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Royal Preston Hospital Requires improvement

Reports


Inspection carried out on 02 July to 08 August 2019

During a routine inspection

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 carried out on 4, 5 and 28 December 2018

During a routine inspection

We carried out this announced inspection on 4, 5 and 28 December 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was carried out by two CQC inspectors and a team leader who were supported by a specialist professional advisor.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Our findings were:

Are services safe?

We found that this service was providing safe services in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

Background

In Lancashire, services for support and examination of people who have experienced sexual assault are commissioned by NHS England and Lancashire Constabulary. The SAFE Centre provides these services. The centre is based at the Royal Preston Hospital, Preston and provides services to adults and children from all over Lancashire.

The centre is a separate building within the hospital grounds and car parking is available outside the centre with level access for people who use wheelchairs and those with pushchairs. Most appointments are pre-booked at times to meet the needs of each patient. The entrance door is secure to safeguard staff and patients and a clear record is kept of all visitors to the centre.

The team consists a mix of permanent full-time staff and bank staff to provide a service day and night. Permanent staff include a centre manager and receptionist, one adult and one child independent sexual violence advisor and a part time clinical director. A new child and young person support worker commenced in post the week of our inspection. Doctors and crisis workers work an on-call rota, to cover daytime, nights and weekends. The service has two medical suites.

The service is provided by Lancashire Teaching Hospitals NHS Foundation Trust (LTH). The centre is included as part of the main services registered at the Royal Preston Hospital. The service is open from 8.30am until 4.30pm, with on call staff available outside of these hours.

During inspection we spoke with the centre manager, director, trust managers for governance and human resources, two independent sexual violence advisors, a crisis worker, the receptionist, and a doctor.

We looked at policies and procedures and other records about how the service is managed. We sampled 15 patients' records.

Our key findings were:

  • The clinical staff provided patient care and treatment which was in line with current guidelines.
  • Staff treated patients with dignity and respect.
  • Not all risks to patients had been identified but managers were developing systems to help identify and manage risk.
  • The service appeared clean and well maintained.
  • Staff knew how to deal with emergencies. Appropriate medicines and emergency equipment were available.
  • The appointment/referral system met patients’ needs.
  • The service had effective leadership and culture of continuous improvement.
  • Staff felt involved and supported and worked well as a team.
  • The service asked staff and patients for feedback.

We identified an area of good practice. The manager and clinical director had agreed that all bank staff would be treated as permanent staff for the purposes of training, appraisal and supervision due to the nature of the work they carried out at the centre. In addition, the centre had developed an accredited two-day sexual assault referral centre training course for staff. This ensured staff were appropriately trained and supported in providing the best possible patient care for patients attending the centre and their families.

There are also areas where the provider SHOULD make improvements. They should:

  • Ensure that governance arrangements are fully embedded into the service including risk assessment, incident reporting and learning, record keeping and audit procedures.

  • Ensure referral arrangements to and from partner health services are formalised.

Inspection carried out on 12 June to 19 July 2018

During a routine inspection

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 carried out on 9, 10, 11 July 2014

During a routine inspection

Royal Preston Hospital is one of two hospitals providing care as part of Lancashire Teaching Hospitals NHS Foundation Trust. It provides a full range of hospital services, including emergency department, critical care, coronary care, general medicine including elderly care, general surgery, orthopaedics, anaesthetics, stroke rehabilitation, paediatrics and midwifery-led maternity care.

Lancashire Teaching Hospitals NHS Foundation Trust as a whole provides services to 390,000 people in Preston and Chorley, and specialist care to 1.5 million people across Lancashire and South Cumbria.

We carried out this inspection as part of our comprehensive inspection programme.

We undertook an announced inspection of the hospital between 9 and 11 July 2014, and an unannounced inspection between 6pm and 8pm on 21 July 2014 at Royal Preston Hospital only. We looked at the management of medical admissions out of hours.

Our key findings were:

Access and flow

  • The hospital had a high number of medical emergency admissions that was resulting in high numbers of medical outliers (patients placed in areas not best suited to their needs). There were times when there were more than 35 patient outliers.
  • Patients sometimes remained in the Emergency Department overnight.
  • There were also occasions when patients were moved from ward to ward many times, sometimes at night.
  • The number of medical outliers placed in surgical beds led to unused theatre capacity.
  • Issues with bed capacity were also made worse by the number of delayed discharges.
  • The management of patient access and flow across the hospital was of immediate concern and remained a significant challenge for managers. The hospital had made arrangements to ensure timely medical review of patients placed in a clinical setting that did not best suit their needs. However, the number of moves across wards and being placed in less appropriate clinical settings was far from ideal and was having a negative effect on patient experience.

