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Royal Sussex County Hospital Requires improvement

CQC carried out a period of listening activity at Brighton and Sussex University Hospitals NHS Trust in December 2013 and January 2014. The report from that exercise, which informed our inspection in May 2014, is available below.

We are carrying out checks at Royal Sussex County Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 August 2017

Brighton and Sussex University Hospitals (BSUH) is an acute teaching hospital with two sites the Royal Sussex County Hospital in Brighton (centre for emergency and tertiary care) and the Princess Royal Hospital in Haywards Heath (centre for elective surgery). The Brighton campus includes the Royal Alexandra Children’s Hospital and the Sussex Eye Hospital.

The trust provides services to the local populations in and around the City of Brighton and Hove, Mid Sussex and the western part of East Sussex and more specialised and tertiary services for patients across Sussex and the south east of England.

The trust was inspected in April 2016 and rated as inadequate. Royal Sussex County Hospital was rated as inadequate. Following publication of the report and our recommendation, the trust was placed into special measures by NHS Improvement.

The trust has now been subject to performance oversight for eight months and this inspection was made to assess progress against the actions required subsequent to the publication of the 2016 report.

In designing this inspection we took account of those services that performed well at the 2016 inspection and as a consequence the services inspected only included emergency care, medical services, surgery, critical care, maternity and gynaecology and outpatients and diagnostics.

The trust board and executive leadership has been unstable for the last twelve months and immediately prior to the inspection management responsibility for the trust had been passed to the board of Western Sussex Hospitals Foundation Trust. As such, it was not pertinent to complete a full assessment of trust wide leadership. However, during the inspection we have followed up the concerning areas of organisational culture of bullying and harassment and discrimination that were evident in the 2016 report.

Our key findings were as follows:

Safe

  • Incident reporting, process and culture was much improved with enhanced analysis. Feedback to staff via "safety huddles" and other communications had also been improved. However, in some areas learning and sharing had not been maximised and in critical care, a significant backlog of incidents had occurred that impeded the opportunity to learn from incidents.

  • Following an improvement initiative, the trust had reduced the number of never events. The root cause analysis of serious incidents was also of a good standard.

  • There was not an overarching strategy for the maintenance of a clean environment and the fabric of some areas of the hospital remained in a poor condition. The concerns relating to fire safety expressed in our last report had been addressed by a process of external review and assessment. However, action plans to complete the work identified lacked documentation of completion and had no corporate oversight mechanism.

  • At times of intensive activity, the trust was still using the corridor area in the emergency department to hold patients. However, processes for risk assessment and clinical oversight were much improved although policies and training for supporting staff caring for patients with mental health conditions in the emergency department require improvement.

  • The trust had ceased using the post-operative recovery area for the inappropriate care of patients transferred from the emergency department or the high dependency unit. This was an observed and reported practice at our last inspection.

  • Staffing levels and recruitment remain challenging for the trust, however, staff are now more likely to report staffing issues as incidents than previously. The trust had met the challenge of medical staffing levels in the emergency department with a highly successful and novel role for clinical research fellows.

  • In both maternity and critical care, required levels of 1:1 care for patients are not consistently maintained. Although the trust has a mitigation plan there remain gaps in the ICU neurosurgical trained nurses’ roster.

  • As at our last inspection, medicines management, safeguarding and duty of candour were well managed and applied appropriately. Although the trust has improved its compliance with mandatory and safeguarding training many departments remain below a low threshold target of 75%.

Effective

  • Staff generally followed established and evidence based patient pathways. Staff had access to up-to-date protocols and policies. We saw a significant improvement in maternity. Sepsis training, awareness and protocols had also improved. However, pathways for bariatric patients being managed in medicine were not optimum.

  • As also reported in 2016 national clinical audits were widely completed. Mortality and morbidity was reviewed in all departments.

  • Pain relief was effectively delivered and the trust had developed its trust wide pain team. However, the service remained unavailable at weekends.

  • Patients' nutritional needs were generally met and the trust had increased efforts to provide protected mealtimes. Comfort rounds had been introduced in the emergency department to assist in the maintenance of hydration. There remained no dedicated dietician support to the critical wards.

  • Appraisal compliance had significantly improved across the trust. However, this was from a low base and many departments still remained below the trust target.

