All inspections: Princess Royal Hospital

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.

Brighton and Sussex University Hospitals (BSUH) is an acute teaching hospital with two sites the Royal Sussex County Hospital in Brighton (centre for emergency and tertiary care) and the Princess Royal Hospital in Haywards Heath (centre for elective surgery). The Brighton campus includes the Royal Alexandra Children’s Hospital and the Sussex Eye Hospital.

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

The trust was inspected in April 2016 and rated as inadequate. Princess Royal Hospital was rated as requires improvement. Following publication of the report and our recommendation, the trust was placed into special measures by NHS Improvement.

The trust has now been subject to performance oversight for eight months and this inspection was made to assess progress against the actions required subsequent to the publication of the 2016 report.

In designing this inspection, we took account of those services that performed well at the 2016 inspection and as a consequence the services inspected only included emergency care, medical services, surgery, critical care, maternity and gynaecology and outpatients and diagnostics.

The trust board and executive leadership has been unstable for the last twelve months and immediately prior to the inspection management responsibility for the trust had been passed to the board of Western Sussex Hospitals Foundation Trust. As such, it was not appropriate to complete a full assessment of trust wide leadership. However, during the inspection we have followed up the concerning areas of organisational culture of bullying and harassment and discrimination that were evident in the 2016 report.

Our key findings were as follows:

Safe

Incident reporting, process and culture was much improved with enhanced analysis. Feedback to staff via safety huddles and other communications had also been improved. However, in some areas learning and sharing had not been maximised and in critical care a significant backlog of incidents had occurred that impeded the opportunity to learn from incidents.
Following an improvement initiative the trust had reduced the number of never events at the trust. The root cause analysis of serious incidents was also of a good standard.
There was not an overarching strategy for the maintenance of a clean environment and the fabric of some areas of the hospital remained in a poor condition. The concerns relating to fire safety expressed in our last report had been addressed by a process of external review and assessment. However, action plans to complete the work identified lacked documentation of completion and had no corporate oversight mechanism.
Although overall consultant cover has increased we remain concerned regarding the provision of paediatric nursing and paediatric anaesthetist cover to the emergency department. The trust is continuing to work with local commissioners regarding the perception and use of the paediatric emergency department by the local population.
IT provision in the emergency department is now aligned with RSCH addressing the risk identified in our last report.
Staffing levels and recruitment remain challenging for the trust. However, staff are now more likely to report staffing issues as incidents than previously.
As at our last inspection, medicines management, safeguarding and duty of candour were well managed and applied appropriately. Although the trust has improved its compliance with mandatory and safeguarding training many departments remain below a low threshold target of 75%.

Effective

Staff generally followed established and evidence based patient pathways. Staff had access to up to date protocols and policies we saw a significant improvement in maternity. Sepsis training, awareness and protocols had also improved. However, pathways for bariatric patients being managed in medicine were not optimum.
As also reported in 2016 national clinical audits were widely completed. Mortality and morbidity was reviewed in all departments.
Pain relief was effectively delivered and the trust had developed its trust wide pain team. However, the service remained unavailable at weekends.
Patients nutritional needs were generally met and the trust and increased efforts to provide protected mealtimes. Comfort rounds had been introduced in the emergency department to assist in the maintenance of hydration. There remained no dedicated dietician support to the critical wards.
Appraisal compliance had significantly improved across the trust. However, this was from a low base and many departments still remained below the trust target.

Caring

As reported at our last inspection, patients received compassionate care throughout the trust and we observed this in the interactions between staff and patients. Patients were very positive in their feedback regarding the care they received.
Patients reported they were involved in decisions about their treatment and care and this was reflected in the care records we reviewed.

Responsive

Similar to our last inspection, referral to treatment time was consistently below the national standard for most specialties. The trust had improved compliance with two week wait and 31 day standard for cancer but was not attaining the 62 day target. Delays were also being incurred in the processing of biopsies for pathology.
The number of patients whose operation was cancelled and who were then not re-seen within 28 days exceeded the national average.
Provisions for the care of patients living with dementia was well developed with appropriate forms of patient identification and well considered design of clinical environment and signage.
Our review of complaints identified a tendency to respond in a defensive manner and a lack of negotiated extended timelines. However, external peer review of complaints over the last three years had not identified issues with the quality of responses.