Mortality rates

  • Mortality rates were within expected limits.

Never events

  • There had been five reported potential surgical never events during the period April 2013 to April 2014. However, three had been declassified, and the trust had taken appropriate steps to reduce the risk of further occurrences.

Infection control

  • The hospital was clean throughout. Staff adhered to good practice guidance in the prevention and control of infection. There was a good rate of compliance with hygiene audits.

Food and hydration

  • Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs were supported by dieticians and the speech and language therapy team.
  • There was a period over mealtimes when all activities on the wards stopped, if it was safe for them to do so. This meant that staff were available to help serve food and assist those patients who needed help. We also saw that a coloured tray system was in place to highlight the patients who needed assistance with eating and drinking.

Medicines management

  • Medicines were provided, stored and administered in a safe and timely way. Some concerns were raised regarding the completeness of prescription charts in outpatients and the timely provision of medicines for patients to take home.

Nurse staffing

  • Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services. However, nurse staffing levels, although improved, remained of concern. The trust was actively recruiting nursing staff using innovative methods of recruitment. These included a number of efforts to improve recruitment and retention through wider access schemes with local universities and dedicated ring-fenced funding to support this. They had also linked into international universities to support this recruitment. However, we found that required staffing levels were not consistently achieved in all core services at the time of the inspection.

Medical staffing

  • Medical treatment was delivered by committed medical staff, however:
  • Medical staffing was not sufficient to provide appropriate and timely treatment and review of patients at all times within the medical division and to maintain timely clinics in outpatients to meet targets. Many of the middle grade vacancies were due to national shortages of trainees and the full allocation not being sent from the regional training schools. It was noted that the North West had historical difficulty in recruiting and retaining doctors and there had been a number of efforts to improve recruitment and retention through wider access schemes with local universities and dedicated ring-fenced funding to support this.
  • Medical staffing was not always appropriate at the location, including medical trainees, long-term locums, middle-grade doctors and consultants.

We saw several areas of good practice, including:

  • Data from the College of Emergency Medicine (CEM) consultant sign-off audit showed that 100% of patients at Preston Emergency Department were seen by an emergency department doctor, compared with a national average of 92%. Also 25% of patients were seen by a consultant, which is well above the national average of 13% in 2012/13.
  • Ultrasound-guided blocks for patients with neck of femur injuries in the Emergency Department.
  • Children’s safeguarding review meeting in the Emergency Department.
  • Chaplaincy service engagement with patients in the Emergency Department.
  • Consistently rapid handover times for patients arriving by ambulance to the Emergency Department.
  • Responsive and flexible training using ‘simulation man’ to deliver trauma training within the Emergency Department at quiet times.
  • The trust was committed to becoming a dementia-friendly environment. An older people’s programme was developing this work and we saw several excellent examples of how this was being put into practice during our inspection. The proactive elderly care team helped staff to identify and assess the needs of older people. The team worked proactively with intermediate care services to ensure the safe discharge of older people and people living with dementia. Activity boxes had been introduced throughout the division to promote and maintain cognitive and physical function and help reduce the unwanted effects of being in a hospital environment.
  • The trust had won the Clinical Innovation category at the North West Excellence in Supply Awards for developing a disposable female urinal.
  • The alcohol liaison service had been nominated for a national Nursing Standards award. Staff spoke highly of the service and the positive contributions they had made in supporting patients with alcohol-related conditions.
  • Our specialist adviser assessed that speech and language therapy input for neonatal babies was likely to improve the long-term outcomes for these children and considered this to be outstanding practice.
  • The end of life team coordinated rapid response for discharge to the preferred place of care. Staff told us there was a multidisciplinary approach to discharge planning, which involved the hospital and the community staff working towards a rapid but safe discharge for patients.

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

Importantly, the trust must:

Staffing

  • Ensure that there are enough suitably qualified, skilled and experienced nurses to meet the needs of medical patients at all times.
  • Ensure that there are enough suitably qualified, skilled and experienced midwives to meet the needs of patients at all times.
  • Ensure that medical staffing is sufficient to provide appropriate and timely treatment and review of patients at all times within the medical division and outpatients.
  • Ensure that medical staffing is appropriate at the location, including medical trainees, long-term locums, middle-grade doctors and consultants.

Supporting staff

  • Ensure that relevant staff receive advanced paediatric life support and moving and handling training.
  • Take steps to enable the trust to confirm the status of mandatory training that staff have completed in the child health directorate, so that staff have received information about the actions required to maintain and promote safety.
  • Improve patient flow throughout the hospital to reduce the number of bed moves and length of stay – particularly in the medical division.
  • Prevent the cancellation of outpatients clinics at short notice and ensure that clinics run to time, particularly within ophthalmology outpatients.

