Archived: Royal Sussex County Hospital

Updated 8 January 2019

The trust provides district general hospital services to the local populations in and around the City of Brighton and Hove, Mid-Sussex and the western part of East Sussex. The trust primarily serves a population of over 539,500 people. They also provide more specialised and tertiary services for patients across Sussex and the south-east of England. Across the trust there are 830 general and acute beds, 80 critical care beds and 72 maternity beds. The Royal Sussex County Hospital provides 565 of these beds.

The Royal Sussex County Hospital provides acute services for the local population. The specialised and tertiary services provided include: neurosciences, neonatal, paediatrics, cardiac, cancer, renal, infectious diseases and HIV medicine. The hospital is also the major trauma centre for the region.

The hospital provides urgent and emergency care services 24 hours a day, seven days a week. The Royal Sussex County Hospital has a type one emergency department which is the regional major trauma centre and is co-located with an urgent care centre for patients with minor illnesses and minor injuries. Emergency services for children are provided at the Royal Alexandra Children’s Hospital and the Sussex Eye Hospital provides an eye casualty service.

The Royal Sussex County Hospital site is currently undergoing a major redevelopment. Major building works are in progress as part of the “3Ts” (trauma, teaching and tertiary care) programme.

We visited the Royal Sussex County Hospital as part of a planned, comprehensive inspection of Brighton and Sussex University Hospitals NHS Trust on 25 and 26 September 2018. During our visit, we spoke with over 268 members of staff and over 66 patients at the Royal Sussex County Hospital site. We reviewed over 64 sets of patients’ records and a variety of policies and performance data.

