The Princess Alexandra Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating remains requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored this quality statement as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

All staff we spoke with told us they would raise incidents and were encouraged to do so by senior leaders. We reviewed incidents reported for the surgery division from August 2025 to October 2025 and this showed staff reporting incidents in line with trust policy.

We reviewed the last 3 investigations related to patient safety within the surgery division and found these followed a structured approach, lessons learnt were highlighted and risk levels were reviewed.

Staff were informed of recently reported incidents within their area, we saw serious incident learning summaries displayed on the quality boards on wards. Staff we spoke to were able to give examples of recently reported incidents and how learning had been implemented to reduce future occurrence. For example, a staff member told us that there had recently been an incident of a patient developing pressure area skin damage. There had been discussion around missed opportunities to prevent this injury at daily huddles and training material available for tissue viability care.

The areas we visited had noticeboards which provided examples of how the department had learned from incidents. Displays also provided guidance on ways staff could reduce the risk of incidents such as a reminder for staff to complete falls risk assessments and skin checks.

From August 2025 to October 2025, 827 incidents had been raised for the surgery division and 579 (70.0%) of these had been closed within the trust closure target of 30 working days. The incidents that have breached the closure target were being investigated through the Patient Safety Incident Investigation (PSII) or Incident Management Group (IMG) process or relate to patients that have breached the referral to treatment standard. These incidents would only be closed once the patient had been clinically reviewed and treatment started.

Staff we spoke to understood their responsibility for duty of candour. Duty of candour is a legal requirement for all health and social care providers to act in an open and transparent way with people receiving care. This means that when something goes wrong that causes, or could cause, significant harm, the provider must inform the person (or their family), explain what happened, offer an apology, and outline next steps. There was an up-to-date duty of candour policy in place. There had been 7 incidents that required duty of candour in the last 3 months whereby staff contacted patients and their representatives to apologise when care and treatment did not go to plan. Of those 7, 2 of these had not been completed in line with the trust policy in that formal duty of candour letters had not been sent.

We scored this quality statement as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

During our onsite visit we found 11 out of 14 patient VTE risk assessments were not completed. Following the inspection we requested 3 months of VTE compliance audit data. The trust informed us that data from the EPR could not be validated and advised that for the last quarter the compliance figure reported was 68.0%. This is below the trust target of 95%. Leaders informed us they have formed a trust wide VTE improvement project to address this concern post inspection.

During our inspection we observed consultant led ward rounds on four wards. These ward rounds were not attended by other multidisciplinary team (MDT) staff involved in patient care such as therapy staff and nurses. Staff we spoke to advised that the information discussed on the ward round, plans for ongoing patient care and required investigations were documented on the EPR. All members of the MDT had access to this information, and urgent requirements would be verbally handed over to the nurse in charge. Staff advised that on occasion this resulted in delays in treatment.

The trust’s policy indicated that the Post Anaesthetic Care Unit (PACU) was not to be used for inpatients requiring ward-based care. However, data provided by the trust confirmed that in October 2025, 59% of patients that had their discharge to a ward delayed. This meant that ward-based care was carried out in the PACU and trust polices were not adhered to. This compromised patient dignity and privacy, as prolonged stays in PACU increased the likelihood of mixed-sex accommodation, contrary to national standards and trust commitments.

During our inspection we found gaps in documentation in patient records and patient risk assessments not being completed appropriately. Following the inspection, we requested copies of the documentation audits for the surgical wards. The results of these audits showed average report scores ranging from 68.8% to 88.4%. We spoke to senior nursing staff and they stated that improvement was needed in this area. The trust did not provide an action plan to address the performance in this area and therefore we were not assured leaders had good oversight and management of risk.

The trust used National Early Warning Score 2 (NEWS2) as a standardised system to detect early signs of clinical deterioration in adult patients, and we observed this used during our inspection. For example, a patient had a high score, indicating potential clinical deterioration, the senior nurse on the ward reviewed the patient and escalated the concern to the appropriate clinician via the trust’s electronic communication tool. This was in line with the trust policy. Following the inspection, we asked to review audit data to ensure this was consistently achieved and were advised that since the introduction of the EPR this report is not available. As such we are not assured that clinical deterioration is consistently detected in accordance with policy.

During our inspection we did observe staff assisting patients to mobilise with the use of appropriate equipment. Staff kept ward areas clutter free therefore reducing risk of inpatient falls. We requested data to ensure patients had an accurate falls risk assessment completed on admission. The trust provided audit results for September 2025 which showed that not all patients on the surgical wards had this assessment completed or a care plan to meet their needs. As such we are not assured that risks of falling were consistently detected in accordance with trust policy.

