed staff throughout the service; nursing and medical.

  • Ward staff were not aware of the need for more frequent observations on patients who had been given rapid tranquillisation.

Urgent and emergency services (A&E)

Requires improvement

Updated 31 January 2018

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

  • Additional patients were cared for in the resuscitation area above the planned capacity. This was not listed on the risk register at the time of the inspection, despite it being reported as happening regularly since last winter. Therefore we could not be assured that suitable mitigation and assessment had been undertaken to ensure that when this occurred patients were cared for safely.

  • It had been recognised that patients, particularly children and young people, had long stays in the ED waiting for a specialist mental health bed. However, the environment was still not made risk free, limited adjustments had been made to make it a suitable and safe place for them to wait and actions to reduce risks in this area had long timescales planned.

  • Despite an increased number of falls in the winter months, including two that were classed as serious incidents, required actions in incident investigation reports had delayed timescales for resolution. As a result we were not assured the risk of similar incidents occurring had been addressed as quickly as they should have been.

  • There was inconsistent recording of information within the patient records reviewed, including completion of falls and pressure ulcer assessments and pain documentation.

  • There were high vacancy levels of middle grade doctors, which meant a number of shifts remained unfilled despite the use of locums.

However:

  • There had been clear improvements in flow through the department into the hospital. This had led to a decrease in ambulance handover times; a reduction in prolonged stays in the ED after the decision to admit; and an increase in the percentage of patients being seen, treated, discharged or admitted within four hours.

  • The department recognised a significant proportion of the patients attending were elderly and had introduced new frailty specialist roles to support a frailty pathway. This had reduced the length of stay for patients over the age of 75.

  • Consultant cover had improved so the department was now able to provide cover between 8am and midnight. Junior staff were positive about the support and teaching they received from senior clinicians.

Surgery

Requires improvement

Updated 31 January 2018

  • Communication between staff and managers at all levels had improved since our last inspection in 2015. Managers had regular contact with staff on the surgical wards, within theatres and other surgical relates areas.

  • Managers ensured staff had the right skills in order to perform their roles to expected standards. Managers met with staff regularly to appraise performance and provided support when required. These measures had helped to improve the morale of staff.

  • Staff knew what incidents to report and were clear what procedures they had to follow to ensure safety was consistently measured and reviewed. There was a formal system to review incidents and staff received feedback and learning arising from investigations to prevent them happening again.

  • The service treated concerns and complaints seriously. There was a clear process for investigating and responding to complaints. Lessons arising from the complaints process were shared with staff.

  • Staff understood the duty of candour and were able to provide explanations to patients and their families when things went wrong and also apologised when standards of care fell short of expectations.

  • Staff treated patients with compassion, dignity and respect. Staff and managers made themselves available to patients and their relatives so they could speak to them when visiting the ward.

  • Patient related performance information was used by managers to monitor the quality of patient care. This information was shared with staff, patients and the public.

  • There was good multidisciplinary working across all areas of surgical services and staff were positive when talking about colleagues they worked with and the support they received from them.

  • Staff followed the clinical policies and procedures, and delivered patient care and treatment in line with National Institute for Health and Care Excellence (NICE) and Royal College guidelines.

  • The staff endeavoured to meet the patients’ needs, particularly for those patients who had dementia, learning difficulties or mental health problems. Patients were encouraged to be involved in decision making and choices related to their treatment and care.

  • Patients and carers gave positive feedback about the care they received. They told us the staff considered their emotional and physical well-being.

Intensive/critical care

Good

Updated 31 January 2018

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

  • Following our inspection in 2015, there had been improvements to the critical care unit. The trust had approved a business plan to expand the unit. Patient records were now comprehensive, with all appropriate risk assessments completed. Medicines were generally stored safely and securely. The unit had purchased new equipment and mitigating plans were in place to alleviate the lack of technical support on site. A larger visitor’s room had been created in the CCU following feedback from patients. The room was spacious and relatives had access to a toilet close to the visitor’s room.

  • There were effective systems in place to protect patients from harm and a good incident reporting culture. The iMobile (critical care outreach) team provided rapid response and stabilisation to patients who needed immediate attention and transfer.

  • Patients received effective, evidence-based care and patient mortality outcomes were within the expected range.

  • Appropriately qualified staff cared for patients. The percentage of nursing staff with post registration qualification was higher than recommended guidelines.

  • Patient feedback for the services inspected were mostly positive. Staff respected confidentiality, dignity and privacy of patients. Patients were engaged through surveys and feedback forms and the response showed high satisfaction with the service.

  • Services were developed to meet the needs of patients. Feedback from patients were taken into consideration in creating a more spacious visitor’s room.

  • There was good local leadership on the CCU. Staff felt valued, were supported in their roles and had opportunities for learning and development. Staff were positive about working on the critical care unit.

However:

  • The unit was very busy and occupancy on the critical care unit consistently ran above 100%.

  • Out of hours, medical staffing was stretched and did not comply with recommended guidelines.

  • Therapy staffing levels were below the recommended guidelines.

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.