Updated 8 January 2019

• Our rating of this service improved. We rated it as good because:
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.
• The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. The service used information to improve the service.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to monitor and prevent the spread of infection.
• The service had suitable premises and equipment and looked after them well. Staff carried out risk management strategies in unsuitable premises and kept patients safe. The service had systems to provide assurance that information relating to Control of Substances Hazardous to Health (COSHH) was available, complete and accurate, and staff understood it.
• The service gave, recorded and stored medicines safely. Patients received the right medication at the right dose at the right time.
• Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
• Staff understood how to protect patients from abuse and the service worked well with other organisations to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• The service provided mandatory training in key skills to all staff and made sure everyone completed it.
• We found staff responded well to the deteriorating patient and there was effective sepsis management.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Staff carried out comprehensive assessments to meet people’s needs and improve their health. This included consideration of clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs. They used special feeding and hydration techniques when required. They adjusted to patients’ religious, cultural and other preferences.
• Staff of different professions worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Outcomes for patients were good. The service performed well in audits such as the quarterly Sentinel Stroke National Audit programme. On a scale of A-E, where A is best, the trust achieved grade A in the latest audit, August 2017 to November 2017.
• The service made sure staff were competent for their roles. Staff had the right qualifications and skills to carry out their roles effectively and in line with best practice. Staff received timely supervision and appraisals of their work performance and they had access to learning and development, including mandatory training.
• Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to information they need to assess, plan and deliver care to people in a timely way. When there are different systems to hold or manage care records, these were coordinated.
• Staff in most areas we inspected understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. Staff understood and monitored the use of restraint and used less restrictive options where possible.
• The service had a strong, visible person-centred culture. Despite staff and financial challenges, staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Relationships between people who use the service, those close to them and staff were strong, caring and supportive. These relationships were highly valued by staff and promoted by leaders.
• We saw staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Feedback from people who use the service, those who are close to them and stakeholders was continually positive about the way staff treat people. People described that staff “go the extra mile” and the care they received exceeds their expectations.
• Staff provided emotional support to patients to minimise their distress. Staff were aware of the impact on patients and carers of the care and treatment they provided.
• Staff involved patients and those close to them in decisions about their care and treatment. Patients were satisfied with the information they had been given and was explained in a way they could understand.
• Staff highly valued people’s emotional and social needs and we saw these were not only embedded in their care and treatment, but they went over and beyond to innovate the “Small Acts of Friendship” programme to help elderly patients retain dignity, social activity, mobility and well-being whilst in hospital.
• The service planned and provided services in a way that met the needs of local people. We saw flexibility, choice and continuity of care were reflected in the services.
• The service had done everything within their remit to improve access and flow. Initiatives such as discharging patients before midday, regular and effective monitoring and managing of medical outliers and the service had recruited a new manager to help with the flow. The service also monitored delayed transfers of care and worked with system partners to improve the position. Capacity to deal with the demand could be fully realised once the trust’s 3Ts project is completed.
• Staff provided coordinated care and treatment with other services and other providers.
• The service took account of patients’ individual needs. Staff accounted the needs of different people when planning and delivering services. For example, on the grounds of age, disability, gender, gender reassignment, pregnancy and maternity status, race, religion or belief and sexual orientation.
• Staff made reasonable adjustments and removed barriers when people find it hard to use or access services.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. It was easy for people to complain or raise a concern and they were treated compassionately when they did so. There was openness and transparency in how complaints were dealt with. Complaints and concerns were always taken seriously, listened to and responded to in a timely way. The service made improvements to the quality of care as a result of complaints and concerns.
• The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. The leadership structure was clear and staff knew their reporting lines and responsibilities.
• The trust had a vision for what it wanted to achieve and workable plans to turn it into action with involvement from staff and patients. Staff could clearly explain what the vision was and were actively engaged in training for the strategic patient first approach to working. Staff could clearly explain why they thought this was a positive initiative to improve patient care.
• The trust used a systemic approach to continually improve the quality of its services and safeguarding its standards of care by creating an environment in which clinical care would flourish.
• The culture was significantly different to previous inspections. Staff displayed a ‘can do’ attitude to any challenges they faced. All disciplines of staff had a shared focus and purpose to ensuring patients received the best possible care and experience. Staff morale was good, and staff were positive about the overall leadership of the trust.
• We saw good local ward and department leadership. Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff we spoke with described they were valued and how they felt there was a culture of collective responsibility between teams and services.
• Staff were engaged, supported and felt valued by senior staff. There was a supportive culture of learning and education and staff told us that this was a real focus and they felt invested in.
• The service engaged with patients, staff, the public and local organisations to plan and manage appropriate services.
• Staff understood candour, openness, honesty and transparency and challenged poor practice. The service had mechanisms to support staff and promote their positive wellbeing. Behaviour and performance inconsistent with the values were identified and dealt with swiftly and effectively, regardless of seniority.
• The service had an effective process to identify, understand, monitor and address current and future risks. They escalated performance issues to the relevant committees and the board through clear structures and processes. We saw clinical and internal audit processes functioned well and had a positive impact on quality governance, with clear evidence of action to resolve concerns.
• The trust managed financial pressures so that they did not compromise the quality of care.

However:

• Patients could not always access services when they needed them. Data provided to us by the trust showed there was 902 black breaches as Royal Sussex County hospital between September 2017 and August 2018. A “black breach” occurs when a patient waits over an hour from ambulance arrival at the emergency department until they are handed over to the emergency department staff. The trust accounted the black breaches to challenges with hospital capacity and flow.
• The percentage of patients in the emergency department waiting between four and 12 hours from the decision to admit until being admitted was worse than the national average.
• Patients referred on a cancer pathway were not always treated within 62 days of referral from their GP. The trust was performing worse than the England average in this area.
• The trust participated in the 2017 Lung Cancer Audit and the proportion of patients seen by a Cancer Nurse Specialist was 64.6%, which did not meet the aspirational audit standard of 90%. The figure had improved since 2016 when it was 60.0% and we saw the trust had an action plan to address this issue. The trust worked with another NHS provider to roll out a streamlined rapid access pathway for new referrals in late 2018/early 2019. The pathway was compliant with National Optimal Lung Pathway.
• Surgical patients sometimes stayed longer than their required recovery time in theatre due to a lack of bed availability in critical care and ward areas.
• In outpatients, critical care and surgical wards and theatres, there were some pieces of equipment that had not been serviced in line with schedule. Fire risk assessment in wards level 8a East and 8a West had identified actions and on both wards, these actions were only partially complete.
• In the surgery core service, there was some inconsistency in recording why medications were not administered. Out of eight charts checked, four showed no documentation of reasons for not administering drugs by using the suggested code, which meant a lack of information when reviewing treatment.
• The trust did not comply with all elements of Guidelines for the Provision of Intensive Care Services, 2015. Coverage from the critical care outreach team was not provided 24 hours a day, seven day a week and there was not a critical care pharmacist.
• No staff in outpatients had received training in the Mental Health Act 1983.
• 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 leadership and governance structures did not provide consistent and visible support to staff working in outpatients, although arrangements were in place to appoint to key management vacancies and address this moving forward.

