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Provider: Portsmouth Hospitals NHS Trust Good

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Reports



CQC inspections of services

Inspection carried out on 17 April 2018

During a routine inspection

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

  • Safety, effectiveness, caring, responsive and well led were requiring improvement overall. We identified improvements to safety were required in five of the services we inspected. Responsiveness and well led remained requires improvement, the same as our previous inspection. While we saw evidence that some services were planned to meet people’s needs and had good leadership this was not consistent across all of the services we visited. Effectiveness was previously rated as good however at this inspection we identified that not all services provided care and treatment to patients which achieved the best outcomes or was based on the best available national guidelines. Caring was previously rated as outstanding. At this inspection we identified some concerns in two of the services we visited and therefore the rating had dropped to requires improvement.
  • Our last inspection of the urgent and emergency services was in February 2017. At this inspection we saw the trust had made some improvements to improve the safety of the service and therefore the rating had improved from inadequate previously to requires improvement. Effectiveness and well led were rated as requires improvement which was the same as the previous inspection. We saw a deterioration in caring, which was rated as good and responsiveness rated as requires improvement in our 2017 inspection. At this inspection caring was rated as requires improvement and responsiveness as inadequate. This gave an overall rating as requires improvement which was the same as our February 2017 inspection.
  • Medical services. We carried out inspections of the urgent medical pathway in February and March 2016, September 2016 and February and May 2017. During those inspections we inspected some areas of the trust’s medical services, but did not inspect them all. This current inspection is the first comprehensive inspection of medical services since 2015. Comparisons to previous ratings relate to the inspection carried out in 2015. The rating for safe and responsive was requires improvement which is the same as our inspection in 2015. We saw a deterioration for effective, caring and well led, which was rated as good in our 2015 inspection. However, although this inspection identified deterioration in the service since the last comprehensive service in 2015, the trust had made improvements in the services since the inspection of the urgent medical pathway in 2017 when safe, effective caring and well led were rated as inadequate and responsive was rated as requires improvement. At this current inspection, medical services were rated overall as requires improvement.

  • Surgery was rated as requires improvement overall at our inspection in 2015. On this inspection the overall rating remained the same however both caring and responsive had risen by one rating from requires improvement to good. Effective had dropped from good and is now requires improvement.
  • Maternity had been rated good overall in our 2015 inspection. However during this inspection all of the domains had declined and we have rated the service as requires improvement.
  • Critical care was rated as outstanding overall, with caring rated as good in 2015. In this inspection all of the domains were rated as outstanding and the service remained outstanding overall.
  • Children and young people’s services were rated good overall with responsive requiring improvement in our 2015 inspection. At this inspection the service remained good overall and responsive was rated as good however safe had dropped to requires improvement.
  • End of life care was rated as requires improvement in our 2015 inspection. Work had been undertaken to improve the safety and effectiveness of the service which were previously requires improvement. At this inspection the service was rated as good overall.
  • Outpatients were good overall in 2015. On this inspection we found some concerns in the well led domain which was previously rated as good, on this inspection we rated well led as requires improvement. Safe, caring and responsive remained good and therefore the service remained good overall.
  • Diagnostic imaging was previously included with outpatients and therefore has not been inspected as a separate service before. We rated all areas as good and therefore the service was rated as good overall.

Inspection carried out on 10 and 11 May 2017

During an inspection to make sure that the improvements required had been made

Portsmouth Hospital NHS Trust is located in Cosham, Portsmouth and is a 975 bedded District General Hospital providing a comprehensive range of acute and specialist services to a local population of approximately 610,000 people. The trust provides specialist renal services to a population of 2.2 million people across Wessex. On our announced inspection on 10 and 11 May 2017, we inspected the key question of ‘well led’ for Portsmouth Hospital NHS Trust.

We carried out a responsive focused inspection of the corporate and leadership functions of Portsmouth Hospital NHS Trust on 10 and 11 May 2017, inspecting the key question of ‘well led’. This inspection was carried out following our inspection of the emergency medical pathway in February 2017 which highlighted concerns regarding culture, governance and leadership within the trust. The specific concerns required us to visit the emergency department and medical care areas as part of the May 2017 inspection in order to review ward to board governance arrangements. During this May 2017 inspection we identified concerns in the emergency department, four medical care wards and the Acute Medical Unit (AMU). The findings are reported in the February 2017 report for the emergency department and medical care services for Queen Alexandra Hospital. To view our findings and report from the February 2017 inspection of the Queen Alexandra Hospital please refer to our website.

During this inspection, we found that there had been deterioration in the quality of services provided, and that improvements had not been sustained. Immediately following our inspection of Queen Alexandra Hospital in February 2017 inspection we issued enforcement action under Section 31 of the Health and social Care Act 2008 to protect patients on the acute medical pathway from the immediate risk of harm. During this inspection, in May 2017, we did not see evidence that services had sufficiently improved following our feedback to the trust senior leadership team in February 2017. Following our inspection of Queen Alexandra Hospital in May 2017, we served further action under Section 31 to protect vulnerable patients from immediate risks of harm. Details of these notices are included at the end of this report.

There was a lack of management oversight and lack of understanding of the detail of issues which we observed on both inspections. We found that the trust had significant capacity issues and were not addressing the concerns regarding the acute medical pathway in a timely or effective way. The pressure on beds meant that patients were allocated the next available bed rather than being treated on a ward specifically for their condition placing patients at risk of harm. Across all areas inspected there were significant concerns regarding the care for vulnerable patients and the application of the Mental Health Act 1983, Mental Capacity Act 2005, and Deprivation of Liberty Safeguards.