Well led

At our last inspection, staff widely reported a culture of bullying and harassment and a lack of equal opportunity. We discussed the findings in individual interviews and staff focus groups and the findings were largely acknowledged as accurate. However, the trust had not clearly communicated its acknowledgment of the issue to the workforce.
The trust has commissioned and commenced an external consultancy to develop a strategy that addresses the current persistence of bullying and harassment, inequality of opportunity afforded all staff, but notably those who have protected characteristics, and the acceptance of poor behaviour whilst also providing the board clear oversight of delivery.
The trust has tried to address bullying and harassment via leadership training and an initiative "Working Together Effectively #stopbullying". This was promoted by a poster campaign using a well-crafted definition of bullying and a supporting intranet web site providing helpful guidance and tools. During our interviews and focus groups very few staff indicated recognition of the initiative.
Some staff indicated during focus groups and interviews that there had been an improvement in the management of poor behaviour, notably in maternity where a behaviour code of conduct had been introduced. However, representative groups described a lack of corporate acknowledgement of discrimination and inequality issues and little change over the last twelve months.
The lack of equitable access to promotion was again raised by members of the BME network citing recent changes in the management of soft FM services as an example of bias. This has resulted in a further review of the soft FM management of change process by the trust and a pause in implementation. Concerns on this issue have been raised by staff.
The role of out-dated human resource policies and their inconsistent application in exacerbating inequality was highlighted in our last report. The human resource team have responded with a comprehensive review of policy and revised training of team and managers. Representative groups viewed that there had been a lack of engagement in the development and review of these policies.
BME staff again indicated the lack of equitable access to training and leadership initiatives. The trust did not maintain data indicating the equality of access to leadership programmes.
Staff in focus groups indicated that staff themselves had not been suitably trained to manage the diversity of patients they treat leading to an inability to manage difficult situations and support staff who have been abused.
The latest staff survey results rank among the worst nationally. Overall the organisational culture and the management of equality remains a significant obstacle to the trust improvement plan.
We observed improvements in local directorate governance arrangements but the complexity of the operational model continues to lead to a lack of clarity in terms of accountability, alignment of strategy and consistent dissemination of information and direction.
Clinical leaders indicated a need for personal development, increased non-clinical time and greater management expertise in order to deliver the required organisational change. This group appeared as highly motivated with an appetite for the challenge ahead. The clinical transformation programme was seen as indicative of the potential this group has for delivery.

There is no doubt that improvements have been made since our last inspection and that the staff involved in the delivery of that change should be congratulated. However, there remains an extensive programme of change to be delivered in order to attain an overall rating of good. The lack of consistent board and executive leadership has hampered the pace of change in the last twelve months and it is anticipated that the incoming management team can provide both stability and clarity of leadership that will lead to sustainable change.

However, I recommend that Brighton and Sussex University Hospitals NHS Trust remains in special measures to provide time for the leadership to become embedded and that the outstanding patient safety, culture and equality issues are addressed.

We saw several areas of outstanding practice including:

The new self-rostering approach to medical cover had a significant impact on Urgent Care service. Medical staff appreciated the autonomy and flexibility this promoted as well as the effective and safe cover for the department. Due to this initiative, the department was able to provide round the clock medical cover without the use of temporary staff.

The introduction of the clinical fellow programme that had improved junior cover in the Emergency Department and also the education and development opportunities for juniors.

Arrangements for the care of patients living with dementia were well developed on Hurstpierpoint Ward. There was a "bus stop" in the ward corridor and this was used as a focal point for patients to meet. Some patients wandered and this enabled them to rest and also provided a distinct reference if a patient could not remember where they were going. Each bay was also painted a distinct colour to support patients to find their way back to their beds. A computer was available for patients to use in order that they could skype family who could not visit every day. We also saw there was a quiet room available for patients and family to meet away from the ward area. This room contained life-sized stuffed animals that were used as therapy due to the health and safety issues around bringing in a pet as therapy dog. The ward also had a reminiscence room that was decorated and set up like a living room from the 1950’s. Staff advised us this area was used for therapy sessions as patients felt more at ease in the surroundings. Inside the room there was also a made-up switchboard for patients with electronic and operator experience.

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

Importantly:

In ED, the trust must ensure that medical gases are stored safely and securely.

In ED, the trust must ensure the current paediatric service provision is reviewed and has a safe level of competent staff to meet children and young people’s needs.

