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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.

Reports


Inspection carried out on 12 October 2017

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

We carried out a focussed, unannounced inspection at Royal Sussex County Hospital (RSCH) on 12 October 2017. The purpose of the inspection was to ensure the trust had appropriate measures in place regarding the Control of Substances Hazardous to Health Regulations.We did not inspect a specific core service we focussed on one key question, “Are services safe?” We did not look at the other key questions relating to effectiveness, caring, responsiveness and well-led as this was a focussed inspection.Our findings did not affect the ratings we gave the hospital after our inspection in April 2017, when Royal Sussex County hospital was rated as requires improvement overall. References to ratings in this report relate to this earlier inspection.

For full details of the inspection undertaken in April 2017 please visit /www.cqc.org.uk/location/RXH01

Our main findings were as follows:

  • Housekeeping assistants had a good knowledge of the Control of Substances Hazardous to Health cleaning products they used and had recently received refresher training.

  • Although nursing staff received Control of Substances Hazardous to Health training as part of their mandatory training programme, the three nurses we spoke with were not clear about their responsibilities in relation to Control of Substances Hazardous to Health.

  • The trust had removed green coloured water jugs (which were implemented to support people with dementia) and only clear jugs were in use. This meant it was possible to see the liquid inside the jug.

  • The trust had instructed all the codes on the cleaning cupboard doors to be changed however, we found not all door lock codes had not been changed.

  • Ward areas had information folders and generally staff knew where these were located. However, the content of the Control of Substances Hazardous to Health folders we reviewed was not always complete. Control of Substances Hazardous to Health risk assessments or data sheets were not available in cleaning cupboards.

  • There was not a system in place which gave assurance that Control of Substances Hazardous to Health information had been read and understood by staff using the substances.

  • Substances subject to Control of Substances Hazardous to Health legislation were not always stored securely. We found products stored in unlocked utility rooms and kitchens and access codes were written in close proximity to digital locks. There were unattended cleaning trolleys containing hazardous substances.

  • There were cleaning products in use, which had not gone through the trust’s procurement policy.

There were areas of poor practice where the trust needs to make improvements.Importantly the trust must:

  • Ensure all products that are subject to Control of Substances Hazardous to Health regulations are stored securely.

  • Introduce systems which give assurance that information relating to substances subject to Control of Substances Hazardous to Health is available in work areas, that this information is complete and accurate, and that staff have understood it.

  • Ensure nursing staff are aware of the regulations and their responsibilities with regard to safe storage and use of Control of Substances Hazardous to Health products.

In addition, the trust should:

  • Consider how Control of Substances Hazardous to Health substances are kept securely on cleaning trolleys.

  • Consider alternatives to the digital lock system to control access to cleaning cupboards.

Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 25 -27 April 2017

During a routine inspection

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 carried out on 4th-8th August 2016

During a routine inspection

The Royal Sussex County Hospital (RSCH) in Brighton forms part of Brighton and Sussex University Hospitals Trust. RSCH is a centre for emergency and tertiary care. The Brighton campus includes the Royal Alexandra Children’s Hospital (The Alex) and the Sussex Eye Hospital.

The hospital 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 has over two sites, the other being the Princess Royal in Haywards Heath, 1,165 Beds; 962 General and acute, 74 Maternity, and 43 Critical care. It employs 7,195.92 (WTE) Staff; 1,050.59 of these are Medical (WTE), 2,302.52 Nursing (WTE), 3,842.81 other.

It has revenue of £529,598m, with a full cost of £574,417m and a Surplus (deficit) of £44,819k

Between 2015-2016 the Trust had 118,233 inpatient admissions; 640,474 Outpatient attendances, and 156,414 A&E attendances.

This hospital was inspected due our concerns about the Trusts ability to provide safe, effective, responsive and well led care. We inspected this hospital on 4-8 April 2016 and returned for an announced inspection on 16 April 2016.