We have not rated the well led element for Portsmouth Hospital NHS Trust as we did not collate sufficient evidence to do as we had only inspected in relation to the emergency department and medical care areas. However, there were significant concerns in safety, responsiveness and leadership, with an apparent disconnect between the trust board and the ward level. It was evident that the trust leaders were not aware of many of the concerns we identified through this inspection. Staff perceived there was bullying and did not feel able to speak out about concerns. We were not assured that the processes for raising concerns internally were open and free from blame.

Our key findings were as follows:

  • There was a lack of leadership oversight of mental health provision at all levels.
  • Not all staff complied with the requirements of the Mental Capacity Act, 2005 and Deprivation of Liberty Safeguards. We raised five safeguarding alerts to the trust for reporting to the local authority during the inspection.

  • We found that in the majority of areas the staff were committed to providing the best care they could with the resource levels, skills and training within the area they were working in.
  • Several staff were identified by the inspection team as being strong in their work.
  • The process for the induction of agency nurses across the trust was not effective. This was because the process for formal checks on the nursing competencies for the administration of IV fluids on the wards was inconsistent.

  • We were concerned that the emergency department medical staff were working outside the scope of their clinical skills and competencies. The emergency department staff were providing acute medical care to patients due to the medical staff not willing to take medical patients outside of their specialist area. This placed the emergency medical doctors at risk.
  • The medical model for acute care was to be launched on 8 May 2017 but some doctors refused to take part in implementation of the model. There were insufficient mitigations in place and this meant emergency department doctors were caring for medical patients for extended periods of time.
  • The culture of medical staff throughout the medical division and unscheduled care was of significant concern to us. We found that there was a culture that was not supportive to patient safety, quality or care. This resulted in delays for patients to receive medical care.
  • Following CQC enforcement action in March 2016, the trust had appointed an Executive Director of the Emergency Care pathway. During our interviews there was a lack of clarity from the Medical Director and the Exec Executive Director of Emergency Care pathway as to who held executive accountability and responsibility for the acute medical pathway.
  • Delayed care and breaches of the four hour timeframe and 12 hour trolley breaches appeared to be normalised.
  • Mortality has increased at a steady rate over the last 12 months. We were not assured this was being addressed. We were informed that mortality was high due to the ‘unscheduled care pathway’. However no audits or evidence had been gathered to support this. Since the inspection, the trust has provided information which demonstrates they are working to improve their processes for monitoring mortality.
  • We were significantly concerned about the processes and practice for safeguarding adults and children within the trust. We were not assured that all known events were being appropriately reported or investigated as safeguarding concerns.
  • The safeguarding children training rates at level three were significantly below what would be expected in some departments including the emergency department.
  • We were made aware of two incidents involving children that demonstrated the trust did not follow best practice safeguarding children procedures.
  • We were significantly concerned about the lack of oversight on safeguarding matters within the trust at senior management and executive board level.
  • The governance processes to highlight issues within the trust were not effective.
  • The private board papers, in the majority, should have been shared in public board to demonstrate an open and transparent approach from the trust.
  • There was a backlog of complaints, and the quality of complaint responses was variable. Some responses did not fully address the concerns raised by the complainant.
  • The quality of incident investigations were very poor. There was limited evidence or assurance that lessons learned from incidents were implemented.
  • The application of the Duty of Candour regulation to incidents was variable, with incidents found where duty of Candour had not been undertaken.
  • We received several positive examples of good practice and positive experiences from staff working throughout the hospital.

  • However, many staff perceived there was bullying and didn’t feel able to speak out about concerns. This was expressed by different staff groups who raised concerns to CQC before, during and after the inspection.
  • We were not assured that the processes for raising concerns internally were open and free from blame. This discouraged staff from feeling free to speak about concerns.
  • The role of the trust’s freedom to speak up guardian was not working effectively. Staff we spoke with in the majority were not aware of who the freedom to speak up guardian was.
  • The process for checking if a person working at board level in the organisation is fit and proper to work in their role, was undertaken in accordance with the regulations.

  • There was work being undertaken to ensure compliance with the workplace race equality standards.
  • Most specialties provided care and treatment in line with NICE guidelines and royal college guidelines. Trust policies were in line with these guidelines
  • During 2015/2016, 38 national clinical audits and eight national confidential enquiries covered NHS services that Portsmouth Hospitals NHS Trust provides. During that period Portsmouth Hospitals NHS Trust participated in 97% (37/38) national clinical audits and 100% (8/8) national confidential enquiries of those it was eligible to participate in
  • Between November 2016 and February 2017, 96% of patients said they would recommend the trust to family and friends, higher than the national average of 95%.
  • Between November 2016 and March 2017 93% of patients said they would recommend the A&E service to family and friends, higher than the national average of 87%
  • There were specific care pathways for certain conditions, in order to standardise the care given. Examples included stroke pathways, sepsis, acute kidney injury, non-invasive ventilation and falls
  • During 2015/2016, Portsmouth Hospitals NHS Trust has participated in a total of 316 clinical research studies, 84% of these studies were NIHR Portfolio adopted.
  • There was an improved and dedicated focus to providing care to patients with a learning disability.
  • Many staff reported good experience of culture and openness within their local departments
  • In areas such as paediatrics, maternity and critical care staff provided good examples of how leadership and culture was positive in their areas. This included being open and raising concerns.

