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Provider: Brighton and Sussex University Hospitals NHS Trust Good

On 08 January 2019, we published a report on how well Brighton and Sussex University Hospitals NHS Trust uses its resources. The ratings from this report are:

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

Read more about use of resources ratings

Read our reports of listening activity in December 2013 and January 2014 and for Community health services for children, young people and families, published on 8 August 2014.

CQC carried out a period of listening activity at Brighton and Sussex University Hospitals NHS Trust in December 2013 and January 2014. The report from that exercise, which informed our inspection in May 2014, is available below.

In August 2014, we published the results of our inspections into the trust. The report for the Community health services for children, young people and families is available to download below.

Reports


Inspection carried out on 25 September 26 September

During a routine inspection

Our rating of the trust improved. We rated it as good because:

  • The trust had made huge improvements since the new executive team had introduced improved systems of working. The trust had a new strategy, vision and values which underpinned a culture which was patient centred. The ‘Patient First Improvement System’ had empowered front line staff by equipping them with the lean tools, methods and a structured process which had helped to build and promote a culture of continuous improvement across the whole trust.
  • A new divisional structure had been created around the pre-existing directorate structure. This had strengthened the existing leadership and management arrangements of the clinical services.
  • Quality was a ‘golden thread’ running through the trust Patient First Strategy. In all the interviews undertaken on inspection this was evident in the use of data both quantitative and qualitative and how this was triangulated and reported through the Quality Steering Group to the Quality Assurance Committee and the trust board.
  • All staff we spoke with on inspection were clear about the trust's approach and priority to deliver high quality sustainable care to patients. Staff knew and understood the trust’s vision, values and strategy and how achievement of these applied to the work of their team. To support the roll-out of Patient First across the trust, a communications plan was developed and implemented. The plan was tailored to different audiences to best reach staff in different parts of the organisation. Staff spoke about feeling that the Patient First Strategy had given them the ability to all speak the same language.
  • The board received holistic information on service quality and sustainability. There was a programme of board visits to services and staff we spoke with told us that that leaders were approachable.
  • Staff felt equality and diversity were promoted in their day to day work. We spoke with the newly formed Black and minority ethnicity working group. The trust had held an event in May where over 200 members of staff had come together to discuss equality and Black and minority ethnicity issues and start the forming of a new strategy. The output of this meeting was three workstreams; communication, recruitment, and education. The group we spoke with told us that they had seen a dramatic change in the past 6-9 months. They described this as powerful, positive and feeling included in the strategy and change. Staff told us that although they had not always felt supported in the past since the new executive team had arrived they now felt confident that they could raise any concerns about staff behaviours towards them with their line managers, and they felt assured that their concerns would be listened to and acted on appropriately.
  • Staff felt respected, supported and valued. The executive teams and divisional leaders told us how they felt that improving the experience and engagement of their staff was fundamental to delivering a culture of high sustainable care and trust strategic objectives.
  • The trust’s Patient First Improvement System empowered staff to make improvements and to be listened to and respected. In areas where ‘Patient First’ had been introduced the level of engagement and motivation had significantly improved as staff felt empowered to make improvements in their work. This was evident both on CQC engagement events at the trust and on inspection.
  • A clear framework set out the structure of ward/service team, division and senior trust meetings. Managers used meetings to share essential information such as learning from incidents and complaints and to act as needed. The trust had governance and management arrangements had been strengthened significantly since the management agreement with Western Sussex Hospitals Foundation Trust and NHS Improvement. These arrangements enabled all clinical and management staff to function in an effective and efficient manner through both line management arrangements and governance arrangements.
  • The board had invited the Good Governance Institute (GGI) carry out a review of the trust’s quality governance structures, which resulted in 31 separate recommendations being made. The trust acted to address these issues and the Good Governance institute carried out a further review reporting on progress against these actions. A focus of this work has been to strengthen quality governance arrangements at divisional level.
  • The trust had effective structures, systems and processes in place to support the delivery of its strategy including sub-board committees, divisional committees, team meetings and senior managers. Leaders regularly reviewed these structures. The trust reported regularly through its governance arrangements on progress against delivery of its strategy to the board, Trust Executive Committee and to other relevant committees. However, the structure needed more time to become fully embedded.
  • The trust executive team had worked hard to roll out Patient First Strategy across the trust. They had done this in a structured way by considering which areas of the trust would benefit the most from the methodology and training. There was no doubt that areas who had imbedded Patient first had made the largest impact on improvement. Although we were impressed at the speed and spread of improvement the trust needed more time to embed this methodology across the whole trust.