In outpatients and diagnostic imaging, the trust must take action to ensure that patient records are kept securely.

In surgery, the trust must ensure that safer sharps are used in all wards and department.

National Specification of Cleanliness (NCS) checklists and audits must be in place including a deep cleaning schedule for theatres.

In critical care, the hospital must take action to ensure that information is easily available for those patients and visitors that do not speak English as a first language.

In critical care, the trust must ensure there is adequate temperature monitoring of medicines fridges.

In critical care, the controlled drug register must comply with legislative requirements.

In critical care, the trust must ensure that pharmacy support meets national guidance.

In critical care, the trust must make arrangements to meet national guidance on dietetic provision.

The trust must ensure that all staff within the medical directorate have attended mandatory training and that there are sufficient numbers of staff with the right competencies, knowledge and qualifications to meet the needs of patients.

The trust must ensure all staff within the medicine directorate have an annual appraisal.

The trust must ensure fire plans and risk assessments ensure patients, staff and visitors can evacuate safely.

The trust must ensure all medical wards where medicines are stored have their ambient temperature monitored in order to ensure efficacy.

In addition:

In ED, the trust should consider how patients with impaired capacity have these risks identify and managed appropriately.

In ED, the trust should consider how mandatory training rates could be improved to meet the trust own compliance rates.

In ED, the trust should consider how it manages continuity with incident, compliant and risk management processes across both sites.

In ED, the trust should provide sufficient housekeeping cover in the department twenty-four hours a day.

In ED, the trust should improve staff engagement at the PRH site.

In outpatients and diagnostic imaging, the trust should improve compliance with mandatory training completion.

In outpatients and diagnostic imaging, the trust should consider how appraisal targets are met.

In outpatients and diagnostic imaging, the trust should discuss incidents regularly with staff and share.

In outpatients and diagnostic imaging, the trust should develop a strategy for the outpatients and diagnostic imaging department.

In surgery, the trust should take steps to consider how the 18 week Referral to Treatment Time is achieved so patients are treated in a timely manner and their outcomes are improved.

In surgery, the trust should continue to work on reducing the waiting list for a specific colon surgery.

In surgery, the trust should make arrangements so all staff have attended safeguarding and all other mandatory training.

In surgery, the trust should ensure the plan to improve staff engagement is fully implemented.

In critical care, the trust should take steps consider altering the record keeping system so it is the same as that at the RSCH.

In critical care, the trust should not store items in corridors or use wooden pallets.

In critical care, the trust should look to change the main door to the unit to one that is motorised.

The trust should take steps to fully meet the national guidelines around the rehabilitation of adults with a critical illness.

The critical care department should improve their performance in relation to the local critical care network measure of quality and innovation.

The critical care department should take steps to ensure that medical staff are given Mental Capacity Act and Deprivation of Liberty Safeguards training.

The critical care department should widely publish information collected from the friends and family test.

The trust should take steps to address the delays that patients have when being discharged from critical care.

The senior leadership team should develop an interim strategy and vision for the critical care department.

The critical care management team should work with the HR team to address the issue of staff working between the trust’s two sites.

The medicine directorate should review the provision of the pain service in order to provide a seven day service including the provision of the management of chronic pain services.

The medicine directorate should review the provision of pharmacy services across the seven day week and improve pharmacy support.

The medicine directorate should prioritise patient flow through the hospital as this impacted on length of stay, timely discharge and capacity.

In maternity, the trust should consider involving the directorate in Morbidity and Mortality meetings to ensure robust learning and review.

Targets for mandatory training in maternity and gynaecology should be reviewed so trust targets can be met, in particular in regards to safeguarding.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The Princess Royal Hospital in Haywards Heath (centre for elective surgery) forms part of Brighton and Sussex University Hospitals (BSUH) which is an acute teaching hospital.

The hospital provides services to the local populations in and around the City of Brighton and Hove, Mid Sussex and the western part of East Sussex.

We inspected this hospital on 4-8 April 2016 and returned for an announced inspection on 13 April 2016.

