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The Princess Royal Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 August 2017

Shrewsbury and Telford Hospital NHS Trust is the main provider of district general hospital services for nearly half a million people in Shropshire, Telford & Wrekin and mid Wales; 90% of the area covered by the trust is rural. There are two main locations, Royal Shrewsbury Hospital in Shrewsbury and Princess Royal Hospital in Telford. The trust also provides a number of services at Ludlow, Bridgnorth and Oswestry Community Hospitals.

The Princess Royal Hospital in Telford was built in the late 1980s. It merged with the Royal Shrewsbury Hospital in 2003, when the Shrewsbury and Telford Hospital NHS Trust was formed. The Princess Royal Hospital provides a wide range of acute hospital services, including accident and emergency, outpatients, diagnostics, inpatient medical care and critical care. The hospital is also the main centre for hyper-acute/acute stroke services, inpatient head and neck surgery, and inpatient women's and children’s services.

This was a focused inspection, following up our inspection that took place in October 2014. At that time the hospital was rated as requires improvement overall, with caring as good.

We rated Princess Royal Hospital as requires improvement overall.

  • The trust was not achieving the Department of Health’s target to admit, transfer or discharge 95% of patients within four hours of their arrival in ED.

  • The trust’s referral to treatment time (RTT) for admitted pathways for surgery have been lower than the England overall performance since September 2015.

  • Insufficient numbers of consultants and middle grade doctors were available.

  • Nursing staff vacancies were impacting on continuity of care and an acuity tool was not used to assess staffing requirements.

  • Compliance with the trust target for completion of staff appraisals was below the trust target.

  • Current safety thermometer information was not displayed on the wards.

  • The maternity specific safety thermometer was not being used to measure compliance with safe quality care.

  • Mortuary staff decontaminated surgical instruments manually; this exposed staff to unnecessary risk and did not provide a high level of disinfection.

  • Mental capacity documentation had not been completed for defined ceiling of treatment decisions when a person had been deemed as lacking capacity.

  • Service-wide sharing of learning from serious incidents was not evident, not all staff could give examples or learning from incidents and there was limited learning across the maternity service. Communication of incident learning was not consistently service wide or fed down to all staff.

  • The maternity service was in a transition period of change and although new senior leaders had begun to make positive changes, we had concerns as to whether this service had an embedded safety and learning culture. Governance processes were under review at the time of our inspection.

However, we also saw that:

  • Openness and transparency about safety was encouraged. Incident reporting was embedded among all staff, and feedback was given. Staff were aware of their role in Duty of Candour.

  • In every interaction we saw between nurses, doctors and patients, the patients were treated with dignity and respect. Staff were highly motivated and passionate about the care they delivered.

  • There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse.

  • Treatment was planned and delivered in line with national guidelines and best practice recommendations.

  • Local and national audits of clinical outcomes were undertaken and quality improvements projects were implemented in order

  • It was easy for people to complain or raise a concern and they were treated compassionately when they did so.

  • There was a clear statement of vision and values, driven by quality and safety. Leaders at every level prioritised safe, high quality, compassionate care.

  • The trust had made end of life care one of its priorities in 2015/2016.

We saw several areas of outstanding practice including:

  • The palliative care team had developed a fast track checklist to provide guidance to ward staff on what to consider when discharging an end of life care patient.

  • Staff told us that if the bereavement office arranged a viewing in the mortuary they would walk the relatives to the mortuary. If the mortuary department arranged the viewing, they would meet relatives at the main entrance and walk them to the mortuary department.

Importantly, the trust must:

  • The trust must ensure ED meets the Department of Health’s target of discharging, admitting or transferring 95% of its patients with four hours of their arrival in the department.

  • The emergency department did not have a compliant mental health seclusion room as described in the Mental Health Act 2007 (MHA).

  • The trust must ensure that it meets the referral to treatment time (RTT) for admitted pathways for surgery.

  • The trust must ensure there are sufficient nursing staff on duty to provide safe care for patients. A patient acuity tool should be used to assess the staffing numbers required for the dependency of the patients.

  • Stroke patients did not always receive timely CT scans due to availability and reliability of diagnostic imaging equipment.

  • The trust must review its medical staffing to ensure sufficient cover is provided to keep patients safe at all times.

  • The trust must ensure that all staff have an understanding of how to assess mental capacity under the Mental Capacity Act 2005 and that assessments are completed, when required.

In addition the trust should:

  • The trust should ensure that up to date safety thermometer information is displayed on all wards

  • The trust should ensure they are preventing, detecting and controlling the spread of infections, associated in the mortuary department by ensuring surgical instruments are decontaminated to a high level and there are arrangements in place for regular deep cleaning.

