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The Princess Alexandra Hospital Inadequate

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

We are carrying out checks at The Princess Alexandra Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Inadequate

Updated 19 October 2016

We carried out a comprehensive inspection on 28 and 29 June 2016 as part of our regular inspection programme. This inspection was carried out as a comprehensive follow up inspection to assess if improvements have been made in all core service since our last inspection in July 2015.

The Princess Alexandra Hospital NHS Trust is located in Harlow, Essex and is a 460 bedded district general hospital providing a comprehensive range of safe and reliable acute and specialist services to a local population of 350,000 people. The trust has five sites; The Princess Alexandra Hospital, St Margaret’s Hospital, Herts and Essex Hospital, and Rectory Lane Clinic. At our inspection on 28 and 29 June 2016, we inspected The Princess Alexandra Hospital. On our unannounced inspection on 2 and 5 July 2016, we inspected The Princess Alexandra Hospital. We reviewed the service provided at the Rectory Lane Clinic and found that this location did not require registration, the trust would be applying to remove this location.

During this inspection, we found that there had been deterioration in the quality of some services provided since our previous inspection in 2015. During this inspection, we found that the trust had significant capacity issues and was having to reassess bed capacity at least three times a day. This pressure on beds meant that patients were allocated the next available bed rather than being treated on a ward specifically for their condition. We found that staff shortages meant that wards were struggling to cope with the numbers of patients and that staff were moved from one ward to cover staff shortages on others. The trust sees on average around 350 patients a day in its emergency department (ED).

We have rated The Princess Alexandra Hospital location as inadequate overall due to significant concerns in safety, responsiveness and leadership, with the apparent disconnect between the trust board leadership level and the ward level. It was evident that the trust leaders were not aware of many of the concerns we identified through this inspection. We found that the staff were very caring in all areas. We have rated the maternity and gynaecology service as outstanding overall.

Our key findings were as follows:

  • Shortages of staff across disciplines coupled with increased capacity meant that services did not always protect patients from avoidable harm, impacted upon seven day provision of services and meant that patients were not always treated in wards that specialised in the care of health issues.
  • The disconnect between ward staff and the matron level had improved. However, some cultural issues remained at this level which required further work.
  • The relationship between staff and the site management team had improved, though this was still work in progress and the trust acknowledged further work was required here.
  • Agency staff did not always receive appropriate orientation, or have their competency checks undertaken for intravenous (IV) care for patients on individual wards. This had improved by the time our unannounced inspection concluded.
  • The storage, administration and safety of medication was not always monitored and effective.
  • Information flows and how information was shared to trust staff were not robust. This meant that staff were not always communicated to in the most effective ways.
  • The staff provided good care despite nursing shortages.
  • There were poor cultural behaviours noted in some areas, with some wards not declaring how many staff or beds they had overnight to try and ease the workloads. This was a result of constant pressure on the service activities.
  • The mortuary fridges had deteriorated since our last inspection and some were no longer fit for purpose. These were repaired and sealed during our unannounced inspection to ensure they provided an appropriate environment for patients.
  • Across surgery, there were notable delays in answering call bells on surgical wards including Kingsmoor and Saunders ward.
  • Gynaecology inpatient care had not improved, but declined, since our previous inspection. The inpatient gynaecology service, which was operated through surgery, was not responsive to the needs of women.

We saw several areas of outstanding practice including:

  • The ward manager for the Dolphin children’s ward had significantly improved the ward and performance of children’s services since our last inspection
  • The tissue viability nurse in theatres produced models of pressure ulcers to support the education and prevention of pressure ulcer development in theatres. This also helped to increase reporting.
  • The improvement and dedication to resolve the backlog and issues within outpatients was outstanding.
  • The advanced nurse practitioner groups within the emergency department were an outstanding team, who worked to develop themselves to improve care for their patients.
  • The gynaecology early pregnancy unit and termination services was outstanding and provided a very responsive service which met the needs of women.
  • The outcomes for women in the maternity service were excellent and comparable with units in the top quartile of all England trusts.
  • MSSA rates reported at the trust placed them in the top quartile of the country.
  • The permanent staff who worked within women’s services were passionate, dedicated and determined to deliver the best care possible for women and were outstanding individuals.
  • The lead nurse for dementia was innovative in their strategy to improve the care for people living with dementia.

