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The Princess Royal Hospital Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 14 August 2020

Our rating of services stayed the same. We rated them as inadequate because:

During this inspection we used our focused inspection methodology. We did not cover all key lines of enquiry. We have rated the service as inadequate and have taken enforcement action as a result of this inspection to promote patient safety. Our enforcement action included the use of our urgent enforcement powers where we placed conditions on the trust’s registration in relation to the assessment and management of risk, care planning, and incident management. We also served two warning notices to the trust requiring them to make improvements in the following areas; end of life care staffing, end of life staff competencies, end of life governance systems and the way the staff support patients in line with their personal preferences and individual needs.

  • 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 end of life care 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 services. 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 services was not centred on the needs and experience of patients.
  • The services 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.
  • Staff did not always complete risk assessments for each patient in a prompt manner. Action was not always taken to remove or minimise risks to patient’s health and wellbeing. Safety incidents were not always managed well to protect patients from avoidable harm. This had not improved since the last inspection.  

Inspection areas

Safe

Inadequate

Updated 14 August 2020

Effective

Inadequate

Updated 14 August 2020

Caring

Requires improvement

Updated 14 August 2020

Responsive

Inadequate

Updated 14 August 2020

Well-led

Inadequate

Updated 14 August 2020

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

Updated 8 April 2020

Critical care

Requires improvement

Updated 29 November 2018

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

  • Mandatory training compliance levels for medical staff were significantly lower than the trust’s target.
  • Medical staffing levels had not improved since our previous inspection and so were not in line with the required standards which meant that people did not always receive safe care and treatment or experience continuity of care in relation to medical personnel.
  • Arrangements for the ward round did not always include multidisciplinary input.
  • Recommended guidelines relating to allied health professional staffing levels were not met.
  • The critical care outreach service did not operate 24 hours a day.
  • The hospital at night team did not always ensure a safe service.
  • Delivery of people’s care, treatment and support was not always in line with legislation, standards and evidence based guidance.
  • The rehabilitation needs of patients were not always addressed which could lead to less favourable outcomes.
  • The collection and monitoring of information about the outcomes of people’s care and treatment was limited.
  • Participation in quality improvement initiatives was limited and there was little evidence relating to benchmarking, accreditation schemes, peer review, research or trials.
  • There was limited evidence relating to participation in a comprehensive programme of clinical audit which specifically related to critical care.
  • Less than 50% of nursing staff had achieved their post registration qualification in critical care nursing.
  • Services were not always available to patients seven days a week.
  • Staff compliance with Mental Capacity Act (MCA) and Deprivation of Liberty training was extremely low.
  • The service did not always identify how it could be developed or improved when patient needs were not addressed.
  • Timely access to initial assessment, test results, diagnosis and treatment was not always possible.
  • Discharge from the critical care unit was not always in accordance with national standards and did not always take place at appropriate times or place.
  • Patient diaries were not in use on the unit.
  • Patients did not have access to formal counselling services for patients.
  • Managers had the right skills and abilities to provide the service but there was lack of overarching managerial arrangements to ensure a coordinated critical care service across both the trust’s hospitals to provide a safe, high-quality and sustainable care.
  • The challenges to quality and sustainability were known to leaders but the actions needed to address them were not being implemented promptly.
  • There was a lack of clinical leadership and it was unclear as to whether there were priorities for ensuring sustainable and effective leadership within the critical care unit.
  • Limited action was being taken to improve the service and there did not appear to be an immediate vision for the critical care unit.
  • The long-term vision and strategy was known to staff but it was unclear as to whether they had collaborated with leadership in shaping them.
  • Structures, processes and systems of accountability to support the delivery of the strategy and good quality, sustainable services were unclear.
  • Governance and management systems were not functioning effectively or interacting with each other appropriately.
  • It was unclear whether there were comprehensive assurance systems or whether performance issues were escalated appropriately through clear structures and processes.
  • There were not always clear and robust service performance measures which were always reported and monitored.
  • The service’s approach to service delivery and improvement was inconsistent.

However;

  • Regular updates and training in the systems and processes were provided to staff which helped to keep people safe and Mandatory training compliance was in line with trust targets.
  • People were protected from abuse, neglect, harassment and breaches of their dignity and respect due to the services safety and safeguarding systems.
  • The service maintained high standards of cleanliness and hygiene.
  • The premises and facilities of the critical care unit were generally designed, maintained and used to keep people safe.
  • Maintenance and use of equipped appeared safe.
  • Risk assessments carried out on people who used services were comprehensive.
  • The planning and review of nursing staffing and skill mix usually ensured people received safe care and treatment.
  • People’s individual care records, including clinical data, were written and managed in a way that kept people safe.
  • Medicine management arrangements kept people safe as they were recorded, administered and stored appropriately.
  • There was a low number of serious incidents.
  • Prevalence of patient harm was recorded using the Safety Thermometer and it was also used to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care.
  • Physical, mental health and social needs of patients were holistically assessed.
  • Good patient outcomes in relation to mortality and unplanned readmissions to the unit were being achieved.
  • The National Organ Donation programme was in operation within the trust.
  • Nutrition and hydration needs were identified, monitored and met.
  • Pain was effectively assessed and managed.
  • The critical care unit was involved in the local critical care network.
  • The assessment, planning and delivery of care involved necessary staff, including those in different teams, services and organisations.
  • The relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005, was understood by staff.
  • The personal, cultural, social and religious needs of patients were understood and respected by staff and were considered when delivering care.
  • Staff took time to interact with patients and those close to them, in a respectful and considerate manner.
  • Patients’ privacy and dignity was always respected, including during physical and intimate care.
  • Patient confidentiality was respected by ensuring conversations took place in private or when at the bedside.
  • Care, treatment and condition was understood by patients.
  • The impact a patient’s care, treatment and condition had on their wellbeing and on those close to them was understood by staff.
  • Carers were treated as important partners in the delivery of patient care.
  • A sensitive approach to relatives was taken when a patient might be a possible eligible organ donor.
  • Patients’ health needs could be addressed on the unit as appropriate equipment was available.
  • Services were delivered, made accessible and coordinated to take account of the needs of different people.
  • Some action was being taken to minimise the length of time people had to wait for care, treatment and advice.
  • Complaints were handled effectively and confidentially, with regular updates provided and a formal record being kept.
  • Local leaders were visible and approachable.
  • The trust had a clear set of values, with quality and sustainability as the top priorities.
  • Staff felt supported, respected, valued and proud to work in the organisation.
  • Arrangements for identifying and recording risks were in place and there was an alignment between recorded risks and what staff say is on their worry list.
  • The service gathered people’s views and experiences to shape and improve the service and culture.

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

Updated 8 April 2020

Urgent and emergency services

Inadequate

Updated 8 April 2020

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.
  • Some 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.