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Alexandra Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 20 September 2019

Our rating of services improved. We rated it them as requires improvement because:

  • The safe key question was rated as requires improvement overall at this hospital.
  • The responsive key question was rated as requires improvement overall.
  • The effective key question was rated as requires improvement overall.
  • We found regulatory breaches of the Health and Social Care Act 2008 in urgent and emergency care, medical care, surgery, outpatients and diagnostic imaging.

However,

  • The effective key question was rated as good overall.
  • The caring key question was rated as good overall.
  • The well led key question was rated as good overall.

Inspection areas

Safe

Requires improvement

Updated 20 September 2019

Effective

Good

Updated 20 September 2019

Caring

Requires improvement

Updated 20 September 2019

Responsive

Good

Updated 20 September 2019

Well-led

Requires improvement

Updated 20 September 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 20 September 2019

  • The service provided mandatory training in key skills to all staff but did not always make sure everyone completed it.
  • While staff knew how to recognise and report abuse, not all staff had received training to an appropriate level for their role.
  • The service did not always have enough medical, nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. However, managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
  • Patients were not always seen and assessed by a consultant within 14 hours of admission.
  • Managers did not consistently monitor the effectiveness of care and treatment and use the findings to improve them. Medical services contributed to national audits relating to patient care. There was poor performance in some national audits relating to patient safety and treatment. For example, the National Lung Cancer Audit 2017; the Hospital Standardised Mortality Ratio (HSMR); the Chronic Obstructive Pulmonary Disease Audit October 2017 to March 2018. We saw that specialities discussed audit results as part of their local governance and, where necessary, had action plans to drive up performance. They compared local results with those of other services to learn from them.
  • The service did not make sure all staff completed their Mental Capacity Act and Deprivation of Liberty Safeguard training.
  • The service did not have processes to ensure staff were competent for their roles. While managers appraised most staff’s work performance and held supervision meetings with them to provide support and development this continued to be below the trust target of 90%.
  • Not all people could access the service when they needed it and receive the right care promptly. However, waiting times from referral to treatment and arrangements to admit, treat and discharge patients was better than the England average.
  • The response rate from the friends and family test was worse than the England average.
  • Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. However, there was no field to evidence the outcomes taken, what mitigation actions had been completed or if the risk had reduced or increased. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care
  • While leaders operated effective governance processes throughout the service and with partner organisations, it did not always have a systematic approach to continually improve the quality of its services. However, they had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.

However,

  • The service-controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
  • Staff completed and updated risk assessments for each patient. Staff identified and quickly acted upon patients at risk of deterioration. Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
  • The service used systems and processes to safely prescribe, administer record and store medicines.
  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. When things went wrong, staff apologised and gave patients hones information and suitable support.
  • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patient’s subject to the Mental Health Act 1983.
  • Staff supported patients to make informed decisions about their care and treatment. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • 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 and gave pain relief in a timely way.
  • Doctors nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Key services were available seven days a week to support timely patient care.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint.
  • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their sills and take in more senior roles.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.