Updated 8 January 2019

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

At our previous inspection in April 2017, we found several concerns such as;

• risk management strategies were not carried out in practice for the wards in the older buildings which were no longer fit for purpose
• no trust wide learning from incidents
• medical services operated in isolation
• culture of silo working and acceptance of poor behaviour amongst staff

At this inspection, we saw ample evidence of improvements made through the trust new strategy such as the “Patient First” programme. Despite significant lack of registered nurses and financial challenges, the service had embedded the programme and made great strides in a measured way not only to improve but ensured concerns found in the previous inspection were addressed. This resulted in us improving the ratings for all the key questions in medical care.

The service had also benefited from changes in the divisional structure and a new model of shared leadership between medical, nursing and operational managers called ‘triumvirates’. These changes had been implemented in August 2017 by the new trust leadership and staff we spoke with agreed that more improvements and innovations had been achieved in the last year. Staff reported the medical services no longer operated in isolation and now learnt and shared information across the services.

Although the medical wards were still located in the older Barry building, we saw risk management strategies put in place such as fire safety risk assessments and beds removed from overcrowded or unsuitable spaces. Meanwhile, the new purpose-built building works were well underway and on schedule for completion by end 2020.

We found a culture of openness and transparency about safety. Staff could raise concerns and report incidents, which were regularly reviewed to aid learning. Lessons learned were effectively shared and we saw changes implemented within the wards as the result of investigations.

There were sufficient numbers of staff with the right qualifications, training and experience to meet the needs of patients. Staffing was reviewed regularly to ensure the correct skill mix and numbers of staff on the wards and throughout the department.

Staff followed trust policies and best practice with regards to the department’s environment and equipment. Premises and facilities were visibly clean and suitable. Infection control and equipment management were regularly monitored.

The service undertook audits to ensure they regularly reviewed the effectiveness of care and treatment of patients. These showed that the care delivered was meeting national standards.

There was a good culture amongst staff. Staff described how they worked together across the medical services and were supported to challenge poor behaviour amongst themselves.

Patients received co-ordinated care from a range of different staff, teams and services. Staff worked collaboratively to meet patients’ individual needs, including their mental health and emotional wellbeing. Patients and relatives we spoke with gave positive feedback about the care they received.

Updated 10 August 2017

We did not inspect this service at this inspection as we rated it outstanding in April 2016.

Updated 8 January 2019

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

• The service had addressed the significant backlog of incidents that had not been investigated. The number of outstanding investigations had stabilised and the number outstanding generally matched the number being reported.
• Incidents were thoroughly investigated and root causes were found. Where incidents were unavoidable, the service sought to try to take any learning that may have been available.
• The environment and equipment was clean and we observed all staff were bare below the elbow. There was a clear sense that infection prevention and control was now treated as a priority.
• Medicines management had improved significantly. Consequently, there were fewer medication errors. A system called the ‘five rights of medicine administration’ had been implemented. This required the staff to check the right patient, right drug, right dose, right route, right time. The five rights would then be checked three times.
• Multi-disciplinary team working was well co-ordinated and utilised the skills of all the staff. Medical, nursing, therapy and dietitian staff had an equal role to play in patient care.
• Staff appraisal rates had risen to 94.4% across all staff groups in the critical care units. Staff told us how their appraisals had real value.
• A programme to give general critical care nursing staff neuro competencies had been established. This had dramatically improved the skill mix across the units. There were now 56% of staff that had neuro competencies and could work with all patients admitted to critical care.
• We saw a significant number of plaudits from patients, relatives and loved ones describing how exceptional the care provided by the critical care team had been both for the physical wellbeing of the patient and the emotional wellbeing of the loved ones.
• Patients and visitors that we spoke with were unanimous in their praise of the care they or their loved ones received. One patient described how they had had frequent visits to the unit, that at no time had they ever been judged and were always treated with kindness.
• We observed many interactions between staff and patients, and staff and relatives. These demonstrated that all were given personalised care and privacy and dignity was always maintained.
• The service had improved the provision of information for patients and visitors that did not speak English as a first language.
• The critical care department carried out research with their interpreting provider to establish the three most common languages used. As a result, a full suite of information had been translated into the three most commonly used languages.
• A large picture that showed all the stages of the critical care pathway had been placed in the relatives’ room on level seven. 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 critical care directorate had a clear vision and strategy for the service.
• 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.
• There had been a significant culture shift where staff described critical care as a more cohesive unit. The differences between the neuro critical care staff and the general critical care staff had been overcome.