For the areas of poor practice the trust needs to make the following improvements.

Importantly, the trust must:

  • Ensure that staff are assessed and signed off as competent to deliver patient care.

  • Ensure that the culture within the organisation of staff not being willing to raise concerns openly and concerns around bullying are given sufficient priority by the board.

  • Review the governance functions and processes for the trust to ensure they are fit for purpose.

  • Improve compliance with regulation 28 coroner reports for preventing future deaths.

  • Ensure that improvements are made to the classification of incidents to ensure that they are reported, escalated and graded appropriately.

  • Ensure that the conditions imposed by the Commission on the Acute Medical unit, and Emergency Department are effectively implemented.

  • Improve identification and management of incidents requiring duty of candour.

  • Improve the quality of Root Cause Analysis investigations.

  • Review the processes for the safeguarding of vulnerable adults and children the ensure that safeguarding processes work effectively in the trust.

  • Improve the processes, policies, staffing and understanding of mental health for staff at ward to board level.

  • Ensure that staff have knowledge of the Mental Capacity Act and Deprivation of Liberty Safeguards, and implement them effectively.

  • Ensure that patients do not have procedures undertaken on them without appropriate consent being obtained, and best interest assessments are completed where applicable.

  • Ensure that records completed for the purpose of care are completed accurately.

  • Immediately review the risks associated with reporting of chest x-rays in radiology. Including the undertaking of a patient harm review on all cases not reported on.

  • Undertake patient harm reviews and audits to identify where lessons can be learned or mortality ratios reduced.

  • Immediately review the medical model within acute care to ensure that patients are seen by a treating physician and treated at the earliest opportunity.

  • Improve the flow and capacity throughout the hospital.

  • Review the board assurance framework, board minutes, and processes for reporting at board to ensure risks are identified and managed by the trust, and that the minutes are appropriately recorded.

  • Develop a vision and strategy for the trust.

  • Improve the complaints processes, oversight of complaints and reduce the backlog of complaints to ensure patients receive responses in a timely way.

Following the inspections of the Queen Alexandra Hospital in February and May 2017 we took immediate action to ensure the safety of patients. We have taken this urgent action as we believe a person will or may be exposed to the risk of harm if we did not do so. Details of this action are included at the end of the report.

Professor Sir Mike RichardsChief Inspector of Hospitals

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 10 – 13 February 2015 and unannounced on 22 February and 2 March 2015

During a routine inspection

Portsmouth Hospital NHS Trust provides a full range of elective and emergency medical and surgical services to a local community of approximately 675,000 people who live in Portsmouth city centre and the surrounding areas of South East Hampshire. It provides some tertiary services to a wider catchment of approximately two million people. The trust also provides specialist renal and transplantation services and is host to the largest of five Ministry of Defence Hospital Units in England. Ministry of Defence staff work alongside NHS staff in the trust but have a separate leadership command structure. The trust employs over 7,000 staff.

Queen Alexandra Hospital is the acute district general hospital of the Portsmouth Hospitals NHS Trust. It is the amalgamation of three previous district general hospitals, re-commissioned into a Private Finance Initiative (PFI) in 2009. The hospital has approximately 1,250 inpatient beds, and has over 137,000 emergency attendances and over 429,000 outpatient attendances each year. There are 6,000 staff employed by the Trust and approximately a further 1,000 are employed by a provide provider in portering, cleaning, maintenance and catering services under a PFI arrangements. The trust has not yet applied for foundation status

The trust also provides outpatient services in community hospitals at Gosport War Memorial Hospital, Petersfield Community Hospital and St Mary’s Hospital. Gosport War Memorial Hospital has a minor injuries unit, inpatient rehabilitation on Ark Royal Ward (16 beds) and the Blake Maternity Unit (six beds). Petersfield Community Hospital has inpatient rehabilitation on Cedar Ward (22 beds) and the Grange Maternity Unit (four beds). There are eight satellite renal dialysis services, with six across Hampshire, one in Salisbury (Wiltshire) and one in Bognor Regis (West Sussex).

We undertook this inspection of Portsmouth Hospital NHS Trust as part of our comprehensive inspection programme.

Services provided at Queen Alexandra Hospital include accident and emergency, medical care, surgery, critical care, maternity and gynaecological services, children and young people’s services, end of life care, and outpatient and diagnostic services. These eight core services are always inspected by the Care Quality Commission (CQC) as part of its new approach to the comprehensive inspection of hospitals. The services provided in community hospitals are integrated into the trust clinical and management structures; we have incorporated these within the core service areas.

The inspection took place between 10 and 13 February 2015, with additional unannounced visits on 25 and 26 February and 2 March 2015. The full inspection team included CQC managers, inspectors and analysts, doctors, nurses, allied healthcare professionals, ‘experts by experience’ and senior NHS managers.

Overall, we rated this trust as ‘requires improvement’. We rated it ‘outstanding’ for providing caring services and ‘good’ for effective services, but the trust ‘required improvement’ for providing safe, responsive and well-led services.

We rated critical care services as ‘outstanding’; maternity and gynaecology, and care of children and young people and outpatients and diagnostic imaging as ‘good’; and urgent and emergency services, medical care, surgery and end of life care as ‘requires improvement’.

Our key findings were as follows:

Is the trust well-led?