In addition the trust should:

In the Emergency Department:

  • Improve mechanisms to achieve and maintain performance to meet the four-hour target set by the government for emergency departments.
  • Address the reasons why patients wait for up to nine hours in the department before being admitted to an inpatient area.

  • Address the appropriateness of the environment for the children’s treatment area in the Emergency Department with regard to visual or audible separation.

  • Address the appropriateness of the environment for the delivery of modern emergency medicine.
  • Review how the constraints of the environment would negatively affect plans to increase services within the department.
  • Review privacy and dignity for patients being handed over by ambulance crews in the corridor area.
  • Address the effectiveness of how services for acute gastrointestinal bleeds are provided out of hours.
  • Review mechanisms for supporting and recording clinical supervision within the Emergency Department.

In the medical division

  • Improve the management of people with diabetes and stroke in line with national guidance.
  • Improve the consistency of access to emergency upper gastrointestinal endoscopy and interventional radiology.

In the

surgical division

  • Consider reviewing the overnight provision for ophthalmology patients who require unplanned overnight stays.
  • Consider reviewing unused theatre capacity within the surgical division.
  • Ensure that checklists for daily cleaning jobs within the surgical division are completed and current.

In critical care

  • Ensure that the use of critical care beds is factored into any trust-wide discussions and solutions for improving patient access and flow. This should include continuing to monitor and report on delayed discharges, cancelled elective procedures and the use of theatre recovery at times of peak demand.
  • The trust is not currently providing a critical care outreach service 24/7. In the absence of this 24/7 service, the trust should ensure that all staff employed within the hospital at night team are suitably qualified and competent to cover the critical care support role.
  • Consider the impact of not having a weekend pharmacy service in the intensive care unit (ICU). Appropriate care of critically ill patients requires frequent review and re-assessment of therapies, including medication.

In maternity services

  • Continue to review patient flow with regard to managing induction of labour and transfer of mothers to the delivery suite.

In children’s services

  • Ensure that all incidents are described in a consistent manner so that details and the action taken can always be easily reviewed.
  • Ensure that the information in the audits is accurate so that the trust can be confident that appropriate steps are taken to promote safety.
  • Consider the security and safety of how expressed milk is stored, as the kitchen and fridge were accessible to anyone on the unit.
  • Be able to provide a comprehensive training record for each member of staff.
  • Review the décor and furnishings in the children’s day surgery waiting room and pre-operative area.
  • Ensure that the Child Health directorate completes a comprehensive audit of the Day Case Unit that includes feedback from all stakeholders to ensure plans incorporate all aspects of the services strengths and weaknesses.
  • Ensure that all opportunities are used to alert staff about the risks identified in relation to safety.
  • Ensure that staff always report all incidents that are concerned with child safety.
  • Ensure that information provided about the safety of children’s services is accurate and consistent.
  • Take more robust action to prevent parents from taking children to Chorley and South Ribble Hospital Accident and Emergency (A&E) department, as there are no children’s A&E services at that site.

Regarding end of life care

  • Review the processes in place for the return of syringe drivers from the community to ensure availability.
  • Ensure that audits are carried out on pain management and pain relief for end of life care.

In outpatients

  • Ensure that the trust receives feedback from patients within the outpatients departments to monitor and measure quality and identify areas for improvement.
  • Ensure that appropriate checks are in place to provide assurance that medicines prescriptions are correctly completed.
  • Ensure that members of staff have the opportunity to discuss any issues or concerns they may have on a regular basis within clinical supervision.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 14, 15, 18 November 2013

During a routine inspection

This was an unannounced inspection carried out over several days. During the inspection we visited a variety of areas including the hospital�s accident and emergency (A&E) department, the medical assessment unit (MAU), rapid assessment unit (RAU) and a number of medical wards.

We spoke to 31 people who were either using the service at the time of our inspection or had recent experience of it. We also spoke with over 40 staff members who included domestic assistants, nurses, health care assistants, doctors and senior managers.

The vast majority of discussions we held were very positive. Most people who were using or who had recently used the service, expressed satisfaction with their care and treatment. However, we did receive a small number of negative comments. The things people told us included:

��I have had absolutely first class care. They have all been brilliant!��

��The staff have been very kind and caring.��

��I cannot thank them enough. They have been wonderful.��

��The doctors have been fine and the nurses have been very friendly.��

��The bay in A & E wasn�t very private, people can hear everything!��

��They need to improve the way they communicate with patients!��

��I felt forgotten about while I was waiting but when I did see the consultant he was brilliant.��

During the inspection we looked at the care people received and how their welfare was promoted. We found that the vast majority of patients received safe and effective care that met their needs. However, we also found people�s experiences were variable in relation to having a lot of ward moves or not being on the correct ward to meet their needs.