However:

• Some pieces of equipment had not been serviced in accordance with their service due dates.
• Critical care staff did not carry out dementia assessments on patients directly, instead asking the dementia lead for the hospital to do so.
• Coverage from the critical care outreach team was not provided 24 hours a day, seven day a week. This was against the Guidelines for the Provision of Intensive Care Services, 2015.
• There was not a critical care pharmacist. This was against the Guidelines for the Provision of Intensive Care Services, 2015.
• There had been occasions when patients’ diaries had gone missing when being discharged from critical care. This meant that some patients could have missed a key component to their continued recovery.
• Patient flow remained a significant problem for the service.
• The service had not met its target of admitting all patients to the critical care unit within four hours of the decision to admit. There were significant delays discharging patients to the general ward environment
• Out-of-hours discharges were well above the 6.3% target in all five months from April 2018.
• The critical care team did not have a wide range of service level agreements with organisations that could assist with patients leaving the critical care environment.
• The critical care team did not have a designated lead for mental health.

Updated 10 August 2017

We did not inspect this service at this inspection as we rated it good in April 2016.

Updated 8 January 2019

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

• The trust had managers at all levels with the right skills and abilities to run the service. Previous concerns about fire safety, theatre ventilation and the operations of the lifts had been addressed and taken seriously.
• The service controlled infection risk well and had suitable premises and equipment which was well maintained.
• Staffing levels were much improved and one to one care labour was achieved 99-100% of the time. Staff had completed mandatory training in line with trust targets. Staff were competent with high appraisal rates and opportunities for further training were identified and supported.
• Risk was well managed within maternity and when incidents did occur they were investigated and lessons learnt were shared among the team and wider directorate. Risk was reviewed through a series of local and trust wide meetings.
• Outcomes for people who use services are positive, consistent and regularly exceeded expectations. Audit had been used effectively to show improvement and high performance was recognised by credible external bodies.
• The department had an awareness that maternity specific tools were needed throughout the department as women’s maternity needs were different to that of other patients within the hospital.
• Women were supported in a caring and compassionate way, with their dignity and privacy maintained. Staff supported women in making their own choices and accommodating these where ever possible.
• Where people’s needs and choices were not being met we saw this was identified and used to inform how services were improved.
• A range of specialist midwives were available to support women. This included mental health, teenage pregnancy, homeless and substance abuse specialist midwives.
• Community teams worked cohesively with the department and a separate homebirth team worked across the trust ensuring a better that national homebirth rate.
• Discharge of patients was well managed and planned. Women undergoing caesarean section were given an estimated discharge date on arrival and recovered under an enhanced recovery protocol.
• The trust had managers at all levels with the right skills and abilities to run the service.
• All staff we spoke to felt supported by their line manager. Midwifery staff spoke positively about the leadership of the department and the support they were offered.
• The trust had systems for identifying risks and planning to eliminate or reduce them. There was a demonstrated commitment to best practice performance and risk management.
• The trust had a vision for what it wanted to achieve and workable plans to turn it into action these were often developed with involvement from staff and patients.

