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Royal Preston Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 April 2017

Royal Preston Hospital provides a full range of district general hospital services including Emergency Department, critical care, general medicine including elderly care, general surgery, oral and maxillo-facial surgery, ear nose and throat surgery, anaesthetics, children’s services, women’s health and maternity, and several specialist regional services including cancer, neurosurgery and neurology, renal, plastics and burns, rehabilitation, and the major trauma centre for Lancashire and South Cumbria.

The hospital has around 700 beds, operating theatre complex, outpatient suites, and education facilities.

We inspected the hospital as a follow up to the inspection in July 2014 where the hospital was found to require improvement in the safe, responsive and well led domains and good in the effective and caring domains. We visited Royal Preston Hospital between 27 and 30 September 2016.

Following this inspection we have rated the hospital as requires improvement overall and the trust needs to make improvements. Staff were noted to be caring and patient focused and the caring domain was rated as good in all service areas. 

We saw several areas of outstanding practice including:

In Outpatients and diagnostic imaging the introduction in dermatology of a computerised diary colour codes patients by procedure enabling the service to plan a block of 12 week care in one go to suit the requirements of each patient. It also flags and calculates potential breeches giving better patient flow, facilitating comprehensive audit of care provision and outcome of treatment.

In Critical Care the trust had launched the Sleep Improvement in Adult Critical Care Programme. Disturbed sleep in critical care patients is associated with delirium, in which patients become confused, restless and experience hallucinations. This can delay their recovery from critical illness. The trust recognised this and identified the potential disturbances to sleep. To minimise disruption to patients during the night, they offered eye masks and earplugs, dimmed lights, anticipated empty infusion alarms, turned down the volume on medical equipment and phones and encouraged staff to talk away from the bedside. Staff were also reminded to check regularly for signs of delirium. The project and associated resources were shared with neighbouring critical care networks and at national meetings. An initial research study showed that making small changes caused a 50% reduction in patient delirium and significantly improved the quality of sleep experienced by patients. The study had won an initiative award at the National Nursing Times Awards.

However there were areas for improvement. 

Importantly, the hospital must:

In Urgent and Emergency Care services

;

  • Ensure access to the main entrance paediatric waiting area is limited to reduce the risk of children exiting the area through the automatic doorway.
  • Ensure intravenous fluids are stored securely and daily checks are completed with actions to address issues identified, completed.
  • Ensure mandatory training, including safeguarding, compliance reaches and consistently achieves the trust target.
  • Ensure clinical staff are aware of and adhering to the requirement for senior review of specific patient groups prior to discharge from the ED
  • Ensure appropriate signage is displayed in areas where close circuit television cameras are used.
  • Ensure action plans following CEM audits target areas of poor performance and improve practice.
  • Improve performance, particularly in relation to the department of health four hour target; wait times following a decision to admit, ambulance handovers.
  • Ensure version control for policies, procedures and guidance is robust and that these are kept up to date and reviewed regularly.
  • Ensure the department has a dedicated risk register with start dates, timelines, mitigating action and responsible person with review dates included.

In Medicine;

  • Ensure that all staff receive appraisals and complete mandatory training to enable them to carry out the duties they are employed to perform.
  • Ensure that records are kept secure at all times, so that they are only accessed by authorised people.
  • Ensure procedures in place around medicine management are robust and that policies are followed.
  • Ensure the risk registers are consistent and demonstrate mitigating actions and review dates

In Surgery;

  • Take appropriate actions to improve staff training compliance in areas such as safeguarding training and life support training.
  • Take appropriate actions to ensure that patients requiring escalation, as part of the national early warning score system (NEWS), are appropriately escalated by staff.
  • Take appropriate actions to improve compliance against 18 week referral to treatment standards.
  • Take appropriate actions to reduce the number of cancelled operations and the number of patients whose operations were cancelled and were not treated within the 28 days.