Services for children & young people

Requires improvement

Updated 5 June 2018

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

  • The service provided mandatory training in key skills to all staff but data provided by the trust showed they did not ensure staff completed it. The trust identified issues with data quality which may have resulted in under reporting of the actual position.
  • Staff understood the need to protect patients from abuse but had not always completed training at the appropriate level to ensure they had the appropriate level of knowledge to do so.
  • Standards of infection prevention and control were not always maintained.
  • The premises and equipment were not well maintained.
  • There was no protocol or standard operating procedure for staff to follow if a child or young person became unwell in the department and nursing staff did not use an early warning score to identify when a patient deteriorated.
  • Staff kept appropriate records of patient’s care and treatment, but some hand written records were not clear and there was an increased risk of unauthorised access to the patient records via unlocked computers.
  • The facilities and premises were not always suitable for the service being delivered. More than two thirds of children were seen in adult outpatient areas. Play specialists were not available to support children in outpatient clinics.
  • The service had an annual audit plan. However, there were few audits which considered the effectiveness of children’s outpatient services.
  • Children’s and young peoples’ pain was not always managed effectively. Staff in fracture clinic did not assess patient’s pain and offer pain relief when needed.
  • The service had systems to monitor the effectiveness of care and treatment for inpatients and used the findings to improve, but there was little monitoring of outcomes of outpatient care.
  • Staff were aware of their responsibilities for obtaining consent for treatment and their roles and responsibilities under the Mental Capacity Act 2005 (MCA). However, staff completion of training in MCA was low and no audits of consent were completed.
  • The service did not monitor waiting times within the clinics for patients. Fracture clinics were busy and patients and staff reported that waiting times could be lengthy and the percentage of patients not attending for a follow up appointment was high.
  • Leadership of children’s services was provided from the Worcestershire Royal Hospital site and the amount of time dedicated to children’s services at the Alexandra Hospital was very limited. There was no oversight of services for children provided in the adult outpatient departments by the children’s directorate team.
  • The service had a vision how children’s services would be configured in the future and what it wanted to achieve, but did not have a documented strategy or action plan to enable the vision to be realised.
  • Governance processes were becoming more established and had improved since the inspection in 2016. However, there was little engagement and involvement of nursing staff at clinic level in governance processes.
  • The service did not have effective systems for identifying risks, and coping with the unexpected. They measured key performance indicators on a monthly basis but there was little evidence of improvement in some indicators over the period of a year.
  • Information on some aspects of performance was available, however, the utilisation of information to bring about improvements was not maximised. Trust information was not always available due to problems with the trust’s IT systems.

However:

  • Staff cared for children and young people with kindness and understanding.
  • Staff provided emotional support to patients to minimise their distress.
  • There were enough medical staff with the right qualifications and experience to provide care in children’s services at the hospital.
  • Suitable arrangements were in place for the ordering, dispensing, prescribing, recording and handling of medicines.
  • Staff recognised incidents and reported them appropriately. Managers investigated incidents and provided feedback to staff. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Multidisciplinary staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • The service took account of patients’ individual needs.
  • The trust promoted a positive culture which valued staff and based on shared values but staff whilst saying they embraced this, did not feel it was embedded within the trust.

Critical care

Good

Updated 20 June 2017

We rated critical care as good because:

  • There was a positive safety culture. Staff recorded incidents, investigations were completed and staff received feedback. The service had a robust safety briefing in place, which was attended by all staff.
  • Staff maintained and monitored patient safety through local audits which included infection control, patient harms and risks. Action plans were developed to address any issues.
  • Patient records were contemporaneous, legible and stored safely. Evidence based assessment tools were used to monitor risk.
  • Mandatory training was generally in line with trust targets.
  • Medications were stored, prescribed and administered safely. There were systems in place to monitor safe storage and staff took appropriate actions in line with local protocol to address any concerns or anomalies.
  • The service used evidence-based guidelines, policies and protocols to monitor patient outcomes. Results were used to compile service dashboards, which were used to present audit results and monitor trends. Clinical leads reviewed these for compliance and trends and discussed results as part of the divisional and trust wide service meetings.
  • The service had a flexible approach to delivering patient care across both critical care units (Alexandra Hospital and Worcestershire Royal Hospital) to maintain patient safety.
  • Patient outcomes were used to benchmark the service against similar organisations to identify areas for improvement.
  • The service had access to additional specialists such as a pain specialist nurse, dietetics, microbiologists and pharmacy.
  • Staff competence was monitored and maintained through annual appraisal and competency reviews. External training was available for staff.
  • There was evidence that the multidisciplinary team was inclusive and well organised.
  • Patients were treated with dignity and respect, and in line with their individual beliefs and were involved with the care and treatment planning. Patients spoke positively about the care they received.
  • Relatives had access to facilities to enhance their stay on the unit, this included overnight accommodation, refreshments and information leaflets.
  • Patients were assessed appropriately for admission to critical care and received a full review by a consultant within 12 hours of admission to the unit.
  • There were no formal complaints regarding the service.
  • The service was well-led with strong local leadership, a service vision and robust governance systems in place.
  • All staff were positive about their roles, enjoyed working for the service and were dedicated to improving the standards of patient care.

However:

  • There were a small number of delayed discharges from critical care, which affected patient flow and experience.