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:

• Some items of clinical equipment in the ophthalmology clinic were seen to be overdue for maintenance.
• The service did not monitor or audit the quality of patient records.
• Although there was a trust wide programme for providing training to staff regarding the Mental Health Act 1983, no staff in outpatients had received Mental Health Act training.
• Patients could not always access the service when they needed it. Overall waiting times from referral to treatment were worse than the national average.
• Patients referred on a cancer pathway were not always treated within 62 days of referral from their GP. The trust was performing worse than the England average in this area.
• 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.
• Department 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 leadership and governance structures did not provide consistent and visible support to staff working in outpatients, although arrangements were in place to appoint to key management vacancies and address this moving forward.
• There were some discussions of governance at the team meetings within the outpatient department, however the interface between local and divisional governance was in its infancy. This meant that governance issues may not be consistently communicated between operational and divisional teams.
• The service had a vision for what it wanted to achieve. A new clinical strategy had been created since our last inspection and we were told that this had involved in depth discussions with divisions and services and had been aligned to the trust strategic objectives. However, we were unable to see the strategy due to it not being approved or ratified, and staff we spoke with had not been involved or engaged with this process.
• There were improvement projects being run within the department, however key staff from the departments were not always included as part of this, such as outpatient improvement meetings where performance information was reviewed.
• Action plans were not in place following poor performance in three areas of the Patient Led Assessment of the Care Environment audits.
• The trust did not always collect, analyse and use information well to support it activities.

However:

• Staff recognised incidents and reported them appropriately. Lessons were learned and improvements made when things went wrong. Staff understood their responsibilities to raise concerns, to report safety incidents, concerns and near misses, and to report them internally and externally.
• Outpatient services were provided from premises where risks were assessed and mitigated, particularly where these had been identified because of the age and design of the buildings.
• The service had enough staff with the right skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean.
• The service provided mandatory training and key skills to all staff and made sure everyone completed it.
• Emergency equipment in all outpatient clinics was accessible and checked in line with trust policy.
• Medicines and medicines-related stationary were managed in a way that kept people safe; prescriptions were tracked and medicines were stored securely.
• The service had systems which promoted patient safety and we saw staff following these. For example, staff were completing the World Health Organisation safety checklist prior to dental extractions which ensured all patient safety checks had been completed.
• Patient’s physical, mental health and social needs were holistically assessed and staff delivered patient care in line with evidence based care and best practice guidelines.
• Staff had the skills, knowledge and experience to deliver effective care, support and treatment. Staff had access to appraisals, ongoing training and assessments of competency.
• All necessary staff, including those in different teams, services and organisations, were involved in assessing, planning and delivering care and treatment.
• Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.
• Staff gave patients enough food and drink, where appropriate, to meet their needs whilst in the outpatient department
• People were treated with compassion, kindness, dignity and respect, when receiving care. Feedback from people who used the service and those who are close to them was positive about the way staff treated people.
• Patients were given timely support and information to cope emotionally with their care, treatment or condition.
• Staff communicated with people so that they understood their care, treatment and condition. At the end of their appointment patients were informed of the next steps, such as when they would receive test results or when their next appointment would be and with whom.
• The service had taken action to address some issues around privacy and dignity since our last inspection. This included the creation of a patient assessment room so that patients no longer had to be weighed in corridors.
• Patients referred on a two week wait pathway for suspected cancer could expect to see a specialist within two weeks of referral from their GP and the trust was performing better than the England average in this area.
• Once a decision to treat had been made for a patient with a cancer diagnosis, they could expect to be treated within the operational standard of 31 days, and the trust was performing better than the England average in this area.
• The service took account of patients’ individual needs. The main outpatient departments were signposted, and the service had addressed issues identified in previous inspections relating to patient needs including the provision of a disabled access toilet in main outpatients.
• Since our last inspection, the central administrative service and outpatients had been merged as a standalone directorate. This meant that the majority of outpatient services were under one directorate, which would enable better governance of key performance figures such as mandatory training.
• Staff felt well supported at a local level by the department manager and individual line managers.
• The culture of the staff in the department was positive and open. Staff put patients at the centre of their work.
• 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.
• The Royal Sussex County Hospital outpatient department was piloting the Patient First Improvement Project for outpatient services across the trust. Staff we spoke with were enthusiastic and engaged with this process.