Our key findings were as follows:

Safe

  • Incident reporting was understood by staff but there was a variation in the departments on completion rates and a lack of learning and analysis.
  • The trust have reported seven never events (5 of which were at RSCH) between Jan’ 15 to Jan’ 16, all seven were attributed to surgery and four of which were related to wrong site surgery incidents.

  • Not all areas of the hospital met cleaning standards and the fabric of the buildings in some areas was poor, and posed a risk to patients, particularly with regard to fire safety.

  • We had particular concerns that the risk of fire was not being managed appropriately. We found that the Barry and Jubilee buildings were particular fire safety risks as they were not constructed to modern safety standards and had been altered and redesigned many times during their long history. They were overpopulated, overcrowded and cluttered with narrow corridors and inaccessible fire exits. We found flammable oxygen cylinders were stored in the fire exit corridors. We found that fire doors with damaged intumescent strips which would not provide half an hour fire barrier in the event of horizontal evacuation.

  • Patients in the cohort area of the emergency department were not assessed appropriately; there was a lack of clinical oversight of these patients and a lack of ownership by the Trust board to resolve the issues.

  • There were no systems in place for the management of overcrowding in the ‘cohort’ area. Staff were not able to provide satisfactory details of “full capacity” protocols or triggers used to highlight demand exceeding resources to unacceptable levels of patients in the area.

  • The recovery area at RSCH in the operating theatres was being used for emergency medical patients due to having to reduce the pressure on an overcrowded ED and to help meet the emergency departments targets such as 12 hour waits. Some patients were transferred from the HDU to allow admission to that area and some patients were remaining in recovery when there was no post-operative bed available. Some patients at were kept in the recovery area for anything between four hours and up to three days

  • Staffing levels across the hospital were on the whole not enough to provide safe care for example the mixed ICU and cardiac ICU frequently breached the minimum staff to patient ratios set by the Intensive Care Society and the Royal College of Nursing.
  • In some areas the trust had systematically failed to respond to staff concerns about this and mitigating strategies had failed.

  • Medicines management in the hospital was generally good, with the exception of Critical Care and out patients, where it was inadequate.

  • We saw that records were well managed and kept appropriately, apart from OPD where we observed records lying in unlocked areas that the public could access.

  • The trust had a safeguarding vulnerable adults and children policy, and guidelines were readily available to staff on the intranet and staff were able to access this quickly. However, safeguarding training for all staff groups was vastly lower than the Trusts target.

  • Staff compliance in mandatory training, statutory training and appraisals fell well below the trust target of 95% for statutory training and 100% for mandatory training, for both nurses and doctors across every department in the hospital.
  • The trust had a Duty of Candour (DOC) policy, DOC template letters and patient information leaflets regarding DOC, and we saw evidence of these. The trust kept appropriate records of incidents that had triggered a DOC response, which included a DOC compliance monitoring database and we saw evidence of these. Most staff we spoke with understood their responsibilities around DOC.

Effective

  • Staff generally followed established patient pathways and national guidance for care and treatment. Although we saw some examples of where some aspects of patient pathway delivery could be improved.

  • National clinical audits were completed. Mortality and morbidity trends were monitored monthly through SHIMI (Summary Hospital-level Mortality Indicator) scores. Reviews of mortality and morbidity took place at local, speciality and directorate level although a consistent framework of these meetings across all specialities was not in place. The trust’s ratio for HSMR was better than the national average of 80%.

  • Staff knew how to access and used trust protocols and guidance on pain management, which was in line with national guidelines.

  • Patient’s nutritional needs were met although patients in the cohort area and recovery did not always have easy access to food and water. In critical care there was no dedicated dietician.

  • Appraisal arrangements were in place, but compliance was low across the hospital. Trust wide only 68% of staff had received an annual appraisal. Accountability for these lapses was unclear.
  • Some services were not yet offering a full seven-day service. For example in medicine constraints with capacity and staffing had yet to be addressed. Consultants and support services such as therapies operated an on-call system over the weekend and out of hours. This limited the responsiveness and effectiveness of the service the hospital was able to offer.

