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Royal Preston Hospital Requires improvement

We are carrying out checks at Royal Preston Hospital. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 October 2018

Our rating of services stayed the same. We rated it them as requires improvement because:

  • The hospital had made improvements to compliance with mandatory training, life support training and safeguarding training in some areas but compliance in other areas such as urgent and emergency services were still not meeting the trust’s targets.
  • The access and flow of patients was an issue for the hospital which was demonstrated by the hospital not meeting national performance targets or performing worse than the England average. There were also a high number of bed moves at night.
  • Some of the areas used for escalation, at times of high demand, were unsuitable for patient use.
  • The hospital did not always have enough staffing in every area. While there had been improvements since the last inspection some areas such as some medical wards and the neo natal unit did not always have enough staff on duty.
  • The hospital was not always managing medicines well. There were different issues with medicines management in areas of the hospital such as patient group directions and to take home medicines.
  • While the number of staff who had received an annual appraisal had improved since the last inspection, in areas it was not at the trust target.
  • Staff lacked understanding and awareness of the Mental Capacity Act and the Deprivation of Liberty safeguards in areas of the hospital.
  • Patient records were not always completed in line with best practice.
  • Risks were not always recorded accurately, with timely action to mitigate risks. Some of the governance processes have recently been developed so were not yet embedded.
  • Policies in a number of areas were not reviewed to ensure that they were up-to-date and in line with best practice.

However:

  • The hospital was managing safety incidents well in most areas. The environment and equipment was kept clean and on the whole used appropriately for the services provided.
  • While policies were not up-to-date, services were provided in line with national guidelines and best practice and services were participating and carrying out local audits to improve practice.
  • Staff throughout the hospital were kind, compassion and caring to patients, their carers and family members. Patients were involved in decisions about their care and given emotional support.
  • Services were planned to meet the needs of people using the hospital and services were in general responsive to the individual needs of patients. The hospital engaged well with patients and members of the local community.
  • Staff were positive about their leaders across the hospital. There was a positive culture and staff were proud to work at the hospital.
  • Staff were committed to making improvements, although some of these processes were yet to be embedded. Staff were positive about the focus on continuous improvement and initiatives such as the safety triangulation accreditation review process.

Inspection areas

Safe

Requires improvement

Updated 17 October 2018

Effective

Requires improvement

Updated 17 October 2018

Caring

Good

Updated 17 October 2018

Responsive

Requires improvement

Updated 17 October 2018

Well-led

Requires improvement

Updated 17 October 2018

Checks on specific services

Critical care

Requires improvement

Updated 21 April 2017

We have previously inspected the hospital in July 2014 and gave critical care services an overall rating of good. Following this inspection we rated critical care services at Royal Preston Hospital overall as requires improvement because:

  • Eighty three percent of the beds on the unit were not compliant with the Department of Health Building Note 04-02 for Critical Care Units that specifies the minimum amount of bed space required to safely locate and utilise required equipment.
  • Plans to expand and rebuild the unit to meet required bed spaces and provide adequate storage, and staff and visitor facilities had not been undertaken due to financial constraints.
  • Flooring in the unit was in a poor condition and presented a tripping hazard and potential infection control risks.

  • There was a shortage of pharmacists, dietitians and physiotherapists to meet the needs of patients across seven days a week.

  • Mandatory training uptake levels were low for some subjects, including safeguarding children and adults training.

  • Appraisal rates were low at 62% and this was a lower rate than at the previous inspection.

  • Audits were not always followed up with action plans and a number of action plans had not been update for years in some cases.

  • The service was not meeting the Intensive Care Standards guidelines for 50% of nursing staff to have undertaken a post-graduate qualification course in critical care nursing.

  • There was limited monitoring of patient satisfaction.

  • Seventy one percent of patients admitted to the critical care units experienced a delay in their discharge.

  • Bed occupancy was consistently higher than the England average.

  • Daily emergency admissions exceeded the anticipated rate for which beds were reserved.