Updated 8 January 2019

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

• Statutory and mandatory training compliance had improved since the last inspection. Staff understood how to protect patients from abuse and worked well with other agencies.
• The service controlled infection risk well. The surgical wards and departments displayed their environmental risk assessments and had up to date records of their cleaning schedules. Theatres had put in place a schedule for deep cleaning. This was an improvement since that last inspection when this information was not easily available.
• The service had improved how it carried out the safe surgery checklist and undertook audit and research to ensure this remained a robust process.
• Anaesthetic machine safety checks were in place. This was an improvement on our last inspection when we found there were gaps in the checking of this equipment.
• The service prescribed, gave recorded and stored medicines well. Recording of supply, administration and wastage of controlled drugs in theatres had improved, with no block signing, all entries checked were legible and correct. Medicines in surgical wards and departments were managed safely.
• Since the last inspection initiatives had been taken to review all patients on the waiting list for specific bowel surgery which meant no patient was waiting 52 weeks or more. The service had improved its referral to treatment time (RTT) since the last inspection.
• There was an improvement on the RTT, compared to the previous inspection, when all specialities were below the England average. Two specialities (Trauma and orthopaedics and ophthalmology) were better than the England average and three were similar (ear, nose and throat, urology, and oral). Three specialities (neurosurgery, general surgery and cardiothoracic) were greater than 5% below the England average.

• Staff knew what incidents to report and how to report them. Managers investigated incidents and shared lessons learned. They identified any themes and monitored near misses.
• Staff provided care and treatment based on national guidance and service policies reflected this. Managers checked to make sure staff followed guidance.
• Managers made sure staff had the right skills to perform their role. They met with staff regularly to appraise performance and encouraged continued professional development. Practice educators on all wards and departments supported staff training within a positive learning environment.
• Doctors, nurses and other health professionals worked together to benefit patients and supported each other to provide good care.
• Staff treated patients with compassion, dignity and respect and supported patients with mental health needs. Patients and those close to them were involved in their plan of care. Patient feedback was positive.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with the staff.
• The service had managers at all levels with the right skills and abilities to run the service, and provide quality care. Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

However:

• In wards and theatres there were some pieces of equipment that had not been serviced in line with schedule and fire risk assessment in wards level 8a East and 8a West had identified actions and on both wards these actions were only partially complete.
• Patients were staying longer than their required recovery time in theatre due to a lack of bed availability in critical care and ward areas.
• There was some inconsistency in recording why medications were not administered. Out of eight charts checked, four showed no documentation of reasons for not administering drugs by using the suggested code, which meant a lack of information when reviewing treatment.
• There was little evidence of patient forums or a way of patients feeding back about specific areas of the service.

Updated 8 January 2019

Our rating of this service improved. This reflects the improvements made to patient safety, education and development of staff, improved medical and nursing leadership and oversight of risk. Positive changes were a result of the trust wide Patient First Improvement System, an empowered and engaged workforce, quality management, maintaining the dignity and respect of patients and a change in culture.

We rated it as good because:

• Staff worked in a culture that empowered them to report incidents. Learning from incidents had improved since our last inspection.
• Staff confirmed they received feedback and learning from incidents was shared. The service managed patient safety incidents well. Staff knew what they would need to report and how to do it.
• The service was delivered by staff that were competent, trained and supported by their managers, and in sufficient numbers, to provide safe and effective care.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Mandatory training and appraisal compliance amongst the nursing staff had improved since our last inspection.
• Staff kept themselves, equipment and the premises clean. They used control measures available to prevent the spread of infection.
• Equipment, including emergency equipment was in working order and was checked daily to ensure it was available. Records we reviewed confirmed this. This was an improvement since our last inspection when records were incomplete.
• The room used for assessing patients with mental health needs was compliant with the Psychiatric Liaison Accreditation Network standard. The room had been refurbished since our last inspection to ensure it was compliant with the standard.
• Substances subject to Control of Substances Hazardous to Health Regulations 2002 were stored securely and staff knew where to find safety information regarding these products.
• Staff had embedded and strengthened the systems and processes relating to the management of deteriorating patients since our last inspection.
• Medical staffing provided 24-hour consultant cover, this met the Royal College of Emergency Medicine guidelines.
• The majority of records we reviewed were clear, up-to-date and available to all staff providing care. Patient records were kept securely and confidentially. This was an improvement since our last inspection
• Monitoring of fridge and room temperature readings where medicines were being stored were carried out regularly in line with trust policy. This was an improvement since our last inspection when we found an inconsistent approach to medicine fridge temperature checks.
• The services provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Staff gave patients enough food and drink to meet their needs and improve their health.
• There was good evidence of multi-disciplinary team work to make sure patients were transferred or discharged to the appropriate location at the right time and with the correct support and involvement of carers and relatives. The mental health liaison team facilitated communication with the community mental health teams and home-based treatment team, enabling people to be discharged from hospital with more intensive mental health support.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. We saw staff reassuring patients who were anxious or upset, with specialist support available if this was needed.
• The divisional and service level leadership, culture and overall governance structure had the capacity, capability and integrity to ensure that the challenges could be resolved and risks to performance addressed.
• The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
• There was a consistent quality of care given to all patients who attended the department regardless of their health needs.
• In the main, patients received treatment within one hour of arrival in line with the best practice guidance.

