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Provider: The Princess Alexandra Hospital NHS Trust Requires improvement

On 31 July 2019, we published a report on how well The Princess Alexandra Hospital NHS Trust uses its resources. The ratings from this report are:

  • Use of resources: Good  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Reports


Inspection carried out on 27 Mar to 24 Apr 2019

During a routine inspection

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

  • We rated safe, effective, responsive and well led as requires improvement.
  • We rated three of the six core services we inspected as requires improvement. Our ratings took into account the previous ratings of services not inspected this time. Our decisions on overall ratings take into account factors including the relative size of services and we use our professional judgement to reach a fair and balanced rating.
  • The rating of the key question of effective had gone down to requires improvement since our last inspection in December 2017.
  • The rating for maternity services at this inspection was requires improvement in safe, effective, responsive and well led.
  • The requires improvement rating remained the same for urgent and emergency services and medical care (including older people’s care).
  • Some issues that contributed to a breach of regulation at our last inspection in December 2017, had not been fully resolved at this inspection; in some services patient records were not always maintained in a timely or consistent manner. Mandatory training compliance remained an area of concern and nurse vacancies were high in some areas.
  • Safety incidents were not always managed in a timely manner and at the time of our inspection, the trust had recently identified significant number of incidents that had not been appropriately dealt with on its electronic reporting system. Some of which dated back to 2013.
  • Governance systems were not fully established or embedded to assess, monitor and improve the quality and safety of services and manage risk across all services within the trust.

However:

  • We rated the trust as good in caring overall. Our rating for the trust took into account the previous rating of services not inspected this time.
  • The rating for children and young people’s services had improved from requires improvement to good overall with outstanding for caring since our last inspection in 2017.
  • The effective key question in end of life care services had improved from requires improvement to good since our last inspection in December 2017.
  • The key question of well led had improved from requires improvement to good in urgent and emergency services and services for children and young people since our last inspection in December 2017.
  • The key question of responsive had improved from requires improvement to good in medical care (including older people’s care), surgery and services for children and young people’s service since our last inspection in December 2017.


CQC inspections of services

Inspection carried out on 5 Dec to 19 Dec 2017

During an inspection looking at part of the service

  • Our rating of the trust improved. We rated it as requires improvement because:
  • Safe and responsive were requires improvement and effective, caring and well-led were good.
  • Urgent and emergency care had improved from inadequate to requires improvement overall. The question of safety went from inadequate to requires improvement. The question of effective went from requires improvement to good and well-led went up from inadequate to requires improvement.  The question of caring remained good and responsive improved from inadequate to requires improvement. The department had made improvements in assessing and responding to patient risk, staff knew how to report incidents and learning from incidents was shared amongst staff. The department had a clear management structure in place and demonstrated effective oversight of risk within the service. Well-led remained as requires improvement.
  • Medical care (including older people’s care) overall rating remained as requires improvement. Safe and responsive remained requires improvement, effective and caring remained good and well-led went down from good to requires improvement. Concerns remained around staffing levels and the low numbers of staff completing mandatory training. Waiting times from referral to treatment and discharge of patients were not in line with targets or national averages. However, staff were kind and compassionate and the service took account of patients’ individual needs and planned around the needs of local people.
  • Surgery services overall rating remained as requires improvement. The safe rating improved from inadequate to ‘requires improvement’ with effective, caring and well-led improving to ‘good’ and responsive remaining ‘requires improvement’. There was improvement in the reporting and learning from incidents. Care was evidenced based and delivered with compassion and there was an improved culture of support with more visible leadership team. However, safeguarding children level three training remained a concern as did medical staff mandatory training and appraisal and referral to treatment performances against national standards were variable.
  • Critical care (CRCU) improved from inadequate to good overall. Safe, effective and well-led all improved to a rating of good, caring remained rated good and responsive improved from inadequate to requires improvement. Concerns remained around the mixed gender accommodation breaches in the CRCU and lack of space in high dependency unit (HDU) due to the outdated design of the estate. Nursing and medical staff were still not meeting mandatory training targets.
  • Services for children and young people remained rated as requires improvement overall. The question of safety improved from inadequate to requires improvement. The questions of effective and caring both remained rated as good. The question of responsive went down from good to requires improvement. The question of well-led stayed as requires improvement. The service had made improvements notably in terms of safeguarding and checks of resuscitation trolleys; and had a strong leadership team in place with a team-based culture. However, we had concerns within the service, notably due to the lack of transition arrangements to meet the needs of adolescent pathways and low compliance with life support training, which remained an issue since the previous inspection. We were also concerned about the arrangements for staffing on Dolphin ward as they were not always in line with the Royal College of Nursing (RCN) guidelines.
  • End of life care services overall improved from inadequate to good. The question for safety improved from requires improvement to good and effective stayed requires improvement. The trust's ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms did were not always completed correctly. There were lack of assurances that the Mental Capacity Act and Deprivation of Liberty Safeguards were always being implemented for people who had DNACPR documentation. Caring remained good. The question for responsive improved from inadequate to good and well-led improved from inadequate to good. The service provided care and treatment based on national guidance and evidence of its effectiveness were monitored.

