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The Princess Alexandra Hospital Requires improvement

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

Inspection Summary


Overall summary & rating

Requires improvement

Updated 31 July 2019

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

A summary of services at this trust appears in the overall summary above.

Inspection areas

Safe

Requires improvement

Updated 31 July 2019

Effective

Good

Updated 31 July 2019

Caring

Requires improvement

Updated 31 July 2019

Responsive

Requires improvement

Updated 31 July 2019

Well-led

Requires improvement

Updated 31 July 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 31 July 2019

We rated safe, effective and well led as requires improvement and caring and responsive as good.

  • The service did not have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The use of facilities and environment in the service did not always keep people safe. We found, inappropriately stored glass waste, one piece of broken equipment in use and a hazardous substance left in an unlocked dirty utility room. We were not assured that risks to patients were always managed positively within the service. Comprehensive risk assessments were not always completed. Staff did not keep clear records of patients’ care and treatment and records were not always written and managed in a way that kept patients safe.
  • Staff within the service did not always monitor the effectiveness of care and treatment. The service had a limited local audit programme and did not provide us with action plans for national audits when we requested them. As a result, we could not see evidence that staff used the findings to improve outcomes for patients.

  • We were not assured that managers at ward level in the service had the right skills and abilities to run a service providing high-quality sustainable care. The service had a vision for what it wanted to achieve however it did not yet have a strategy that was regularly reviewed and updated by senior leaders within the service. The service had structures, processes and systems of accountability in place to support the delivery of the trust’s strategy. However, ward level governance structures were not always embedded. There were not effective systems in place to identify and manage local risks on some of the wards we inspected.

However:

  • 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 but the service did not meet their targets for safeguarding training for medical staff. The service had effective systems in place to manage deteriorating patients. Staff were aware of how to escalate concerns with patients and we were assured that patients observations were being undertaken regularly. The service prescribed, administered, recorded and stored medicines well. Patients received the right medication at the right dose at the right time. 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 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. The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • 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 including other healthcare providers and the local sustainability and transformation partnership. 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.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.

Services for children & young people

Good

Updated 31 July 2019

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

  • The service had enough staff to care for patients and keep them safe. Staff received 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 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:

  • Although staff understood how to protect patients from abuse, not all staff had received safeguarding training in line with national guidance.
  • A nurse trained in advanced paediatric life support (APLS) or European paediatric advanced life support (EPALS) was not available on every shift. This was not in line with standards set by the Royal College of Nursing.
  • Access to allied health professionals was limited, particularly on the Neonatal Intensive Care Unit.
  • Discharge summaries were not consistently sent to GPs within 72 hours of discharge.
  • Transition arrangements had improved since our last inspection but there was still more work to be done. Transitional pathways for children with epilepsy and children with complex allergies were under development.
  • There was currently no formal strategy specifically for the service. Service leads had a plan to develop a strategy with involvement from staff, patients, and key groups representing the local community.

Critical care

Good

Updated 21 March 2018

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

End of life care

Good

Updated 31 July 2019

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

  • All nursing staff in the end of life care team had completed their mandatory training.
  • The maintenance and use of equipment kept patients safe, syringe drivers were maintained and used appropriately.
  • Records were well maintained and kept securely.
  • There were systems and processes in place to report incidents and staff told us they were encouraged to do so.
  • Patient’s needs were assessed, and care and treatment delivered in line with evidence-based guidance to achieve effective outcomes.
  • Pain was assessed and managed and there were assessment processes in place for patients who have difficulty communicating.
  • The service ensured that staff had the skills, knowledge, and experience to deliver effective care, support, and treatment.
  • The service ensured that patients were treated with kindness, respect, and compassion, and that they were given emotional support when needed.
  • Patients were supported to be actively involved in making decisions about their care.
  • Patients at the end of life were generally nursed in side rooms and there were facilities available for relatives to stay overnight.
  • The special palliative care team would generally visit the patient on the day of referral.
  • Leaders were visible and approachable. They had the skills needed and understood the challenges to quality and sustainability for end of life care services.
  • Staff felt positive and proud of the quality of end of life care delivered and there was a strong culture of quality end of life care throughout that included both specialist and generalist staff.
  • Risk registers included identified risks in relation to end of life care and these were regularly reviewed and actioned.

Outpatients and diagnostic imaging

Good

Updated 19 October 2016

Outpatient and diagnostic imaging services at The Princess Alexandra Hospital have been rated as good overall. Safe, caring and well-led have been rated as good with responsiveness requiring improvement. We do not rate effective in outpatient and diagnostic services due to there being an inconsistent data set for services of these types.