Caring

  • Our last report indicated issues of dignity and privacy within the outpatients department. Staff had clearly striven to deliver improvements and this was recognised in our observations. The environment within the eye clinic still remained problematic in terms of delivering care in a confidential and dignified manner.

  • The privacy and dignity of patients cared for in the corridor area in emergency care, had been alleviated by the introduction of privacy screens. However, there were not enough screens to ensure the privacy of all patients at times of high demand.

  • Patients reported they were involved in decisions about their treatment and care and this was reflected in the care records we reviewed.

  • Throughout the trust patients received compassionate care and we observed this in the interactions between staff and patients. Patients were very positive in their feedback regarding the care they received.

Responsive

  • As we found at our last inspection, referral to treatment time was consistently below the national standard for most specialties. The trust had improved compliance with two week wait and 31 day standard for cancer but was not attaining the 62 day target. Delays were also being incurred in the processing of biopsies for pathology.

  • The number of patients whose operation was cancelled and who were then not re-seen within 28 days exceeded the national average.

  • The trust had implemented revised escalation procedures to manage surge activity in the emergency department. However, the trust was showing a deteriorating position with respect to the four hour emergency care standard and also for patients waiting between four and twelve hours following a decision to admit. A similar trend was seen for the number of patients waiting longer than one hour for transfer from ambulance to the emergency department.

  • Provisions for the care of patients living with dementia was well developed with appropriate forms of patient identification and well considered design of clinical environment and signage.

  • Complaints responses continue to exceed the trust target time and are of an inconsistent quality.

Well led

  • At our last inspection, staff widely reported a culture of bullying and harassment and a lack of equal opportunity. We discussed the findings in individual interviews and staff focus groups and the findings were largely acknowledged as accurate. However the trust had not clearly communicated its acknowledgment of the issue to the workforce.

  • The trust has commissioned and commenced an external consultancy to develop a strategy that addresses the current persistence of bullying and harassment, inequality of opportunity afforded all staff, but notably those who have protected characteristics, and the acceptance of poor behaviour whilst also providing the board clear oversight of delivery

  • The trust has tried to address bullying and harassment via leadership training and an initiative "Working Together Effectively #stopbullying". This was promoted by a poster campaign using a well-crafted definition of bullying and a supporting intranet web site providing helpful guidance and tools. During our interviews and focus groups very few staff indicated recognition of the initiative.

  • Some staff indicated during focus groups and interviews that there had been an improvement in the management of poor behaviour, notably in maternity where a behaviour code of conduct had been introduced. However, representative groups described a lack of corporate acknowledgement of discrimination and inequality issues and little change over the last twelve months.

  • The lack of equitable access to promotion was again raised by members of the BME network citing recent changes in the management of soft FM services as an example of bias. This has resulted in a further review of the soft FM management of change process by the trust and a pause in implementation. Concerns on this issue have been raised by staff.

  • The role of outdated human resource policies and their inconsistent application in exacerbating inequality was highlighted in our last report. The human resource team have responded with a comprehensive review of policy and revised training of team and managers. Representative groups viewed that there had been a lack of engagement in the development and review of these policies.

  • BME staff again indicated the lack of equitable access to training and leadership initiatives. The trust did not maintain data indicating the equality of access to leadership programmes.

  • Staff in focus groups indicated that staff themselves had not been suitably trained to manage the diversity of patients they treat leading to an inability to manage difficult situations and support staff who have been abused.

  • The latest staff survey results rank among the worst nationally. Overall the organisational culture and the management of equality remains a significant obstacle to the trust improvement plan.

  • We observed improvements in local directorate governance arrangements but the complexity of the operational model continues to lead to a lack of clarity in terms of accountability, alignment of strategy and consistent dissemination of information and direction.

  • Clinical leaders indicated a need for personal development, increased non-clinical time and greater management expertise in order to deliver the required organisational change. This group appeared as highly motivated with an appetite for the challenge ahead. The clinical transformation programme was seen as indicative of the potential this group has for delivery.

There is no doubt that improvements have been made since our last inspection and that the staff involved in the delivery of that change should be congratulated. However, there remains an extensive programme of change to be delivered in order to attain an overall rating of good. The lack of consistent board and executive leadership has hampered the pace of change in the last twelve months and it is anticipated that the incoming management team can provide both stability and clarity of leadership that will lead to sustainable change.

