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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 a review of quality at Princess Royal University Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 12 June 2019

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

  • Although the mandatory training completion rates had improved since our previous inspection, some subjects including the safeguarding of vulnerable people had not been completed by all the required staff.

  • The environment in which people received treatment and care was not always suitably safe and risks had not been fully considered in some areas. The privacy of patients in some areas was less than expected.

  • Equipment was not always checked, and some consumable items were out of date.

  • Staffing in some areas was not always ideal, which impacted on the ability of staff to deliver timely holistic care. In some areas staff did not work effectively together and there were some variations in leadership style and department culture.

  • Medicine optimisation was not always achieved to a consistent level.

  • Infection prevention and control practices were less than expected in some areas.

  • Patient risk assessments and instructions were not completed with consistency, and treatment and care was not always provided in accordance with best practice guidance. The monitoring of effectiveness of treatment and care was not always reviewed.

  • Patients could not access care and treatment in a timely way. Waiting times for treatment and arrangements to admit, treat and discharge patients were worse than the England average and national standard.

    However:

  • Staff were knowledgeable about the incident process and learning from incidents were discussed in departmental and governance meetings and action was taken to follow up on the results of investigations.

  • Staff understood their responsibilities to protect people from avoidable harm and were knowledgeable about safeguarding procedures. They were also aware of their responsibilities under the mental capacity act.

  • Staff had opportunities for professional development and were competent to perform the required treatment and care in their respective areas.

  • There had been improvements in palliative care provision with the introduction of a clinical nurse specialist seven-day service since April 2018.

  • Services were generally arranged and delivered considering the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances.

Inspection areas

Safe

Requires improvement

Updated 12 June 2019

Effective

Requires improvement

Updated 12 June 2019

Caring

Good

Updated 12 June 2019

Responsive

Requires improvement

Updated 12 June 2019

Well-led

Requires improvement

Updated 12 June 2019

Checks on specific services

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.

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.

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.

End of life care

Requires improvement

Updated 12 June 2019

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

  • The service did not always provide care and treatment based on national guidance or evidence its effectiveness.
  • Staff did not always complete and update risk assessments for each patient or have an action plan to address any identified risk. We found little evidence of individualised planning or regular review of the dying patient in place.
  • The end of life care plan was not integrated into the electronic patient record and we were not assured there was an identified date by which this would be available.
  • There was incomplete documentation of discussions with relatives when recoding ‘do not attempt cardio pulmonary resuscitation’ status on patient treatment escalation plans (TEP).
  • There was no on-site consultant presence at weekends.
  • It was not always clear whether all patients were offered the opportunity to meet with a member of the chaplaincy.

However:

  • There was an improved palliative care clinical nurse specialist seven-day service introduced in April 2018. Referrals to the SPCT were responded to in a timely manner with 91% of referrals seen within one day of referral and 98% within three days.
  • The specialist palliative care team (SPCT) now included a palliative care social worker who provided emotional support for patients and their families.
  • There was improved weekday on-site provision of palliative care medical staff with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment.
  • Patients and their family members told us staff treated them with dignity, respect and compassion. They said staff explained what was happening and were caring. There were no visiting time restrictions for family and friends in the last days or hours of a person’s life.
  • End of life care had a clear governance framework. This ensured responsibilities for end of life care went right up to trust board level. End of life priorities had been identified and there was an action plan for the service based on these priorities.

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.

 

Surgery

Requires improvement

Updated 12 June 2019

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

  • There had been no improvements in mandatory training completion rates for medical staff since our last inspection. The 80% target was not met for any of the 22 mandatory training modules for which medical staff were eligible.

  • Safeguarding training completion rates for medical staff were below the trust target with completion rates as low as 12% for level 3 safeguarding children training.

  • The endoscopy unit was not suitable and there were insufficient procedure rooms to meet the demands for the service. Endoscopy decontamination took place in theatres due to space constraints. Decontamination of endoscopes was carried out in a room used for both clean and dirty equipment.

  • Plans to improve endoscopy services had not been implemented since our last inspection.

  • Medicine audit results showed the service performed below trust standards for a number of indicators.

  • Vacancy rates for medical staff were worse than the trust’s target.

  • Staff felt there was a disparity in the way resources were allocated across trust sites.

  • The trust did not always provide services in a way that met the needs of local people. There was a significant number of medical outliers in surgical wards. Mixed specialities were admitted on surgical wards due to bed pressures.

