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The Princess Alexandra Hospital Requires improvement

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

Reports


Inspection carried out on 27 Mar to 24 Apr 2019

During a routine inspection

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 carried out on 5 Dec to 19 Dec 2017

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

Inspection carried out on 28 and 29 June 2016, 2 and 6 July 2016

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

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 carried out on 21 – 23 July 2015 and 30 July 2015

During a routine inspection

We carried out a comprehensive inspection between 21 and 23 July 2015 as part of our regular inspection programme. In May 2015 the intelligence monitoring system showed that there were two elevated risks and ten risks. The elevated risks were around mortality and the risks included risks from survey questions and audit data such as the four hour target in the A&E department.

The Princess Alexandra Hospital NHS Trust is located in Harlow, Essex and is a 419 bedded hospital excluding maternity and children's services and escalation areas. The hospital provides a comprehensive range of safe and reliable acute and specialist services to a local population of 258,000 people. The trust has 5 sites; Princess Alexandra Hospital, St Margaret’s Hospital, Herts and Essex Hospital, Cheshunt Community Hospital and Rectory Lane. At our inspection on 21- 23 July we inspected The Princess Alexandra Hospital. On our unannounced inspection on 30 July 2015 we inspected The Princess Alexandra Hospital, St Margaret’s Hospital and the Herts and Essex Hospital.

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 number of patients and that staff were moved from one ward to cover staff shortages on others. The trust sees on average around 300 patients a day in its emergency services.

We have rated this location as requires improvement overall due to concerns in safety, responsiveness and the apparent disconnect between ward staff and the middle managers. We found that the staff were exceptionally caring and that they went the extra mile for their patients.

Our key findings were as follows:

  • Shortages of staff across disciplines coupled with increased capacity meant that services did not always protect patients form 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 security of women, babies and children was not always maintained within the hospital.
  • There was a disconnect between ward staff and the duty matron level as capacity pressures were managed.
  • Agency staff did not always receive appropriate orientation or training to assist them in the care of patients on individual wards.
  • The storage, administration and safety of medication was not always monitored and effective.
  • Information flows were not always robust.
  • The staff provided good care despite nursing shortages and often went the extra mile to ensure that patients had a good experience within the hospital.
  • Staff were compassionate and ensured that patients dignity and privacy was respected.

We saw several areas of outstanding practice including:

  • The acting ward manager for the Dolphin Children’s ward had made a significant improvement in a short time to the ward and showed outstanding leadership and determination.
  • The play specialist providing dedicated time to fundraise to purchase toys and set up playgroups for the children was outstanding.
  • The teenage zone within the children’s ward was outstanding and was very responsive to the needs of teenagers.
  • The gynaecology outpatient and emergency service as a function, including the termination of pregnancy service was outstanding and provided a very responsive service which met the needs of women.
  • The outcomes for women in the maternity service were outstanding and comparable with units in the top quartile of all England trusts.
  • 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.

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

Importantly, the trust must:

  • Ensure that there is a system in place to protect patients from avoidable harm whilst awaiting an outpatient appointment.
  • Ensure that an end of life care pathway is in place so that patients receive appropriate care and treatment.
  • Ensure that disposable items of equipment are not reused on patients.
  • Ensure that the maternity unit is secure and that there is an effective system in place to ensure the safety of babies from abduction from the unit.
  • Ensure that the child abduction policy is updated, reflective of current practice and tested.
  • Ensure that the escalation policy is reviewed to prevent medical outliers being placed on the birthing unit at times of high capacity.
  • Ensure that medicines administered to patients take into account the patient’s allergy status and that the policy for the administration of medicines is adhered to. That medicines are stored appropriately and that appropriate checks are maintained to ensure the safety of medicines.
  • Ensure that all staff are appropriately trained, appraised and inducted for their roles, including agency and temporary staff.
  • Ensure that equipment is checked in accordance with trusts policies including resuscitation equipment.
  • Ensure that all guidelines and policies within the children’s accident and emergency high dependency room are up to date with current practice.

Action the hospital SHOULD take to improve

  • The trust should continue to work towards improving the levels of all disciplines of staff in order to provide appropriate staffing levels and in order to provide a seven day a week service.
  • Review the provision of maternity services at the trust to ensure that the service provision can be sustained beyond the next twelve months.
  • The trust should review the level of understanding of the major incident policy amongst all staff.
  • The trust should review the level of understanding of safeguarding processes in the children’s and young people’s services.
  • Review the information flows within the directorates to ensure that all staff are aware of audit information and learning from incidents and complaints to improve services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 17, 18, 19 July 2013

During a routine inspection

People we spoke with were generally positive about the hospital and care. Comments included: “Very good. The nurses are very nice. I’m quite satisfied,” “They are wonderful to me - nothing but superb service,” “They’re understaffed but it’s improved over the last few years.”

