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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.

Reports


Inspection carried out on 5th September 2017 and 5th and 6th October 2017

During a routine inspection

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 carried out on 13 - 17 and 22 April 2015

During an inspection to make sure that the improvements required had been made

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 carried out on 2-4 and 10 December 2013

During a routine inspection

King’s College Hospital NHS Foundation Trust is one of London's largest and busiest teaching hospital trusts, with a strong profile of local services primarily serving the boroughs of Lambeth, Southwark and Lewisham. Its specialist services are available to patients across a wider catchment area, providing nationally and internationally recognised work in liver disease and transplantation, neurosciences, haemato-oncology and foetal medicine. The trust is one of four founder partners of King’s Health Partners, one of England’s five academic health science centres for research collaboration.

The trust provides general and specialist services to patients in South London, and also coordinates, or is a part of, various regional centres for trauma, breast screening, diabetes, cystic fibrosis, stroke and liver disease.

The Princess Royal University Hospital (PRUH) was acquired by King’s College Hospital NHS Foundation Trust on 1 October 2013. Before this it was part of the South London Healthcare Trust, which was placed into administration by the Secretary of State in July 2012.

This report relates to the acute services provided by the Princess Royal University Hospital. The hospital has over 500 beds and serves a population of approximately 300,000 in the borough of Bromley of which 91.6% are White and 8.4% are Black or minority ethnic people.”

Prior to being dissolved, the South London Healthcare Trust experienced severe financial challenges, which impacted on many areas of care and systems for monitoring the quality of care provided. The due diligence reports carried out by King’s College Hospital NHS Foundation Trust, dated June 2013, identified a number of significant problems, including the processes for managing risk, complaints and clinical effectiveness, which were perceived to be weak and understaffed. They highlighted the urgent need for clinical governance systems to be put into place at all levels of the PRUH. The current trust is aware of the issues and has developed action plans and started to address the problems.

The scale, number and longstanding history of many of the problems the current trust has inherited should not be underestimated. They include long waiting times in the accident and emergency (A&E) department and significant problems with the availability of medical records. Poor management of patient movement (“flow”) around the hospital means some patients are having their elective surgery cancelled and some patients cannot be transferred from the critical care unit. Systems for monitoring the quality of care had also been much reduced.

Along with (until recently) a lack of resources and support, staff were working in very difficult circumstances and under enormous pressure to provide safe care. Despite the history of problems morale amongst the majority of staff was good and staff were motivated and keen to improve care and services. They are to be commended for maintaining their commitment while working in difficult circumstances for a long period of time. The current trust has recognised that it needs to invest and support staff and has started to do this by increasing staffing levels, and providing a clear management structure for each of the divisions and a dedicated site management team.

During the inspection we were concerned about the degree of urgency in responding to the long waiting times that patients were experiencing in A&E and the lack of capacity within the hospital. To mitigate some of the risk, more staff were being brought in to care for patients. Although senior managers/executives reassured us that they were taking prompt action, this was not supported by what the inspection team saw during the inspection. Some staff working in clinical areas appeared to have become resigned to the situation and worked around the problems rather than addressing them. This attitude was evident in some interviews with staff and during our observations of clinical areas. The plans of senior managers had not yet had enough visible impact on the delivery of care.

At the time of the inspection, the trust was implementing its escalation plan which is now in place, although there has been no improvement in the A&E waiting times.

There was also a significant lack of data available about the quality and effectiveness of the care and treatment provided to patients.

We also identified a number of areas where we felt the trust could and should be taking more prompt action – for example, improving the waiting times in the A&E department.

Some action has been taken to improve the availability of medical records in the outpatients department, but this has yet to have an impact on the service. More action is in process but a lack of records meant that at times patients were undergoing complex medical procedures without clinicians having access to complete set of notes. We reported these areas to the trust and, since the inspection, we have received a letter outlining the immediate action the trust intends to take.