End of life care

Good

Updated 20 June 2017

We rated the end of life care service as good because:

  • Staff understood their responsibilities to raise concerns and to record safety incidents. Incidents relating to end of life care were reviewed by the lead nurse for specialist palliative care. DNACPR (do not attempt cardiopulmonary resuscitation) records were generally completed well and the trust were making use of audits and learning from incidents to drive improvements.
  • There was good identification of patients at risk of deterioration and those in the last days of life. There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. There was consistent promotion of the delivery of high quality person centred care. Several audits had been undertaken to evaluate the service with associated action plans to address improvements identified.
  • A comprehensive programme of end of life care training was available for the full range of staff within the trust. However, we were not able to establish compliance with mandatory training (including safeguarding adults training) for specialist palliative care staff, including their annual appraisals rates. Evidence for this was requested but not provided by the trust.
  • There was good evidence of multidisciplinary working and involvement of the specialist palliative care team throughout the hospital including allied healthcare professionals as well as medical and nursing members. The specialist palliative care team provided a seven day face to face assessment service across the trust.
  • The trust had taken action to improve the service since the previous inspection. This included the replacement of fridges, flooring and improving the hot water facilities within the mortuary. Issues relating to obtaining syringe drivers had been addressed and appropriate anticipatory prescribing was used at the end of life.
  • There was clear evidence of the trust using national guidance to influence the care of patients at the end of life. The trust had begun to record and audit preferred place of care and there were clear systems in place to make improvements in this area.
  • The specialist palliative care team responded quickly to referrals and would see patients within a few hours if the need was urgent. The majority (92%) of patients were seen within 24 hours and there was a good balance between cancer patient and non-cancer patient referrals.
  • Patients and relatives told us that the staff were caring, kind and respected their wishes. We observed staff communicating with patients and relatives in a manner than demonstrated compassion, dignity and respect.
  • There was a clear vision for the service and a draft strategy was in place, highlighting the key areas the trust were focusing on in relation to end of life care.

Maternity and gynaecology

Requires improvement

Updated 8 August 2017

We carried out a focused inspection to review concerns found during our previous comprehensive inspection on 22 to 25 November 2016. We inspected parts of four of the five key questions but did not rate them. We found significant improvements had not been made in these areas:

  • Despite assurances from the trust, we saw no evidence that obstetrics and gynaecology mortality and morbidity reviews were held. Furthermore, whilst perinatal mortality and morbidity meetings were minuted, we were not assured that action was taken to address any learning identified from case reviews.
  • The trust had monitoring systems in place to ensure medicines were stored within recommended temperature ranges. However, these were not consistently followed across the service.

We also found other areas of concern:

  • Surgical nursing staff, who cared for gynaecology patients on the designated wards, had not received any specific gynaecology training, such as management of surgical miscarriage and bereavement care. However, the gynaecology medical team were available for advice as needed.

However, we found improvements in some areas:

  • All clinical areas we visited were clean and there was good adherence to infection control policies and the use of personal protective equipment.
  • There had been an improvement in compliance with safeguarding children level three training. Staff demonstrated awareness of safeguarding guidance, including female genital mutilation. Staff understood their responsibilities and were confident to raise concerns. However, training compliance was still below the trust target.
  • Equipment was clean, maintained and serviced to ensure it was safe for patient use.
  • Compliance with Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) training had improved. Staff demonstrated awareness of relevant consent and decision making requirements relating to MCA and DoLS, and understood their responsibilities to ensure patients were protected.

Surgery

Requires improvement

Updated 20 September 2019

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

  • People could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit treat and discharge patients were not in line with good practice. Services were planned in way that ensured surgical patients were allocated a surgical bed. At the time of the inspection, there were no surgical outliers. Surgical outliers is a term used when there are not enough surgical beds for surgical patients meaning these patients are cared for in another speciality bed, usually on a medical ward.
  • We noted that medical device training was below the agreed trust compliance. We requested current medical device training compliance which showed that both theatre and ward compliance remained low.
  • We saw some episodes where infection prevention control measures were not used in line with the infection control policy and recognised best practice.
  • Mandatory and safeguarding training for medical staff, although improved did not meet trust targets. The trust had reviewed their approach to training to improve completion rates.

However,

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration. Staff assessed risks to patients and monitored their safety. Assessments were in place to alert staff when a patient’s condition deteriorated.
  • The service generally had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction
  • 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.
  • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. We observed staff treating everyone with kindness and respect.
  • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.