We requested data to ensure patients had an accurate Malnutrition Universal Screening Tool (MUST) risk assessment completed on admission. MUST is widely used five step method in healthcare to identify adults at risk of malnutrition, undernutrition or obesity. The trust provided audit results for August 2025, September 2025 and October 2025 with an average audit score of 81.1%. The data showed that not all patients on the surgical wards had this assessment completed or a care plan to meet their needs. The trust has provided an action plan to address poor compliance that includes the practice development nurse working with the ward managers and ward nutrition champions to identify learning needs. However, during our inspection we observed patients at risk of malnutrition being assisted at meal times and the wards we visited utilised “mealtime ambassadors” to ensure mealtimes were safe and supported.

We scored this quality statement as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

The trust had a safeguarding of adults at risk of abuse policy that was due for review in October 2025. Staff we spoke to understood safeguarding and told us if they were concerned for someone’s welfare, they would escalate this to their manager, this was in accordance with the trusts policy. Staff were able to identify certain categories of abuse but were less able to identify categories less commonly encountered. For example, when asked about female genital mutilation staff did not feel this was a concern given the hospitals patient demographic.

Nursing staff training compliance for safeguarding adults and children was 90%. Medical staff compliance was 53%. This was below the trust target of 95%.

Nursing staff training compliance for learning disability awareness was, 96.6% meeting the trust target. Medical staff training compliance was below target at 65.1%

We scored thisquality statement as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During our assessment we looked for documentation of conversations with patients and their relatives around resuscitation status. We were unable to find this recorded on the EPR system. The trust provided audit data from September 2025 that reviewed 137 patients’ health records, of these 72% had a discussion with the patient and their relatives documented. Not all surgical wards were included in this audit.

During our assessment patients told us that staff explained treatment options to them and their relatives and gave them time to ask questions before making a decision. Patients told us explanations were given to them in a way that they could understand.

Staff communicated with patients so that they could understand their care and treatment. This included finding effective ways to communicate with patients with communication difficulties. For example, staff had access to translation services and hearing loops.

We scored this quality statement as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Surgical wards and operating theatres were accessed via intercom. A visitor sign in book was present in the main operating theatre and visitors without a trust identification badge were professionally challenged and asked to sign in. Of the wards we visited we observed a lack of professional curiosity to challenge visitors without trust identification posing a direct safety and welfare risk.

There was clear signage for fire exits on wards identifying a fire escape route in the event of an emergency. However, on some wards, these were found to be obstructed by equipment such as drip stands and patient weighing scales. This was highlighted to staff who rectified this during the assessment.

During our inspection running water was not available on Penn Ward. Staff had escalated this to the onsite facilities team and temporary hand-washing facilities were provided until the issue was resolved. This was in line with the trust's infection prevention and control guidance.

Equipment, including special or adaptive, was available and used to deliver care and treatment that was suitable for the intended purpose. Equipment was clean and ready for use and up to date electrical testing was displayed where required. We reviewed 15 items across surgical care wards and found all were labelled and tested in line with health and safety executive (HSE) guidelines. Within the operating department equipment was stored in disused operating theatres and these were observed to be dusty and poorly organised; this was fed back to staff during the assessment.

During our inspection we observed oxygen cylinders being stored incorrectly in the operating theatre department and this posed a safety risk. This was escalated at the time to staff and rectified during our visit. Areas where medical gases were stored were not clearly identified.

The hospital used ‘boarding’ practice to maintain flow during periods of high demand to increase bed capacity. This meant that people were admitted to a ward where a bed was not immediately available. This resulted in corridor care. Corridor care refers to the practice of caring for patients in non-designated clinical areas. During our assessment we observed people being cared for in corridor spaces on Penn and Saunders Wards. These areas had call bells for patients to request staff assistance. The area on both wards was in the main corridor and although privacy screens were available these would not effectively screen the patient to achieve privacy and dignity. During our assessment these patients were nursed on trolleys and not patient beds reducing comfort and increasing the risk of developing pressure sore skin damage. Following our assessment leaders told us that patients are assessed for the risk of developing pressure damage in the ED. Staff reported it was sometimes challenging to attend to a patients’ hygiene needs on these trolleys. Staff further reported that there was often a delay in a bed being provided for these patients. During our assessment we were unable to locate risk assessments for these patients and were not assured their suitability to occupy such a space was fully assessed.

Following our assessment the trust has told us they have developed a process where ward staff now identify the lowest risk patient to move into the corridor ensuring the newly admitted patient occupies a bed space.