  • The trust had a three year strategy that aimed to deliver high quality patient care, working in partnership and supporting innovation in healthcare. There was a focus on emergency care with plans to transform services to reduce admissions to hospital and deliver care closer to home. However, many of these priorities were underdeveloped and the trust was dealing with the immediacy of capacity issues. Clinical services did not have joined up strategies and did not work effectively to support the flow of patients through hospital.
  • The leadership team was in the process of change and development. There was the commitment to improve and deliver excellent services, but there were gaps in operational performance and delivery, particularly around the unscheduled care pathway. The trust had worked with the wider health economy but did not have clear plans to deliver service improvements and had not effectively delivered consistent improvement. There was a wide variation in the quality and safety of services across the trust, although many services were good or outstanding some areas of performance failures were not appropriately recognised. There had not been a recent formal assessment of the board’s performance.
  • The trust had all the elements of an effective governance framework but these were not being used effectively. There was a comprehensive integrated performance report to benchmark quality, operational, financial and workforce information and each clinical service centre had a quality dashboard. However, some risks were not identified and the action taken on known risks did not always mitigate these and were not always timely. Some risks had been on risk registers for several years without a clear resolution of the mitigating actions or a monitoring statement for risks that cannot be fully mitigated.
  • We served two warning notices for the trust failure to respond to patient safety issues, and the failure to effectively assess and manage the risks to patients in the emergency department.
  • Staff were positive about working for the trust and the quality of care they provided. The trust was similar to other trusts for staff engagement, but its staff survey had demonstrated year on year improvement. The trust ‘Listening into Action’ programme had demonstrated changes and improvements to services based on staff innovations. The staff had a strong sense of identify that was focused on care.
  • There was a focus on improving patient experience and public engagement was developing. Safety Information was displayed in ward and clinic areas for patients and the public to see.
  • The trust had a culture of innovation and research and staff were encouraged to participate. The trust had won a national award for clinical impact research. The award recognised the trust “Research in Residence Model” and its ability to harness clinical research to improve services and treatments for its patients.
  • Cost improvement programmes were identified but savings were not being delivered as planned and the trust was having to take further action to reduce the risks of financial deficit.

Are services safe?

  • Patients who arrived by ambulance at the emergency department (ED) were at risk of unsafe care and treatment. We served two warning notices to the trust requiring immediate improvement to be made to the initial assessment of patients, the safe delivery of care and treatment, and the management of emergency care in the ED.
  • Patients were sometimes assessed according to the time that they arrived in the ED and not according to clinical need. Some patients with serious conditions waited over an hour to be clinically assessed, which meant that their condition was at risk of deteriorating. Many patients waited in corridors and in temporary bay areas. Patient in these areas and in the majors queue area were not adequately observed or monitored.
  • The trust had introduced an initial clinical assessment by a healthcare assistant to mitigate risks, but this was not in line with national clinical guidelines.
  • The environment in the ED did not enhance patient safety. The ED had been extended and its majors treatment area and children’s treatment area were now a considerable distance from the resuscitation room. Staff had to negotiate crowded public areas in order to gain access to the resuscitation room. Patients were in areas, some temporary, where there was no access to essential equipment or call bells, and there was no safe area to support patients with a mental health condition.
  • Nurse staffing levels were regularly reviewed using an appropriate and recognised management tool. There were high vacancy levels across the hospital, notably in the ED, the medical elderly care wards and the surgical assessment unit, where staffing levels were not always met and there were insufficient staff for the number of patients and the complexity of their care and treatment needs. Staffing levels were reviewed on a shift-by-shift basis and according to individual nursing requirements. Staff were transferred across units on a shift basis to try to reduce risk, but this affected the availability of expertise and continuity of care in other areas. There was high use of internal bank and agency staff, particularly on night shifts. Agency staff received an induction and safety briefing on wards before beginning their shift.
  • Midwifery staff ratio was an average of 1:29 which was in line with the England average. The maternity dashboard clinical scorecard showed that the ratio had varied from 1:27 to 1:33 over the past 10 months. This reflected the actual number of midwives to birth and did not include maternity support workers The recommendations of the Royal College of Obstetricians and Gynaecologists’ guidance (Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour, October 2007) that there should be an average midwife to birth ratio of 1:28. Midwives, however, were working flexibly and one to one care was being provided for women in labour and with additional staff or strategies were provided to ensure the safety of antenatal and postoperative care.
  • The trust had higher numbers than the England average of consultant medical staff in post, although it was not meeting national recommendations for consultant presence in maternity and for consultant staffing in end of life care. The trust had fewer middle-grade doctors and junior doctors compared with the England average and their workload was high in some specialties. For example, surgery and consultants in the ED were being stretched in an unsustainable way to cover posts and ensure safe services.
  • Medical patients who were in the ED overnight and those on non-medical wards (outliers) were not always reviewed by specialist doctors in a timely way.

  • Most services had a culture of openness and transparency. Staff understood the principles of duty of candour, and information, guidance and training were available to support staff to understand and implement the requirement of being open when things go wrong.

  • The NHS Safety Thermometer is a monthly snapshot audit of the prevalence of avoidable harms, including new pressure ulcers, venous thromboembolism (blood clots), catheter-related urinary tract infections and falls. The information was monitored throughout the hospital and the results were displayed for the public in clinical areas. The prevalence of catheter-related urinary tract infections was consistently low but the incidence of pressure ulcers and falls had not reduced but was increasing. Some pressure ulcer incidents were deemed unavoidable. However, the trust had not met its own targets for reduction in pressure ulcers and falls. There was evidence of actions taken in response but this varied; for example, the falls care bundle was used on medical wards but this was not used consistently on surgical wards.