  • The trust should ensure all staff received an annual appraisal.

  • The trust should consider using the maternity specific safety thermometer to measure compliance with safe quality care.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 16 August 2017

Effective

Requires improvement

Updated 16 August 2017

Caring

Good

Updated 16 August 2017

Responsive

Requires improvement

Updated 16 August 2017

Well-led

Requires improvement

Updated 16 August 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 16 August 2017

The maternity service was in a transition period of change and although new senior leaders had begun to make positive changes, we had concerns as to whether this service had an embedded safety and learning culture.

Communication of incident learning was not consistently service wide or fed down to all staff. Service-wide sharing of learning from serious incidents was not evident across the maternity service and not always timely. The maternity service chose not to use the maternity specific safety thermometer. Medicines management was poor in several maternity wards despite pharmacy audits raising concerns. There was poor compliance with the checking of resuscitation equipment. We observed poor handovers between both midwifery and obstetric staff; they lacked leadership, organisation and consistency.

Governance processes were under review at the time of our inspection. We saw evidence that although processes were in place, they were not fully embedded in the culture of the service.

However, we saw there was a positive incident reporting culture. Staff understood the importance of reporting and learning from incidents. Serious incident investigations had improved and involved families in the process.

Staff were kind and professional and attentive to patients’ needs. Patients felt informed and involved in their care.

Policies and procedures were based on up-to-date, evidence-based guidance. Risk registers were up-to-date, showed clear ownership and actions completed or in progress. Senior managers recognised areas for improvement and engaged with staff to drive improvement.

Medical care (including older people’s care)

Good

Updated 16 August 2017

We found that incidents were reported, analysed, and learning was shared with staff. We saw an electronic board system, which displayed patient information and allowed quick and easy access for all staff. We saw staff caring for patients in all areas that we inspected.

We saw staff using hand held electronic devices to record and monitor patient observations. This was linked to the early warning system which would alert staff if the patient results became concerning.

However, the numbers of nurses on medical wards regularly fell below the safe minimum number established requiring agency staff to be used. Ward managers told us that they relied on bank and agency to cover shifts

There was not a consistent approach to oxygen prescribing on wards, in particular ward 6. Staff knew the requirement to prescribe it but when patient notes were checked there had been no evidence of prescribing on the adult prescription and administration record.

Staff in medical services were not fully compliant with the trust’s mandatory safeguarding training target of 100%. Between September 2015 and November 2016, medical services achieved 58% in safeguarding adults at level 2 and 44% in safeguarding children at level 2.

Urgent and emergency services (A&E)

Requires improvement

Updated 16 August 2017

Poor medical staffing levels meant that consultants regularly worked in excess of their contracted hours. Nurse staffing and skill mix meant that there were not sufficient numbers of trained children’s nurses to ensure that one was on duty at all times.

The department was consistently failing to meet the 4-hour waiting time standard.

Paper records were not always completed accurately or in a timely manner. Electronic patient information boards were not used consistently by all staff. The department did not have a compliant mental health seclusion room as described in the Mental Health Act 2007 (MHA).

Service level agreements for children and adolescent mental health services with external providers meant that patients did not always receive timely interventions. Uncertainty about the future of the department, led to low morale even though managers tried to support staff with information.

Stroke patients did not always receive timely CT scans due to availability and reliability of diagnostic imaging equipment.

However, patients were treated with respect and kindness by all staff in the department. Incidents were reported, analysed, and learning was shared with staff. Compliance with mandatory training was good. Care and treatment was based on patients’ individual needs and followed recognised guidance and best practice. Multidisciplinary Team working was seen throughout the service.

Patient outcomes were largely in line with England averages, where audits identified shortfalls we saw how action plans were created to address issues and improve performance.

Local management was good, managers understood their role and how to support their staff and they felt engaged and supported.

Surgery

Requires improvement

Updated 16 August 2017

We saw and staff told us that information was not always documented appropriately therefore it was at time unclear whether risk assessments or other processes had been followed and what the outcome of these were. There was no use of an acuity tool to ensure that staffing levels met the needs of patients.

Ward staff showed a lack of understanding about their role with assessing patient’s capacity to consent. We saw that medicines and intravenous fluids were left insecurely in theatres. Some patients reported delays of up to three hours in the receipt of pain relief whilst on the wards.

The service was consistently not meeting the Referral to Treatment Time target of 90%. The 2016 Hip Fracture Audit highlighted that 61% of patients with a hip fracture received surgery on the day or day after admission. This was worse than the national standard of 85%.

Staff were unaware of the trust vision and strategy and what their role in working towards this was. Staff did not feel the executive team were visible or had an understanding of the issues facing them and did not feel involved with future plans for the service. There were no ward meetings so staff did not have the opportunity to receive full updates or information about current issues.