In Maternity and Gynaecology;

  • Ensure midwifery and support staffing levels and skill mix are sufficient in order for staff to carry out all the tasks required for them to work within their code of practice and meet the needs of the patient.
  • Ensure  there is a safe system for protecting babies from abduction.
  • Ensure all necessary staff completes mandatory training, including Level 3 safeguarding training and annual appraisals.
  • Ensure that the assessment and mitigation of risk and the delivery of safe patient care is in the most appropriate place.
  • Complete risk assessments for midwives carrying medical gases in their cars and develop a Standing Operating Procedure (SOP) or protocol for carrying medical gases by car.
  • Ensure that all staff receive medical devices training to ensure all equipment is used in a safe way.

In Critical Care;

  • Ensure that escalation procedures are followed appropriately across the hospital where patients’ National Early Warning Scores (NEWS) are greater than five and the patient may need to be assessed for admittance to the critical care unit.
  • Ensure that any patients admitted to Ward 2A, who are assessed as Level 2 high dependency patients, receive nursing care at a ratio of 1:2 in accordance with national standards.
  • Address action points on a gap analysis that showed that there was no availability for endoscopy for urgent gastro intestinal bleeds 24 hours a day.

In Children and Young People’s services;

  • Ensure that staffing levels in neonatal and children’s services are maintained in accordance with national guidelines.
  • Ensure that all relevant staff having regular contact with children, as defined by intercollegiate guidance, complete level three safeguarding training.
  • Ensure that indicators for managing the changing condition of ill children are consistently used and responded to appropriately on the children’s ward.
  • Ensure that the isolation room used on the children’s ward is free from access to ligature points
  • Ensure that patient records are kept securely in the children’s out patients department.
  • Ensure that checks on emergency resuscitation equipment, are completed and accurately recorded on the neonatal unit.
  • Ensure that secure access to the neonatal unit and children’s ward is maintained at all times by staff, parents and visitors.

In Outpatients and Diagnostic Imaging;

  • Ensure that clear processes and structures are in place for the management and reviewing of governance, quality and risks.
  • Review the processes for managing access and flow for outpatient services to ensure patients are not put at risk.
  • Ensure staff complete mandatory training as per the trust policy.

In addition the trust should:

Urgent and Emergency Services

  • The service should work to embed the forthcoming escalation process to support staff when capacity issues arise.
  • The service should have access to information in languages other than English
  • The service should improve attendance at monthly ED safeguarding meetings

Medical Care (including older peoples care)

  • The service should ensure that patients are discharged as soon as they are fit to do so.

  • The service should ensure that patients are not moved ward more than is necessary during their admission and are cared for on a ward suited to meet their needs.
  • The service should consider improving the environment of the discharge lounge to maintain patient’s privacy and dignity.
  • The service should ensure that patients have access to pressure relieving equipment at all times.
  • Consider implementing formal procedures for the supervision of staff to enable them to carry out the duties they are employed to perform.

Surgery

  • The service should take appropriate actions to maintain safe nurse staffing levels across the surgical wards.
  • The service should take appropriate actions to improve the general environment in the theatre areas.
  • The service should take appropriate actions to improve staff appraisal completion rates.
  • The service should take appropriate actions to improve infection rates following knee replacement surgery.

Critical Care

  • The trust should ensure intravenous fluids are stored appropriately and are not accessible to patients or visitors on the critical care unit.
  • The trust should make every effort to secure funding to expand the critical care unit in order to bring bed spaces within the recommended guidelines, make the flooring safe and to reduce the level of bed occupancy.
  • The Critical Care Governance Team should follow up the request for a review of the risk rating of the lack of a specialist critical care trained pharmacist on a weekend.
  • The trust should ensure that all staff in critical care receive mandatory training so that trust mandatory training targets are met.
  • The trust should ensure that all staff in critical care (especially nursing staff) receive an annual appraisal, in line with trust targets.
  • The service should ensure that action plans arising from audits are kept up to date until complete or actions should be removed.
  • The service should ensure that GPICS guidelines for 50% of nursing staff to have undertaken a post qualification course in critical care nursing is achieved as soon as possible.
  • The trust should for any mitigating actions that could reduce the number of delayed discharges from critical care.
  • The trust should look for ways that Speech and Language therapy (SALT) assessments can be carried out in a more timely manner.

