Archived: Princess Royal 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 Princess Royal Hospital provides 327 of these beds.

Princess Royal Hospital provides acute services for the local population. Services provided at the Princess Royal Hospital site include general elective surgery, orthopaedics, medicine (including elderly, dermatology and respiratory), critical care, maternity and rehabilitation. The hospital ‘s emergency department provides urgent and emergency care services 24 hours a day, seven days a week.

Princess Royal Hospital does not have a children’s inpatient unit. Therefore any children requiring hospital admission are transferred to the Royal Alexandra Children’s Hospital, the trust’s dedicated hospital for children and young people.

We visited Princess Royal 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 152 members of staff and 45 patients on the Princess Royal Hospital site. We reviewed 67 sets of patient’s records and a variety of policies and performance data.

Updated 8 January 2019

Our rating of services improved. We rated it them as good because:

• 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.
• When things went wrong, staff apologised and gave patients honest information and suitable support. Staff were aware of their responsibilities regarding duty of candour and we saw current examples of duty of candour being used in practice.
• 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 controlled infection risk well. Staff kept themselves, equipment and the premises clean through the use of effective control measures such as daily and weekly checklists, to prevent the spread of infection. All staff had a good understanding of control of substances hazardous to health regulations.
• There was significant improvement in training compliance since our previous inspection. The service provided mandatory training in key skills to all staff and made sure everyone completed it across most of the core services we inspected.
• The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
• The trust had introduced several safety programmes to improve multidisciplinary working and monitor deteriorating patients to respond promptly. This included the sepsis bundle and NEWS2.
• Care and treatment provided was based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• The service monitored the effectiveness of care and treatment and used the findings to improve them. Information about the outcomes of people’s care and treatment were routinely collected and monitored.
• 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 at all levels worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• The service managed patients’ pain effectively and provided or offered pain relief regularly. Patients we spoke with told us staff offered pain relief quickly when they reported pain.
• Staff gave patients enough food and drink to meet their needs and improve their health. We saw staff prioritised mealtimes and there were enough staff to support patients that needed help eating and drinking. The service made adjustments for patients’ religious, cultural and other preferences.
• The service was working toward seven-day services in line with National Health Service Improvements (NHSI), Seven-day services in the NHS. We saw in the trust operational plan 2018-2019, that they plan to deliver the Seven Day Service standards for all admitting specialities by 2020.
• Staff understood their roles and responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Staff knew the processes for ensuring deprivation of liberty safeguards documentation was complete and up to date as well as how to support those who lacked the capacity to make decisions about their care.
• Staff cared for patients with compassion. All staff we spoke with were very passionate about their roles and were dedicated to making sure patients received the best patient-centred care possible. Feedback from patients was positive about the care they received.
• Staff provided emotional support to patients to minimise their distress.
• There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promoted dignity. Staff were caring and supportive of patients which was encouraged by management.
• Patients were active partners in their care. Staff were committed to working in partnership with patients and their families. Staff empowered patients to reach their potential and we found this in particular on Lindfield ward.
• The service took account of patients’ individual needs. The trust employed specialist nurses to support the ward staff. The service made reasonable adjustments and took action to remove barriers for patients who found it hard to use or access services. This included interpreting services, services for patients living with dementia, those with sensory loss or impairment and facilities for bariatric patients.
• 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. There was a clear management structure at directorate and departmental levels.
• The trust had a strategy for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and patients. All staff we spoke with were very aware of the ‘Patient First’ strategy and had ‘bought in’ to the initiative.
• The trust used a systematic approach to continually improve the quality of its services, by creating an environment in which clinical care would flourish. The department had systems for identifying risks, planning to eliminate or reduce them.
• The trust engaged with patients, staff and the public to plan and manage services. We saw the staff encouraged patients to complete the family and friends test on their care and treatment.
• The trust was committed to improving services by learning when things go well and when they go wrong, promoting training, research and innovations.
• There was a culture of collective responsibility between teams and services. There were positive relationships between staff and leaders, where conflicts were resolved quickly and constructively, and responsibility was shared. 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.
• The board and other levels of governance in the organisation functioned effectively and interacted with each other appropriately.

However:

• Risks to self-presenting patients in the emergency department were not always assessed in line with guidance when they first arrived.
• There was a risk that there were not always enough nurses to ensure the safe care of the patients that attended the emergency department.
• Patients could not always access the service when they needed it. For example, overall waiting times from referral to treatment and for those patients referred on a 62-day cancer pathway were worse than the national average.
• Patient flow through the hospital remained an issue in some areas. For example, the percentage of critical care bed days occupied by patients with discharge delayed more than 8 hours was 12.0% compared to the national aggregate of 4.9%.
• In outpatients, 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 outpatients core 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 outpatients vision and strategy was not developed with involvement from key staff. Staff we spoke with in outpatients had no knowledge of, or involvement in developing these goals.
• A clinical pharmacist did not visit all wards daily; for example, Plumpton ward did not receive a regular pharmacy visit.