However, staff treated patients in a caring and compassionate manner, they felt supported by their immediate line managers and that there was a positive culture at the hospital. There were effective tools and processes in place to meet patient’s individual needs including learning disabilities and dementia. Systems were in place and staff were clear of the protocols for assessing patient risks and managing deteriorating patients and there was a positive incident reporting culture. Evidence based care was provided and care pathways were based on relevant and current guidance.

Intensive/critical care

Requires improvement

Updated 20 January 2015

Critical care services were found to require improvement overall. There were insufficient, suitably skilled and experienced staff on the unit, which represented a significant risk to patients. When we highlighted the staffing shortfalls to the trust, they took immediate action to ensure that sufficient and appropriate nursing staff were available to care for patients in the intensive care unit (ICU), high dependency unit (HDU) and the coronary care unit.

Critical care services were obtaining good quality outcomes, and patients received treatment that was based on national guidelines. The critical care service staff were caring and compassionate, and we judged that this domain was good.

The general capacity of beds in the hospital was a challenge. Bed capacity had also impacted on critical care services, both in the availability of the beds within critical care, and also in delays in discharging patients to other wards. Improvements were required to the leadership of the critical care services, to ensure that the management responded appropriately to staff, and that the service provided met national guidelines.

Services for children & young people

Good

Updated 20 January 2015

Services for children and young people were found to be good. Children received good care from dedicated, caring and well trained staff, who were skilled in working and communicating with children, young people and their families. There were processes in place for children’s safeguarding, and concerns were identified and referred to the relevant authorities.

The trust had provided good flexible staffing levels, an adequate skill mix, and had encouraged proactive teamwork to support a safe environment. There were arrangements in place to implement good practice, learning from any untoward incidents, and an open culture to encourage a strong focus on patient safety and risk management practices.

Outcomes for patients were good, and treatment was in line with national guidelines. There were clear strengths in specialist areas in treating children. Staff felt valued, and had clear lines of communication though the trust. Staff felt confident in raising concerns, and felt listened to regarding ideas to improve services.

End of life care

Requires improvement

Updated 16 August 2017

We were concerned about infection control measures we saw in the mortuary department. We saw that the department was not visibly clean and tidy, there was no specific audit programme in place to monitor cleanliness, there were no arrangements in place for regular deep cleaning, surgical instruments were decontaminated manually and infection prevention training was not part of mandatory training for staff. We also observed mortuary staff not following trust infection control policy. We found a range of consumable items that were out of date

Doctors had not completed mental capacity documentation for defined ceiling of treatment decisions when the doctor had deemed the person as lacking capacity.

There was only one palliative care nurse at the hospital they did not have enough time to spend with patients or to always follow up on them. Staff from the palliative care and EoLC team were not up to date with mandatory training.

Staff did not always ask end of life care patients where they wanted to be cared for in their last days. There was no specific data on how many people had died in their preferred location or how quick discharge took place in end of life care patients. Not all risks evident in EoLC were recorded on the trusts risk register.

However, staff were highly motivated and passionate in providing EoLC and there was a drive for change and improvement. Staff at all levels and from all departments understood the importance of a dignified death. There was evidence of good working relationships across all areas of EoLC.

The trust had made EoLC one of its priorities in their 2015-2016 strategy and had an end of life care steering group.

The trust had rolled out the Swan scheme across the hospital, providing resources for staff and practical measures for patients and families which included Swan boxes, bags and end of life information files for staff.

Funding for a full time consultant in palliative medicine had recently been approved. All staff had completed an appraisal within the past year.

Patients had their needs assessed and their care planned in line with evidence-based guidance, standards and best practice. The palliative care team had developed a fast track checklist to provide guidance to ward staff on what to consider when discharging an end of life care patient.

The trust took part in the national end of life care audit. The trust had taken a number of actions in response to the audit.

Outpatients

Good

Updated 20 January 2015

Overall, we rated this service as good. During the inspection we did identify a small number of areas where the trust could improve. Outpatients and diagnostic services were safe; the trust had prioritised statutory training; however, refresher mandatory training had not been completed by the majority of staff. Staffing levels were in line with national guidance.

We saw good practice and effective, compassionate care. Patients were very complimentary about all the staff they had come into contact with. We found that clinics followed national guidance and good practice relative to their individual specialities.

Diagnostic services at the Princess Royal Hospital did not have access to a screening room which was suitable for paediatric services. We saw how a patient who might have benefited from appropriate screening equipment had to undergo an alternative treatment. Whilst the alternative had been safe and appropriate, staff told us that the method used would not have been their first choice had they had an option.

Services were managed well at a local level.