  • There were innovative and pioneering approaches to care with evidence-based techniques and technologies used to support the delivery of high quality care and improve patient outcomes in children and young peoples services

Caring

  • Staff were caring and compassionate to patients’ needs, and patients and relatives told us they received a good care and they felt well looked after by staff.
  • Children and young people at the end of their lives received care from staff who consistently went out of their way to ensure that both patients and families were emotionally supported and their needs met.
  • Privacy, dignity and confidentiality was compromised in a number of areas at RSCH, particularly in the cohort area, out patients department and on the medical wards in the Barry building.
  • The percentage who would recommend the trust (Family and Friends Test) was lower than the England average for the whole time period until the most recent data for Dec ’15, where is it currently above the England average.
  • Patients reported they were involved in decisions about their treatment and care. This was reflected in the care records we reviewed.
  • We saw no comfort rounds taking place whilst we were in the ED department. This meant patients who were waiting to be treated may not have been offered a drink nor have their pressure areas checked.

Responsive

  • The admitted referral to treatment time (RTT) was consistently below the national standard of 90% for most specialties. The trust had failed to meet cancer waiting and treatment times.
  • The length of stay for non-elective surgery was worse than the national average of for trauma and orthopaedics, colo-rectal surgery and urology
  • The percentage of patients whose operations were cancelled and not treated within 28 days was consistently higher than the England average.
  • According to data provided by the trust, between January 2015 and December 2015 3,926 people waited between 4 to 12 hours (and 71 people over 12 hours) from the time of “decision to admit” to hospital admission. Since the inspection an additional 12 patients have been reported as waiting over 12 hours.
  • Interpreters were available for those patients whose first language was not English. This was arranged either face to face or through a telephone interpreter. Staff told us that under no circumstances would a family member be able to act as an in interpreter where a clinical decision needed to be made or consent needed to be given.

  • We saw examples of wards including the dementia care ward that operated the butterfly scheme. The butterfly scheme is a UK wide hospital scheme for people who live with dementia. We also saw that they had a dignity champion. This is someone who works to put dignity and respect at the heart of care services.

Well Led

  • There was a clear disconnect between the Trust board and staff working in clinical areas, with very little insight by the board into the key safety and risk issues of the trust, and little appetite to resolve them.
  • The trust had a complex vision and strategy which staff did not feel engaged with. There was a lack of cohesive strategy for the services either within their separate directorates or within the trust as a whole. Whilst there were governance systems in place they were complex and operating in silos. There was little cross directorate working, few standard practices and ineffective leadership in bringing the many directorates together.

  • The trust had a complex vision and strategy which staff did not feel engaged with. There was a lack of cohesive strategy for the services either within their separate directorates or within the trust as a whole. Whilst there were governance systems in place they were complex and operating in silos. There was little cross directorate working, few standard practices and ineffective leadership in bringing the many directorates together.

  • The culture at RSCH was one where poor performance in some areas was tolerated and 50% of staff said in the staff survey they not reported the last time they were bullied or harassed.

  • There was a problem with stability of leadership within the trust. There were several long term vacancies of key staff such as matrons and clinical leads. During the inspection we noted a number of senior management staff had taken leave for the period of the inspection.

  • BME staff felt there was a culture of fear of doing the wrong thing so nothing was done. They told us this was divisive and did not lead to a healthy work place where everyone was treated equally.

  • Ward managers and senior staff reported that they received little support from the trust’s HR department in managing difficult consultants or with staff disciplinary and capability issues. They told us that HR advised staff to put in a grievance as a first step in resolving any issue.

  • The relocation of neurosurgery intensive care from Hurstwood Park to Brighton in June 2015 had been inadequately managed and lacked evidence of robust staff consultation. This had led to a culture in which nurses did not feel valued and there was significant and sustained evidence of non-functioning governance frameworks.
  • The executive team failed on multiple occasions to provide resources or support to clinical staff in critical care to improve safety and working conditions and there was no acknowledgement from this team that they understood the problems staff identified.