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 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.
• The service controlled infection risk well and had suitable premises and equipment.
• Staffing levels were much improved and one to one care labour was achieved 99-100% of the time. 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 used maternity specific tools 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 than 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.
• All staff we spoke with 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 demonstrative 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:

• 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 8 January 2019

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

• The service provided statutory and mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies.
• Staff assessed risks to patients and monitored their safety, so they were supported to stay safe. There were effective systems in place to report incidents. Incidents were monitored and reviewed and staff gave examples of learning from incidents. Staff understood the principles of Duty of Candour regulations, were confident in applying the practical elements of the legislation.
• The service controlled infection risk well. There were policies in place to manage effective infection control and hygiene processes. The service had suitable premises and systems were in place to ensure equipment was well looked after.
• Staff kept appropriate records of patient care and treatment. Records were available to all staff providing care, however, we did find some inconsistencies. The service prescribed, gave, recorded and stored medicines well.
• Theatres complied with the minimum staffing as per Association of Perioperative Practice (AfPP) safe staffing recommendations (2014). Planned staffing levels on the wards were not always met. Data supplied to us by the trust showed as of July 2018, the vacancy rate for the surgical division was 9.9%, and was on track to meet the March 2019 target. Patients told us they felt safe, on the ward, and there were adequate numbers of staff on the wards to meet their needs.
• The service provided care and treatment based on national guidance. Staff had access to up to date policies, procedures and clinical guidelines.
• The service monitored the effectiveness of care and treatment and used the findings to improve them. Information about the outcomes of people’s care and treatment were routinely collected and monitored. Staff gave patients enough food and drink to meet their needs and improve their health. The service managed patients’ pain effectively and provided or offered pain relief regularly.
• The service made sure staff were competent for their roles. Staff training and professional development needs were identified, we saw 94% of staff had an up to date appraisal.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• The service was working toward seven-day services in line with National Health Service Improvements (NHSI), Seven-day services in the NHS. We saw in the trust operational plan 2018-2019, that they plan to deliver the Seven Day Service standards for all admitting specialities by 2020.
• Staff supported patients to manage their own health, care, and well-being and to maximise their independence following surgery and as appropriate.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with dignity and respect. Staff involved patients and those close to them in decisions about their care and treatment. Staff communicated well with patients and those close to them in a manner so they could understand their care, treatment and condition.
• The service planned and provided services in a way that met the needs of local people. The service had systems and staff in place to aid the delivery of care to patients in need of additional support, such as initiative to support patients with learning disabilities or those living with dementia.
• People could mostly access the service when they needed it. The service took account of patients’ individual needs. The trust employed specialist nurses to support the ward staff.
• The service treated patient’s concerns and complaints seriously and investigated them, we saw lessons were learned from complaints and shared with all 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.
• The trust had a vision for what it wanted to achieve and workable plans to turning it into actions. The trust vision and strategy focused upon quality and sustainability.
• The trust used a systematic approach to continually improve the quality of its services, by creating an environment in which clinical care would flourish. The department had systems for identifying risks, planning to eliminate or reduce them.
• The service collected, analysed, managed and used information to support all its activities, using secure electronic systems with security safeguards.
• The trust engaged with patients, staff and the public to plan and manage services. We saw the staff encouraged patients to complete the family and friends test on their care and treatment.
• The trust was committed to improving services by learning when things go well and when they go wrong, promoting training, research and innovations.

However:

• Some wards such we visited, we found some of the walls, fixtures, and fittings were not intact. For example, we saw sink surrounds, which were damaged with exposed wood, this is not in line with the Department of Health’s Health Building Note (HBN) 00-09: infection control in the built environment. Non-intact surfaces, flooring and walls can harbour dirt and dust and make the cleaning difficult.
• Patient consent to care and treatment was not always sought in line with legislation and guidance. Not all consent forms we looked at for elective surgery were signed before the day of surgery, this is not with guidance from the Royal College of Surgeons Good Surgical Practice 2014.
• Not all staff had the correct information or competencies to do their role. Although all staff we spoke with told us they had an attended the trust wide induction, we found three locum doctors who had not had a local induction to the hospital or ward they were working on.
• Signposting around the hospital was poor, and made it difficult for people who were unfamiliar with the hospital to find their way around. We saw multiple visitors, and patients lost or unable to locate the ward or department they needed to find. This was an issue we highlighted in our previous inspection in 2017.
• The trust was in the process of developing Local Safety Standards for Invasive Procedures (LocSIPPs) using the National Safety Standards for Invasive Procedures (NatSSIPs), some of which were available to staff on the trust intranet. For example, we saw the local safety standards for invasive procedures for surgical and procedure site verification was available on the trust website. We found not all staff were aware of local safety standards for or their availability.

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.