Inspection carried out on 28 and 29 June 2016, 2 and 6 July 2016

During an inspection looking at part of the service

We carried out a comprehensive inspection on 28 and 29 June 2016 as part of our regular inspection programme. This inspection was carried out as a comprehensive follow up inspection to assess if improvements have been made in all core services since our last inspection in July 2015.

The Princess Alexandra Hospital NHS Trust is located in Harlow, Essex and is a 460 bedded District General Hospital providing a comprehensive range of safe and reliable acute and specialist services to a local population of 350,000 people. The trust has 5 sites; Princess Alexandra Hospital, St Margaret’s Hospital, Herts and Essex Hospital, Cheshunt Community Hospital and Rectory Lane Clinic. At our inspection on 28 and 29 June 2016, we inspected The Princess Alexandra Hospital. On our unannounced inspection on 2 and 5 July 2016, we inspected The Princess Alexandra Hospital. We reviewed the service provided at the Rectory Lane Clinic and found that this location did not require registration. The trust informed us that they would be applying to remove this location.

During this inspection, we found that there had been deterioration in the quality of services provided since our previous inspection in 2015. There was a lack of management oversight and lack of understanding of the detail of issues which we observed. We found that the trust had significant capacity issues and was having to reassess bed capacity at least three times a day. This pressure on beds meant that patients were allocated the next available bed rather than being treated on a ward specifically for their condition. We found that staff shortages meant that wards were struggling to cope with the numbers of patients and that staff were moved from one ward to cover staff shortages on others. The trust sees on average around 350 patients a day in its emergency department (ED).

We have rated the Princess Alexandra Hospital location as inadequate overall due to significant concerns in safety, responsiveness and leadership, with an apparent disconnect between the trust board leadership level and the ward level. It was evident that the trust leaders were not aware of many of the concerns we identified through this inspection. However, we found that the staff were very caring in all areas. We have rated the maternity and gynaecology service as outstanding overall.

Our key findings were as follows:

  • Shortages of staff across disciplines coupled with increased capacity meant that services did not always protect patients from avoidable harm, impacted upon seven day provision of services and meant that patients were not always treated in wards that specialised in the care their condition.
  • The disconnect between ward staff and the matron level had improved, however some cultural issues remained at this level which required further work.
  • The relationship between staff and the site management team had improved, though this was still work in progress and the trust acknowledged further work was required here.
  • Agency staff did not always receive appropriate orientation, or have their competency checks undertaken for IV care for patients on individual wards. This had improved by the time our unannounced inspection concluded.
  • The storage, administration and safety of medication was not always monitored and effective.
  • Information flows and how information was shared to trust staff were not robust. This meant that staff were not always communicated to in the most effective ways.
  • The staff provided good care despite nursing shortages.
  • There were poor cultural behaviours noted in some areas, with some wards not declaring how many staff or beds they had overnight to try and ease the workloads. This was a result of constant pressure on the service activities.
  • The mortuary fridges had deteriorated since our last inspection and were no longer fit for purpose. These were replaced during our unannounced inspection to ensure they provided an appropriate environment for patients.
  • Across surgery, there were notable delays in answering call bells on surgical wards including Kingsmoor and Saunders ward.
  • Gynaecology inpatient care had not improved, but declined, since our previous inspection. The inpatient gynaecology service, which was operated through surgery, was not responsive to the needs of women.

We saw several areas of outstanding practice including:

  • The ward manager for the Dolphin children’s ward had significantly improved the ward and performance of children’s services since our last inspection
  • The tissue viability nurse in theatres produced models of pressure ulcers to support the education and prevention of pressure ulcer development in theatres. This also helped to increase reporting.
  • The improvement and dedication to resolve the backlog and issues within outpatients was outstanding.
  • The advanced nurse practitioner groups within the emergency department were an outstanding team, who worked to develop themselves to improve care for their patients.
  • The gynaecology early pregnancy unit and termination services was outstanding and provided a very responsive service which met the needs of women.
  • The outcomes for women in the maternity service were outstanding and comparable with units in the top quartile of all England trusts.
  • MSSA rates reported at the trust placed them in the top quartile of the country.
  • The permanent staff who worked within women’s services were passionate, dedicated and determined to deliver the best care possible for women and were outstanding individuals.
  • The lead nurse for dementia was innovative in their strategy to improve the care for people living with dementia.