On the wards we observed that call bells were accessible to patients if they needed support. However, staff told us there had been complaints from patients and relatives regarding the time they waited for staff to respond to call bells and delays were observed during our assessment,

During our assessment we observed x-ray aprons used in operating theatres to be in disrepair. This equipment is required to protect staff from unnecessary x-ray radiation. The trust’s radiology department protocol was for the equipment to be screened and visually inspected annually. Data provided indicates some equipment had not been reviewed since 2022. Following our inspection the equipment has now been reviewed, the trust has identified issues and is replacing faulty equipment.

Although doors to sluices or storage rooms were not always locked, cupboards containing hazardous substances were locked securely. This ensured hazardous substances were locked away safely from reach.

Staff disposed of clinical waste safely. Sharps bins were labelled correctly and not over-filled. Staff separated clinical waste and used the correct bins.

We scored this quality statement as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The trust used an electronic system to calculate the number and grade of nurses and healthcare assistants required to manage the acuity of the patients on the wards. This was reviewed three times a day to support the matron to make decisions regarding safe staffing across the division and organisation. When staffing issues were escalated managers told us they moved staff to where they were most needed within the division. However, some staff told us that they did not always have staff deployed to them when numbers were low. Staff we spoke to told us that movement had a negative impact on morale.

During our on-site assessment, we saw wards did not always have the planned number of staff on duty to meet enhanced care needs for some patients. Enhanced care means providing a higher level of support and attention to meet a person’s more complex health or wellbeing needs. We observed a surgical division staffing meeting where staffing numbers were discussed and the matron redeployed staff to mitigate risk. For August 2025, September 2025 and October 2025 there were 37 occasions where fundamental care needs were delayed or not provided as a result of nurse staffing shortages. We checked data provided by the trust and these incidents were reported via the incident reporting system. We are unaware of an action plan to address staffing numbers to prevent further occurrences.

We requested to review current mandatory training compliance for nursing and medical staff in the surgical division. Data showed that medical staff had an overall compliance rate of 64.1% against a trust target of 95%. They did not meet compliance in any of the mandatory training topics. Nursing staff had an overall compliance rate of 92.9%. Therefore, we were not assured that all staff within the surgical division were completing mandatory training to ensure they had the necessary skills and knowledge whilst providing care and treatment.

Nursing vacancy and sickness rates were 8.7% and 4.5% against the trust target of 9% and 4.5% respectively. Medical staff vacancy and sickness rates were 7.9% and 1.5%. This indicates stability within the frontline workforce.

Physiotherapy and occupational therapy services were provided to the surgical division by a fully established team. Cover was provided Monday to Friday supporting patients that had surgery and had complex rehabilitation needs and an on-call service was available at the weekends. They also worked with the wider MDT to support with discharge planning.

We scored this quality statement as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

During our inspection we observed patients being cared for in single occupancy rooms due to infection risks. The rooms had appropriate signage to alert staff to infection status without compromising patient dignity. Five rooms were observed to have the doors open posing an infection control and prevention risk. We were unable to locate risk assessments and a rationale for the doors not being closed. This has been highlighted as a repeated concern on Saunders and Penn wards in the trusts internal auditing process. After a conversation with the CQC staff closed the door for one patient and provided a risk assessed rationale for leaving the others open.

Within the operating department equipment was stored in disused operating theatres and these were observed to be dusty. Therefore, we were not assured this equipment was regularly checked and maintained.

The wards we inspected were kept visibly clean. Cleaning records were up to date and demonstrated that all areas were cleaned regularly. We observed equipment being cleaned after each patient contact. We observed staff following Infection, Prevention and Control (IPC) principles, including the use of personal protective equipment, effective handwashing and being bare below the elbows. Hand hygiene signage was displayed throughout the wards. All waste and clinical specimens were observed to have been managed appropriately.

We scored this quality statement as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Medication storage rooms on the wards we inspected had security keypads on the doors and locked cabinets within the room.

Medication requiring to be stored in a cooler environment was kept in fridges. We saw temperatures were checked and signed for daily to ensure the correct temperature was monitored. In most cases there was an alarm fitted to the fridges which would alert staff if the temperature changed and was out of tolerance.

Controlled drugs (CDs), which are controlled under the Misuse of Drugs legislation (and subsequent amendments), were disposed of appropriately by trained staff. All CD destruction was logged in an ongoing record and monitored by the pharmacy team.

We observed staff accessing CDs and they followed the correct procedure.

The wards were supported by the pharmacy technicians to complete medicines reconciliation. The pharmacy team reviewed high risk medications, patients who had been an inpatient over a week and prepared medications required for discharge therefore supporting safe medication management.

Safe and secure medication handling audits were completed in September 2025 for the surgical wards, Post Anaesthetic Recovery Unit (PACU) and operating theatres showed good compliance in all areas with the exception of Saunders and Penn Wards scoring 68% and 77% respectively. An action plan to improve compliance was in place.