During this inspection we followed up on a number of areas which we found to be inadequate or requiring improvement during our last inspection in July 2015. The previous issues related mainly to patients having to wait unsafe amounts of time before being offered an appointment. We found that the service had taken action and improvements were seen.

We rated this service as good because:

Staff were aware of how to report incidents and when this should be done. There was a clear escalation pathway for safeguarding concerns and medication was stored appropriately, in line with manufacturer’s guidance. Mandatory training compliance was good and staff were competent in their roles. However, the main outpatient department was dated and in need of repair and refurbishment, and 10 out of the 11 patient records we reviewed did not contain up to date patient information.

Policies and procedures were developed using relevant national best practice guidance and patient outcomes were monitored via national audit arrangements. However, the local audit plan was limited in content meaning that there was limited opportunity to improve patient outcomes locally.

Staff provided compassionate and respectful care to patients. We observed that staff were understanding and maintained patient dignity. The majority of patient feedback that we received during our inspection was positive, and the latest Friends and Family Test (FFT) results demonstrated 96% of patients would recommend the service.

Outpatient and diagnostic imaging services were well-led. There was a cohesive leadership team and staff felt managers were approachable and that there was a strong open culture. Patients and staff were engaged in the running of the service and staff were enabled to be innovative. Since our previous inspection, governance systems had been reviewed and a clear structure had been put in place.

Surgery

Good

Updated 31 July 2019

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

  • Mandatory training for nursing staff had improved significantly since our last inspection and mostly met the 90% target. Medical staff mandatory training had also improved to 60% with an action plan to improve to 90% by July 2019.
  • Staff understood how to protect patients from abuse and safeguarding training had also improved with the addition of level three safeguarding for children.
  • Staff collected safety monitoring information and shared results with staff, patients and visitors.
  • The service generally controlled infection risk well and used control measures to prevent the spread of infection.
  • The service made sure patients received the right medication at the right dose at the right time including assessing for pain relief.
  • The service provided care and treatment that was planned and delivered in line with current evidence-based guidance. Managers monitored the effectiveness of care and treatment and used the findings to improve them.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • Managers ensured staff were competent for their roles appraised staff’s work performance and held supervision meetings with them to provide support.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Staff cared for patients with compassion and dignity and provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The service planned and provided services in a way that mostly met the needs of local people.
  • The service took account of patients’ individual needs and developed services to meet them.
  • The service treated concerns and complaints seriously, learned from them and shared these with staff.
  • Service leads had the skills and abilities to run the service providing high-quality sustainable care.
  • Managers across the service promoted a positive culture that supported and valued staff.
  • The service used a systematic approach to quality improvement creating an environment in which generally reflected best practice. Governance structures, processes and systems of accountability were clearly set out.
  • The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
  • The service was committed to improving services by learning from when things went well or wrong, promoting training, research and innovation.

However:

  • The service did not take timely action to protect patients from harm following recognition of patient risk, and we were not assured that duty of candour was always applied when things went wrong.
  • Staffing remained a concern with significant vacancies both within the nursing teams and some medical staff teams.
  • There was a lack of oversight in ensuring that deteriorating patients received the appropriate level of observations according to trust policy.
  • Staff but did not always consent patients for surgery in line with best practice.
  • There was a lack of oversight in ensuring that all out of date policies were reviewed and available for staff to use for example the fasting policy had been under review since 2014.
  • People could not always access the service when they needed it. Waiting times from referral to treatment were not always in line with good practice or the England average.
  • The service had systems to identify risks and risk management processes to eliminate or reduce them, but we were not assured that actions were always taken in a timely way.

Urgent and emergency services

Requires improvement

Updated 31 July 2019

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

  • The service provided mandatory training in key skills to staff but did not ensure everyone completed it.
  • The service did not have enough nursing staff with the right qualifications, skills, training and experience to keep patient's safe from avoidable harm and to provide the right care and treatment.
  • Staff did not always keep detailed records of patients care and treatment.
  • People could not always access the service when they needed it.
  • The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. From February 2018 to January 2019 the trust consistently failed to meet the standard and consistently performed worse than the England average.
  • From February 2018 to January 2019 the trust’s monthly percentage of patients waiting more than four hours from the decision to admit until being admitted was worse than the England average in 10 out of 12 months.
  • From February 2018 to January 2019 the trust’s monthly median total time in ED for all patients was higher than the England average for eight of the nine months for which data were available.
  • The trust leadership team did not ensure that all staff completed mandatory training.
  • Managers did not ensure that key performance targets were consistently met in relation to patient flow and waiting times.

However:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service-controlled infection risk well. Equipment and premises were clean. Staff used control measures to prevent the spread of infection.
  • The service had systems, processes and practices in place to manage the environment and equipment to keep people safe.
  • The service had enough medical staff with the right qualifications, skills, training and experience to keep patient's safe from avoidable harm and to provide the right care and treatment.
  • The service prescribed, administered, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
  • The service reported safety incidents well, staff recognised incidents and reported them appropriately.
  • The service monitored performance and activity to understand risks and provide a clear accurate picture of patient safety.
  • The service provided care and treatment that was planned and delivered in line with current evidence-based guidance.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • Staff assessed and monitored patients regularly to see if they were in pain.
  • The service made sure staff were competent for their roles.
  • Staff of different kinds worked together as a team to benefit patients.
  • Key services were available seven days a week to support patient care.
  • Staff were proactive in supporting patients to live healthier lives.
  • Staff obtained consent to care and treatment in line with legislation.
  • Staff treated patients with compassion, dignity and respect during interactions.
  • Patients were given support to cope emotionally with their care, treatment or condition.
  • Staff involved patients and those close to them in decisions about their care, treatment and changes to the service.
  • Services were tailored to meet individual needs and person-centred pathways involved other providers.
  • The service demonstrated a pro-active approach to understand the needs of the different patient groups to deliver care to meet those needs, which is accessible and promotes equality.
  • The service managed and responded to concerns and complaints.
  • Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • Governance arrangements are proactively reviewed and reflected best practice. A systematic approach was implemented to work with other organisations to improve patient experiences and outcomes.
  • The service had good systems to identify risks, plan to eliminate or reduce them, and cope with both the expected and unexpected.
  • The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
  • The service was committed to improving services by learning from when things went well or wrong, promoting training, research and innovation

Maternity

Requires improvement

Updated 31 July 2019

  • The overall rating went down by two ratings from outstanding to requires improvement as the service was not providing assurance that changes required to reduce risks and the improve safety of care provided to women and their babies were fully implemented and embedded.
  • The service provided mandatory training in key skills to all staff, however not everyone completed it. The service did not always make sure staff were competent for their roles. Not all staff had the skills and competencies for their roles.
  • The service did not always control infection risk well. We found dirty equipment in maternity theatres and theatre circulation staff did not wear surgical masks in line with national guidance.
  • Staff did not always complete and update risk assessments for each patient. They did not always keep clear records and complete mandatory training necessary to manage risks to patients. Staff did not keep detailed records of patients’ care and treatment.

  • The service had enough midwifery staff and medical staff, but we were not assured staff had the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • Records did not always contain information such as completed fetal growth charts and records were not always signed and dated correctly.
  • The service did not always follow best practice when prescribing, giving, recording and storing medicines. Medicines were not always stored securely on the labour ward.

  • The service did not manage patient safety incidents well. Staff recognised incidents and reported them appropriately, but managers did not always investigate incidents and share lessons learned with the whole team and the wider service.
  • The service did not always provide care and treatment based on national guidance and evidence of its effectiveness. Managers did not always check to make sure staff followed guidance.

  • The service had not fully implemented changes required to reduce risks and increase the safety of the service provision. The trust did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The service did not have robust systems in place to improve safety and quality of care, despite monitoring the quality and standards of its services and care.

However, we also found:

  • 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.

  • Managers appraised staff’s work performance to provide support and monitor the effectiveness of the service.
  • Staff gave women enough food and drink to meet their needs and improve their health. The service made adjustments for patients’ religious, cultural and other preferences.

  • Staff assessed and monitored women 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 against local and national targets.
  • Staff of different kinds worked together as a team to benefit women. Doctors, midwives and other healthcare professionals supported each other to provide co-ordinated care.
  • Staff understood how and when to assess whether women had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.
  • Staff cared for women with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff involved women and those close to them in decisions about their care and treatment and provided emotional support to minimise their distress.
  • The trust mostly planned and provided services in a way that met the needs of local people and took account of patients’ individual needs. The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • 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.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, women, and key groups representing the local community. Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The trust collected, analysed, managed and used information to support all its activities, using secure electronic systems with security safeguards.
  • The service mostly engaged well with women, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
  • The service had developed initiatives to improve services when things went wrong.