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

Importantly, the trust must:

  • Ensure that safeguarding children’s processes, reporting and investigations for the safeguarding of children are improved.
  • Ensure that staff caring for children and young people have appropriate levels of life support training in line with the Royal College of Nursing ‘Health care service standards in caring for neonates, children and young people’.
  • Ensure that staff are provided with appraisals, that are valuable and benefit staff development.
  • Improve mandatory training rates, particularly around (but not exclusive to) safeguarding children level three, moving and handling, and hospital life support.
  • Ensure that there are safe and efficient staffing levels at all times.
  • Ensure that resuscitation trolleys and difficult airway trolleys are routinely checked, stocked and kept in a safe condition for emergency use.
  • Ensure that fridge temperatures are monitored, and acted upon when concerns are identified.
  • Ensure that women undergoing elective gynaecology procedures, including but not exclusive to termination of pregnancy (TOP) procedures, are cared for by staff trained in the clinical, holistic and social needs of women.
  • Ensure that rapid discharge of patients at the end of their life is monitored, targeted and managed appropriately.
  • Ensure that trust staff are knowledgeable and provide care and treatment that follows the requirements of the Mental Capacity Act 2005.
  • Ensure that governance arrangements, including the risk register and board assurance framework are embedded, robust, and actively reflect the risks within the organisation.
  • Ensure that the quality of record keeping on critical care improves.
  • Reduce the impact or likelihood of mixed sex accommodation breaches on the high dependency unit (HDU).
  • Ensure that complaints are learnt from, and learning is shared throughout the trust.
  • Ensure that patients arriving by ambulance into the ED are appropriately assessed and triaged in a timely manner in accordance with The Royal College of Emergency Medicine (RCEM) guidelines.

As a result of the findings from this inspection I have recommended to NHS Improvement that the trust be placed into special measures. It is hoped that the trust will make significant improvements through receipt of support from the special measures regime prior to our next inspection.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Inadequate

Updated 19 October 2016

Effective

Requires improvement

Updated 19 October 2016

Caring

Good

Updated 19 October 2016

Responsive

Inadequate

Updated 19 October 2016

Well-led

Inadequate

Updated 19 October 2016

Checks on specific services

Maternity and gynaecology

Outstanding

Updated 19 October 2016

Overall we rated maternity services as outstanding. With caring and well-led outstanding and safety, effective and responsiveness being rated as good.

Incident reporting and learning from incidents was embedded within the service. The environment within the unit was secure. The service was consistently providing 60 hours, or more, of consultant time to the labour ward per week. Staffing levels were monitored and managed effectively.

Outcomes for women who used services were generally better than expected when compared with other similar sized services. However caesarean section rates were higher than the national average. Breastfeeding rates were better than the England average and natural vaginal delivery rates were the best in the East of England and comparable with the national average for England. The service had an outstanding process for auditing, learning from national reports and recommendations as well keeping up to date with current guidelines. The termination of pregnancy service was outstanding and followed all elements of national guidelines and legislation.

The maternity service was rated as outstanding for being caring because staff providing both maternity and gynaecology care were dedicated, compassionate, caring and they consistently went beyond the call of duty to deliver the best experience possible for the women.

The services were delivered working in partnership with commission teams and community services within Essex and across the borders. However, we also found that the lack of a gynaecology in-patient ward meant that women did not always receive timely care whilst accommodated in various wards across the trust.

The governance and risk management systems within maternity and gynaecology services were robust and well established. The medical, midwifery and operational leadership team were respected and staff spoke highly of the clinical leads for the service and how involved and approachable they were, which created an open culture.

Medical care (including older people’s care)

Requires improvement

Updated 19 October 2016

We have rated medical care at The Princess Alexandra Hospital as requires improvement overall, with safety and responsiveness rated as requires improvement and the other domains rated as good.

Nurse staffing levels did not always meet the expected established staffing requirements on the wards. Agency nurses were administering intravenous medications without providing evidence of training competencies, which placed patients at risk. However, the trust took immediate action to resolve this. There were gaps in the checking of the resuscitation equipment and medicines fridges. There were gaps in the records for the controlled drugs register checks. Staff were not always aware of outcomes from local audits. Appraisal rates had reduced since our last inspection.

There were high numbers of out of hours discharges reported. The trust acknowledged that there were issues with speciality input and bed availability as patients could not always be placed on the appropriate specialist ward.

There was a clear leadership structure across the service. Staff showed a commitment to the service and demonstrated pockets of innovation in their area of work. However, we also identified risks to the service that had not been identified on the risk register. We were concerned about some of the poor cultural practices of the nursing staff in the medical care services.

Staff demonstrated a kind, compassionate and caring approach to patients.  However, we also found that there was a theme in complaints relating to staff communication issues with patients and their relatives.

Urgent and emergency services (A&E)

Inadequate

Updated 19 October 2016

Overall we rated the emergency department (ED) at The Princess Alexandra Hospital as inadequate. Safety and responsiveness of services was rated as inadequate, how effective and well-led the service was has been rated as requires improvement, and caring was rated as good.