Maternity and Gynaecology

  • The service should improve the recording of the review dates and version control of all policies and procedures.
  • The service should strengthen the risk registers to support the management of risk.
  • The service should improve attendance at governance meetings.
  • The service should consider the safe storage of patient’s notes on the gynaecology wards.
  • The service should consider the safe storage of expressed breast milk on the postnatal ward.
  • The service should consider the dignity and privacy of patients within the clinical areas, especially where curtains are used between bed areas and waiting areas that are positioned near procedure rooms.
  • The service should continue to monitor consultant labour ward presence with an aim of extending weekday and weekend cover.
  • The service should ensure that the capacity within the obstetrics and gynaecology theatres prevent delays in patient procedures.
  • The service should continue to ensure that processes for the storage, recording and traceability of fetal pregnancy remains on the gynaecology wards are robust.
  • The service should improve staff annual appraisal rates.
  • The service should increase staff training uptake for Female Genital Mutilation (FGM) training.
  • The service should work to better understand the variation in unplanned home birth rates to ensure safety of patients and babies.

Services for Children and Young People

  • The service should use an evidence-based dependency tool to manage appropriate staffing ratios for nursing care on the children’s ward.
  • The service should appropriately meet the continuing needs of patients who are admitted for child and adolescent mental health services, with adequate support and training for nursing staff where this is required.
  • The service should accurately record the completed temperature checks for breastmilk fridges and stores on the neonatal unit.
  • The service should maintain appropriate environmental temperatures on the children’s ward.
  • The service should maintain neonatal guidelines in an up to date and accessible format for staff to use on the neonatal unit.
  • The service should that complete and maintain appropriate records for staff supervision and appraisals on children’s and neonatal wards
  • The service should collect patient feedback responses on the children’s ward using the NHS Friends and Family Test

End of Life services

  • The service should improve compliance for mandatory training particularly safeguarding, life support and care of the dying education.
  • SPC staff appraisal rate should meet the trust target of 85%.
  • The service should address the low numbers of registered nurses who were trained in delivery of end of life care, particularly surgical staff.
  • The service should create a system for monitoring numbers of staff trained in syringe driver use to assure competency.
  • The service should consider they take steps to meet the needs of patients by providing a seven day specialist palliative care service.
  • The service should review staffing levels to ensure they are adequate to maintain the excellent results of the donor retrieval team.

Outpatient and diagnostic imaging services

  • The service should continue to monitor and review the procedures for caring for vulnerable patients attending for cancer therapy.
  • The service should consider improving the environment in the Outpatients department to ensure privacy and dignity is maintained.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 21 April 2017

Effective

Requires improvement

Updated 21 April 2017

Caring

Good

Updated 21 April 2017

Responsive

Requires improvement

Updated 21 April 2017

Well-led

Requires improvement

Updated 21 April 2017

Checks on specific services

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 21 April 2017

We rated medical services at Royal Preston Hospital as requires improvement overall because:

  • There were staff vacancies in most areas and there were occasions on wards when there had been a reliance on agency or bank nurses as well as locum doctors. Data provided showed there were times when the staffing levels were less than 80%.
  • Overall compliance with mandatory training for all staff was below trust target. The trust target was 80%.
  • There was a risk that personal information was accessible to members of the public as patient’s records were not always stored securely.
  • There were systems for handling and disposing of medicines however staff did not always evidence they followed policy and procedure and improvement was required.
  • Clinical staff had access to information they required, for example diagnostic tests and risk assessments. However, we found patients records were left unsecured on the wards we visited.
  • There were issues with access and flow across the medical wards with high bed occupancy rates and delayed discharges due to patient choice and complexities.
  • Some patients were being nursed in escalation or non-speciality beds and were moved on more than one occasion during their hospital stay with some moved during the night.
  • Recent audits performed showed further improvements were required in the care of patients with diabetes or who had suffered a heart attack or stroke.
  • There were governance structures in place which included a risk register. However there were inconsistencies across the divisional and trust risk register. 
  • Policies and procedures were in place however we are not assured all of these reflected current practice as they were not always reviewed and updated as planned.