However;

  • The critical care services were well-led and staff were aware of the trust’s vision and values.
  • We found that there were governance frameworks in place and risks were appropriately identified and monitored.
  • There was clear leadership throughout the service and staff spoke positively about their leaders.
  • Staff were able to report incidents and were knowledgeable about the types of incident they should report.
  • We saw evidence that learning from incidents and complaints was routine and this learning was disseminated.
  • Infection control was effectively managed and the department was visibly clean. Routine infection control audits were undertaken.
  • Nurse and medical staffing was sufficient to meet patients’ needs.
  • Patients received effective care and treatment that followed national clinical guidelines, was tailored to their individual needs, and was delivered by competent and professional staff.
  • The service participated in local and national audits.
  • Staff sought appropriate consent from patients before delivering treatment and care.
  • Staff were knowledgeable about the Mental Capacity Act and considered this where relevant.
  • Staff treated patients with kindness, dignity and respect and provided care to patients while maintaining their privacy, dignity and confidentiality.
  • Patients spoke positively about the way staff treated them.

Outpatients and diagnostic imaging

Requires improvement

Updated 21 April 2017

At the previous inspection in July 2014 we rated this service overall as requires improvement. Following this inspection we have maintained the overall rating because:

  • The outpatients and diagnostics service was predominantly managed through the diagnostics and support services division. However key outpatient departments such as orthopaedics and ophthalmology were under a separate management structure. The recent changes in the divisional structure had led to some lack of clarity in terms of performance and governance.
  • At our last inspection we found staff had not received clinical supervision, as required by the hospital’s own policy and procedures. At this inspection we found this was still the case. Some staff told us that they had regular morning briefings and managers were accessible but they had not received and the trust did not provide details of staff uptake of clinical supervision.
  • At our last inspection we found concerns within the ophthalmology department; clinics were sometimes cancelled at short notice and frequently ran late. At this inspection we found there were still issues regarding medical staffing and access to services in ophthalmology. In Ophthalmology there had been follow- up capacity pressures which had led to service governance concerns. The service had reported two serious incidents related to delays in accessing care and treatment.
  • The environment was very cramped and did not assist staff in meeting the needs of individuals by providing appropriate consultation areas.
  • The trust performed worse than the England average for referral to treatment times for non-admitted referral to treatment pathways in October 2015 and remained below the average each month to June 2016. Of the 16 separate specialties reported nine were below the England average, the lowest scoring being neurosurgery at 71%.
  • For incomplete pathways of the 16 separate specialties reported, nine were below the England average, the lowest scoring being plastic surgery at 75%.
  • The percentage of people waiting less than 62 days from urgent GP referral to first definitive treatment was worse than the standard for three of the four most recent quarters.
  • Although there was a clear process for reporting and investigating incidents, staff told us they had not received outcomes of incidents submitted. We found that improvements were required by the trust to ensure that staff received regular feedback on incidents.
  • We found some areas did have significant vacancies such as radiology and ophthalmology. Overall staffing numbers and skill mix met the needs of the patients.
  • Care provided was evidence based and followed national guidance. Patients were treated with dignity and respect by caring staff. Patients spoke positively about staff and felt they had been involved in decisions about their care.
  • Across outpatients and imaging services we found there was good local leadership and staff were committed to meeting the needs of their patients. Overall staff worked well as a team and supported each other. However we noted the recent changes to the directorate structures had had an impact on frontline staff with some staff unsure about reporting structures.