  • Staff were reporting incidents and lessons were learnt and practice was changed as a result. On one surgical ward, however, staff were concerned that disciplinary action could be instigated unfairly for pressure ulcer incidents. The trust had said that staff may face disciplinary action if they failed to care for patients appropriately, but not if it was beyond their control. Recent hospital data, however, indicated a decrease in the reporting of pressure ulcers on this ward.
  • The wards were visibly clean, and infection control practices were followed. The trust infection rates for MRSA and Clostridium difficile were within an expected range and the trust had not had a norovirus outbreak for five years. However, infection control arrangements in the surgical high care unit did not meet professional guidelines.
  • Items of necessary equipment such as pressure-relieving mattresses, blood pressure monitors and medication pumps were not always readily available for patients when required. This meant that patient care and treatment could be delayed or adversely affected. The cardiac arrest call bell system in the E level theatres did not identify the location in which an emergency took place.
  • Medicines were stored safely. However, the staff on a unit designated as an escalation ward told us they sometimes ran out of essential medications and had to borrow them from another ward. As a result there were delays in the timely administration
  • Patients whose condition might deteriorate were being identified through the use of the early warning score. The trust had an electronic monitoring system for patients and this was used effectively, for example for the critical care outreach team to prioritise patients. However, early warning scores were not being used as part of bed management allocations.
  • Staff were not always aware of standardised protocols or agreed indicators for pre-assessment to support them in making decisions about the appropriateness of patients for day case surgery
  • Safeguarding processes to protect vulnerable adults, and children and young people were embedded across the hospital. There was a recent safeguarding policy and procedure, staff had attended appropriate training, and there was a culture of appropriate reporting.
  • Staff were undertaking mandatory training and progress towards trust targets was good for many staff disciplines with the exception of medical staff where attendance rates were low.
  • The completion of patient records varied in some areas it was very good and in some places information could be missing, and it was not clear if this was part of the electronic or paper record. New end of life care plans were being piloted in response to the national withdrawal of the Liverpool Care Pathway. However, where these care plans were not used, the documentation, of care was not appropriate to properly assess and make decisions about patient care and treatment. Do not attempt cardiopulmonary resuscitation forms were not always appropriately completed.

Are services effective?

  • Services provided care and treatment in line with national best practice guidelines, and outcomes for patients were often better than average or improving. However, operating procedures in theatres needed updating and end of life care guidance needed to be further developed across the trust. The trust needed to improve the management of stroke patients and it was not meeting the target for 90% of stroke patients to be cared for in a stroke unit.
  • There was good participation in national and local audit programmes, although the trust did not fully participate in the National Care of the Dying Audit – Hospitals 2013/14.
  • Patient outcomes, as measured by national audits, were either better than or similar to the England average; where they were below the average they were improving. Each clinical service centre had a quality dashboard to monitor patient safety outcomes although these needed further development to focus on clinical outcomes.
  • The trust’s mortality rates were within the expected range.
  • Patients received good pain relief, in particular after surgery, in critical care and in end of life care. There were some delays, however, for patients who had arrived by ambulance in the ED.
  • Patients, particularly older patients, were supported to ensure their hydration and nutrition needs were met. Although there were areas of concern identified on ward E3 for all patients and in end of life care on the acute medical unit.
  • Staff were supported to access training and there was evidence of staff appraisal, although clinical supervision for nursing staff was under developed.
  • Staff worked in multidisciplinary teams to centre care around patients. Physiotherapists on medical wards told us that although they did see medical patients, they could not always provide sufficient therapy sessions for their individual requirements.
  • Discharge summaries giving GPs information on patient care were delayed. The trust was not meeting Department of Health standards for letters to be sent within 48 hours and there could be delays of up to two weeks. Renal outpatient letters were taking 35 days to be typed and sent to the patients’ GP because the renal department had a separate IT system from the rest of the trust. This had caused significant delay in GPs receiving updated information regarding their patients’ treatment.
  • Seven-day consultant-led services were developed in all areas, with the exception of outpatient services. Support services such as imaging, pharmacy, physiotherapy and occupational therapy were also available seven days a week.
  • Staff had appropriate knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards to ensure that patients’ best interests were protected. Guidance was available for staff to follow on the action they should take if they considered that a person lacked mental capacity. Notification of Deprivation of Liberty Safeguards applications were correctly submitted to the Commission.
  • Critical care services demonstrated outstanding innovations in delivery of effective care, ensuring there were robust systems to deliver and monitor care to high standards by highly skilled staff.

Are services caring?

  • The trust had a culture of compassionate care. Staff were caring and compassionate, and treated patients with dignity and respect. Many patients and relatives told us that although staff were very busy, they were supported with compassion, patience, dignity and respect, with time being given to the delivery of personalised care.
  • Staff were responsive to patients’ emotional care needs. Emotional care was also provided by the chaplaincy department and patients and relatives told us show much they valued this service, which had supported them at difficult times.
  • We observed outstanding care and compassion in critical care, maternity and gynaecology and children and young people’s services. Staff were person-centred and supportive, and worked to ensure that patients and their relatives were actively involved in their care.
  • Data from the NHS Friends and Family Test demonstrated that patients were satisfied with the care they received. Overall results were above the England average and the trust was in the top quarter of all trusts. Results were clearly displayed in ward areas.
  • Patients’ experiences of care was variable, however. There were concerns, particularly for patients on the surgical ward E3 where staff were busy and essential and timely personal care was not delivered and patient dignity and confidentiality was not always maintained. Some patients with end of life care needs on wards E3 and the acute medical unit did not always get the timely care the families thought necessary or appropriate, and care was sometimes given by relatives instead.