CQC inspections of services

Service reports published 8 August 2014
Inspection carried out on To Be Confirmed During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Inspection carried out on 5th-8th April 2016

During a routine inspection

The Royal Sussex County Hospital (RSCH) in Brighton forms part of Brighton and Sussex University Hospitals Trust. RSCH is a centre for emergency and tertiary care. The Brighton campus includes the Royal Alexandra Children’s Hospital (The Alex) and the Sussex Eye Hospital.

The hospital provides services to the local populations in and around the City of Brighton and Hove, Mid Sussex and the western part of East Sussex. and more specialised and tertiary services for patients across Sussex and the south east of England.

The Trust has two sites, Royal Sussex County in Brighton and the Princess Royal Hospital in Haywards Heath, consisting of 1,165 Beds; 962 General and acute, 74 Maternity, and 43 Critical care. It employs 7,195.92 (WTE) Staff; 1,050.59 of these are Medical (WTE), 2,302.52 Nursing (WTE), 3,842.81 other.

It has revenue of £529,598km; with a full cost of £574,417k and a Surplus (deficit) of £44,819k

Between 2015-2016 the Trust had 118,233 inpatient admissions; 640,474 Outpatient attendances, and 156,414 A&E attendances.

This hospital was inspected due our concerns about the Trusts ability to provide safe, effective, responsive and well led care. We inspected this hospital on 4-8 April 2016 and returned for an announced inspection on 16 April 2016.

Our key findings were as follows:

Safe

  • Incident reporting was understood by staff but there was a variation in the departments on completion rates and a lack of learning and analysis.

  • The trust had reported seven never events (5 of which were at RSCH) between Jan’ 15 to Jan’ 16, all seven were attributed to surgery and four of which were related to wrong site surgery incidents.

  • Not all areas of the hospital met cleaning standards and the fabric of the buildings in some areas was poor, and posed a risk to patients, particularly with regard to fire safety.

  • We had particular concerns that the risk of fire was not being managed appropriately. We found that the Barry and Jubilee buildings were a particular fire safety risks as they were not constructed to modern safety standards and had been altered and redesigned many times during their long history. They were overpopulated, overcrowded and cluttered with narrow corridors and inaccessible fire exits. We found flammable oxygen cylinders were stored in the fire exit corridors. We found that fire doors with damaged intumescent strips which would not provide half an hour fire barrier in the event of horizontal evacuation.

  • Patients in the cohort area of the emergency department were not assessed appropriately; there was a lack of clinical oversight of these patients and a lack of ownership by the Trust board to resolve the issues.

  • There were no systems in place for the management of overcrowding in the ‘cohort’ area. Staff were not able to provide satisfactory details of “full capacity” protocols or triggers used to highlight demand exceeding resources to unacceptable levels of patients in the area.

  • The recovery area at RSCH in the operating theatres was being used for emergency medical patients due to having to reduce the pressure on an overcrowded ED and to help meet the emergency departments targets such as 12 hour waits. Some patients were transferred from the HDU to allow admission to that area and some patients were remaining in recovery when there was no post-operative bed available. Some patients were kept in the recovery area for anything between four hours and up to three days

  • Staffing levels across the hospital were on the whole not enough to provide safe care for example the mixed ICU and cardiac ICU frequently breached the minimum staff to patient ratios set by the Intensive Care Society and the Royal College of Nursing.

  • In some areas the trust had systematically failed to respond to staff concerns about this and mitigating strategies had failed.

  • Medicines management in the hospital was generally good, with the exception of Critical Care and out patients, significantly below the standard expected.

  • We mostly saw that records were well managed and kept appropriately, However in OPD we observed records lying in unlocked areas that the public could access.

  • The trust had a safeguarding vulnerable adults and children policy, and guidelines were readily available to staff on the intranet and staff were able to access this quickly. However, safeguarding training for all staff groups was lower than the Trusts target.

  • Staff compliance in mandatory training, statutory training and appraisals fell below the trust target of 95% for statutory training and 100% for mandatory training, for both nurses and doctors across every department in the hospital.

