Princess Royal Hospital

Updated 14 February 2024

Princess Royal Hospital is one of the hospitals of University Hospitals Sussex NHS Foundation Trust and provides clinical services to people living in and around Haywards Heath.

At this inspection we inspected the surgery core service at Princess Royal Hospital. We found there was a deterioration in the quality and safety of the surgery service since the last inspection of surgery in 2019, resulting in a drop in their rating. There was no change to the overall rating of Princess Royal Hospital. More detail about the findings and required improvements can be found in the surgery core service section of this report.

Updated 8 January 2019

Our rating of this service improved.

This reflects the improvements made since our inspection in 2017. At this inspection we saw positive changes to the culture with a workforce that felt engaged and able to contribute, the ‘Patient First’ improvement strategy was embedded and staff had bought into the premise, management at all levels was praised and the caring culture was outstanding.

The main concerns from our previous inspection included:

• Mandatory training compliance did not meet trust standards
• There were insufficient fire plans and risk assessments to ensure patients and visitors were able to evacuate safely
• Staff did not regularly receive an appraisal and appraisal completion rates were below the trust standard
• Patient flow through the hospital did not expedite the timely discharge of patients which impacted capacity and length of stay at the hospital
• There was a culture of silo working that impacted on learning from incidents
• Poor behaviour amongst staff was unchallenged and managers were not sufficiently supported by the human resources department.

At this inspection we saw many improvements.

• We saw there had been a concerted effort to improve mandatory training compliance rates in order to meet trust targets. The trust provided comprehensive training. Ward managers were aware of which staff members were up-to-date with their training and those who were out-of-date were closely monitored. The introduction of e-learning enabled staff to complete online training in their own time, which had helped increase completion rates. Service leads were assured that there were sufficient numbers of staff with the right qualifications, training and experience to meet the needs of patients.
• Fire safety improvements had been made with staff at all levels aware of the content and location of fire plans and risk assessments. Evacuation practices had become the norm, and staff were confident they knew what to do in case of a fire.
• The trust had ensured staff had received an appraisal within the last 12 months. Staff we spoke with advised us that they were given adequate time to complete their appraisal, they were given the opportunity to discuss personal development and that the appraisals were useful and not just a tick box exercise.
• The trust had implemented a number of initiatives to support the flow of patients through the hospital. We had previously found the discharge lounge to be inconsistently used with issues around to-take-home medication and planning of transport. At this inspection, we saw the service had a comprehensive plan to support staff to ensure these measures were organised and in place before the expected date of discharge.
• The culture across the department was more positive and there was a sense of openness and transparency. The trust had reviewed human resource training to ensure all staff and managers received the same level of support and that there was consistency in how policies were applied. Staff felt empowered to challenge poor behaviour. The culture had also improved in terms of incident reporting and shared learning, as there was no longer a blame culture.
• The trust had introduced several safety programmes to improve multidisciplinary working and monitor deteriorating patients in order to ensure quick response times. For example, the sepsis bundle and NEWS2, the availability of a clinical nurse specialist lead for sepsis, safeguarding huddles and safety huddles. We saw health care assistants led safety huddles which also demonstrated the improved culture within the trust, as there was no evidence of a ‘them and us’ culture.

Updated 8 August 2014

We found the special care baby unit (SCBU) to be safe. There were adequate procedures to follow in the event of any incidents or accidents. The unit was clean and staff followed the trust’s policies on the prevention and control of infection.

Medicines were managed appropriately and baby’s records were comprehensive and included appropriate risk assessments.

Nursing and medical, including advanced neonatal nurse practitioners (ANNPs) staffing levels were adequate and there were enough appropriately skilled and experienced staff on duty at all times.

The services for babies on the SCBU were effective. The unit used evidence-based care and treatment and had a clinical audit programme in place.

There was evidence of effective multidisciplinary working and the service operated safely over the seven-day week.

There were procedures in place to ensure competent staff. However, half of the ANNPs had not received an appraisal within the past 12 months. The matron told us that there were plans in place to address this.

Staff were compassionate and provided effective emotional support to parents. Parents were positive about their experience. One person said, “I am 100% satisfied with the care we have received.”

Parents were involved in decisions about their baby’s care and treatment.

We found services responsive. Service planning and delivery to meet the needs of local people and flow arrangements were in place.

People’s individual needs were met and there were effective systems in place to receive and act on feedback from parents.