However, I recommend that Brighton and Sussex University Hospitals NHS Trust remains in special measures to provide time for the leadership to become embedded and that the outstanding patient safety, culture and equality issues are addressed.

We saw several areas of outstanding practice including:

  • In ED, the new self-rostering approach to medical cover had a significant impact on the department. Medical staff appreciated the autonomy and flexibility this promoted as well as the effective and safe cover for the department. Because of this initiative, the department was able to provide round the clock medical cover without the use of temporary staff.

  • The introduction in ED of the clinical fellow programme that had improved junior cover in the department and also the education and development opportunities for juniors.

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

Importantly:

  • The trust must ensure that the (WHO) Five Steps to Safer Surgery checks are fully completed for all patients undergoing surgery.

  • The trust must ensure that safer sharps are used in all wards and departments.

  • The trust must ensure anaesthetic equipment checks are consistently completed.

  • National Specification of Cleanliness (NCS) checklists and audits must be in place including a deep cleaning schedule for theatres.

  • The trust must ensure that in theatres controlled drug dose given and amount destroyed is consistently recorded.

  • The trust must ensure records in ED are held securely and kept confidential.

  • The trust must ensure ED patients dignity and privacy is respected by ensuring there is adequate space in holding areas, adequate screening is available and by avoiding the use of mixed sex accommodation.

  • The trust must ensure that medications in ED are stored safely, securely and at the appropriate temperatures.

  • The trust must ensure that all staff within the medicine directorate have attended mandatory training, and there are sufficient numbers of staff with the right competencies, knowledge and qualifications to meet the needs of patients.

  • The trust must ensure all staff within the medicine directorate have an annual appraisal.

  • The trust must ensure fire plans and risk assessments ensure patients, staff and visitors can evacuate safely.

  • Medical wards must ensure all areas where medicines are stored have their ambient temperature monitored in order to ensure safety and efficacy.

  • The trust must take action to ensure that information in the critical care department is easily available for those patients and visitors that do not speak English as a first language.

  • In critical care, measures must be put in place to check that stock levels of controlled drugs in critical care correct and that the list of authorised signatories is also correct and up to date.

  • In critical care, the trust must make arrangements so pharmacy provision meets the national guidelines.

  • The critical care department must employ a dedicated dietitian to meet national guidance with a critical care pharmacist for every critical care unit.

  • The trust must ensure that adequate oversight of laser safety is provided and that laser protection supervisors who are assigned to look at this at a local level are sufficiently trained to oversee and enforce this. All laser machines must be serviced annually and taken out of use if annual service check has expired.

  • The trust must ensure that worn protective eyewear in outpatients and diagnostic imaging is replaced.

  • The trust must take action to ensure that patient privacy and dignity is maintained, particularly in the Sussex Eye Hospital and CT waiting area.

  • In maternity, the trust must ensure that fire safety issues are addressed, monitored and reviewed to ensure that all areas where patients receive care and treatment are safe and well-maintained.

  • The trust must ensure appropriate measures are taken to improve the ventilation system in the obstetric theatre on level 13.

In addition:

  • The trust should take steps to ensure the 18 week Referral to Treatment Time is addressed so patients are treated in a timely manner and their outcomes are improved.

  • The trust should continue to work on reducing the

    waiting list for a specific colon surgery.

  • In surgery the trust should improve attended mandatory training rates.

  • The trust should review patient flow through the surgical assessment unit.

  • The trust should review its policy of boarding patients on the ward areas before a bed is available.

  • The trust should effectively communicate the clinical strategy to all staff and arrange for the plan to improve staff engagement to be fully implemented.

  • The trust should make arrangements for patients in ED with impaired capacity to have these risks identified and managed appropriately.

  • The trust should improve ED mandatory training and appraisal rates to meet the trust's own compliance rates.

  • The trust should consider how to improve continuity with incident, complaint and risk management processes across both ED sites.

  • The trust should improve engagement between the ED's in RSCH and PRH site.

  • The trust should improve learning and the sharing of best practice between ED's at the RSCH and PRH site.

  • The trust should review any possible data confidentiality issues that may occur from the use of large electronic displays at the nursing hub in ED.