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

Importantly, the trust must:

  • Ensure that fit and proper persons processes are ratified, assessed and embedded across the trust board and throughout the employment processes for the trust.
  • Ensure that the risk management processes, including board assurance processes, are reviewed urgently to enable improved management of risk from ward to board.
  • Ensure that safeguarding children’s processes are improved urgently and that learning from previous incidents is shared.
  • Ensure that staff are provided with appraisals, that are valuable and benefit staff development.
  • Improve mandatory training rates, particularly around (but not exclusive to) safeguarding children level 3, moving and handling, and hospital life support.
  • Ensure that trust staff are knowledgeable and provide care and treatment that follows the requirements of the Mental Capacity Act 2005.

These are the areas the trust should improve on:

  • Review the priority improvement programme to ensure that the mortuary is refurbished.
  • Review the cleaning schedules for the public areas throughout the hospital, and review the disposal of rubbish arrangements from the portering area to reduce the impacts of waste build up.
  • Review the processes of how ward to board escalation is embedded to ensure that all concerns are captured where possible.

As a result of the findings from this inspection I have recommended to NHS Improvement that the trust be placed into special measures. It is hoped that the trust will make significant improvements through receipt of support from the special measures regime prior to our next inspection.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21 – 23 July 2015 and 30 July 2015

During a routine inspection

We carried out a comprehensive inspection between 21 and 23 July 2015 as part of our regular inspection programme. In May 2015 the intelligence monitoring system showed that there were two elevated risks and ten risks. The elevated risks were around mortality and the risks included risks from survey questions and audit data such as the four hour target in the A&E department.

The Princess Alexandra Hospital NHS Trust is located in Harlow, Essex and is a 419 bedded hospital excluding maternity and children's services and escalation areas. The hospital provides a comprehensive range of safe and reliable acute and specialist services to a local population of 258,000 people. The trust has 5 sites; Princess Alexandra Hospital, St Margaret’s Hospital, Herts and Essex Hospital, Cheshunt Community Hospital and Rectory Lane. At our inspection on 21- 23 July we inspected The Princess Alexandra Hospital. On our unannounced inspection on 30 July 2015 we inspected The Princess Alexandra Hospital, St Margaret’s Hospital and the Herts and Essex Hospital.

During this inspection we found that the trust had significant capacity issues and was having to reassess bed capacity at least three times a day. This pressure on beds meant that patients were allocated the next available bed rather than being treated on a ward specifically for their condition. We found that staff shortages meant that wards were struggling to cope with the numbers of patients and that staff were moved from one ward to cover staff shortages on others. The trust sees on average around 300 patients a day in its emergency services.

We have rated this location as requires improvement overall due to significant concerns in safety, responsiveness and the apparent disconnect between ward staff and the middle managers. We found that the staff were exceptionally caring and that they went the extra mile for their patients.

Our key findings were as follows:

  • Shortages of staff across disciplines coupled with increased capacity meant that services did not always protect patients form avoidable harm, impacted upon seven day provision of services and meant that patients were not always treated in wards that specialised in the care of health issues.
  • The security of women, babies and children was not always maintained within the hospital.
  • There was a disconnect between ward staff and the duty matron level as capacity pressures were managed.
  • Agency staff did not always receive appropriate orientation or training to assist them in the care of patients on individual wards.
  • The storage, administration and safety of medication was not always monitored and effective.
  • Information flows were not always robust.
  • The staff provided good care despite nursing shortages and often went the extra mile to ensure that patients had a good experience within the hospital.
  • Staff were compassionate and ensured that patients dignity and privacy was respected.

We saw several areas of outstanding practice including:

  • The acting ward manager for the Dolphin Children’s ward had made a significant improvement in a short time to the ward and showed outstanding leadership and determination.
  • The play specialist providing dedicated time to fundraise to purchase toys and set up playgroups for the children was outstanding.
  • The teenage zone within the children’s ward was outstanding and was very responsive to the needs of teenagers.
  • The gynaecology outpatient and emergency service as a function, including the termination of pregnancy service was outstanding and provided a very responsive service which met the needs of women.
  • The outcomes for women in the maternity service were outstanding and comparable with units in the top quartile of all England trusts.
  • The permanent staff who worked within women’s services were passionate dedicated and determined to deliver the best care possible for women and were outstanding individuals.

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

Importantly, the trust must:

  • Ensure that disposable items of equipment are not reused on patients.
  • Ensure that the maternity unit is secure and that there is an effective system in place to ensure the safety of babies from abduction from the unit.
  • Ensure that the child abduction policy is updated, reflective of current practice and tested.
  • Ensure that the escalation policy is reviewed to prevent medical outliers being placed on the birthing unit at times of high capacity.
  • Ensure that medicines administered to patients take into account the patient’s allergy status and that the policy for the administration of medicines is adhered to. That medicines are stored appropriately and that appropriate checks are maintained to ensure the safety of medicines.
  • Ensure that all staff are appropriately trained, appraised and inducted for their roles, including agency and temporary staff.
  • Ensure that equipment is checked in accordance with trusts policies including resuscitation equipment.
  • Ensure that all guidelines and policies within the children’s accident and emergency high dependency room are up to date with current practice.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


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.