We inspected the area of cleanliness and infection control and found the Trust had good arrangements in place to help ensure that people were cared for in a clean, hygienic environment and were protected from the risk of infection.

We assessed staffing levels. We found there were safe staffing levels in most areas and that the Trust had implemented a number of positive measures to maintain safe staffing levels. However, we did find that not all areas of the service used procedures for responding to unexpected, short notice requirements effectively.

Arrangements for the monitoring of quality and safety were assessed. We saw there were good processes in place that enabled managers to monitor standards, identify risk and respond appropriately to adverse incidents.

We looked at how the Trust enabled people to raise concerns and their processes for responding. We found this area was in need of improvement.

Inspection carried out on 14 February 2013

During an inspection looking at part of the service

We spoke with four patients about their medicines. Everyone we spoke with was positive about their stay. One patient we spoke with about medication handling told us, �they�re really, really good, they explained how everything worked�. Documents for assessing and supporting patients to self-administer medication were available and in use. Patients choosing to do so were; where possible, supported to look after their own medicines. Patients told us that they had enough information about the medicines they were taking and about any changes to their medicines.

Inspection carried out on 15, 16 October 2012

During a routine inspection

During this inspection we looked specifically at the maternity services provided at the hospital. The hospital provides a full range of maternity services including a 52 bed ward and 12 labour rooms.

We spoke with 12 patients who were receiving care and 18 staff members including midwives, health care assistants and managers.

We received very positive feedback from the majority of patients we spoke with. Patients told us that they were happy with the care they had received and the way they had been treated.

Comments included;

��We are very pleased with everything. The staff have been brilliant.�'

��They seem very competent and professional, but they are nice with it.��

��I was really pleased with the way they looked after me in labour. They were lovely.��

��I have no complaints. I�ve found everything really good.��

We looked at six areas during the inspection including the ways in which patients were enabled to make decisions about their care, the quality of care provided and the way in which patients' medicines were managed. Other areas included arrangements for the safeguarding of patients from abuse and staff training. We also looked at how the Trust monitored the safety and quality of the service.

The Trust were able to provide evidence of compliance with the majority of areas we inspected. However, some concerns were identified in relation to the management of medication. We have asked the Trust to take action to address this.

Inspection carried out on 20 March 2011 and 20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

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

Inspection carried out on 24 January 2012

During an inspection looking at part of the service

During our visit we were able to speak with a number of patients and in some cases, their relatives. People that we spoke with were very complimentary about the care and treatment they had received at the hospital and spoke highly of staff providing their care.

Comments from patients included;

��We have such a laugh with them (the staff), it passes the time away.��

��So far, everyone I have had looking after me has been great.��

��They can�t do enough for you � whatever you ask for they will try to sort out.��

One patient commented, ��They are so very kind and attentive. I will be sad to be going home.��

Visiting relatives also expressed satisfaction with the care their loved ones were receiving and told us that they had felt fully involved at all times. One relative said, ��You can tell they really care about the patients here. They always seem to have time for people.��

Other relatives� comments included;

��The staff here are so good. I come in every day and see everything going on and I can tell you this is a good place.��

��They are great and they make you feel so comfortable.��

No person that we spoke with during our visit expressed concerns about any aspect of the care they or their loved one had received. People told us that staff took time to understand their individual needs and that their requests for assistance were always answered promptly.

Inspection carried out on 29 March 2011

During a themed inspection looking at Dignity and Nutrition

The majority of people we spoke with were very complimentary about the care they were receiving and spoke highly of staff. Comments included;

��I feel lucky to be here, they are absolutely brilliant with me.��

��I felt scared when I came but they soon put my mind at rest.��

��We are treated very well, if the younger generation are treated as well as us then this is a very good place.��

Most people felt that their care needs were met well and that they were cared for in a way that they wanted.

People told us that they felt their dignity and privacy was respected and everyone we spoke with told us that they had never been made to feel embarrassed during their stay.

Whilst people were generally very positive about their care, some did express concerns. Some people commented that, at times, they had to wait a long time to get assistance and generally felt that this was due to staffing levels sometimes being low.

We received generally positive feedback about the quality and variety of meals available. People told us that they thought there was a good choice of food made available. However, several people told us that they didn�t always get the meals they had ordered.

People said that they were confident that staff understood their nutritional needs. One patient told us that she had been very underweight on her admission but had managed to achieve a steady weight gain throughout her stay.

Inspection carried out on 22 June 2010

During an inspection looking at part of the service

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.