  • The trust should review the provision of the medical pain service in order to provide a seven day service including the provision of the management of chronic pain services.

  • The trust should review the provision of pharmacy services across the seven day week and improve pharmacy support.

  • The trust should prioritise patient flow through the hospital as this impacted on length of stay, timely discharge and capacity.

  • The trust should devote sufficient time and resources to address the backlog of incident investigations in critical care.

  • In critical care, the trust  should make arrangements for mandatory training modules to be completed in a timely manner and any outstanding modules to be completed.

  • In critical care, level two training in child safeguarding should be completed to meet the trust target.

  • In critical care, the trust should take action to improve compliance with the trust policy that says staff should be bare below the elbow.

  • The practice of removing used bed pans from side rooms in critical care should be done in accordance with the trust’s infection prevention and control policy.

  • The trust should introduce a method to monitor the temperature across the unit on level five critical care.

  • In critical care, the trust should take action to ensure that patients are clearly identified in their records, that no records are kept loose and care bundles are filled in.

  • In critical care, the trust should consider how to improve screening for venous thromboembolism.

  • Arrangements should be made so neurology trained nursing staff are available to cover the critical care area where ventilated neurology patients would be cared for.

  • The trust should take action to ensure it meets its own standard/KPI of discharging all patients with a rehabilitation prescription.

  • The trust should display that any information collected in relation to the friends and family test in critical care is available on the NHS England website.

  • In critical care, the trust should introduce a process to follow when they take a patient under the age of 18 and that paediatric input is sought in these circumstances.

  • The critical unit should clarify with the site management team what would amount to a mixed sex breach on their unit.

  • The critical care unit should replace the neurology fill educator post which was vacant.

  • The trust should improve mandatory training completion in the outpatient and diagnostic imaging departments.

  • The trust should make arrangements for outpatient and diagnostic imaging staff to receive annual appraisals.

  • The trust should share learning form incidents and complaints handling with staff to prevent recurrence within outpatient and diagnostic imaging services.

  • The trust should have systems to check fridge temperatures within outpatient and diagnostic imaging. They should be undertaken in line with trust policy and national guidance.

  • The trust should monitor that compliance with WHO audits in interventional radiology and improve performance.

  • Consent for interventional radiology procedures should be taken in line with best practice.

  • The trust should develop a strategy in place for the outpatients and diagnostic imaging department.

  • In maternity, the trust should fully explore recent hypoxic-ischaemic encephalopathy (HIE) numbers and consider an internal investigation into the high numbers to identify any common themes.

  • In maternity, the trust should consider how improvement to training targets are met and consider revising the target percentage.

  • In maternity the trust should make arrangements to update the risk register to reflect all risks to the service, and check that there are clear reasons documented for any changes to risk ratings.

  • In maternity the trust should consider how targets for adult and child safeguarding level three are met.

  • The maternity department should consider participation in morbidity and mortality meetings to ensure robust learning and review.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Inadequate

Updated 10 August 2017

Effective

Requires improvement

Updated 10 August 2017

Caring

Good

Updated 10 August 2017

Responsive

Requires improvement

Updated 10 August 2017

Well-led

Requires improvement

Updated 10 August 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 10 August 2017

On our last inspection we rated the maternity and gynaecology services as requires improvement. At this inspection we have rated the service as good. This is because:

  • During this inspection we found incident reporting was much improved and feedback routinely given via a number of methods. We saw noticeboards for governance in every clinical area within maternity and gynaecology. These included information on the risk register, recent serious incident investigations and recent learning from complaints.

  • Guidelines had been reviewed and were in date with good monitoring processes in place for further reviews.

  • The department had recently employed more consultants and on this inspection consultant numbers were in line with trust expectations. A range of specialist midwives were available ensuring women’s individual needs were met.

  • There was now a separate theatre team in obstetric theatres to ensure that the midwives role in theatre was to care for mother and baby only.

  • Staff were committed to providing and promoting normal birth. Women were offered a choice of birthing options and the trust had high homebirth rates. Targets for elective caesarean sections were had improved, recent figures showed improvement with the trust target being met from November 2016 through to January 2017. However, the maternity department were not meeting expected targets for some patient outcome indicators. These included vaginal birth after caesarean (VBAC), emergency caesarean section, and meconium aspiration.