  • The trust had a Duty of Candour (DOC) policy, DOC template letters and patient information leaflets regarding DOC, and we saw evidence of these. The trust kept appropriate records of incidents that had triggered a DOC response, which included a DOC compliance monitoring database and we saw evidence of these. Most staff we spoke with understood their responsibilities around DOC.

Effective

  • Staff generally followed established patient pathways and national guidance for care and treatment. Although we saw some examples of where patient pathway delivery could be improved.

  • National clinical audits were completed. Mortality and morbidity trends were monitored monthly through SHIMI (Summary Hospital-level Mortality Indicator) scores. Reviews of mortality and morbidity took place at local, speciality and directorate level although a consistent framework of these meetings across all specialities was not in place. The trust’s ratio for HSMR was better than the national average of 80%.

  • Staff knew how to access and used trust protocols and guidance on pain management, which was in line with national guidelines.

  • Patient’s nutritional needs were generally met although patients in the cohort area at RSCH, ED at PRH and recovery RSCH did not always have easy access to food and water. In critical care there was no dedicated dietician.

  • Appraisal arrangements were in place, but compliance was low across the hospital. Trust wide 68% of staff had received an annual appraisal against the trust target of 75%. Accountability for these lapses was unclear.

  • Some services were not yet offering a full seven-day service. For example in medical care  constraints with capacity and staffing had yet to be addressed. Consultants and support services such as therapies operated an on-call system over the weekend and out of hours. This limited the responsiveness and effectiveness of the service the hospital was able to offer.

  • There were innovative and pioneering approaches to care with evidence-based techniques and technologies used to support the delivery of high quality care and improve patient outcomes in children and young peoples services

Caring

  • Staff were caring and compassionate to patients’ needs, and patients and relatives told us they received a good care and they felt well looked after by staff.

  • Children and young people at the end of their lives received care from staff who consistently went out of their way to ensure that both patients and families were emotionally supported and their needs met.

  • Privacy, dignity and confidentiality was compromised in a number of areas at RSCH, particularly in the cohort area, out patients department and on the medical wards in the Barry building.

  • The percentage who would recommend the trust (Family and Friends Test) was lower than the England average for the whole time period until the most recent data for Dec ’15, where is it currently above the England average.

  • Patients reported they were involved in decisions about their treatment and care. This was reflected in the care records we reviewed.

  • We saw no comfort rounds taking place whilst we were in the ED department. This meant patients who were waiting to be treated may not have been offered a drink or had their pressure areas checked.

Responsive

  • The admitted referral to treatment time (RTT) was consistently below the national standard of 90% for most specialties. The trust had failed to meet cancer waiting and treatment times.

  • The length of stay for non-elective surgery was worse than the national average for trauma and orthopaedics, colo-rectal surgery and urology

  • The percentage of patients whose operations were cancelled and not treated within 28 days was consistently higher than the England average.

  • According to data provided by the trust, between January 2015 and December 2015 3,926 people waited between 4 to 12 hours (and 71 people over 12 hours) from the time of “decision to admit” to hospital admission. Since the inspection an additional 12 patients have been reported as waiting over 12 hours.

  • Interpreters were available for those patients whose first language was not English. This was arranged either face to face or through a telephone interpreter. Staff told us that under no circumstances would a family member be able to act as an in interpreter where a clinical decision needed to be made or consent needed to be given.

  • We saw examples of wards including the dementia care ward that operated the butterfly scheme. The butterfly scheme is a UK wide hospital scheme for people who live with dementia. We also saw that they had a dignity champion. This is someone who works to put dignity and respect at the heart of care services.

Well Led

  • Staff in general reported a culture of bullying and harassment and a lack of equal opportunity. Staff survey results for the last two years supported this. Staff from BME and protected characteristics groups reported that bullying, harassment and discrimination was rife in the organisation with inequality of opportunity. Data from the workforce race equality standard supported this. Staff reported that inconsistent application of human resource policies and advice contributed to inequality and division within the workforce and led to a lack of performance and behaviour management within the organisation. These cultural issues had been longstanding within the trust without effective board action.

  • There was a clear disconnect between the Trust board and staff working in clinical areas, with very little insight by the board into the key safety and risk issues of the trust, and little appetite to resolve them.