We received other comments about the lack of staff; the mixed quality of the food and that some areas were not as clean as they should be. We raised these with management over the course of our inspection and were pleased to see they took swift action to address these matters.

We are aware that the trust is operating under financial constraints and is in the middle of a recruitment campaign to address the low staff numbers. Other pressures within the local health economy are affecting the trust and its ability to provide a safe service. These matters are being reviewed with commissioners.

Despite these problems, we acknowledge the hard work that the current board and staff have put into improving morale and its governance processes. As a result of this, we have confidence that the current board will continue to make improvements. However, we found a number of areas of non-compliance that need to be addressed. These include proper and consistent patient risk assessments, proper completion of ‘do not attempt resuscitation’ forms, pressure ulcer care, discharge planning, support for staff and learning from audits and incidents.

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

We did not speak with people using the service as part of this review.

Inspection carried out on 24 July 2012

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

People that we spoke with told us that the service they received at the accident and emergency department was good. They said that nursing and medical staff were caring and professional. They told us they were well informed about their care and treatment and were treated with dignity and respect.

Inspection carried out on 21 March and 25 May 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 6 March 2012

During an inspection in response to concerns

People that we spoke with said that a good service was provided at the accident and emergency department. People said that they felt well informed about their care and what was going to happen, from both the nursing and medical staff. They also told us that they thought the staff were professional and caring.

Inspection carried out on 24 October 2011

During an inspection in response to concerns

During our visit to The Princess Alexandra Hospital on 24 October 2011 we spoke with a number of people. Patients were very complimentary about the staff. One patient told us “I know why I am here; they have told me everything that I need to know." Another patient said "I think the hospital has improved. The staff have improved, it really has improved. The staff are brilliant, always helpful, they are really good.”

Patients told us that they were called by the name they preferred. A relative whose loved one had no verbal communication told us that they were very happy with the way staff treated them. They told us “They call X by the name X prefers and explain just as though X is able to communicate. Nothing is too much trouble.”

People said that they could not fault the nursing staff. “We ask questions and they explain everything. They have been absolutely marvellous, wonderful.”

One patient told us "I have not pushed my button (call bell) yet but I have seen the staff respond as quickly as they can to other people, they are very hard working." One patient told us "The doctors always pull the curtains and I have never felt embarrassed at all."

In addition to this we were told, “I would describe the meal times as relaxed and calm, no problems at all." Other comments we received were "The food is tasty.” Another relative told us “They have tried everything, explained every option to X, even finger foods.”

People we spoke with told us they found the ward to be very clean. One patient told us "I am listened too….., the people that clean are really good, they clean even where I didn’t think possible to clean." Another patient told us "Staff wear those gloves all the time, the nurses, the consultants and the doctors do too." "It’s a wonderful place the staff at all levels really do a great job."

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

We did not speak with patients or their relatives during this review

Inspection carried out on 6, 27 April 2011

During a themed inspection looking at Dignity and Nutrition

Patients we spoke with were mostly very positive about their experiences of care and treatment. Patients stated that they were kept informed and were involved in making decisions about treatment options.

They also commented that they were given enough information both written and verbally to help with this process. One patient said “Everyone’s been brilliant, I couldn’t wish for better. Staff explained everything and encouraged questions”. Most patients also said that they had their care needs met and had been treated respectfully.

Example comments included staff described as being “very good” and “kind”. One patient said “absolutely” when asked if their care was given in a respectful way and “I am always treated with dignity”. Another patient told us “They do listen”. One patient commented that the nursing staff “Were excellent and could not do enough for me”.

Complaints data submitted to the Care Quality Commission however, highlighted that there were problems with communication and patients and their representatives were not always given accurate information.

Relatives told us they visited at different times and had been impressed by the care provided and had observed staff giving drinks regularly to patients other than their relatives. They commented that the staff made an effort to make mealtimes a pleasant experience.

Patients told us that they were generally satisfied with the standard of food and were well supported to eat and drink. Some wanted the option of different portion sizes. One patient who wanted smaller portions said “I don’t like waste”. Patients commented that there was a good choice of food, including meals that met different cultural requirements. One patient said “Meals are well organised”. They had seen another patient being assisted with their meal and said “It was well done”.

During an inspection in response to concerns

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.