  • Referral to treatment times had much improved and women were being seen in a timely way, in-line with expected targets. All patients received diagnostic tests with six weeks between July 2016 and February 2017, which was better than the national target.

  • There were strict criteria the department followed to ensure patients were not admitted inappropriately to the gynaecology ward as outliers.

  • Previous issues with gaining valid consent had been addressed through a variety of means and we saw consent was given the appropriate importance and staff followed trust policy.

  • There was now a designated triage team allowing for better continuity of care and improved communication via an online shared drive and an improved system for recording calls. The improvements have led to a reduced number of triage closures and reduced complaints about triage.

  • Appraisal rates had improved significantly from 59% at our last inspection to 91%. The trust employed a dedicated preceptorship midwife and a midwifery placement educator who met with midwives throughout their employment.

  • Staff treated patients with dignity and respect. We saw compassionate interactions between all staff members and patients.

  • Universally staff felt that there had been improvements in the culture of the organisation. They reported that it was a different place to work than a year ago and that positive changes to the consultant body and leadership had been the driving force behind the changes. Staff we spoke with during this inspection were positive about the leadership team.

  • There was a clear strategic direction. The women’s directorate had three, six and 12 month plans which were drawn up in March 2017. This included short and long term initiatives.

  • There were examples of innovation. For example, the trust is one of 44 trusts throughout the country engaged in the Maternal and Neonatal Health Safety Collaborative. This is a three-year programme to support improvement in the quality and safety of maternity and neonatal units across England.

However, we also found:

  • There was some improvement in mandatory training figures however; the trust’s target for mandatory training was lower than other similar NHS hospitals with completion targets at 75%. Despite having a low target, the department was still falling behind in some areas with worse than expected mandatory training attendance. Safeguarding training targets had improved but still fell below expected targets in level three safeguarding in both adults and children.

  • Staff felt they were under pressure despite an increase in staff numbers. We saw an improvement in staff numbers and 1-1 care in labour had improved, but the service was still not achieving the national and hospital target of 100%.

  • There were a higher than expected number of hypoxic-ischaemic encephalopathy (HIE) cases within one year. This had not been fully explored by the department and although individual Root Cause Analysis (RCA) reports had been completed there was not an overarching internal investigation into the high numbers to identify any common themes. The directorate did not take part in specific morbidity and mortality meetings.

  • The ventilation system in obstetric theatre on L13 is over ten years old and failed the recommended air change frequency level for each hourly period. This has remained on the risk register but had not been addressed and still posed a potential risk to patients.

  • There were 13 outstanding fire safety concerns highlighted since June 2016. There had been no trust wide collation of any actions as a result of these concerns being completed.

  • Despite improvements to the governance structure we still found that some staff were not fully engaged and messages from the board were not routinely heard by all staff groups.

Medical care (including older people’s care)

Requires improvement

Updated 10 August 2017

At our previous inspection we rated medical care as requires improvement. At this inspection we have retained this rating. This is because:

  • Fire safety plans and risk assessments and actions were not complete and there was no overarching governance around fire risks. Not all staff had completed mandatory fire safety training.

  • Although issues regarding the environment remained, we saw some improvement as risk assessments were completed on a regular basis to ensure the suitability of individual patients within the Barry Building. However, this adversely affected patient flow through the hospital and the number of bed moves experienced by patients.

  • Incident reporting was variable across directorates in the medical service and there continued to be a lack of learning from these. Silo working had improved within directorates, but we found there was no cross directorate learning from incidents or complaints.

  • Each directorate still had its own risk register, which did not feed into an overarching risk register. Therefore, managers did not have an effective method for identifying, monitoring, or managing the risks in all six medical directorates.

  • Risks associated with cleanliness, hygiene and infection prevention and control were not always fully recognised, assessed or managed.

  • Nursing staff numbers did not always meet planned levels. There was no guarantee that the nurse co-ordinator for each shift was supernumerary and therefore they could not always fulfil their supervisory responsibilities.

  • Staff had difficulty accessing learning and development. Mandatory training rates were generally low; the lowest completion rate was in basic life support. Not all staff had received an annual performance review or had opportunities to discuss and identify learning and development needs through this review.