Are services responsive?

  • The trust was not meeting national targets for the timely handover of patients from ambulances. The trust had not met the emergency access target for 95% of patients to be admitted, discharged or transferred from A&E within four hours since November 2013. There was no hospital-wide escalation response to overcrowding in the ED to improve flow in the hospital.
  • Specialty teams were often delayed in seeing patients who had been in the ED overnight.
  • Bed occupancy across the hospital was 92% (January 2014 to March 2015). This was consistently above both the England average of 88%, and the 85% level at which it is generally accepted that bed occupancy can start to affect the quality of care provided to patients and the orderly running of the hospital.
  • Patients were not always admitted to wards according to their clinical needs and were being placed where beds became available. This meant that the necessary level of specialist expertise and experience may not always have been available to them.
  • Patients could be moved several times during their admission. This happened at night and for non-clinical reasons. The trust identified that older patients, patients with high dependency and acuity needs and end of life care patients should not be moved. However, older patients, including patients who were confused, or living with dementia and who may have had complex conditions, were being moved.
  • Patient moves were tracked but the information was not used effectively at ward level. Some medical staff told us they did not always know where to find them and this could lead to a delay in treatment. Patients’ relatives also told us that they had difficulty finding patients.
  • The critical care unit experienced discharge delays out of hours and delays to admission because of pressure on beds in the hospital. The unit had taken action to mitigate risks and this included comprehensive discharge summaries and a retrieval team who care for patients on the ward while they waited for admission.
  • The national referral to treatment time target for 90% of patients to have surgery within 18 weeks was not met overall, although this was a planned fail in agreement with commissioners to address patients on the waiting list. Targets were not achieved in general surgery, trauma and orthopaedics, urology and ENT. In relation to urology, the trust attributed delays to limited staffing capacity, which had led to the cancellation of over 200 elective surgeries and a reduction in the number of elective patients admitted.
  • Capacity issues within the hospital resulted in elective procedures being cancelled. Some patients told us their operations had been cancelled several times; although the majority did go on to have their surgery within 28 days.
  • The trust was meeting the cancer waiting time target for 93% of patients to have referral from a GP to see a specialist within two weeks. The trust was also meeting the target for 96% of patients to have diagnosis to definitive treatment within one month (31 days). The trust had also met the target for 85% of patients to be waiting less than two months (62 days) from referral to start of treatment from April 2014 to December 2014. However, the target had not been met in January 2015 to March 2015.
  • The trust was meeting referral-to-treatment time targets for most outpatient specialities but there were long waiting times for patients attending colorectal clinics, back pain clinics and the gastroenterology clinic. There was evidence of action being taken to address the long waits.
  • Patient had timely follow up outpatient appointments although there were patients waiting beyond their due date in colorectal surgery, orthopaedic and gastro specialities. Ophthalmology had a high number of patients with significant delays to follow-up and who were on an outpatients waiting list. This had been on the service risk register since 2009, but as a result of a serious incident requiring investigation that occurred as a result of this backlog, it was escalated to the trust risk register In April 2013. The waiting list had been reduced but the number of patients waiting was still significant
  • The trust was now meeting the diagnostic waiting time target after extending the service times.
  • Discharge plans were expected to commence on admission but this varied across wards, as did planning around simple and complex discharges. There were some delays in discharging patients and patients told us they had to wait a considerable time (hours) for their medications to take home. A discharge lounge was available and was used appropriately. Patients were able to have food and drink while waiting for discharge.
  • The trust had delayed transfers of care and national data showed the main causes of delayed transfers of care at this trust (which could prevent a patient from being discharged) included waiting for nursing home places, waiting for social care arrangements, and patient/family choice. The trust was working with its partners to alleviate this problem and data published by NHS England (December 2014 to January 2015) demonstrated that the trust had a comparatively smaller number of delayed discharges compared with other similar trusts.
  • The integrated model which the trust maternity service runs (Nurture programme) allowed flexible use of staff to maintain 1:1 care in labour. This had kept women’s denied choice of place of birth to a minimum.
  • There was a rapid access discharge service within 24 hours and the number of patients discharged to their preferred place and who were able to die at home was higher than the national average.
  • In most clinical areas there was adequate provision to protect a patient’s privacy and dignity. However, this was not the case for ambulance patients waiting in corridors in the emergency department and also for patients in the dialysis unit on the Isle of Wight. Patients attending for outpatient appointments had to walk through the dialysis unit where patients were receiving treatment in their beds to attend their consultations. In ophthalmology department at Queen Alexandra Hospital, patients receiving treatment (pupil dilation) were being treated in a room that was glass walled, enabling any person walking by to observe a patient being treated.
  • Staff across the hospital demonstrated a good understanding of how to make reasonable adjustments for patients with a learning disability. However, care for patients living with dementia varied. Training, assessment, the use of the dementia care bundle and making reasonable adjustments to reduce stress and anxiety, we being used but not consistently. In some areas the care needs of people living with dementia were not always met. Some areas demonstrated excellent examples of the care such the ‘memory lane’ service on the elderly care wards. This was held once a week and included engaging patients in remembering their past times by means of music, games, reading material and communication.
  • An interpreting service was available for people whose first language was not English and the service was used. All information for patients was only available in English. In radiology, easy-to-read leaflets were available for patients with a learning disability, where language style had been adjusted and pictures used to explain procedures. We did not see any other information in an easy-to-read format.
  • Information from complaints was reviewed and acted on; although some patients told us they were not always given information about how to make a complaint.