However:

  • The trust were monitoring and taking actions regarding staffing levels including rolling recruitment, including overseas and regular monitoring of staffing levels during the day to help mitigate the risk.
  • Wards were visible clean and staff followed good hand hygiene practices.
  • All staff were aware of the trusts values and vision.
  • Staff were proud of the work they did and well supported by their managers and worked collaboratively together to ensure patient were cared for.
  • Staff treated patients and their relatives with respect and dignity and communicated with them effectively. Patients we spoke to were happy with their care, felt informed, and were involved in care planning.

Urgent and emergency services (A&E)

Requires improvement

Updated 21 April 2017

In our previous inspection in July 2014 report, we gave Urgent and Emergency Services an overall rating of ‘Good’. Following this inspection, we have changed this rating to ‘Requires Improvement’. This was because:

  • The entrance and exit from the paediatric waiting area opened automatically onto a thoroughfare for vehicles, allowing children to exit potentially unnoticed.
  • Although medicines and controlled drugs were stored correctly in the emergency department (ED), we found intravenous fluids were not stored securely in the emergency medical decision unit (EMDU). We also found temperature ranges for fridges storing medicines at low temperature were not always checked in the EMDU and where they were found to be out of range action to address the issue was not taken.
  • Compliance with staff training was low with only 42% of doctors and nurses compliant overall.
  • Not all medical staff were aware of the need to obtain senior clinical review prior to discharging certain high risk patients such as those suffering chest pain.
  • Whilst local guidance was in place and accessible, we found that review and update processes were not robust and some guidance appeared to be several years out of date.
  • Although the department took part in national audit programmes, we saw little evidence of action to address poor results. Instead staff relied on incidents of poor practice to help them identify required action.
  • We noticed that patients brought to the department by ambulance sometimes had to wait in a corridor which impacted on their privacy and dignity. Staff tried to minimise the impact by creating as much space as possible between these patients.
  • Despite making attempts to manage the flow of patients through the department, targets for providing care and treatment in a timely way were consistently not being met.
  • Although leaflets were available which provided information for people following discharge from the ED, none of these were displayed in languages other than English. When we asked staff about this they were unsure how to obtain leaflets in other languages.
  • Although risk registers were in place, these did not include enough information and were not specific to the ED. Some risks such as issues with meeting national targets were not included.
  • Closed circuit television (CCTV) was in use but we saw no evidence of signage to warn people about this.
  • Governance was in place in the department but this was not robust. For example, data was collected centrally but not broken down specifically to departmental level. This left us concerned that staff were unaware of basic governance matters such as overall cleanliness or record quality.

However:

  • There was an open, no-blame culture.
  • Staffing was adequate for both medical and nursing staff.
  • Areas were visibly clean and tidy with cleaning staff available 24 hours a day to ensure areas were cleaned, decontaminated and available for use as soon as possible.
  • Despite our findings in relation to the requirement for senior clinical review for some patients, other risks to patients were managed through triage, rapid assessment, escalation of deterioration and post discharge reviews.
  • Safeguarding was managed centrally; with useful flow charts and support from lead nurses should staff have any queries.
  • Guidelines were based on national guidance, pain was monitored and pain relief was available if required.
  • A range of food and refreshments were available for patients and loved ones visiting the department.
  • Staff competencies were maintained using information sharing and teaching. Revalidation was monitored regularly.
  • ED staff worked with a range of staff from different teams both within the hospital and externally to ensure a multi-disciplinary approach to care. Services were available throughout the week and staff had access to all the information they required to provide care for patents.
  • Staff were aware of the need for consent and assessment of patients lacking capacity. They documented capacity assessments and made decisions based on patient best interests for those unable to provide consent.
  • Patients told us the care they received was ‘great’ and that staff were ‘lovely’.
  • Patients completed surveys which showed 73% would recommend the service to friends and family members. In another survey 100% of 31 people surveyed said they were happy with the care provided.
  • In the CQC Accident and Emergency Survey 2014, patients said they were given enough time to discuss their problems with staff, had confidence in staff, felt they could summon staff if needed and felt involved in their own care. They also felt staff gave them enough privacy and dignity.
  • We saw staff caring for patients in a kind and empathetic manner, providing blankets to ensure they were comfortable.
  • Staff were familiar with the needs of local people. Telephone translation and web based video sign language translation were available for patients whose first language was not English or who had hearing problems, a wide range of chaplaincy services were available and services for patients living with dementia were also provided.
  • Complaints were managed through an established process with changes made to improve services where possible and information circulated to staff.
  • The culture was positive, and we saw that staff at all levels formed a cohesive team built on peer support and dedication.
  • Leaders engaged with staff at all levels and helped during busy periods.

  

Surgery

Requires improvement

Updated 21 April 2017

The surgical services were previously rated as requires improvement for safe, responsive and well-led in November 2014 following our last inspection. This was because we had concerns around staffing levels, mandatory training compliance and poor compliance against 18 week referral to treatment standards. At this inspection we rated the surgical services at the Royal Preston Hospital an overall rating of Requires improvement. This was because: -

  • During this inspection, we found that although some improvements had been made, there were still areas where further improvement was needed.
  • Most staff had completed mandatory training. However, less than 50% of staff had completed adult safeguarding training and the proportion of staff that had completed adult and paediatric life support training was below the hospitals expected levels.
  • Most staff had completed their annual appraisals (71%), but the hospitals internal target for 82% appraisal completion had not been achieved.
  • Most clinical areas were clean and well maintained. However, we found some theatre areas were aged and displayed signs of wear and tear.There was no scheduled refurbishment programme in place to upgrade or refurbish the theatre areas in the near future.
  • The national early warning score system (NEWS) audit from May 2016 showed a patient monitoring plan was completed and followed on 46% of occasions and patients were appropriately escalated on 48% of occasions. This meant there was a potential risk that deteriorating patients may not receive timely care and support.
  • The surgical wards did not have sufficient numbers of substantive trained nursing and support staff. Staffing levels were maintained through the use of bank and agency staff and through the daily management and deployment of the existing staff.
  • A recruitment programme was underway and a number of nursing and healthcare assistant posts had been appointed. However, the majority of nursing recruits were newly qualified staff and were scheduled to commence employment between January 2017 and March 2017.
  • The services performed worse than the England average for 18 week referral to treatment (RTT) waiting times between August 2015 and June 2016 for most surgical specialties. There was a worsening trend in performance which meant the number of patients waiting longer than 18 weeks for treatment had steadily increased since the start of 2016.
  • As part of the surgical division RTT recovery plan, a review identified seven specialty areas with an imbalance in capacity and demand that would lead to increasing waiting lists. The recovery plan included actions to improve 18 week wait times and to improve patient flow and efficiency in the wards and theatres by March 2017.
  • The proportion of elective patients whose operations were cancelled and were not treated within the 28 days across the trust was significantly worse that the England average between July 2014 and June 2016. 
  • Performance shortfalls were reported on monthly performance dashboards and routinely reviewed at departmental and divisional meetings. However, the services had failed to implement timely and effective remedial actions to address these issues in order to improve the services.
  • A new divisional structure had been in place since December 2015 and most staff felt this was a significant improvement from the previous organisational structure. However, the governance and performance reporting systems were still being imbedded as a result of personnel changes and new reporting structures.