  • Care and treatment did not always reflect evidence based guidance. For example, there was no care pathway for bariatric patients. Outcomes from national audits were mixed and were below expectations when compared with similar services. However, staff had access to policies based on national best practice guidance from all professional disciplines, the service had been awarded Joint Advisory Group on GI (JAG) accreditation and had made adjustments to the rehabilitation pathway to ensure it was fully compliant with national guidance.

  • Referral to treatment times were worse than the England average. The hospital had a high rate of mixed sex breaches and outliers, which impacted on flow.

  • The hospital was not yet offering a full seven-day service. Not all patients had access to a consultant and other members of the multi-professional team on a daily basis.

  • Staff satisfaction was mixed and staff did not always feel actively engaged or empowered.

  • Staff advised us there were still issues with HR processes, stating support depended on who the HR representative was. Although policies and standard practices were in place, not all HR representatives followed them.

However, we also found:

  • Medicines were always supplied, stored and disposed of securely.

  • Patients had a comprehensive assessment of their needs, which included clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs. Expected outcomes were identified and documented, regularly reviewed and updated.

  • Feedback from people who used the service, those who were close to them and stakeholders was positive about the way staff treated people. The hospital continued to deliver a good service for patients living with dementia.

  • Assessments carried out to comply with the Mental Capacity Act (2005) and consent forms were completed appropriately.

Urgent and emergency services (A&E)

Requires improvement

Updated 10 August 2017

At our previous inspection in April 2016, overall, we rated the ED as inadequate. On this inspection, we have changed this rating to ‘requires improvement’. This reflects the improvements to patient safety, risk and quality management, maintaining the dignity and respect of patients, strengthened senior leadership and oversight, and an improved culture.

  • The environment was not fit for purpose as it did not have the physical capacity to meet demand. As a result flow through the department was impeded and this was a cause of mixed sex  accommodation usage. Additionally, staff were unable to protect patients from the risk of health care acquired infections because the department became very overcrowded.

  • Records were not always stored securely, medicines were not always managed in line with national guidance and vulnerable patients did not always have their capacity to consent to treatment  assessed.

  • Nursing staffing and retention remained a concern.

  • Mandatory training and appraisal rates were low but had improved since our last inspection although the department supported staff to develop in their roles. There were  new competency based assessment tools to promote personal development and give assurance staff had the right level of training to meet people's individual care needs.

However:

  • There was a notable culture shift, with a more positive emphasis apparent. Staff worked hard to maintain patients' dignity despite the circumstances. Staff worked cohesively as a team. Staff found the senior leadership team to be effective and visible. Engagement processes with external organisations and care providers had greatly improved.

  • Patients' feedback was generally positive. "Comfort rounds" were regularly undertaken and these helped ensure patients' needs for food and drink, and their other social care needs were met.

  • Care and treatment given reflected best practice and national guidance.

  • There were new processes to improve department performance, the patients’ journey and the quality of the care delivered such as single clerking and the clinical fellow initiative.

  • The department had an electronic tool that estimated and monitored patient attendance and discharge rates. This showed  the department was exceeding the set discharge target of 90 patients a day.

  • Systems to monitor incidents clinical and departmental risks had significantly improved. Staff used information from trend and theme analysis to improve the service, to prevent recurrence and aid learning. Managers had strengthened governance processes, for example, comprehensive morbidity and mortality meetings and a multi-disciplinary approach to governance.

Surgery

Requires improvement

Updated 10 August 2017

When we inspected the Royal Sussex County Hospital in April 2016 we rated surgery as requires improvement. At this inspection we have retained this rating because:

  • Since the last inspection there have been a number of programmes and training events to reinforce the importance of the WHO safe surgery checklist. However, between April 2016 and April 2017 there have been two further Never Events. Following surgery the debriefing of staff was not consistently completed meaning the (WHO) Five Steps to Safer Surgery was not fully completed.

  • The theatre department was not complying with The Health and Safety (Sharp instruments in Healthcare) regulations 2013. Anaesthetic equipment checks were not consistently complete and medicines were not always managed in line with current legislation.

  • National Specification of Cleanliness (NSC) checklists and audits were not carried out, including a deep cleaning schedule for theatre.