  • The trust had a complex vision and strategy which staff did not feel engaged with. There was a lack of cohesive strategy for the services either within their separate directorates or within the trust as a whole. Whilst there were governance systems in place they were complex and operating in silos. There was little cross directorate working, few standard practices and ineffective leadership in bringing the many directorates together.

  • The culture at RSCH was one where poor performance in some areas was tolerated and 50% of staff said in the staff survey they had not reported the last time they were bullied or harassed.

  • There was a problem with stability of leadership within the trust. There were several long term vacancies of key staff. During the inspection we noted a number of senior management staff had taken leave for the period of the inspection.

  • BME staff felt there was a culture of fear and of doing the wrong thing. They told us this was divisive and did not lead to a healthy work place where everyone was treated equally.

  • Ward mangers and senior staff reported that they received little support from the trust’s HR department in managing difficult consultants or with staff disciplinary and capability issues. They told us that HR advised staff to put in a grievance as a first step in resolving any issue. However the Trust workforce evidence that HR Department supported 36 disciplinary matters and 16 dismissals and that the grievance rate had reduced significantly during 2015/16.

  • The relocation of neurosurgery intensive care from Hurstwood Park to Brighton in June 2015 had been managed without appropriate planning and risk assessment and also lacked evidence of robust staff consultation. This had led to a culture in which nurses did not feel valued and there was significant and sustained evidence of non-functioning governance frameworks.

  • The executive team failed on multiple occasions to provide resources or support to clinical staff in critical care to improve safety and working conditions and there was no acknowledgement from this team that they understood the problems staff identified.

We saw several areas of outstanding practice including:

  • The play centre in The Alex children’s hospital had an under the sea themed room with treasure chests full of toys and a bubble tank. There was also an interactive floor where fish swam around your feet and changed direction according to your footsteps.

  • The children’s ED was innovative and well led, ensuring that children were seen promptly and given effective care. Careful attention had been paid to the needs of children attending with significant efforts taken to reassure them and provide the best possible age appropriate care.

  • The virtual fracture clinic had won an NHS award for innovation. It enabled patients with straightforward breaks in their bones to receive advice from a specialist physiotherapist by telephone.It reduced the number of hospital attendances and patients could start their treatment at home.

  • We found that an outstanding service was being delivered by dedicated staff on the Stroke Unit (Donald Hall and Solomon wards). The service was being delivered in a very challenging ward environment in the Barry building. Staff spoke with passion and enthusiasm about the service they delivered and were focused on improving the care for stroke patients. The results of audits confirmed that stroke care at the hospital had improved over the past year.

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

Importantly the trust must:

  • Ensure that there are sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience to meet the needs of patients using the service at all times.

  • Ensure that all staff have attended mandatory training and that all staff have an annual appraisal.

  • Ensure that newly appointed overseas staff have the support and training to ensure their basic competencies before they care for and treat patients.

  • Undertake an urgent review of staff skill mix in the mixed/neuro ICU unit and this must include an analysis of competencies against patient acuity.

  • Establish clear working guidelines and protocols, fully risk assessed, that identify why it is appropriate and safe for general ICU nurses to care for neurosurgery ICU patients. This should include input from neurosurgery specialists.

  • Take steps to ensure the 18 week Referral to Treatment Time is addressed so patients are treated in a timely manner and their outcomes are improved. The trust must also monitor the turnaround time for biopsies for suspected cancer of all tumour sites.

  • Ensure that medicines are always supplied, stored and disposed of securely and appropriately. This includes ensuring that medicine cabinets and trollies are kept locked and only used for the purpose of storing medicines and intravenous fluids. Additionally the trust must ensure patient group directives are reviewed regularly and up to date.

  • Implement urgent plans to stop patients, other than by exception being cared for in the cohort area in ED.

  • Adhere to the 4 hour standard for decision to admit patients from ED, i.e. patients should not wait longer than 4 hours for a bed.

  • Ensure that there are clear procedures, followed in practice, monitored and reviewed to ensure that all areas where patients receive care and treatment are safe, well-maintained and suitable for the activity being carried out. In particular the risks of caring for patients in the Barry and Jubilee buildings should be closely monitored to ensure patient, staff and visitor safety.