Urgent and emergency services

Requires improvement

Updated 17 October 2018

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

  • We identified regulation breaches by the service relating to safe care and treatment, staffing competency, medicines, the environment and governance.
  • Mandatory training, life support training and safeguarding training compliance was low and did not meet the trust’s targets. Managers were not assured that staff were competent as the service’s nursing appraisal rates were low.
  • The service’s mental health assessment, monitoring and treatment room was not fit for the purpose it was being used for. Staff awareness of the deprivation of liberty safeguards was poor.
  • The current processes for booking patients into the service and referral between the service and the urgent care service, in combination with lack of beds elsewhere in the trust, meant the trust’s performance against national targets was poor, and had shown a deteriorating trend.
  • To take home medicines were not audited, and labels did not include information required by medicines regulations.
  • The service did not meet the Royal College of Emergency Medicine’s benchmarked standards on a number of measures.
  • Despite the service’s leaders appropriately identifying the risks and contributory factors affecting the department, the service did not meet most of the national targets for urgent and emergency care. Performance in a range of internal trust targets in training, safeguarding, and staff appraisals remained below trust target. Improved performance as a result of planned recruitment and physical developments had yet to be realised.

However:

  • The service managed incidents well, and staff could demonstrate knowledge of how they would report incidents and safeguarding concerns.
  • The trust had recently agreed additional staffing for the service and it was actively recruiting to raise staff numbers. The service had plans for physical development of the department, which would enable it to provide a rapid assessment and treatment service, and to more effectively stream, transfer and manage patients with the on-site urgent care centre provider.
  • Staff were kind, compassionate and caring in their interactions with patients, and involved them and their carers or relatives in decisions about their care and treatment.
  • The service’s local leaders had the right skills, competency, experience and vision to lead the service and were visible to staff. Although the service’s performance was challenged, the leaders promoted a positive culture that was evident from the staff we spoke with.

Maternity

Good

Updated 17 October 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our ratings directly with the previous ratings.

We rated it as good because:

  • Staff safeguarding training was improving, the baby tagging system worked well on the postnatal ward and the areas and equipment appeared visibly clean.
  • There was a significant midwifery staffing shortfall but the service had put in place measures to mitigate this as much as they could, such as having an extra band seven midwife on all the time and having twice daily safety huddles.
  • Women’s maternity records were kept securely and there was good reporting of, and good learning from, incidents.
  • Staff worked well with each other and with other maternity services and national bodies to improve care for women and provide evidence based care. Women were offered a variety of conventional and non-conventional pain relief. However, medical devices training and staff appraisal rates were below targets.
  • We found the department to be caring as they provided compassionate care to women and their families. Women were encouraged to ask questions and be involved in their care and women’s dignity was protected and respected.
  • We found that the service was responsive to the needs and wishes of service users. The trust had specialist midwives to co-ordinate care for women with specific needs. A small team of midwives provided continuity of care throughout elective caesarean section births and mothers and babies stayed together at all times by administering baby intravenous antibiotics on the postnatal ward.
  • We found the department to be well led. The head of midwifery was a very well-respected leader by all the staff that we spoke to during our inspection. There was a very good culture of nurturing staff to develop their initiatives and, despite the staffing shortfall, the team were all working together for the benefit of the women. There was good engagement with staff and service users. However, guidelines had not all been updated.

Outpatients

Good

Updated 17 October 2018

We previously inspected outpatients jointly with diagnostic imaging in September 2016, so we cannot compare our new ratings directly with previous ratings.

We rated the service as good because:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Care and treatment was delivered in line with best practice guidance. Patient outcomes were reviewed during clinic appointments to make sure patients were receiving appropriate care and treatment.
  • Staff demonstrated a consistently caring attitude to supporting patients that was compassionate and kind. Patients’ dignity was always maintained.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • Patients could access care and treatment in a timely manner.
  • Staffing numbers and skills were flexibly managed to make sure there was sufficient staff to support the clinics as needed.
  • There was a clear strategy based on best practice and values that assisted the service in developing quality care and treatment.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However:

  • The assessment and recording of a patient’s mental capacity and staff understanding of the Mental Capacity Act 2005 was not always consistent.
  • Systems designed to flag patients needing extra support were not consistently used.
  • Information for patients was not always available in formats that met their needs
  • Appropriate records of patients’ care and treatment were not being kept in all outpatient clinics. Some records were not clear, up to date and available to all staff providing care.