  • Staff had achieved a rate of 75% with statutory and mandatory training; although this met the trust target, the target itself was low. However, Staff reported that appraisals were being carried out annually.

  • Whilst improvements had been made to reduce the admitted referral to treatment time (RTT), they still remained below the national standard for all specialities apart from cardiac surgery. Work had been done on identifying patients on the waiting list for a specific colon (bowel) surgery but there was still a backlog of patients waiting for surgery.

  • The surgical assessment unit had a high number of inpatients and were not always able to take patients from the emergency department as intended and this impacted on patient flow. This resulted in the practice of ‘boarding’ patients on the ward which put strain on the ward management and staffing. Boarding meant that patients from the emergency department were put on the ward before a bed was available. However, patients were no longer inappropriately admitted to the recovery area in theatre due to lack of capacity.

However, we also found:

  • Staff continued to report incidents and spoke of an open and transparent reporting culture. Safety meetings (huddles) were established on all wards and departments to discuss any patient or department incidents or concerns to promote a safe culture.

  • There was a sufficient number of staff appropriate to the workload with the necessary skills and qualifications to meet patients' needs.

  • Progress had been made on reviewing and ensuring improved consent processes.

  • Patient feedback was generally positive. We observed the care to be respectful, patient-centred and delivered with compassion. Patients were treated with dignity and respect.

  • The service treated patients in accordance with best practice and recognised national guidelines and demonstrated collaborative working across directorates to deliver joined-up care which ensured the timely management of patients through their care pathway.

  • Governance structures across the four directorates were established and developing and staff were able to identify risks within their departments and risk registers were in place and kept under regular review.

  • The trust had a plan for redevelopment and a clinical strategy. Each of the four directorates had strategies and business plans in place which could demonstrate progress over the last year.

  • Staff reported an improvement in the culture at the hospital but they were still concerned at number of changes in the hospital senior management. They looked forward to a period of stability and increased visibility of the new management team.

Intensive/critical care

Inadequate

Updated 10 August 2017

When we inspected Royal Sussex County Hospital in April 2016 we rated critical care as inadequate. At this inspection we retained the rating of inadequate. This is because:

  • The critical care department had a large incident report backlog dating back to 2015 that still required investigation. However, there had been the appointment of a Clinical Risk Nurse to review and investigate the large backlog of incident reports.

  • Although pharmacy staffing had improved, it was still not in line with the Guidelines for the Provision of Intensive Care Services. The hospital still did not have a permanent dietitian working in critical care. Incidents relating to medication errors were high. There were no investigations or analysis undertaken of these incidents which meant themes and lesson learnt could not be identified. However, medicines waste was handled appropriately in line with current legislation and best practice. CCTV had been placed in the room that contained the drug cupboards and fridges on level seven. This mitigated the risk identified during the previous inspection of drug fridges remaining unlocked.

  • Dietetic support for the unit did not meet national guidance.

  • Patients’ records were not always kept secure.

  • Not all staff complied with the “bare below the elbows” policy when delivering direct patient care. Some other infection risks were not recognised. For example, a side room on level seven was being used for a patient that was highly infectious. Bedpans were being taken from the side room to the main dirty utility area due to the lack of sluice in the room.

  • There was a lack of impetus from the senior management team to drive improvements and develop a plan for improvement and the vision and strategy for the service had yet to be finalised.

  • The critical care service at RSCH had failed to meet key performance and quality targets. For example, the unit had failed to meet a number of its own key performance indicators in regard to the rehabilitation of patients. The number of patients with a delayed discharge of more than eight hours was much worse than the national average. Between April 2016 and December 2016, there were 70 incidents of cancelled elective surgery due to a lack of a bed in critical care.

  • There was a lack of information available to patients or relatives in any language other than English despite the hospital seeing patients of different nationalities.

  • There were not always appropriately skilled and qualified nurses to care for neurology patients. However, there were systems that allowed staff to gain and maintain the necessary skills to care for neurology patients. There was a divide between the neurology nurses and the general intensive care nurses. This meant there was not a cohesive approach to nursing on the units and this affected staff morale.

  • The ITU at Royal Sussex County Hospital (RSCH) and the Princess Royal Hospital (PRH) are part of one department, sharing management and staff. However, the sites did not share a common patient IT system.