We saw several areas of outstanding practice including:

  • The play centre in The Alex children’s hospital had an under the sea themed room with treasure chests full of toys and a bubble tank. There was also an interactive floor where fish swam around your feet and changed direction according to your footsteps.

  • The virtual fracture clinic had won an NHS award for innovation. It enabled patients with straightforward breaks in their bones to receive advice from a specialist physiotherapist by telephone. It reduced the number of hospital attendances and patients could start their treatment at home.
  • We found that an outstanding service was being delivered by dedicated staff on the Stroke Unit (Donald Hall and Solomon wards). The service was being delivered in a very challenging ward environment in the Barry building. Staff spoke with passion and enthusiasm about the service they delivered and were focused on improving the care for stroke patients. The results of audits confirmed that stroke care at the hospital had improved over the past year.

  • The children’s ED was innovative and well led, ensuring that children were seen promptly and given effective care. Careful attention had been paid to the needs of children attending with significant efforts taken to reassure them and provide the best possible age appropriate care.

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

Importantly:

  • The trust must ensure that there are sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience to meet the needs of patients using the service at all times.
  • The trust must ensure that all staff have attended mandatory training and that all staff have an annual appraisal.
  • The trust must ensure that newly appointed overseas staff have the support and training to ensure their basic competencies before they care for and treat patients.
  • The trust must undertake an urgent review of staff skill mix in the mixed/neuro ICU unit and this must include an analysis of competencies against patient acuity.
  • The trust must establish clear working guidelines and protocols, fully risk assessed, that identify why it is appropriate and safe for general ICU nurses to care for neurosurgery ICU patients. This should include input from neurosurgery specialists.

  • The trust must 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 must also monitor the turnaround time for biopsies for suspected cancer of all tumour sites.
  • The trust must ensure that medicines are always supplied, stored and disposed of securely and appropriately. This includes ensuring that medicine cabinets and trollies are kept locked and only used for the purpose of storing medicines and intravenous fluids. Additionally the trust must ensure patient group directives are reviewed regularly and up to date.

  • The trust must implement urgent plans to stop patients, other than by exception being cared for in the cohort area in ED.

  • The trust must adhere to the 4 hour standard for decision to admit patients from ED, ie patients should not wait longer than 4 hours for a bed.
  • The trust must ensure that there are clear procedures, followed in practice, monitored and reviewed to ensure that all areas where patients receive care and treatment are safe, well-maintained and suitable for the activity being carried out. In particular the risks of caring for patients in the Barry and Jubilee buildings should be closely monitored to ensure patient, staff and visitor safety.

  • The trust must ensure that patient’s dignity, respect and confidentiality are maintained at all times in all areas and wards.

  • The trust must stop the transfer of patients into the recovery area from ED /HDU to ensure patients are managed in a safe and effective manner and ensure senior leaders take the responsibility for supporting junior staff in making decisions about admissions, and address the bullying tactics of some senior staff.

  • The trust must review the results of the most recent infection control audit undertaken in outpatients and produce action plans to monitor the improvements required.

  • The trust must ensure its governance systems are embedded in practice to provide a robust and systematic approach to improving the quality of services across all directorates.

  • The trust must urgently facilitate and establish a line of communication between the clinical leadership team and the trust executive board.

  • The trust must undertake a review of the HR functions in the organisations, including but not exclusively recruitment processes and grievance management.

  • The trust must develop and implement a people strategy that leads to cultural change. This must address 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.

  • Review fire plans and risk assessments ensuring that patients, staff and visitors to the hospital can be evacuated safely in the event of a fire. This plan should include the robust management of safety equipment and access such as fire doors, patient evacuation equipment and provide clear escape routes for people with limited mobility.

In addition the trust should:

  • Review the consent policy and process to ensure confirmation of consent is sought and clearly documented.

  • Review the provision of the pain service in order to provide a seven day service including the provision of the management of chronic pain services.