Patients arriving by ambulance were not routinely being initially assessed within 15 minutes as required. Many patients were in the ambulance waiting area for prolonged periods, with patients not being assessed or handed over to the trust teams. Levels of nurse staffing in the resuscitation room were unsafe. There was no clinical oversight or view of the waiting room. Regular checking of equipment, including resuscitation trolleys and defibrillators, was not taking place. Fridge temperatures were not routinely monitored to ensure safe storage of medicines. Mandatory training compliance for the department was low, especially on paediatric life support.

The service was mostly following guidelines known to them from the Royal College of Emergency Medicine (RCEM) and National Institute for Health and Care Excellence (NICE). However, staff were not familiar with all recent guideline updates. Staff had not received regular appraisals. The unplanned patient re-attendance rate was consistently higher than the England average. Concerns were raised about how staff were trained, developed and progressed in their roles within the ED. There was a lack of clinical audit taking place.

The service had not achieved the four hour performance standard since August 2014. The percentage of patients waiting four to 12 hours from the decision to admit until being admitted has been longer than the England average since May 2015. Ambulance delays over 30 minutes were some of the worst in England. Black breach rates were high. Calls bells went unanswered for prolonged periods of time when the emergency department was busy.

Staff we spoke with were unaware of the trust’s values. There was a business plan, vision and strategy for the service with some basic objectives for the ED to improve around four hour performance. However, it was limited to four hour performance and financial penalties, rather than linking it to patient safety and outcomes.

Caring was good because the trust had systems in place to offer multi-faith support and bereavement services. Care provided by staff to patients was seen as kind and compassionate.  

Surgery

Requires improvement

Updated 19 October 2016

Surgery services required improvement overall. Safe was rated as inadequate, with effective, caring, responsive and well-led rated as requires improvement.

The reduction in nurse staffing had direct impact on patient safety on Kingsmoor and Saunders ward with delayed care. Establishment nursing numbers did not match patient acuity consistently. Management of incident reporting was not robust. Monitoring of staff competencies was poor. Mandatory training rates were low across surgery. Storage of intravenous (IV) fluids on Saunders ward was not secure. Medication prescription and administration was not time specific. The difficult intubation trolley in theatres was not appropriately stored or regularly checked. The quality of mortality and morbidity meetings was poor.

Not all guidelines were updated in line with national guidance. The trust results in the National Emergency Laparotomy Audit indicated four out of 11 measures reported were rated amber. Appraisal rates were poor. Consent on the day meant there was a very limited opportunity for patients to consider all the information prior to the procedure taking place.

Staff delivered care in a compassionate, supportive and considerate manner. Patients provided consistently positive feedback about their care and treatment. Friends and Family Test data (FFT) showed an average of 97.8% of patients on surgical wards said that they would recommend the service.

Call bells were not answered in a timely manner. Patients were not always aware of which ward they would be admitted to after surgery. Referral to treatment times (RTT) standard of 92% was met in only four of 11 specialties. Theatre utilisation was impacting on service delivery. Discharge planning was not consistent. Out of hours transfers between 10pm and 7am were high. The number of patients being held in the post anaesthetic care unit (PACU) for more than 12 hours was high.

There was instability within the senior management team. Oversight to risk and quality management was limited. Staff at a local level were not supported to ensure that risks were identified, reported and managed in a timely manner.  Failure to retain and recruit staff was impacting on staff morale.

Intensive/critical care

Inadequate

Updated 19 October 2016

Overall we rated critical care services at The Princess Alexandra Hospital as inadequate. Safe, responsive and well-led were rated as inadequate. Effective was rated as requires improvement, and caring was rated as good.

There was evidence of poor medicines management practices, which posed potential serious risks to safety. Concerns included unsafe practices with morphine, carelessness in the storage and transfer of potassium chloride, and access to controlled drugs by non-registered staff. There was poor and inconsistent documenting of patient records. There was little evidence of learning from incidents and sharing feedback among staff, meaning there was an increased potential risk of incidents reoccurring. The difficult airway trolley was disorganised, incomplete and had items on it that were not part of the trolley. We saw that the last check carried out on the trolley was five months prior to the inspection. Daily checks were not being carried out on resuscitation trolleys. We were concerned about the competencies and induction processes for agency staff as the unit was not conducting internal competency checks. The quality of mortality and morbidity meetings was poor.

There was a lack of effective multidisciplinary (MDT) working. Physiotherapists did not have sufficient input to maximise patient outcomes and physiotherapy staffing did not meet national standards, which could have an impact on patient rehabilitation needs. Documentation of MDT working in patient records and handovers was poor. Ward rounds did not routinely involve MDT input. Staff gave negative feedback about the training they received to maintain competencies. Appraisal rates were the lowest in the trust at 23%.