However, we also found that: -

  • Patient safety was monitored and incidents were investigated to assist learning and improve care. Medicines were stored safely and given to patients in a timely manner. Patient records were completed appropriately.
  • Patients spoke positively about the care and treatment they received. Patient feedback from the NHS Friends and Family Test showed that most patients were positive about recommending the surgical wards to friends and family.
  • The services participated in national and local clinical audits and performed in line with similar sized hospitals and performed within the England average for most safety and clinical performance measures.
  • There was effective teamwork and visible local leadership within the services. Staff were positive about the culture within the surgical services and there was routine public and staff engagement.

Intensive/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.

Services for children & young people

Requires improvement

Updated 21 April 2017

At the last inspection in July 2014 the service was rated as Good overall. At this inspection we rated this service as requires improvement overall because:

  • Nurse staffing levels on the children’s ward did not reflect Royal College of Nursing (RCN) standards (August 2013) and the ward was short staffed on a regular basis, however staff numbers were reported to senior managers on a daily basis.
  • Nurse staffing levels on the neonatal unit did not meet standards recommended by the British Association of Perinatal Medicine (BAPM), with managers advising that they were 80% compliant with these.
  • Paediatric early warning scores were not actioned consistently and we saw some evidence that actions were not recorded when a patient’s score changed from amber to red.
  • There were insufficient staff available to provide one to one nursing supervision for patients admitted for Child and Adolescent Mental Health Services. Staff reported frequent additional demands in providing for the care needs of these and other patients whose needs were highly complex.
  • Staff working with children in various roles, including nursing staff, reported they had completed level two safeguarding training only, which was below nationally recommended levels for this training. In addition, the trust’s training records were inconsistent with ward training records in order to accurately confirm this.
  • We saw evidence that checks on emergency resuscitation equipment were not consistently documented on the neonatal unit, with checks on the emergency transfer incubators and special care emergency box incomplete
  • Records in the children’s outpatient department were left unsecured in an administrative area overnight, where there was potential for public access when the department was unsupervised after clinic hours.
  • Appraisal rates for nursing staff did not meet the trust target on the children’s ward and some nurses said they had not fully completed their preceptorship supervision.
  • The children’s community nursing service only provided cover during weekdays, meaning that some children requiring continued treatment after their discharge needed to come back to the ward at weekends.
  • Physiotherapy services for the children’s areas did not use competency tools and general physiotherapy staff who supported the on call service lacked confidence in paediatric techniques.

However:

  • Risks were identified and managed through a risk register, with systems in place to share learning with staff from incidents that had occurred.
  • There were sufficient numbers of staff available on every shift who had completed advanced paediatric life support training for the children’s ward and 98% of staff on the neonatal unit had completed newborn life support training.
  • A paediatric staffing review paper had identified the shortage of nursing staffing on the children’s ward and recruitment had already started, based on these recommendations. A recruitment programme for the neonatal unit had previously been implemented during 2015, towards meeting national standards for staffing.
  • Medicines were stored safely in all ward and department areas, with staff following clear protocols for recording and administering medications.
  • Ward areas on children’s and neonatal unit, also the children’s outpatient department, were visibly clean and orderly, with staff working in accordance with infection control procedures.
  • A number of care pathways were in place which followed national guidance from the National Institute for Health and Care Excellence (NICE) and the Royal College of Child Health and Paediatrics (RCPCH). Specific development had been undertaken which supported young people with diabetes and epilepsy during their transition from children’s to adult services
  • A targeted development in response to outcomes from the National Neonatal Audit Programme had resulted in improved breastfeeding rates.
  • We saw many examples of multidisciplinary team working and communications in place with providers of services external to the trust.
  • Complaints were at a low level and were mostly about waiting times
  • Staff worked hard to deliver the best care they were able to, despite frequent staff shortages. There was a positive culture of staff supporting each other and covering extra shifts to provide nursing care and ensure rotas were filled.
  • Staff reported that new leadership had brought some changes and felt more assured that the day to day challenges in paediatrics and neonatal services were now being acknowledged ‘from the top’.

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.

Outpatients

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.