The service was well-led. All of the staff we spoke with told us that there was a positive culture within the unit and effective leadership.

There were regular safety and governance meetings, as well as effective processes for measuring and ensuring quality standards.

Innovation and sustainability was evident within the unit.

Updated 8 January 2019

Our rating of this service improved. We rated it as good because:

• The service improved its mandatory training compliance since the last inspection. Overall compliance rates for mandatory training where above the 90% target identified by the trust.
• Staffing levels and skill mix were planned, implemented and reviewed to keep people safe at all times.
• Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Staff felt supported when doing so. We also saw that the service had addressed the significant backlog of incidents that had not been investigated.
• Staff managed medicines consistently and safely. Medicines were stored correctly, and disposed of safely. Staff keep accurate records of medicines. This was an improvement on the findings from our previous inspection
• People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. This was monitored to ensure consistency of practice.
• Mortality rates were within expected limits. This assured us that the intended outcomes for people using this service were being achieved.
• Staff were competent and the service provided good opportunities for learning and professional development. An example of this was the advanced critical care practitioner course and preceptorship programme. We saw evidence how staff appraisal rates had gone up to 96% in August 2018.
• Feedback from patients we spoke with was consistently positive and praised staff’s care and availability. People were treated with dignity, respect and kindness during all interactions with staff and relationships with staff were positive.
• A large poster board that showed all the stages of the critical care pathway had been placed at the entry of the unit. The pictures displayed could be understood by adults and children alike as well as those who did not speak English as a first language. Included in the picture were links to a wide variety of support groups and information sources. These could be directly accessed by using a smartphone to link to the QR code.
• The service had recorded zero non-clinical transfers between April 2018 and August 2018. Additionally, the service did not record any patients being readmitted to critical care within 48 hours of discharge.
• There was a clear statement of vision and values, driven by quality and sustainability. The vision and strategy were aligned to the trust’s true north objective where the patient is at the heart of everything that is done. We saw that progress against delivery of the strategy and local plans was monitored and reviewed.
• There was a culture of collective responsibility between teams and services. The service proactively engaged and involved all staff ensuring that the voices of all staff were heard and acted on to shape services and culture.
• We heard from a variety of staff how the arrival of the new executive team and the move to a new structure, in which critical care was its own directorate in the specialist services division, had shown real benefits to critical care.

However:

• We found dirty and cluttered storage cupboards during inspection. The service did not have cleaning schedules in these rooms to assess when the cleaning rota was last completed and there were no records easily available. There were also no checklists to show that clinical staff made a daily check of their clinical area and cleaned the equipment in use. Once our concerns were raised the service was proactive in addressing the cleanliness issues and we saw that floors and cupboards had been cleaned and reorganised.
• We found that staff missed opportunities to comply with the hand hygiene standards. This in association with the cleaning issues we encountered in storage areas led us to question the accuracy of audit reporting with the hand hygiene audit and environmental cleanliness standards audit. These issues were raised with the matron and leadership team and we were assured immediate action would be taken to strengthen the reliability and validity of the auditing process being undertaken
• At the time of inspection critical care rehabilitation and pharmacy support did not meet the Guidelines for the Provision of Intensive Care Services (GPICS) standards 2015; The service was aware of this and had listed improving rehabilitation as a driver for their patient first programme. There were arrangements in place to minimise the impact of not having a permanently allocated pharmacist on the critical care ward.
• Patient records, we reviewed, did not have any formal assessments for dementia undertaken in the critical care unit.
• Patient flow remained a significant problem for the service. This was also an issue as it was a potential source for mixed sex breaches in the critical care unit.
• Signposting at PRH was not clearly visible or presented in dementia or visual deficit friendly colours. Additionally, there was no different colouring for different services and all indications were written in brown letters.
• The critical care directorate did not have a specific lead for mental health within the service. Additionally, we were not made aware of any senior staff members required to regularly report on aspects of patients’ mental health or emotional well-being.

Updated 10 August 2017

We did not inspect end of life care as we rated this service good in 2016.