  • Consider improving the environment for children in the Outpatients department as it is not consistently child-friendly.

  • Ensure security of hospital prescription forms is in line with NHS Protect guidance.

  • Ensure that there are systems in place to ensure learning from incidents, safeguarding and complaints across the directorates.

  • Ensure all staff are included in communications relating to the outcomes of incident investigations.

  • Implement a sepsis audit programme.

  • Provide mandatory training for portering staff for the transfer of the deceased to the mortuary as per national guidelines.
  • Ensure there is a robust cleaning schedule and procedure with regular audits for the mortuary as per national specifications for cleanliness and environmental standards.
  • Review aspects of end of life care including, having a non-executive director for the service, a defined regular audit programme, providing a seven day service from the palliative care team as per national guidelines and recording evidence of discussion of patient’s spiritual needs.
  • The trust should ensure all DNACPR, ceilings of care and Mental Capacity assessments are completed and documented appropriately as per guidelines.
  • The trust should implement a formal feedback process to capture bereaved relatives views of delivery of care.

On the basis of this inspection, I have recommended that the trust be placed into special measures

.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 22 and 23 June 2015

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

Royal Sussex County Hospital (RSCH) is an acute hospital for the Brighton and Sussex University Hospitals NHS Trust(BSUH), providing acute services to the population of people across the Brighton, Hove, Mid Sussex and parts of East Sussex. The hospital provides maternity services, a special care baby unit, outpatient services and medical care. The hospital is the centre for emergency tertiary care with specialised and tertiary services including neurosciences, vascular surgery, neonatal, paediatric services based at The Royal Alexandra Children’s Hospital, the Sussex Eye Hospital, cardiac, cancer, renal, infectious diseases and HIV medicine. The trust is also the major trauma centre for Sussex and the South East.

We carried out this focused unannounced inspection following information received and as a result of our regular visits to the hospital during which we had concerns about the safety and experience of patients requiring unscheduled care using emergency pathways.

We focused our inspection on the Urgent and Emergency Services and Acute Medical Admissions Unit provided at The Royal Sussex County Hospital only. We did not inspect other core services during this inspection.

At the time of our inspection the concerns about the trust emergency department were being managed and supported by a multi-stakeholder risk summit process that included NHS England, Trust Development Authority, local commissioning groups and Healthwatch.

Our key findings were as follows:

  • Compassionate and good clinical care was provided to patients by staff.
  • Physical capacity and staffing numbers and skill mix did not support the timely assessment of patients arriving at the department.
  • Patients were not cared for in the most appropriate environment due to overcrowding in the emergency department and poor patient flow into the main hospital.
  • Lack of management capacity and effective board challenge and support had resulted in a lack of progress in addressing issues over the last 18 months

Due to the multi-agency risk summit structure that was in place to support and manage improvements in the emergency pathway we have not initiated any regulatory action as a result of this inspection. The trust will however regularly report, in a single and standard approach, the improvements in quality to all stakeholders through the risk summit process.

Importantly, the trust must:

  • Reduce the numbers of patients cared for in the cohort area within the emergency department (and the regularity with which congestion occurs in this area) and ensure timely assessment of patients arriving in the department.
  • Ensure that appropriate staffing levels and skill mix is in place to meet the needs of the patients within the department and support the process of improvement.
  • Enhance board level effectiveness to ensure progress with the emergency department improvement plans.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21-23 May 2014

During a routine inspection

Royal Sussex County Hospital is an acute hospital for the Brighton and Sussex University Hospitals NHS Trust, which provides acute services to the population of people across the Brighton, Hove and Mid Sussex. The hospital provides maternity services, a special care baby unit, outpatient services and medical care. The hospital is the centre for emergency tertiary care with specialised and tertiary services including neurosciences, vascular surgery, neonatal, paediatric services based at The Royal Alexander Hospital, cardiac, cancer, renal, infectious diseases and HIV medicine. The trust is also the major trauma centre for Sussex and the South East.

