You are here

The Princess Royal Hospital Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 13 April 2021

The Shrewsbury and Telford Hospital NHS Trust is the main provider of district general hospital services for nearly half a million people in Shropshire, Telford and Wrekin and mid Wales. The trust has two main hospital sites: Royal Shrewsbury Hospital and Princess Royal Hospital in Telford. Together the hospitals have just over 700 beds and assessment & treatment trolleys.

The trust provides acute inpatient care and treatment for specialties including cardiology, clinical oncology, colorectal surgery, endocrinology, gastroenterology, gynaecology, haematology, head and neck, maternity, neonatology, nephrology, neurology, respiratory medicine, stroke medicine, trauma and orthopaedics, urology and vascular surgery.

Princess Royal Hospital is the trust’s specialist centre for inpatient head and neck surgery. It includes the Shropshire Women and Children’s Centre, the trust’s main centre for inpatient women’s and children’s services.

Approximately 90,000 children are within the trust’s catchment area. Children and young people’s services at this location consists of; a children and young people’s inpatient ward, children’s haematology and oncology, a children’s assessment unit, children’s outpatient department and children’s day surgery.

We carried out this unannounced, focused inspection of the children’s and young people’s service because we had received concerning information about the safety and quality of the provision of the assessment and treatment of children and young people who presented to the service with acute mental health needs and/or learning disabilities.

At this inspection we inspected using our children and young people’s framework. Children and young people’s services at the trust were last inspected in November 2019 where it was rated as requires improvement overall.

In November 2019, in response to trust wide concerns we urgently imposed a condition on the trust’s registration that stated they must have an effective system in place to ensure de-escalation management and restrictive interventions were completed in line with relevant national guidance. At this inspection, we found the systems around restrictive interventions were not in place within children and young people’s services.

We have inspected other core services at the trust since November 2019. At inspections in June 2020 and October 2020, we took enforcement action and told the trust it must make significant improvements in relation to two specific issues. However, at this inspection we found these improvements had not been made in the children and young people’s services.

In June 2020, we urgently imposed a condition onto the trust’s registration that stated they must devise a process to ensure the accurate clinical risk assessment and care planning of future patients. At this inspection, we identified that this process was not in place in children and young people’s services.

In October 2020, we served a warning notice to the trust that told them they needed to make significant improvements to its safeguarding systems by 1 February 2021. At this inspection, we found these improvements had not been made in children and young people services.

Please refer to our previous trust and location reports for further details of regulatory action taken.

We did not inspect any other services as this was a focused inspection in relation to children’s and young people’s services. We did not enter any areas designated as high risk due to COVID – 19. We continue to monitor the trust closely to identify new and emergency risks and track the trust’s progress against their improvement plan.

Using the children’s and young people’s framework, we inspected elements of the key lines of enquiry of safe, effective, responsive and well-led. Our rating of this location went down. We have rated the service as inadequate and have taken enforcement action as a result of this inspection to promote patient safety.

We also used our urgent enforcement powers and placed conditions on the trust’s registration in relation to: inadequate safeguarding systems that exposed children and young people to the risk of abuse and harm; inadequate assessment and management of risks relating to children and young people’s mental health, those with learning disabilities and those with behaviours that challenged which placed children and young people at risk of avoidable harm; and inadequate staff training which meant children and young people with mental health and learning disability needs were not being cared for my staff who had the skills to keep them safe.

We also served a warning notice telling the provider they must make improvements to ensure all care plans are individualised and meaningful for each child and young person.

During our inspection we visited the children’s ward and two adult wards where young people between 16 and 18 years of age had been admitted. These two wards were the Acute Medical Assessment Unit (AMU) and an escalation ward which was a temporary medical ward.

We reviewed the records of five children and young people who were receiving care in hospital at the time of our inspection. We also reviewed the records of two children and young people who had been detained under Section 2 of the Mental Health Act 1983 at the trust during November 2020. Detention under Section 2 of the Act means that a person has been legally detained for assessment of their mental health; this can last for up to 28 days.

Following our inspection, we reviewed records relating to three additional children and young people who had been admitted to the hospital over the five days following our inspection

We spoke with 14 nurses, two ward managers, two play specialists, a doctor, a student nurse, a security supervisor, a teacher, the deputy chief operating officer, the mental health matron, the paediatric lead for transition, the lead nurse for women and children, a pharmacist and the lead safeguarding nurse for children. We also spoke with four children and young people and three carers and parents.