Maternity and gynaecology

Requires improvement

Updated 21 April 2017

At the last inspection in July 2014 we rated the service as good overall. Following this inspection we rated this service as Requires Improvement because:

  • The system for protecting babies from abduction was not robust. Due to a shortage of electronic baby security tags, not all babies were issued with a tag on the postnatal ward and concerns regarding the level of observation at the one main entrance, through the antenatal ward, to get to the postnatal ward. Baby security issues were raised with the trust at the time of our visit, immediate action was taken, and all babies were tagged before we left site.
  • The system for recording and storing fetal pregnancy remains on the gynaecology ward was not robust. This was immediately raised with the trust and at the time of the unannounced visit, we observed changes in practice to assure us that pregnancy remains were stored safety and sensitively and recorded appropriately. 
  • All staff reported a shortfall in staffing and an increasing quantity of work and activity within the service. Management told us that the midwifery staffing levels had not been formally reviewed since 2011. However they were waiting for the Birthrate Plus (a national tool available for calculating midwifery staffing levels) review and report Staffing levels was also raised as a concern at the last CQC inspection in 2014. Although it was noted that since2014, there had been an increase in 10 full time midwives.

  • Due to staffing issues and sickness absence rates, there was a heavy dependence on midwives working extra hours. The trust did not use agency staff but used their in-house bank staff on an ongoing basis. Additional midwifery staffing was provided by midwives working over and above their normal working hours. 
  • All midwifery staffing, including community were flexed to meet the needs of the service user. Managers were aware of the staffing shortfall and recruitment was underway; however, the current measures in place were not sustainable and insufficient to mitigate the risk of harm.
  • Due to the pressures of work, staff morale was low but staff of all professions supported each other well to work as a team. There was a desire to provide the best care they could to the patients and the inability to achieve this led to dissatisfaction amongst midwives.
  • Gynaecology beds were used on a daily basis, including weekends, for patients with other medical, surgical or orthopaedic conditions. This resulted in access and flow issues and delays in some gynaecological procedures.
  • Obstetric consultant cover for delivery suite was 80 hours per week. The trust were monitoring this closely as it did not meet the recommended hours required on delivery suite (Standards for Safer Childbirth, 2007). This was also a concern raised at the last CQC inspection in 2014.
  • There was only one dedicated obstetric theatre, set up every day for obstetric emergencies. There was lack of a second dedicated obstetric theatre. Elective caesarean sections were usually performed in one of the two adjoining gynaecology theatres, which could lead to delays of operative procedures.
  • Not all staff attended annual mandatory training or received their annual appraisal
  • There was some discrepancy among senior staff about what level of safeguarding training provided to staff. 
  • Expressed breast milk (EBM) was not securely stored. Fridge temperature recordings were inconsistent.
  • The trust did not complete any risk assessment for midwives carrying medical gases in their cars and did not have a Standing Operating Procedure (SOP) or protocol for carrying medical gases by car.
  • Policies and guidelines were not robustly updated. Of the maternity polices and guidelines reviewed, 30% were out of date.

However:

  • Care in the Preston Birth Centre was provided in a calm, relaxed and spacious environment that had been specifically designed and equipped to support normal births. 
  • There were clear systems for reporting incidents and managing identified risk within the service.
  • The service was proactive in learning from complaints and concerns.
  • Access and flow issues on the gynaecology wards were managed well by the clinical lead who had good oversight to move patients accordingly and work flexibility across all areas.
  • Daily multidisciplinary team (MDT) staff safety huddles took place. 
  • Medicines were delivered, stored and dispensed safely.
  • The wards were adequately maintained and equipment was readily available and fit for immediate use. Resuscitation equipment was available and fit for use by suitably trained staff.
  • We found that committed and compassionate staff delivered maternity and gynaecology services. All staff treated patients with dignity and respect. People we spoke to were positive about the care they had received.
  • Gynaecology staff informed us that referral to treatment times met the national recommendations, with rapid access to clinics available.