We carried out this comprehensive inspection because the Brighton and Sussex University Hospitals NHS Trust was an Aspirant Foundation Trust. The inspection took place between 21 and 23 May 2014. We also carried out unannounced inspections on Tuesday 27 May between 7pm and 11pm and then on Friday 30 May between 3pm and 6pm.

Overall, this hospital requires improvement. We rated it ‘good’ for being caring and effective, but it requires improvement in providing safe care, being responsive to patients’ needs and being well-led.

Our key findings were as follows:

  • We observed staff communicating with and supporting people in a very caring and compassionate way. Patients and their families spoke highly of the care they had received. The overwhelming majority of the feedback given to the team from all sources was positive.
  • Staff spoke very positively about the Chief Executive who they said was highly visible, engaged, focused and committed to improvement. Staff across the trust and at every level referred to communication having been “transformed” since his arrival. Nursing staff also spoke positively about the Chief Nurse and the impact that she was having.
  • With very few exceptions staff across the trust described their pride in the services they were delivering and the support they received from colleagues and managers. Staff were excited about the recent announcement of the £420m redevelopment of the Royal Sussex Hospital site which was described as a “huge boost”.
  • The areas of the trust that we visited appeared clean and cleaning was taking place throughout our inspection. The age of some of the buildings made them more difficult to keep clean. The trust’s infection rates for C.difficile are within an acceptable range taking account of the size of the trust and the national level of infections. The trust reported five cases of MRSA infections in the last twelve months with the infections occurring in April and October 2013. This is slightly higher than would be expected. The trust has an effective infection control team and we observed good hygiene practices by staff.
  • The older buildings and some aspects of the lay out of the Royal Sussex County Hospital campus presented a significant challenge in delivering care, for example patients cannot be moved between buildings during bad weather. Some issues would not be resolved until the planned building programme is complete but in the meantime work had been carried out to make improvements where possible. An example of the latter was the new dementia service, the Emerald Unit in the Barry Building.
  • There were issues with the flow of patients into, through and out of hospital. This was having an impact on care and patient experience in the Emergency department, in the medical assessment units, in surgery, in critical care, on the wards and also on the planning and support that people received when they were ready to leave. Some patients were being cared for in wards which were not with their required speciality. The trust needed to achieve 100 discharges a day and at the time of the inspection were achieving between 65 and 70.
  • The pressures on the emergency department were significant and connected to the flow issues described above. The department does not have enough physical space to deal with the number of patients that attend. The department is consistently failing to meet the target to admit, transfer or discharge 95% of patients within four hours.
  • The implementation of a centralised booking system (known as “the Hub”) for outpatient and follow up appointments had not gone smoothly and had caused problems for patients and staff alike. The problems included late notice of appointments, cancelled appointments and clinics, delays in dealing with urgent referrals and clinics running without patients booked for them. The trust had a comprehensive action plan in place and improvements were being seen.
  • The trust was dealing with a number of significant cultural issues. These included improving engagement with staff, improving and promoting race equality and dealing with some long standing issues in respect of that, addressing the issues that have influenced the staff survey results and improving the take up of appraisals and access to training.
  • Staffing levels, particularly in medicine and surgery and the high use of bank or agency staff placed pressure on staff and placed patients at risk of their care needs not being appropriately met. These pressures meant that staff were not always able to attend training as required. Concerns about the quality of food were a recurring theme in patient feedback during the inspection and in patient survey results. Patient records showed that nutritional risk assessments are being carried out using the MUST tool and additionally staff were completing food and nutrition charts for patients who were at risk of weight loss. Fluid charts were also being completed appropriately.

We saw several areas of outstanding practice including:

  • We were particularly impressed with how the day case ward met the needs of children going to theatre. There was a ‘one-way’ system that ensured children going into theatre did not see the children that were leaving the theatre. Small children could ride in motorised cars to theatre if they chose to do so. There were booklets available for children to read that explained what they could expect to happen while they were in hospital. These were in the format of a monkey telling a story. Parental feedback about the booklets was exceptionally good.