  • Ensure that patient’s dignity, respect and confidentiality are maintained at all times in all areas and wards.

  • Stop the transfer of patients into the recovery area from ED /HDU to ensure patients are managed in a safe and effective manner and ensure senior leaders take the responsibility for supporting junior staff in making decisions about admissions, and address the bullying tactics of some senior staff.

  • Review the results of the most recent infection control audit undertaken in outpatients and produce action plans to monitor the improvements required.

  • Ensure its governance systems are embedded in practice to provide a robust and systematic approach to improving the quality of services across all directorates.

  • Urgently facilitate and establish a line of communication between the clinical leadership team and the trust executive board.

  • Undertake a review of the HR functions in the organisations, including but not exclusively recruitment processes and grievance management.

  • Develop and implement a people strategy that leads to cultural change. This must address the current persistence of bullying and harassment, inequality of opportunity afforded all staff, but notably those who have protected characteristics, and the acceptance of poor behaviour whilst also providing the board clear oversight of delivery.

  • Review fire plans and risk assessments ensuring that patients, staff and visitors to the hospital can be evacuated safely in the event of a fire. This plan should include the robust management of safety equipment and access such as fire doors, patient evacuation equipment and provide clear escape routes for people with limited mobility.

In addition the trust should:

  • Review the consent policy and process to ensure confirmation of consent is sought and clearly documented.

  • Review the provision of the pain service in order to provide a seven day service including the provision of the management of chronic pain services.

  • Consider improving the environment for children in the Outpatients department as it is not consistently child-friendly.

  • Ensure security of hospital prescription forms is in line with NHS Protect guidance.

  • Ensure that there are systems in place to ensure learning from incidents, safeguarding and complaints across the directorates.

  • Ensure all staff are included in communications relating to the outcomes of incident investigations.

  • Implement a sepsis audit programme.

  • Provide mandatory training for portering staff for the transfer of the deceased to the mortuary as per national guidelines.

  • Ensure there is a robust cleaning schedule and procedure with regular audits for the mortuary as per national specifications for cleanliness and environmental standards.

  • Review aspects of end of life care including, having a non-executive director for the service, a defined regular audit programme, providing a seven day service from the palliative care team as per national guidelines and recording evidence of discussion of patient’s spiritual needs.

  • The trust should ensure all DNACPR, ceilings of care and Mental Capacity assessments are completed and documented appropriately as per guidelines.

  • The trust should implement a formal feedback process to capture bereaved relatives views of delivery of care.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21-23, 27 & 30 May 2014

During a routine inspection

Brighton and Sussex University Hospitals Trust is an acute teaching hospital located in Sussex. There are eight sites registered with the Care Quality Commission (CQC). These are the Royal Sussex County Hospital in Brighton, the Princess Royal Hospital in Haywards Heath, Bexhill Hospital, Hove Polyclinic and the Park Centre for breast care services, Lewes Victoria hospital, Brighton General hospital and Worthing hospital Dixon ward. The Brighton campus includes the Royal Alexandra Children’s Hospital and the Sussex Eye Hospital, and the Haywards Heath campus includes the Hurstwood Park Neurosciences Centre. The trust also provides some community services from the Brighton site and these were included in this inspection. We visited all sites except the Park Centre as part of this inspection.

We carried out a comprehensive inspection for a number of reasons. Brighton and Sussex University Hospitals Trust was an aspirant foundation trust, it was also an example of a ‘medium risk’ trust, according to our Intelligent Monitoring model. We also wanted to follow up on the issues that had been raised by staff as part of the listening event held in December 2013. The inspection took place on 21-23, 27 and 30 May 2014.

The trust is dealing with very significant and long standing cultural issues that are reflected in the staff survey results. The current leadership of the trust are tackling issues that have remained unresolved for a number of years. The increased pace of change and improvement dates from the chief executive’s arrival in July 2013. The team noted major strides in the six months since the listening event in December 2013.

Overall, Brighton and Sussex University Hospitals Trust requires improvement. We rated it as good for providing services that are effective and caring. It requires improvement in providing services that are consistently safe, in being responsive to patients’ needs and in being well-led.