Medical care (including older people’s care)

Requires improvement

Updated 17 October 2018

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

  • The safety of patients had been compromised by inappropriate areas of the hospital being used as escalation areas at times of high activity, specifically, the cardiac catheterisation lab.
  • We were not assured that there were robust systems in place to ensure patients who were placed as medical outliers had their care and treatment routinely reviewed by a doctor. The existing system was open to human error and nursing staff told us that they were uncertain of the arrangements for medical cover in relation to patients who were categorised as outliers.
  • There was not always enough nursing staff available on every ward to meet people’s needs.
  • We observed a nursing handover that took place at the patient’s bedside which meant that the privacy and confidentiality of patient’s information was not always maintained. Staff told us that it was the trust policy for handovers to take place at the bedside.
  • Staff lacked understanding of their role in the application of the Mental Capacity Act (2005). Do not attempt cardio pulmonary resuscitation (DNACPR) forms had been completed for patients documented as lacking capacity without a formal mental capacity assessment having taken place.
  • Patients did not always receive care which was centred around their needs. Patients were frequently moved to other wards at night.
  • We found that on a number of wards, patient records were being stored at the bedside and in bays which meant that these were easily accessible and not securely stored.

However:

  • Patients were cared for by staff who were compassionate, approachable and kept them informed of their treatment plans.
  • The service carried out regular safety triangulation accreditation reviews (STAR) on each ward to monitor safety and performance and there was an action plan in place for each ward to address performance issues identified.
  • Newly qualified staff were supported in their role and had their competencies assessed as part of a robust preceptorship programme.
  • We saw examples of good practice in relation to the care of patients with cognitive impairment.
  • There was a new leadership team in place at the time of our inspection. Staff we spoke to felt that leaders within the service were visible and approachable.
  • Staff were positive about recent changes that had been implemented such as the new medical assessment unit and said that they felt empowered to make improvements within their specialisms and areas of work.

Surgery

Good

Updated 17 October 2018

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

  • The service provided mandatory training in key skills to all staff and prompted them to complete it.
  • Staff understood how to protect patients from abuse and had training on how to recognise and report abuse.
  • The service continued to control infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. The service had suitable premises and equipment and looked after them well.
  • Staff monitored and responded to risks in good time. The service had enough medical staff with the right qualifications and experience to keep people safe and to provide the right care and treatment.
  • Staff kept appropriate records of patients’ care and treatment. Staff recorded and stored medicines well.
  • The service managed patient safety incidents and monitored results well. Staff continued to provide care and treatment based on national guidance.
  • Staff gave patients enough food and drink to meet their needs and promoted health improvement. They monitored the level of pain in patients, providing pain relief when required.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • The service made sure staff were competent for their roles. Staff of different kinds worked together as a team to benefit patients.
  • Ward rounds took place seven days a week by a consultant. Patients were comprehensively assessed so that their clinical needs and general health status could be considered.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness and staff involved patients and those close to them in decisions about their care and treatment.
  • The service planned and provided services in a way that met the needs of local people. Staff took account of patients’ individual needs and concerns and complaints were treated seriously, investigated and lessons were learned from the results.
  • The service had managers at all levels with the right skills and abilities to run a service.
  • The service had a vision for what it wanted to achieve and managers promoted a positive culture amongst most staff that supported and valued them.
  • The service used a systematic approach to improve the quality of its services and maintained existing and effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems.
  • The service continued to engage with patients and staff to plan and manage appropriate services.
  • The service remained committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

However:

  • People could access the service when they needed it but waiting times for treatment and arrangements to admit, treat and discharge patients remained a challenge.