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

Importantly, the trust must:

  • Ensure that the environment is suitable for patient investigations, treatment and care and that hazards related to the storage of equipment that impact on staff, are minimised.
  • Ensure that electrical equipment, used directly for patient treatment or care needs, is suitably checked and serviced, to ensure that it is safe and fit for use.
  • Ensure that planning and delivery of care on the obstetrics and gynaecology (O&G) units meets patients’ individual needs.
  • Ensure the appropriate use of beds spaces which are suitable by their position, design and layout within wards including the Stroke Unit, Grant ward and Baily Ward.
  • Ensure that the values, principles and overall culture in the organisation, supports staff to work in an environment where the risk of harassment and bullying is assessed and minimised and where the staff feel supported when it comes to raising their concerns without any fear of recrimination.
  • Ensure that relationships and behaviours between staff groups irrespective of race and ethnicity is addressed to promote safety, prevent potential harm to patients and promote a positive working environment.
  • Ensure patients who require access to urgent referrals for treatment through the Hub are supported to do so as a matter of urgency and patient safety.
  • Take action to ensure that staff receive mandatory training, in line with trust policy.
  • Take action to ensure that staff receive an annual appraisal.
  • Evaluate the effectiveness of the current patient flow and escalation policy and implement mechanisms to improve patient flow within the ED and other wards across the trust.
  • Review the current cohort protocol to ensure that there are clear lines of clinical accountability and responsibility for patients, which all trust staff and ambulance trust staff are aware of.
  • Review the current cohort area within the ED to ensure the privacy and dignity of patients. Ensure that women using the day assessment unit have their privacy and confidentiality maintained.
  • Ensure that staff reporting incidents receive feedback on the action taken and that the learning from incidents is communicated to staff.
  • Ensure that there are enough suitably qualified, skilled and experienced staff to meet the needs of all patients. In O&G consultants support must be available at all times.

In addition the trust should:

  • Ensure that the functions of the booking Hub are addressed, so that patients who need to be seen post-operatively have access to the correct consultant, at the correct time.
  • Medical staff should ensure that patients have the opportunity to ask questions within the doctor’s round, so that they are fully informed.
  • Make improvements to the efficiency around the discharging of patients from postoperative wards.  
  • Ensure that staff at all levels feel confident about reporting incidents so that learning and improvements to practice can take place.
  • Critical care staff should ensure that patient information is secure and confidential at all times and that it cannot be viewed by anyone who is not authorised to do so.
  • Ensure same sex breaches are being managed in acute areas such as AMU (Acute medical unit).
  • Continue the work to introduce more midwife-led pathways to help normalise birth and reduce the rates of caesarean sections.
  • Ensure IT connectivity across all clinical bases is at a level where all community midwives can review essential information.
  • Ensure that cover is in place for specialist services as part of the workforce planning.
  • Ensure that there are robust governance systems in place to enable more effective management of the outpatient services at the Royal Sussex County Hospital.
  • Ensure good communication between outpatient services and the medical records department.
  • Ensure that staff understand their role in the event of a major incident, as appropriate to their designation.
  • Ensure parity across wards/units regarding access to training, education and study leave.
  • Ensure that there are effective human resources and processes to assist patient flow.
  • Ensure that information on how to complain is available in languages other than English.
  • Ensure that there are effective working arrangements between all staff groups.
  • Review the current NHS Friends and Family Test response rate and methodology to ensure they are consistent with national return rate.
  • Ensure end of life strategy is given appropriate consideration at board level.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 8 May 2013

During an inspection in response to concerns

The inspection team included an advisor with specialist knowledge of infection control, and five inspectors. During the inspection we spoke with 44 staff, in a range of roles, including matrons, maintenance engineers, healthcare support workers, housekeepers, nursing staff, consultants, doctors, directors, managers and contractors. We also observed care and spoke with 19 patients and visitors. We visited a sample of elderly care and rehabilitation wards, orthopaedic, surgical and maternity wards. We also visited the eye hospital and the children’s hospital site.