However:

• Due to limited space within the department, the risk of infection was not always controlled well during busy periods. We observed that during busy periods, patients were on trolleys next to each other in the ‘cohort area’ which did not minimise the risk of the spread of infection. This was consistent with our last inspection, however, we observed it happening less frequently during this inspection.
• Patient’s privacy and dignity was not respected whilst in the ‘the cohort area.’ Mixed sex patients were cared for there with only a privacy screen separating them.
• The number of black breaches remained a concern as patients were delayed in receiving their treatment. Data provided to us by the trust showed there was 902 black breaches as Royal Sussex County hospital between September 2017 and August 2018. A “black breach” occurs when a patient waits over an hour from ambulance arrival at the emergency department until they are handed over to the emergency department staff. The trust accounted the black breaches to challenges with hospital capacity and flow.
• The service was closely monitoring reasons for black breaches and performance was reviewed weekly and discussed at daily huddles. The service was using Patient First Improvement System to address challenges surrounding delays in handovers, triage and assessment of patients. Delays in ambulance handovers was identified as a key driver in the Patient First Improvement System. Each delay was reviewed and discussed at daily huddles. The service had plans on how to address the delays for example, having a senior nurse where the ambulances arrive who could receive handover make an initial assessment and direct the patient to the most appropriate location. A training programme to ensure the nurses had the correct skills and knowledge to undertake this was being developed.
• Mandatory training compliance amongst doctors was 77% which was below the trust target. Only 81% of doctors had completed Safeguarding Adults at Risk training and 81% had completed level 3 Safeguarding Children and Young People training.
• Compliance with advanced life and trauma training amongst nurses was low. Sixty-seven percent of eligible staff had up to date training which was worse than the trust target, this was due to funding of the courses However, the service had an effective plan in place to ensure all nurses had undertaken advanced life and trauma training.
• The department took part in national audits to compare treatment results with other hospitals. However, their data was combined with that of the Princess Royal Hospital and so it was not possible to be specific about the effectiveness of treatment at the Royal Sussex County hospital. The service had addressed this issue and we saw ongoing audits and planned audits were separated by hospital site.
• Intravenous (into a vein) fluids were not prescribed in line with trust policy. The prescription prostration for the intravenous fluid did not include a time frame for it to be given. Giving intravenous fluids either too quickly or too slowly could have an adverse effect on the patient.
• Patients may not have been aware of their right to have a chaperone when being examined as there were no posters advising patients of this.
• The trust strategy remained confused. The strategy the leaders described to us did not match the trust strategy.
• Data provided to us showed there was regular delays in assessing the risk for patients who brought themselves to the emergency department. The median time patients waited for assessment at Royal Sussex County hospital was longer than best practice. However, all patients were streamed by an experienced nurse and were directed either to the emergency department or the emergency ambulatory care unit. Streaming is the process of allocation of patients to the most appropriate physical areas of a hospital, and the most appropriate clinical pathways.
• If a self-presenting patient booked in at reception with a serious condition such as chest pain, reception staff escalated this immediately to the streaming nurse.
• The service did not have an effective process which ensured medicines were checked to ensure they were still in date. We checked 20 different medicines and found four were past the expiry date.
• The percentage of patients waiting between four and 12 hours from the decision to admit until being admitted was worse than the national average.