We reviewed the care records of 10 children and young people and reviewed staff training records, and governance records; such as minutes of safeguarding audit information and relevant policies and procedures.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/whatwe-do/how-we-do-our-job/what-we-do-inspection.

Inspection areas

Safe

Inadequate

Updated 13 April 2021

Effective

Inadequate

Updated 13 April 2021

Caring

Requires improvement

Updated 13 April 2021

Responsive

Inadequate

Updated 13 April 2021

Well-led

Inadequate

Updated 13 April 2021

Checks on specific services

Medical care (including older people’s care)

Inadequate

Updated 14 August 2020

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

  • Staff did not always complete risk assessments for each patient in a prompt manner. They did not always act to remove or minimise risks or update the assessments when risks changed. This had not improved since the last inspection.
  • Staff did not keep detailed records of patients’ care and treatment. Records were not always clear or up-to-date. This had not improved since the last inspection. However, records were stored securely and easily available to all staff providing care.
  • The service did not always manage patient safety incidents well. Safety incidents and lessons learnt were not always shared with staff to prevent further incidents from occurring. Managers did not always ensure that actions from patient safety alerts were implemented and monitored.
  • The service did not always provide care and treatment based on national guidance and evidence-based practice.
  • The service did not ensure that all staff were competent for their roles. This had not improved since the last inspection.
  • Staff did not consistently support patients who lacked capacity to make their own decisions or were experiencing mental ill health in line with legislation and national guidance. At times, patients continued to be unlawfully restricted. This had not improved since the last inspection. 
  • The service did not take into account the individual needs and preferences of patients. This had not improved since the last inspection.
  • Leaders did not demonstrate that they had the skills and abilities to run the service. They did not demonstrate that they understood and managed the priorities and issues the service faced. They were not always visible and approachable in the service for patients and staff. 
  • The culture of the service was not centred on the needs and experience of patients.
  • The service did not operate effective governance systems to improve the quality of services. This had not improved since the last inspection.

Services for children & young people

Inadequate

Updated 13 April 2021

Critical care

Requires improvement

Updated 3 March 2021

End of life care

Inadequate

Updated 14 August 2020

Our overall rating of this service went down. We rated it as inadequate because:

  • Staff did not keep detailed records of patients’ preferences for care and treatment provided at the end of their life. This had not improved since the last inspection. 
  • The service did not ensure that all staff were competent for their roles, placing patients at risk of receiving unsafe and inconsistent care. This had not improved since the last inspection. 
  • Staff did not consistently support patients who lacked capacity to make their own decisions.  
  • The service did not have enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. This had not improved since the last inspection and was identified at our inspection in 2018. 
  • Specialist palliative care services were not available on site seven days a week to support timely patient care.  This had not improved since the last inspection. 
  • It was possible that palliative and end of life care patients could be missed due to the lack of systems to identify patients. This had not improved since the last inspection.  
  • Leaders did not demonstrate that they had the skills and abilities to run the service. They did not demonstrate that they understood and managed the priorities and issues the service faced.
  • The culture of the service was not centred on the needs and experience of patients. 
  • The service did not operate effective governance systems to improve the quality of services. Leaders had not effectively implemented new ways of working to drive improvement and they were not always available to provide day to day support to staff. This had not improved since the last inspection. 

Surgery

Requires improvement

Updated 8 April 2020

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

  • The service had not ensured all staff had completed mandatory training in key skills and safeguarding training.
  • There were inconsistent infection control practices across the service. A patient in isolation had their side room door left open on two consecutive days.
  • There was frequent wrong site of surgery marked on patients and within the operating list and consent forms. (These were highlighted during the World Health Organisation (WHO) surgical checks.)
  • Medical outliers in the day surgery unit blocked beds causing cancellation of operations.
  • From August 2018 to July 2019 the trust’s referral to treatment time for admitted pathways for surgery was lower than the England average in 10 out of 12 months. From March 2019, fewer than 50% of patients were admitted within 18 weeks of referral each month.
  • We were not assured the service had robust systems in place to include all relevant risks on the risk register and proactively manage and mitigate risks.

However,

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety 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, 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 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 to plan and manage services and all staff were committed to improving services continually.