Our key findings were as follows:

  • Every service at each location was found to be caring. We observed staff communicating with, and supporting, people in a very caring and compassionate way. Patients and their families spoke highly of the care they had received. The overwhelming majority of the feedback given to the team from all sources was positive.
  • People were receiving care, treatment and support that achieved good outcomes.
  • The trust had a significant change programme underway. The Foundations for Success programme, which started in August 2013, had involved work on vision and values, clinical structure, clinical strategy and accountability and management systems. There was also a long-term development plan that included a major building project and the reconfiguration of services, including the movement of services between sites.
  • The board, executive team and senior management demonstrated a shared understanding of the challenges and risks facing the trust and had plans in place to deal with them. 
  • Staff spoke very positively about the chief executive, who they said was highly visible, engaged, focused and committed to improvement. Staff across the trust and at every level referred to communication having been “transformed” since his arrival. Nursing staff also spoke positively about the chief nurse and the impact that she was having.
  • With very few exceptions, staff across the trust described their pride in the services they were delivering and the support they received from colleagues and managers. Staff were excited about the recent announcement of the £420m redevelopment of the Royal Sussex Hospital site, which was described as a “huge boost”.
  • Mortality rates were within expected ranges and there were no indicators flagged as being a risk or an elevated risk. There has been one mortality outlier alert in adult cardiac surgery that was raised in July 2013, which had been dealt with. There had not been any outlier alerts in maternity.
  • The areas of the trust that we visited appeared clean and cleaning was taking place throughout our inspection. The age of some of the buildings made them more difficult to keep clean. The trust’s infection rates for Clostridium difficile were within an acceptable range, taking into account the size of the trust and the national level of infections. The trust reported five cases of MRSA infections in the last 12 months, with the infections occurring in April and October 2013. This is slightly higher than would be expected. The trust had an effective infection control team and we observed good hygiene practices by staff.
  • The older buildings and some aspects of the layout of the Brighton campus presented a significant challenge in delivering care. For example, patients could not be moved between buildings during bad weather. Some issues could not be resolved until the planned building programme is complete, but, in the meantime, work had been carried out to make improvements, where possible. An example of the latter was the new dementia service, the Emerald Unit in the Barry Building.
  • There were issues with the flow of patients into, through and out of hospital. This was having an impact on care and patient experience in the emergency department (ED), in the medical assessment units, in surgery, in critical care, on the wards and also on the planning and support that people received when they were ready to leave. Some patients were being cared for in wards that were not with their required speciality. The trust needed to achieve 100 discharges a day and, at the time of the inspection, it was achieving between 65 and 70.
  • The pressures on the emergency department were significant and connected to the flow issues described above. The department does not have enough physical space to deal with the number of patients that attend. The department is consistently failing to meet the target to admit, transfer or discharge 95% of patients within four hours. Immediately after the inspection the trust reviewed progress with these work streams to address flow and escalated their actions, in particular the management of the co-hort area in the ED. The trust has been working further with the key stakeholders and has shared these actions and their plans to ensure the effective management of these concerns with us. We are pleased to note the trusts response and will be monitoring and reviewing the impact of these actions.
  • The implementation of a centralised booking system (known as the ‘Hub’) for outpatient and follow-up appointments had not gone smoothly and had caused problems for patients and staff alike. The problems included late notice of appointments, cancelled appointments and clinics, delays in dealing with urgent referrals and clinics running without patients being booked for them. The trust had a comprehensive action plan in place and improvements were in progress.
  • The trust was dealing with a number of significant cultural issues. These included improving engagement with staff, improving and promoting race equality and dealing with some long-standing related issues, addressing the issues that had influenced the staff survey results and improving the take-up of appraisals and access to training.
  • Staffing was an issue. The trust increased its staffing levels from April and filling vacancies had been a challenge. Changes to nursing bank rates had had an impact and some shifts have been hard to fill. The trust still paid the highest NHS bank rates in Sussex, although some staff we met were unaware of that. The trust had invested in improved nursing ratios and supernumerary band 7 nurses from 1 May 2014. Not all posts were filled and the impact of this investment was not yet evident across all services.
  • Staffing levels, particularly in medicine and surgery, and the high use of bank or agency staff placed pressure on staff and put patients at risk of their care needs not being appropriately met. These pressures meant that staff were not always able to attend training, as required.
  • The current arrangements for cleaning services at the trust did not seem to be meeting the needs of all departments in a consistent way.
  • Concerns about the quality of food were a recurring theme in patient feedback during the inspection and in patient survey results. Patient records showed that nutritional risk assessments were being carried out using the Malnutrition Universal Screening Tool (MUST) and, additionally, staff were completing food and nutrition charts for patients who were at risk of weight loss. Fluid charts were also being completed appropriately.
  • Hove Polyclinic was providing outpatient services and was running 63 specialist clinics each week, together with a pain management service. The Polyclinic had a clean and bright environment and patients spoke highly of the care they received. The issues with the implementation of the Hub appointment system had impacted on patients, who were frustrated with the delays and cancellations they had experienced. Two patients whose urgent referrals were not actioned, subsequently required emergency admission to hospital. Additional clinics were being run to clear the backlogs.  
  • The Children’s Community Nursing Team (CCNT) was providing a good service that was appreciated by children and their families. The team communicated well with other professionals and agencies involved with supporting children and their families.
  • The Renal Dialysis Unit at Bexhill Hospital was well managed and had good links with the renal service in Brighton. The service was clean and well maintained, staff had a good rapport with patients and patients spoke highly of the care they received. At the previous inspection, the service was found to be in breach of four regulations relating to safeguarding, cleanliness and infection control, staffing and supporting workers. Bexhill Hospital had taken effective action and these areas were found to be compliant.