Updated 29 July 2022

Updated 15 May 2023

Updated 8 January 2019

Our rating of this service stayed the same, although we saw that improvement had been made. We rated it as requires improvement because:

• The service did not always share feedback from patient safety incidents. We did not see evidence of incidents being discussed in team meeting minutes. There were daily staff huddles but these did not have incidents as a set part of the agenda.
• Patients could not always access the service when they needed it. Overall waiting times from referral to treatment and for those patients referred on a 62-day cancer pathway were worse than the national average.
• The service did not always take account of people’s individual needs. The patient led assessment of the care environment audits for dementia and disability scored significantly worse than the national average across four outpatients areas that were assessed. The trust wide dementia strategy did not have any outpatient related actions.
• The service did not collect, analyse and action data to improve waiting times. Waiting times for individual clinics were not recorded or collected by the services.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results. However, trust wide not all complaints were responded to within the timeframe set in the trust guidelines.
• The service leads could describe a vision for what it wanted to achieve with clear priorities for delivering good quality and sustainable care. However, this was in a draft format that we were not able to view, and was not developed with involvement from key staff. Staff we spoke to in outpatients had no knowledge of, or involvement in developing these goals.
• There was a plan to implement systems and processes to ensure the governance of the department, but these were not embedded. There was no evidence that governance issues such as incidents were discussed at local level or fed into the overarching divisional or trust governance meetings. 

• The service had managers with the right skills and abilities to run a service providing high quality, sustainable care, however there were key vacancies at the time of our inspection which left some staff without formal line management or face to face supervision. Visibility of the service senior leadership team was poor.

However:

• The service provided mandatory training to all staff and made sure everyone completed it. We saw a significant improvement in training compliance since our previous inspection, with training compliance better than the trust target.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. All areas we visited appeared visibly clean and cleaning audits were consistently at a high standard.
• The service responded appropriately when things went wrong. Staff apologised and gave patients honest information and suitable support.
• Staff cared for patients with compassion. Feedback from patients via the Friends and Family Test and from patients we spoke with at our inspection was positive regarding the care they received from staff.
• Staff involved patients and those close to them in decisions about their care and treatment. Patients confirmed that they felt involved in decision-making and medical and nursing staff shared enough information to support this.
• Patients referred on two-week wait and 31-day cancer pathways could access the service when they needed it. The trust was performing better than the national average in these areas.
• A change in the structure of the service enabled better oversight of staff and management of key performance indicators. Since our previous inspection where outpatient services were within the head and neck directorate, a divisional restructuring had taken place across the trust. Since April 2018 general outpatients and central administration services had operated within the central clinical services division.
• The service demonstrated a commitment to improvement and innovation. There had been a significant improvement in the friends and family response rates and the successful roll out of the e-referral system.

Updated 14 February 2024

Updated 8 January 2019

Our rating of this service improved. We rated it as good because:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• The service monitored safety and managed patient safety incidents well. Staff recognised incidents and reported them in line with policy. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
• The service had suitable premises and equipment and staff controlled the risks to infection well.
• Staff followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.
• The service had enough medical staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment.
• Care and treatment provided was based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Managers made sure staff were competent for their roles and monitored the effectiveness of care and treatment. They usually compared local results with those of other services to learn from them.
• Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.
• Patients were cared for with compassion. Feedback from patients, and our own observations, confirmed that staff treated them well and with kindness.
• Most people could access the service when they needed it. There was a steady flow of patients through the department with few delays for diagnosis or treatment. Patients were consistently treated, admitted and discharged more quickly than most other hospitals in England. Staff were familiar with the hospital’s full capacity protocol which gave guidance when the department experiences a surge in patient attendances.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
• The emergency department leadership team promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

However:

• Risks to patients were not always assessed in a timely manner when they first arrived. We observed delays in the initial assessment of patients who had not arrived by ambulance. Information from the trust showed that almost half of patients, including children, waited more than 19 minutes for a nurse to assess them. Early warning scores were not always calculated as often as they needed to be to detect patients who were at risk of deterioration.
• There was a risk that there were not always enough nurses to care for the number of patients that attended the emergency department. No acuity-based review of nurse staffing had taken place since the department had been enlarged. There was only one nurse looking after patients in the resuscitation room and there were sometimes no nurses in the ambulance assessment area.
• Patient’s records were not always easy to follow, and some of them did not contain all the information required. The records of patients who had who had been admitted rarely contained copies of observation charts or admission documents.
• Staff did not always assess and monitor patients regularly to see if they were in pain. Pain scores were not always recorded when patients first arrived or after pain relief had been given.
• Although the service provided mandatory training in key skills to staff it did not make sure everyone completed it. Not all nurses had received training in immediate life support for adults and children.
• Senior staff told us that the ambulance service was not always able to arrive quickly when needed to transfer patients to hospitals in Brighton.