Bed occupancy was consistently at 100% or over. There were mixed-sex accommodation breaches on the unit owing to the lack of capacity, and no evidence of action taken to mitigate this. Critical care patients regularly had to be treated in the post anaesthetic care unit (PACU) because of the lack of bed space. The longest length of stay in the PACU was over 72 hours. Delayed discharges were a significant risk owing to the problems with access and flow on the unit. There was a high rate of out of hours discharges at over twice the rate on average for similar units nationally. There was no clear formal system in place for learning from complaints and concerns in order to improve the service for patients.

There was a lack of information sharing between the service leads and the staff on the unit. The risk register did not include several of the risks to patient safety we observed during our inspection such as the poor culture surrounding medicines management and controlled drugs, and the inconsistent documentation of patient records. We were concerned about some aspects of the culture as some members of staff told us leadership was not visible or approachable, and felt unsupported.

Services for children & young people

Requires improvement

Updated 19 October 2016

Children and young people’s services were rated as requires improvement overall, with the safe domain rated as inadequate, well-led rated as requires improvement, and the remaining domains rated as good.

The service was rated as requiring improvement for safety because root cause analysis investigations and three day investigation reports were not always completed to a good standard. Processes for safeguarding children were not robust, as reflected by five serious safeguarding incidents. This was a long standing issue from our previous inspection. Mandatory training levels were below the trust target across the service, and were at their lowest for medical staff.

Daily safety checks for emergency trolleys, controlled drugs and drug fridge temperatures were not consistently completed. This was reflective of a poor culture on Dolphin ward and the neonatal unit around daily checks. An audit into antibiotics usage on the neonatal unit showed that babies waited over double the time recommended to receive antibiotics when required.

The service was not in line with Royal College of Nursing guidelines relating to staff training levels for life support training. The transition service was disjointed for long term conditions and the service did not have a transition nurse, with provision in place for diabetic children but not epileptic children. Staff were not trained in supporting children with mental health problems despite mentally unwell children regularly being admitted to the ward.

Response rates for the Friends and Family Test were very low and did not give any context to the results of the survey. Parents and carers on the neonatal unit felt that communication was lacking. Arrangement of the environment in the day surgery unit and recovery areas meant that children had to walk past adult areas to get to the anaesthetic room, and adults in recovery would often directly face the children’s bay.

We were concerned that there was a lack of grip from the leaders of this service in regards to management monitoring and actions regarding the safeguarding of children. There were significant risks for safeguarding children that were thematic and were similar to themes from the last inspection that had not been addressed.

End of life care

Inadequate

Updated 19 October 2016

End of life care at The Princess Alexandra NHS Trust was rated inadequate overall. Safe and effective have been rated requires improvement, with caring rated as good. Well-led and responsive have been rated as inadequate.

The mortuary environment was not fit for purpose, with damage and inefficiencies in the workings of the fridges and freezers. Medical staffing was not in line with national guidance, with the equivalent of 0.4 whole time equivalent palliative care consultants. Medical staffing was being provided on a service level agreement from two local hospices. Safeguarding was not included within the anticipated last days of life care plan. There was a risk nursing staff may not consider safeguarding when undertaking care planning. Medication was being prescribed and administered without documenting times on medication charts.

Patient outcomes were not routinely or robustly being monitored. The trust had a decrease in the number of clinical outcomes achieved within the End of Life Care Audit, published in March 2016. There were no end of life care champions in clinical areas. Multidisciplinary team meetings were attended by palliative care nurses and a palliative care consultant. However, no other professions attended, for example physiotherapy, occupational therapy or social workers. There was inconsistent knowledge amongst staff around the Mental Capacity Act.

No formal counselling or emotional support was available for patients at the end of life or their families. One patient stated they felt no member of staff was taking the lead on their care.

The trust did not routinely monitor patients preferred place of care or preferred place of death. The fast track discharge process was not being monitored or audited for patients at the end of life. Patients were at risk of waiting extended periods of time to be discharged.

There was no vision or strategy in place for end of life care. A non-executive director had been appointed to lead end of life care. However, this was in May 2016 and they were not yet fully established in post. There was a disconnect between clinical staff and the executive lead for end of life care. The executive and non-executive leads showed limited oversight of the service. There was no risk register which collated risks for end of life care that could be monitored. The risks identified by the specialist palliative care team and the executive team did not match the risks that had been documented. There was a decline in compliance with ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) form completion, despite executive oversight. The trust had limited improvement plans in place at the time of inspection.

Outpatients

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.