However, we also found:

  • All areas we viewed, including clean utility rooms, toilets and showers were visibly clean.

  • A simulation room was used in the recruitment process for band five nurses to enable potential recruits to demonstrate their clinical skills. There were systems to identify patients at risk of deterioration. We saw good use of National Early Warning Scores (NEWS) and there was good awareness of this system across the critical care department.

  • Nursing staff treated the patients with dignity and respect. Patients and relatives expressed satisfaction with the care received. The commitment to the welfare of the patients was evident from both clinical and non-clinical staff. Staff had been able to accommodate some family members of patients so they could visit outside of normal visiting hours. However, there were frequent occasions when male and female patients were cared for in the same bay whilst awaiting bed placement in the hospital.

  • There were some examples of innovative practice. For example, each patient on ICU had a ‘patient diary’. This was a diary written to record what had happened to the patient and how they had been cared for. The patient could then take this with them when leaving the unit.

Services for children & young people

Outstanding

Updated 10 August 2017

We did not inspect this service at this inspection as we rated it outstanding in April 2016.

End of life care

Good

Updated 10 August 2017

We did not inspect this service at this inspection as we rated it good in April 2016.

Outpatients

Requires improvement

Updated 10 August 2017

When we inspected the Royal Sussex County Hospital in April 2016 we rated outpatients and diagnostic imaging as inadequate. At this inspection we have changed the rating to requires improvement. This is because:

  • Consent for interventional radiology procedures was taken immediately before the procedure, which was not in line with best practice. World Health Organisation (WHO) checklist compliance was worse than the target set in interventional radiology. There was no paediatric cover for diagnostic imaging outside of normal hours.

  • Local rules for lasers were not updated and signed, and the policy was overdue review.

  • Room cleaning checklists had variable rates of completion across the outpatient department. Mobile equipment in diagnostic imaging had not been cleaned. However, rooms were consistently cleaned and this documented in the diagnostic imaging department.

  • Staff understood their responsibilities to report incidents and near misses and "safety huddles" were in use across outpatients and diagnostic imaging. However, incidents were not regularly discussed at team meetings so learning points could be identified and shared. There were two serious incidents that occurred between March 2016 and February 2017, but root cause analysis for these incidents was not made available.

  • Risk registers were not complete. Some risks that staff told us about in outpatients were not documented on the risk register. The head and neck directorate business continuity plan was incomplete.

  • Mandatory training compliance rates and staff appraisal rates were worse than the trust target.

  • There was variable compliance with national access targets. The trust was not meeting national targets for patients that should be seen within 18 weeks of their referral, or receive cancer treatment within 62 days or urgent referral. However, the trust was meeting national targets for patients that should receive their urgent appointment within two weeks of referral and receive their cancer treatment within 31 days of a decision to treat being made. The trust could not provide us with data for the turnaround time of biopsies which meant there was no oversight of delays or issues within this department.

  • Patients’ privacy and dignity was potentially compromised in some areas. The PLACE score for privacy and dignity was worse than the England average.

  • There was no formal strategy in place for the outpatient or diagnostic imaging departments. Not all staff were aware of management structure or directorate leads in their area.

However, we also saw:

  • The diagnostic imaging department had policies and procedures which reflected national and best practice guidance. People's care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. The diagnostic imaging department had been re-accredited by the Imaging Services Accreditation Scheme (ISAS).

  • Medicines were managed in line with legislation and national guidance. Prescription forms were stored safely and securely. We observed good radiation compliance with Ionising Regulations, 1999 and Radiation (Medical Exposure) Regulations (IR(ME)R), 2000.

  • Friends and Family test (FFT) results were better than the England average for four out of six months we reviewed. Patients’ verbal feedback and that from comment cards was positive. We saw positive interactions between staff and patients. However, signage around the outpatient departments was poor and patients' fedback they had found it hard to navigate.

  • Call abandonment figures had significantly improved since our last inspection. Two-way texting for patient appointments had been introduced and supported to this improvement The hospital monitored waiting times for patients in clinic which meant they were aware of problem areas or clinics.

  • All complaints were investigated and closed within the trust-wide target for investigating complaints.

  • Local leadership and line management were good and managers were visible across the departments. There was staff engagement at department level with team meetings and forums for staff to attend and discuss best practice.