Services for children & young people

Good

Updated 17 October 2018

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

  • The trust had made improvements since the last inspection to safeguarding training levels. Safeguarding training levels had improved significantly since the last inspection, although were still lower than the trust target.
  • The service was taking action to assess and respond to patient risks. The service was using early warning scores more consistently to monitor deteriorating patients which was an improvement from the last inspection.
  • The service kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care. Although signatures were not always clearly identifiable. Records in outpatients were kept securely which was an improvement from the last inspection.
  • The service had suitable premises and equipment and controlled infection risk. This was an improvement since the last inspection. The trust had improved the security in all areas and was checking resuscitation equipment daily.
  • The service had improved nurse staffing on the paediatric ward since the last inspection.
  • Staff were competent in their roles and mandatory training was close to the trust’s target.
  • The service managed patient safety incidents well, as staff recognised incidents and reported them appropriately using the trust’s reporting system.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • The service gave patients enough food and drink to meet their needs and pain relief when it was required.
  • Staff were caring, involved patients and those close to them in decisions about their care and treatment and provided emotional support to patients who needed it.
  • Services were planned to meet the needs of patients and patient’s individual needs were met.
  • While a number of the leaders were new in post, staff were positive about the leadership team. The leaders promoted a positive culture that supported and valued staff. Staff were open, honest and proud to work within the service.
  • There was a clear governance structure and clear lines of accountability for staff at all levels and effective systems for identifying and mitigating risks.
  • The service engaged well with children, their parents and carer, staff, the public and local organisations and was committed to improving services.

However:

  • While the service prescribed, gave and recorded medicines well, all the hard copies of the patient group directives, were out of date and that there were lots of dates for different fridges where the temperature had either not been checked, or not recorded.
  • In our previous inspection we reported that staffing levels in the neonatal unit needed to be maintained in accordance with national guidelines. We found that the neonatal unit, they were still not compliant with British Association of Perinatal Medicine (BAPM) although had taken action to mitigate the risks. There were still some issues with medical staffing levels.
  • Policies were not all within their review dates.
  • The decorations of the paediatric ward were not all child friendly.
  • There were gaps in the information the service collected, analysed, managed and used to support all its activities, such as information about timeliness of medical reviews.

End of life care

Good

Updated 21 April 2017

At the previous inspection in July 2014 we rated this service as good overall at both hospitals. At this inspection we will only report on End of Life services within the Royal Preston Hospital report as the service delivered is by the same team across both hospital sites, however we did inspect both hospital sites. Following this inspection we have maintained this good rating because:

  • There was good use of the individualised plan of care document throughout the hospital. All health care records were completed to a high standard to ensure patient safety. There was evidence of comprehensive risk assessments regularly performed and patients’ goals and wishes were recorded.
  • There was evidence of changes and improvements made as a result of feedback from patients and other staff.
  • The palliative care team delivered training to all levels of staff, using a variety of teaching methods to capture the maximum staff available. Online guidance was provided via the trust intranet that ensured all staff had access to the most current information at all times.
  • The end of life care (EOLC) team demonstrated excellent management of patients in their last days/hours of life. The team had used the National Institute for Health and Care Excellence (NICE) Care of the Dying guidance to develop a ‘Think CLEAR’ policy for all staff to follow. The team had performed on or better the national average on 11 out of 13 of the key performance indicators on the 2016 Dying in Hospital Audit.
  • The team attended daily multidisciplinary team meetings across the hospital specialities in order to provide knowledge and input into patients’ end of life care. The hospital team also participated in local and national groups to share information and learn from peers.
  • Staff respected patients and their relatives and valued them as individuals. The care provided by the palliative care team was person centred and the culture within the team reflected this. All interactions between staff that we witnessed were patient centred and displayed compassion and respect.

However:

  • The team were not providing a seven-day palliative care service that meant rapid discharge between Friday and Monday could not always be facilitated. This meant that some patients may not die in their preferred place.
  • Due to staffing difficulties, the number of eye retrievals had decreased in recent months.
  • The educational facilitator was having difficulties ensuring an end of life link nurse was available on every ward, due to staff movement within the hospital.
  • Staff compliance with mandatory training and appraisal was below the trust target.