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Royal Preston Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 November 2019

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

  • The hospital did not always have enough substantive staff with the right qualifications, skills, training and experience to meet national staffing standards and provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and were recruiting to vacancies at the time of our inspection.
  • Staff did not always support patients to make informed decisions about their care and treatment. Patients who lacked capacity were not always supported to make decisions around there care and treatment. In medical care we saw that where mental capacity assessments had been completed, the use of physical restrictions or restraint was indicated without rationale.
  • Patients could not always access services when they needed it. Patients waiting for emergency treatment had to wait longer than national standards and patients waiting for planned care had to wait longer than the England average. In surgery, there were regular theatre overruns and cancelled operations were above the England average.
  • In critical care, the design, maintenance and use of facilities and premises did not enable staff to always keep people safe. Not all of the doors from the unit were secure. Staff did not always use equipment and control measures to protect patients, themselves and others from infection. The trust was building new facilities at the time of the inspection.
  • In urgent and emergency care, patients at risk of deterioration within the waiting area were not always identified or acted.

  • In medical care, records were not always stored securely and patients’ consent was not always gained for bedside storage.
  • In surgery, risk assessments for blood clots, and for patients at risk of self-harm were not always completed. We found medicines management systems processes were not always being used effectively.
  • In medical care, the service had not improved in all of the areas we identified in the last inspection and did not always share good practice. Risk management processes could be improved within medical better identify and mitigate risks.
  • Services across the hospital had not always worked together to improve patient flow out of the emergency department at Royal Preston Hospital.

However,

  • Staff generally had training in key skills, understood how to protect patients from abuse, and managed safety well. In most areas the hospital controlled infection risk well. Staff in most areas assessed risks to patients, acted on them and kept good care records. They generally managed medicines well. The hospital managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and generally gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The hospital planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The hospital engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.
Inspection areas

Safe

Requires improvement

Updated 7 November 2019

Effective

Requires improvement

Updated 7 November 2019

Caring

Good

Updated 7 November 2019

Responsive

Requires improvement

Updated 7 November 2019

Well-led

Good

Updated 7 November 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 7 November 2019

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

  • The service did not always have enough registered nurse and medical staff to meet the needs of patients. Since our last inspection, the service had increased staffing levels but was working to recruit to these vacancies at the time of our inspection. This meant that a significant number of shifts were filled by bank and agency staff. The service also employed more healthcare assistants than planned to meet patient’s needs.
  • Staff lacked understanding of their role in the application of the Mental Capacity Act (2005) and the completion of mental capacity assessments was inconsistent. This was identified at our previous inspection. We found examples where mental capacity assessments had been completed inconsistently and, in some instances, a mental capacity assessment had not been completed when staff had identified patients as lacking capacity to make decisions about their care and treatment.
  • We were not assured that patients were protected from the inappropriate use of restraint or physical restrictions. We found examples where all reasonable steps had not been taken to mitigate the risk of patient aggression before physical restraint was considered. Staff did not undertake a regular review where physical restrictions had been deemed necessary to ensure that this was still a proportionate response.
  • People could not always access the service when they needed it. There were not enough medical beds to meet demand and so patients were placed where there was a bed available. This meant that medical patients were often placed on surgical wards and wards of other specialties. The referral to treatment times for admitted pathways was consistently below the England average.
  • 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. This was identified at our previous inspection.
  • Senior managers had been slow to implement improvement plans and make significant changes to service provision. Managers told us this was due to a lack of stability in the senior leadership team for the service.
  • Some issues which had been identified during our last inspection had not been resolved.

However;

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

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.

Critical care

Good

Updated 7 November 2019

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

  • The service had enough registered nurse and medical staff to meet the needs of patients. The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse. Staff completed and updated risk assessments for each patient and took action to remove or minimise risks. They managed medicines well. The service managed safety incidents well and learned lessons from them. Records were clear, up-to-date, easily available to all staff providing care and stored securely.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. staff made reasonable adjustments to help patients access services. The service admitted, treated and discharges patients in line with national standards. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
  • The service had managers at all levels with the right skills and abilities. Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The service collected, analysed, managed and used information well to support all it’s activities, using secure electronic systems with security safeguards. The service engaged well with staff and local organisation to plan and manage appropriate services. The service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

However:

  • The design, maintenance and use of facilities and premises did not enable staff to always keep people safe. The design of the environment was not in line with national guidance and the flooring was in a poor condition. Not all of the doors from the unit were secure.
  • Staff did not always use personal protective equipment, such as aprons and gloves when disposing of waste.
  • The service did not have enough allied health professionals with the right qualifications, skills, training and experience to provide the right care and treatment.
  • Not all staff were aware of the vision or strategy for the unit.

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.

Surgery

Good

Updated 7 November 2019

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

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff kept good care records. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients, and advised them on how to lead healthier lives. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • People generally could access the service when they needed it. The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However,

  • Staff did not always assess all patient risks. The service did not have enough substantive staff. The service did not use systems and processes to safely prescribe, administer, record and store medicines.
  • Staff did not always understand how and when to assess whether a patient had the capacity to make decisions about their care.
  • There were regular theatre overruns and several surgical wards had medical outliers. Cancelled operations were above the England average, which was the same at the last inspection.
  • Leaders did not always operate effective governance processes. Not all risks we saw on the inspection had been identified and acted on.

Urgent and emergency services

Requires improvement

Updated 7 November 2019

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

  • The service did not have enough staff to care for patients and keep them safe.
  • People could not access the service when they needed it and had to wait too long for treatment
  • Pain relief was not always administered in a timely way.

However,

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

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.