Are services well-led?

  • Many staff were committed to the values of the trust: ‘best hospital, best people, best care’.
  • Most services did not have a formal written strategy, although aspects of future plans could be verbalised by staff. Staff in the ED were not aware or confident that there were clear plans and strategies to address significant concerns in a timely way.
  • Departmental strategies and vision were generally well understood, except in medicine where no discernible long-term strategy could be described by staff.
  • Clinical governance arrangements were well developed to assess and manage the quality of service provision. However, better management of risks was needed. Not all risks were appropriately identified, escalated and mitigated across service areas. The pressures in the ED were long-term and significant risks to patients had not been appropriately managed.
  • Many staff told us overall they had good support from the local clinical leaders, for example ward managers and consultant staff. However, there were concerns, including: the support from managers at senior levels, the capacity of managers in the ED, of some ward managers and the fragmentation of management in end of life care.
  • Many staff commented on the visible and approachable presence of the chief executive officer.
  • Staff were positive and proud to work for the trust; many staff had worked in the trust for their entire career. There was an open and honest culture and a strong sense of teamwork across most areas. However, there were a few areas of concern and these were identified as the lack of hospital support and clinical engagement for the pressures in ED, the lack of integrated working across clinical service centres, the concern by staff on one ward of being unfairly disciplined for pressure ulcer incidents in surgery and the dysfunction team working in the colorectal team.
  • There were innovative approaches to patient and public engagement across services, which included survey, focus groups, consultation, committee representation and the use of social media.
  • Staff engagement was good, and the latest staff survey showed significant improvement in key areas. The trust was in the top 20% of trusts for staff engagement. The Listening in Action programme was cited as a particular example of involving staff in improving the quality of their services.
  • There was a strong and visible commitment to research and development.
  • Innovative ideas and approaches to care were encouraged and supported, and the trust was the recipient of many awards, both national and international, for the excellence of some of its services.
  • The leadership in the critical care unit was outstanding.

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We saw many areas of outstanding practice including:

  • A ‘Coffee and conversation’ group was held for patients in the stroke wards. This gave patients an opportunity to share their experiences, provide peer support and education. Patients were also given information about support available in the community.
  • There were good arrangements for meeting the needs of patients with a learning disability, particularly in theatres. The staff showed good awareness of the specialist support that patients with complex needs sometimes require. Staff used a specialist pain management tool for assessing pain levels in patients who could not verbally communicate their experiences of pain.
  • The trust had developed bespoke safeguarding training modules to meet the specific needs of staff and their working environments. For example, there was safeguarding training specific to the issues identified for staff working in theatres and specific types of wards.
  • The practice of daily safety briefings on the intensive care unit (ICU) ensured the whole multidisciplinary team was aware of potential risks to patients and the running of the unit.
  • In the ICU there were innovative approaches to the development and use of IT systems and social media. Secure Facebook and Twitter accounts enabled staff to be updated about events affecting the running of the service. This included information about risks, potential risks and incidents. Electronic ‘Watch out’ screens in the unit displayed information about incidents and the unit’s risk register. The education team advertised information about training opportunities on the education Twitter account.
  • In the ICU, innovative electronic recording systems supported the effective assessment and monitoring of patients.
  • The electronic monitoring system used in the hospital for monitoring patients’ vital signs enabled staff to review patient information in real time and the outreach team to monitor patients on all wards and prioritise which patients they needed to attend to. This early warning system was developed in response to delayed care in deteriorating patients. Its adoption has saved over 400 deaths, and overall has reduced our mortality levels by 15%.
  • Innovative and practical planning of emergency trolleys meant that all equipment needed to manage a patient’s airway, including equipment to manage difficult airways and surgical equipment, was stored in a logical order and was immediately accessible.
  • In most critical care services, beds are positioned to face into the ward. On some units beds were positioned so that conscious patients could look out of the window. Queen Alexandra Hospital’s critical care unit had learnt that some patients were frightened when they could not see the ward and wanted to be able to see into the unit for reassurance. In response, the unit had equipment that could position beds at an angle so patients could see out of window as well as into the unit.
  • In response to difficulties in recruiting middle-grade (registrar) doctors, the ICU in partnership with the University of Portsmouth was developing a two-year course in Advanced Critical Care Practice (ACCP). The planned outcome from this course was that Advanced Critical Care Practitioners would be employed in the unit to fulfil some of the medical tasks and release medical staff to do more complicated work. This was the first initiative of this kind in the UK.
  • To reduce the risks for patients requiring critical care who were located elsewhere in the hospital, the ICU had an innovative practice of retrieving the patient from elsewhere in the hospital. Patients admitted into the emergency department (ED) requiring critical care were treated by the critical care team in the ED, before admission to the unit. The same practice was followed for patients requiring admission to the unit from the general wards.
  • The innovative use of grab packs meant staff had instant guidance about what to do in the event of utility failure, emergency telephone breakdown and major incidents.
  • The critical care unit had developed their own innovative website that included educational information and guidance documents. There was guidance, tutorials and podcasts from recognised intensive care organisations, Portsmouth intensive care staff and other intensive care staff about the use of intensive care equipment and procedures. This was accessible to staff, staff from other trusts and the general public.
  • A perineal clinic had been designed and implemented to provide outpatients care and treatment to women who had sustained third- and fourth-degree tears following delivery. This service enabled women to access treatment sooner than under previous systems. Staff also provided treatment, support, information and education to women who had experienced female genital mutilation.
  • There was a telephone scheme for women who had experienced complex or traumatic deliveries to talk about, and have a debrief conversation, with a midwife following their discharge. The outcomes from the conversations were used as part of the governance processes and this had demonstrated a reduction in the number of complaints.
  • A mobile telephone application (app) had been developed by the trust and the Chair of the Midwife Liaison Committee together with women who used the services. The app provided information on choices of place of birth and was being developed to include additional information. The app won an award from NHS England in the excellence in people category and the service had also been recognised with an innovation award from Portsmouth Hospitals NHS Trust.
  • The multidisciplinary team in the children’s and young people’s services had made a commitment to creating an open culture of learning, reflection and improvement. This included listening to and empowering and involving staff, children, young people and their families. We found all staff, at all levels, were involved in working towards this goal and this was having a positive impact on improving the safety and quality of services for children, young people and their families.
  • There was a new initiative called a ‘talent panel’, which was a mechanism to discover and develop staff, both for individual career development and the future sustainability of the service. Staff of all grades were encouraged to submit their career aspirations to a panel so that steps to support them could be identified.
  • The trust had introduced a volunteer programme for people who wanted to work as a chaplain’s assistant. Volunteers were trained on how to support patients through visiting them. Through this training programme, the trust had over 50 volunteers coming to help and support patients.
  • The trust received a national award for clinical research impact. The award recognised the trust “Research in Residence Model” and its ability to harness clinical research to improve services and treatments for its patients. The trust identified the development of the early warning system, mobile application for pregnant mothers (cited above), and developing methodologies to reduced respiratory exacerbations and admissions and detect upper and lower gastrointestinal cancer more effectively.