On the day of our inspection we found that the hospital was clean and procedures were in place to prevent and control the spread of infections. We spoke with many patients who were generally very positive about the standards of cleanliness. Most commented that they had observed staff wash their hands frequently, and made use of gloves and aprons when necessary. For example one patient told us," It’s definitely clean, the bathrooms area is always clean which is amazing on a maternity ward”.

We found some areas of the hospital where the fabric of the building had become compromised. This presented a continual challenge for staff in their attempts to maintain acceptable levels of cleanliness. The provider had in place appropriate policies that assessed environmental risks and maintained the premises in order to ensure that people’s rights to privacy, dignity, choice, autonomy and safety were protected.

Inspection carried out on 9, 10, 11, 15 April 2013

During an inspection in response to concerns

We carried out this review in response to concerns centred on the provision of emergency care. The trust had already been subject to external review which led to our decision to inspect the trust and also informed our inspection report. The trust had developed action plans to address the review's recommendations, but they were at an early stage of implementation.

Most patients we met said staff were dedicated and caring. However, the current inability to effectively discharge and manage the flow of patients through the hospital meant some patients were not treated with the privacy and dignity they should have been given. This was particularly the case in the emergency department, as pressure from elsewhere in the hospital impacted on them most acutely. In this and some other parts of the hospital, the pathways of care for patients were not working or organised effectively. This meant some patients were staying longer than clinically required.

The hospital was working well to play its part in cooperating with other providers of care. However, the trust was not doing enough to get sufficient support from the local health and social care community to alleviate pressures on the hospital. The trust had responded to staff shortages in some acute areas and had reviewed the way it effectively deployed staff to provide safe care. However, the governance of the hospital and leadership of services had not been effective in order to avoid or limit the current pressures.

Inspection carried out on 7 November 2012

During a routine inspection

We took the opportunity to speak with many women during our visit and found that they were generally very complementary about the care and dedication of the staff looking after them. We were told that communication was good, staff referred to individual birth plans and women felt supported and listened to. A woman and her partner told us that they were aware that there was a virtual tour of the maternity unit on the hospital’s website. We spoke with women attending antenatal appointments, during labour and on the post natal ward. All told us that they were very happy with the care they had received. One person commented, “It was really good.” Another said “I feel really supported and safe here”.

Women were happy to talk with us and confirmed that they were generally very happy with their care. They said they been provided with enough information and had their treatment fully explained with them. One woman commented, “I wanted to be quite flexible on the day.” Another told us that they had brought their birth plan in when they were due to give birth, and staff had referred to it during her labour. They all told us that they would recommend the unit to friends.

Inspection carried out on 22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

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

Inspection carried out on 5 July 2011

During an inspection in response to concerns

People who use this hospital said that they felt supported by the staff to receive the care they need. They told us that every effort is made by the staff to help them maintain their mobility, independence and regain confidence to help them live independently when they are discharged, wherever possible. We spoke to many patients and were told that people felt able to express their preferences and that as far as practicable and in accordance with their wishes and individual care plans, people were enabled and encouraged to make choices about their daily lives.

As part of our compliance review of The Royal Sussex County Hospital we visited Accident and Emergency departments, Chichester, Donald Hall, Bristol, Fleming and Lister, Albion, Solomon, Vallance, Jowers and Lewes wards. All units and wards were found to be well managed and the staff we spoke with were confident and competent in their roles. The environment was found to be clean and generally well maintained.

Patients in all areas of the hospital appeared to be safe, generally comfortable and well cared for. This was supported by positive comments from patients and their relatives and also evident from direct observation of individuals being supported in a professional, sensitive and respectful manner. We were told by one patient that “the staff are all so kind and friendly and the care they provide is second to none”. Another told us that “we feel very involved with the hospital and we are kept informed about what is happening”.

As far as practicable and in accordance with their wishes and individual care plans, people were telling us that they were enabled and encouraged to make choices about their daily lives and the care they were to receive.