Urgent and emergency services

Requires improvement

Updated 20 September 2019

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

  • There were breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. See end of this report for a list of current breaches.
  • While the service controlled most infection risks well, not all staff followed the trust hand hygiene or personal protective equipment (PPE) policy. There was no evidence of this impacting on patient care or causing harm. Equipment and premises were visibly clean.
  • The department was not of a sufficient size to meet the demands of the local population. There were insufficient quantities of some equipment. Incidents had occurred where emergency equipment had not been checked, or where it was not available.
  • There were not enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care at all times. Patients’ needs were met during our inspection. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
  • Staff did not always monitor or record patients’ pain, and the effectiveness of pain relief given was not always documented. There were some delays in providing pain relief.
  • Privacy and dignity could not always be protected due to overcrowding.
  • Patients could not always access the service when they needed to due to overcrowding. Some patients had long delays in accessing emergency care and treatment.
  • The service was unable to meet the standards of performance expected of an emergency department (ED) due to the high number of patients using the service, and the lack of sufficient staff at times.
  • Some concerns raised during the June 2018 and January 2019 CQC inspections had not been addressed and remained a concern during this inspection. While leaders encouraged innovation and participation in research, the service was constrained by a lack of staff, an unsuitable environment, and the high number of patients using the service.

However,

  • Staff cared for patients with compassion and kindness. Most feedback from patients confirmed that staff treated them well and with kindness.
  • Local leaders were visible and approachable for patients and staff. They supported staff to develop their skills and take on more senior roles. Leaders had the integrity, skills and abilities to run the service, and they understood and managed the priorities and issues the department faced.
  • Staff working in the ED were committed to continually learning and improving services, and had a good understanding of quality improvement methods,
  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses.
  • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patient’s subject to the Mental Health Act 1983.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
  • The service was inclusive and took account of patients’ individual needs and preferences.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.

Diagnostic imaging

Requires improvement

Updated 20 September 2019

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

  • There were ongoing staff shortages in some modalities that impacted patient care and the delivery of the service.
  • There was evidence of delays to care and treatment as a result of short staffing in some modalities, failing equipment and poor communication and multidisciplinary working from other trust departments. Staff were aware of the risks related to these issues and submitted incident reports appropriately. However, there was limited evidence of meaningful improvement from the trust.
  • Some staff described limited opportunities for professional development.
  • Although services were benchmarked against best practice, there was limited evidence of audits taking place to identify areas for development.
  • There were some gaps in the presence and availability of leadership at directorate level and we were not assured the senior team was addressing the most pressing issues in the department.
  • The mammography service was isolated from the rest of radiology and there was no evidence of directorate-level support or involvement.
  • Staff described highly variable relationships with the trust, with limited evidence of engagement.

However,

  • Staff in the service had addressed the areas for improvement we found at our previous inspection, including a significant improvement in the number of staff with up to date Mental Capacity Act (2005) training.
  • Staff delivered care to a very high standard and routinely went above and beyond their duties to provide an individualised service. This included recognising each patient’s personal needs and addressing their anxieties.
  • The service had significantly reduced a backlog of plain film x-rays and ultrasounds awaiting a report and implemented measures to prevent a similar situation in the future.
  • Staff had initiated a series of waiting list initiatives to reduce waiting times following a referral, which had significantly improved access.

Outpatients

Good

Updated 20 September 2019

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

  • The service provided mandatory training in key skills to all staff and most staff were up-to-date with it. 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. The design, maintenance and use of facilities, premises and equipment kept people safe.
  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
  • The service had enough nursing staff, with the right mix of qualification, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. The service used monitoring results well to improve safety.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
  • Staff assessed and monitored patients to see if they were in pain.
  • The service made sure staff were competent for their roles.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent.
  • Staff treated patients with compassion, kindness, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
  • 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.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services.
  • The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
  • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
  • The service had a vision for what it wanted to achieve and a strategy to turn it into action developed with all relevant stakeholders.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • Leaders operated effective governance processes, throughout the service. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.
  • Leaders and teams identified and escalated risks and issues. They identified actions to reduce their impact. They had plans to cope with unexpected events.
  • The service collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements.
  • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services.
  • Staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them.

However,

  • Patients’ privacy was not always protected in the phlebotomy department.
  • People could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were generally worse than the England average.
  • Performance against the national cancer standards for patients on two week waits and patients waiting less than 62 days for treatment were not in line with national standards.
  • Operational performance such as clinic waiting times was not routinely monitored.