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

Importantly, the trust must ensure that:

  • Patients are appropriately assessed and monitored in the ED to ensure they receive appropriate care and treatment.
  • Ambulance patients are received and triaged in the ED by a qualified healthcare professional.
  • There are effective system to identify, assess and manage the risks in the ED.
  • There is an adequate supply of basic equipment and timely provision of pressure-relieving mattresses.
  • The cardiac arrest call bell system in E level theatres is able to identify the location of the emergency.
  • Medication is prescribed appropriately in surgery and is administered as prescribed in gynaecology
  • The emergency resuscitation trolley on the gynaecology ward is appropriately checked.
  • Appropriate standards of care are maintained on ward E3 and the acute medical unit.
  • There is a hospital wide approach to address patient flow and patient care pathways across clinical service centres.
  • Patients’ bed moves are appropriately monitored and there is guidance around the frequency and timeliness of bed moves so that patients are not moved late at night, several times and for non-clinical reasons.
  • Patients are allocated to specialist wards, when clinical need requires this, and medical outliers are regularly reviewed by medical consultants.
  • Nurse staffing levels comply with safer staffing levels guidance.
  • There are adequate numbers of medical staff on shifts at all times.
  • All wards have the required skill mix to ensure patients are adequately supported by competent staff.
  • The falls action plans are followed in a consistent way across the medical services.
  • There is compliance with the WHO Surgical Safety Checklist.
  • Staff awareness of standard protocols or agreed indicators for pre-assessment improves to support them in making decisions about the appropriateness of patients for day case surgery.
  • Staff on all wards are able to raise concerns above ward level, particularly when this impacts on patient care, and there is a response to these concerns.
  • Discharge summaries are sent out in a timely manner and include all relevant information in line with Department of Health (2009) guidelines.
  • Staff observe recognised professional hand hygiene standards at all times.
  • The surgical high care unit is risk-assessed for infection control risks.
  • Medical and dental staff complete mandatory and statutory training.
  • Nursing staff receive formal clinical supervision in line with professional standards.
  • Nursing handovers provide sufficient information to identify changes in patients’ care and treatment and to ensure existing care needs are met.
  • Nursing staff are appropriately trained in the safe use of syringe drivers.
  • All pharmacists have an appropriate understanding of insulin sliding scales and where such information should be recorded.
  • Patient confidentiality is protected so that patients and visitors cannot overhear confidential discussions about patients’ care and treatment.
  • Records are kept relating to the assessment and monitoring of deteriorating patients in recovery.
  • Patient records and drug charts are complete and contain all required information relating to a patient’s care and treatment.
  • Do not attempt cardiopulmonary resuscitation forms are completed appropriately and mental capacity assessments, where relevant, are always performed.
  • Patient records are stored so that confidentiality is maintained.
  • The trust fully participates in all national audits for which it is eligible on end of life care.
  • Action is taken to improve the leadership where there are services and ward areas of concern.

At a trust level:

  • The trust clinical strategy is supported by clear improvement plans and these are monitored and evaluated appropriately.
  • Governance arrangements are managed effectively so that there is appropriate assurance around risk and performance.
  • The trust board has a development programme and there should be appropriate and timely assessment of its performance.
  • There is continued investment in PALS.
  • Complaints are appropriately monitored and responded to in a timely manner.

In addition, the trust has a number of actions that it should take and these are identified in the location report for Queen Alexandra Hospital.

Professor Sir Mike Richards, Chief Inspector of Hospitals

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.