Urgent and emergency services

Inadequate

Updated 8 April 2020

  • Managers did not make sure that everyone completed their mandatory training. Not all staff had completed their safeguarding training. The trust’s mandatory training target was met by nurses for only three of the 11 mandatory training modules and three of the nine mandatory training modules for medical staff.
  • The design and use of facilities for patients were not designed to keep people safe. Streaming and triaging in the department was not managed in a way to keep people safe. Staff did not follow a consistent approach to triage, monitoring and recording of observations. During busy periods we were not assured of the levels of staff were available to manage children and patients safely in the corridor. The service had variable rates around vacancy and bank usage for their staff. The service sometimes had enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
  • Staff sometimes kept detailed records of patients’ care and treatment. Records were sometimes clear, up-to-date. The service sometimes used systems and processes to safely prescribe, administer, record and store medicines.
  • The service did not always provide care and treatment based on national guidance and evidence-based practice. Managers sometimes ensured that staff followed guidance and were kept up to date on evidence-based practice. Patient outcomes were worse than national averages. The service did not always make sure staff were competent for their roles and managers did not always appraise staff’s work performance.
  • Staff did not always support patients to make informed decisions about their care and treatment. They did not always follow national guidance to gain patients’ consent. They did not always support patients who lacked capacity to make their own decisions or were experiencing mental ill health. Patients were not always respected of their privacy and dignity or considered their individual needs. Staff were not always able to offer emotional support to patients, families and carers to minimise their distress.
  • The service sometimes planned and provided care in a way that met the needs of local people and the communities served. The trust sometimes worked with others in the wider system or local organisations to plan care. The service did not always take account of patients’ individual needs and preferences. Staff sometimes made reasonable adjustments to help patients access services. Patients could not always access the service when they needed it in a timely way. This meant that patients experienced unacceptable waits to be admitted into the department, receive treatment and be discharged. Waiting times and arrangements to admit, treat and discharge patients were not in line with good practice.
  • Leaders did not always understand or manage the priorities and issues the service faced. The trust did not always use a systematic approach to continually improve the quality of its services. Governance was not effective to monitor and manage risks on a regular basis to improve. This placed patients at significant risk of harm. The department did not always have effective systems for identifying risks. The service did not always collect reliable data. Data or notifications were not consistently submitted to external organisations as required.
  • The department had not learnt from some of the findings from the last inspection.

Maternity

Requires improvement

Updated 8 April 2020

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

We rated effective, caring and responsive as good. Safe and well led were rated as requires improvement. 

  • Staff did not always complete training in key skills. Staff did not protect patients from abuse in line with trust policy staff were not asking about domestic abuse in line with trust policy. Safety incidents were not always graded and reported incidents correctly according to harm. Staff did not always ensure medical staff assessed risks to patients. The service did not always ensure women received one to one care in labour. Staff did not always complete all risk assessments.
  • Leaders did not have the skills and abilities to effectively lead the service and did not operate effective governance processes throughout the service. Leaders and teams did not always use systems to manage performance effectively. Not all performance data was formatted in line with national guidance. Leaders did not always operate effective governance processes, throughout the service and with partner organisations.

However,

  • 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 women enough to eat and drink, and gave them pain relief when they needed it. Managers mostly monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of women, 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 women 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 women, families and carers. 
  • The service planned care to meet the needs of local people, took account of women’s individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment. 

  • 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 women receiving care. Staff were clear about their roles and accountabilities. The service engaged well with women and the community to plan and manage services and all staff were committed to improving services continually.  

Outpatients

Good

Updated 8 April 2020

This is the first time we have rated outpatients separately from diagnostic imaging. We rated it as good because:

  • The service had enough nursing staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed most 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 had the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix and gave locum staff a full induction.
  • Staff provided good care and treatment. 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.
  • 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. Most people could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s values, and how to apply them in their work. Staff felt respected, supported and valued by their immediate managers. 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.

However,

  • The service did not always have enough medical staff provided clinic appointments for some specialities quickly enough.
  • The phlebotomy room used chairs which were in a poor state of repair and not compliant with infection prevention and control guidelines. Remedial action for this was in progress. The service controlled infection risk well in all other areas.
  • Not all patient consultation records were clear and fully legible.
  • Nursing staff did not always complete mental capacity act (MCA) assessments. Nurses relied on medical staff conducting MCA assessments. Staff were not up to date with (MCA) training. The trust had a plan to remedy this.
  • Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not consistently in line with national standards for some cancer specialities.