We saw several areas of outstanding practice including: 

  • The team felt that the trust was exceptionally open and engaged with the inspection. Information requested was readily supplied without the need for executive-level authorisation, as had been the case in some other trusts. Staff had been encouraged to speak to inspectors and many came forward to speak to us outside of meetings, focus groups and time on the wards.
  • The awareness of staff of the work on values and behaviours was almost universal. With one exception, all the staff we talked to about this had been involved directly in this work, knew a colleague who had been, or were aware of the opportunities that they had had to engage with and influence this work.
  • Care for patients with dementia was very good in both Royal Sussex County Hospital and Princess Royal Hospital, where staff had been innovative and creative in order to provide a safe and stimulating environment for people. Awareness of dementia has been raised across the trust through the ‘Dementia is my business’ campaign and a new care pathway had been launched. The trust presented its work around dementia at the National Dementia Congress in November 2013.
  • The critical care teams at the Royal Sussex County Hospital and the Princess Royal Hospital were strong, committed and compassionate. The feedback from patients was overwhelmingly positive.

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

Importantly, the trust must:

  • Evaluate the effectiveness of the current patient flow and escalation policy and take action to improve the flow of patients within the ED and across the trust. Improvements are needed with discharge planning and arrangements to ensure people are able to leave hospital when they are ready. The trust must continue to engage with partners and stakeholders to achieve sustainable improvement.
  • Ensure that there are enough suitably qualified, skilled and experienced staff to meet the needs of all patients.
  • Ensure that the values, principles and overall culture in the organisation supports staff to work in an environment where the risk of harassment and bullying is assessed and minimised and where the staff feel supported when it comes to raising their concerns without any fear of recrimination.
  • Ensure that relationships and behaviours between staff groups, irrespective of race and ethnicity, is addressed to promote safety, prevent potential harm to patients and promote a positive working environment.
  • Ensure that the environment is suitable for patient investigations, treatment and care and that hazards related to the storage of equipment, which may impact on staff, are minimised.
  • Ensure that all equipment used directly for patient treatment or care is suitably checked and serviced to ensure that it is safe and fit for use.
  • Ensure that the planning and delivery of care on the obstetrics and gynaecology (O&G) units meets patients’ individual needs.
  • Ensure that there are effective systems in place so that patients needing urgent referrals for assessment or treatment are dealt with promptly.
  • Continue the work to ensure that the Hub is providing an effective service to patients and staff.
  • Ensure that staff are supported to receive mandatory training in line with trust policy.
  • Ensure that staff receive an annual appraisal.
  • Review the current cohort protocol to ensure there are clear lines of clinical accountability and responsibility for patients that all trust staff and ambulance trust staff are aware of.
  • Ensure that the privacy of dignity of patients is maintained within the ED, including the current cohort area.  
  • Ensure that staff reporting incidents receive feedback on the action taken and that the learning from incidents is communicated to staff.
  • Review the provision and skills mix of staff to ensure they are suitably trained to meet the needs of children who use the service.

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.