  • Waiting times from referral to treatment were not always in line with good practice.

However:

  • Nurse staffing had improved since our last inspection. The service had enough nursing staff with the right mix of qualifications and skills, to keep patients safe and provide the right care and treatment.

  • Staff kept records of patients’ care and treatment. Staff completed risk assessments and followed escalation protocols for deteriorating patients.

  • There were effective systems to protect people from avoidable harm. Learning from incidents were discussed in departmental and governance meetings and action was taken to follow up on the results of investigations.

  • Staff provided evidence-based care and treatment in line with national guidelines and local policies. There was a program of local audits to improve patient care.

  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance.

  • Staff were aware of their responsibilities under the mental capacity act.

  • There was effective multidisciplinary working, including liaison with community teams, to facilitate timely discharge planning.

  • Feedback for the services inspected were positive. Staff respected confidentiality, dignity and privacy of patients.

  • There was good local leadership on surgical units. Staff felt valued and they were supported in their role. There was a good governance structure, both within surgical care and within the directorate.

Urgent and emergency services

Inadequate

Updated 12 June 2019

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

  • Patients were not always protected from avoidable harm. There were significant handover delays for patients arriving by ambulance. The management of patients requiring resuscitation was poor due to flow challenges across the emergency care pathway.

  • Staffing levels and skill mix were not sufficient to meet the needs of patients as a result; patients did not have their care and treatment carried out in a timely manner.

  • The emergency department did not manage patient safety incidents well. Whilst staff recognised the types of incidents they should report, including near misses, lessons learned were not always effectively introduced across the department resulting in similar incidents occurring.

  • The layout of the emergency department was not suitable for the number of admissions the service received. There was significant overcrowding, and, at times, patients were being cared for on trolleys along corridors. At times, two patients were nursed in cubicles designed for only one person. There continued to exist inherent ligature risks. Equipment was not consistently checked, and a range of consumable equipment was found which had expired.

  • Staff did not always work together as a team to deliver effective care and treatment. There was not always consistency in working practices, practices would change daily, depending on who was leading the team that day. Medical staff faced challenges when referring patients to individual specialties, with patients often waiting a significant length of time to be seen.

  • Patients were not always involved and treated with compassion, kindness, dignity and respect.

  • Patients could not access care and treatment in a timely way. Waiting times for treatment and arrangements to admit, treat and discharge patients were worse than the England average and national standard.

  • There was not the leadership capacity and capability to deliver high-quality, sustainable care. Leadership within the department was not effective, there did not appear to be one individual taking overall responsibility for the day to day running of the department. Front line staff did not feel supported, respected or valued by their immediate line manager(s). Staff were not engaged and morale in the department was low; frustrations around leadership, low staffing, capacity and flow and the environment had led to a culture of acceptance with staff lacking the drive to challenge systems and processes within the department.

Outpatients

Requires improvement

Updated 12 June 2019

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

  • The service did not take steps to ensure all staff completed the required mandatory training. Compliance rates for required safety related training amongst medical staff was poor.

  • The service did not always have suitable premises or equipment and did not always look after them well.

  • Patient’s privacy and dignity was not always maintained due to the environments staff were working in, although staff tried their best to maintain standards where possible.

  • Outpatient services showed generally poor performance in referral to treatment (RTT) and cancer waiting times. The trust was performing worse than the England average and national standard for both the RTT incomplete pathway, where patients should be seen within 18 weeks, and for urgent cancer referrals, where patients should be seen within two weeks. This meant the service was not always responsive and could not always meet patient urgent clinical needs in a timely manner.

  • Services did not always provide the right information to service users prior to their appointments. Incorrect telephone numbers were often printed on appointment letters.

  • Morale amongst administrative staff across most services was low.

  • Not all risks on the risk register for OPD had not been reviewed recently, and it was not clear if all risks were being addressed.

  • There were some additional plans for the long-term future of the OPD, but these were not an immediate priority due to the current challenges faced by the department. Plans did not always have clear timescales, and staff could not give examples of being involved in such plans.

However:

  • 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.

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

  • Services were delivered and co-ordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances.

  • The trust used a mostly systematic approach to continually improving the quality of its service, with clear escalation and reporting structures.

Medical care (including older people’s care)

Requires improvement

Updated 30 September 2015