Our key findings were as follows:

Safe

Staff compliance in mandatory training, statutory training and appraisals fell well below the trust target of 95% for statutory training and 100% for mandatory training, for both nurses and doctors across every department in the hospital.
Staff were reporting incidents. However staff feedback on learning from incidents and staff understanding of what incidents they should be reporting varied across departments.
The trust had a Duty of Candour (DOC) policy, DOC template letters and patient information leaflets regarding DOC, and we saw evidence of these. The trust kept appropriate records of incidents that had triggered a DOC response, which included a DOC compliance monitoring database and we saw evidence of these. Most staff we spoke with understood their responsibilities around DoC, although this varied with poor staff awareness in critical care.
Staff we spoke with were generally aware of the principles of the prevention and control of infection (IPC). The hospital was generally clean at the time of our inspection however there was room for improvement with curtain changing regimes. The cleanliness of the hospital was being audited by the facilities department. There had been some significant concerns over the cleanliness of the hospital and the validity of the auditing of cleanliness by a previous contactor. Hospital cleaning and auditing was now being performed ‘In House’ and staff had recognised that this had improved as a result.
However, Staff did not comply with national and European regulations on the safe storage and disposal of hazardous waste or on the safe storage of chemicals in critical care.
Medicines were not consistently being managed safely across all hospital departments. We found issues with secure and safe storage temperatures of medications along with stock management.
The IT systems used in the hospital caused problems for staff in all areas. Information was difficult to locate and stored in a variety of formats which made it difficult for staff to access information when required. Locums and agency staff reported that they were unable to use the system.
The trust had a safeguarding vulnerable adults and children policy, and guidelines were readily available to staff on the intranet and staff were able to access this quickly. However, safeguarding training for all staff groups was vastly lower than the Trusts target.
Nurse staffing across the service was variable with some wards and areas being understaffed. Nursing staff numbers, skill mix review and workforce indicators such as sickness and staff turnover were assessed using the electronic rostering tool, the Safer Nursing Care Tool. The planned and actual staffing numbers were displayed on the wards visited. Agency and bank staff were used where needed to supplement nursing numbers.
In ED the emergency medicine consultant cover breached the CEM standard and as such may adversely affect the quality of patient care and safety during the times when EMC cover is absent.

Effective

Staff generally followed established patient pathways and national guidance for care and treatment. Although we saw some examples of where some aspects of patient pathway delivery could be improved.
National clinical audits were completed. Mortality and morbidity trends were monitored monthly through SHIMI (Summary Hospital-level Mortality Indicator) scores.Reviews of mortality and morbidity took place at local, speciality and directorate level although a consistent framework of these meetings across all specialities was not in place. The trust’s ratio for HSMR was better than the national average of 80%.
Although local audits were evident, there was a lack of robust, embedded learning and practice change based on audits. This included the lack of a sepsis audit programme.
Mandatory training attendance was low across the whole hospital and we saw that some specific training needs were not met. For example, there were low levels of nursing and medical staff with specialist resuscitation and trauma course attendance.
There were inconsistencies in the documentation in the recording of Mental Capacity Act (MCA) assessments and recording ceilings of care for DNACPR.
Appraisal arrangements were in place, but compliance was low across the hospital. Trust wide only 68% of staff had received an annual appraisal. Accountability for these lapses was unclear.
The nutritional needs of patients were assessed at the beginning of their care in pre-assessment through to their discharge from the trust. Patients were supported to eat and drink according to their needs. There was access to dieticians and medical or cultural diets were catered for.
The trust did not meet the requirements of the key performance indicators of the National Care of the Dying Audit 2014. They did not have access to specialist palliative support, for care in last days and hours of life, as they did not have a service seven days a week. They did not have a non-executive director for end of life care services. Also they did not have a formal feedback process regarding capturing bereaved relative’s views of delivery of care.

Caring

Staff were caring and compassionate to patients’ needs, and treated patients with dignity and respect.
Patients and relatives told us they received a good care and they felt well looked after by staff.
The staff mostly respected confidentiality, privacy and dignity.
The majority of patients we spoke with felt involved in their care and participated in decisions regarding their treatment. They said staff were aware of the need for emotional support to help them cope with their treatment.
We saw no comfort rounds taking place whilst we were in the ED department. This meant patients who were waiting to be treated may not have been offered a drink nor have their pressure areas checked.

Responsive
The ED encountered issues around the department’s inability to meet surges in demand; escalation protocols, leadership and record keeping all caused delays to assessment and treatment. Many of these issues were longstanding and had been brought to the trust’s attention previously.
Some people were unable to access services for treatment when they need to. The hospital did not take the needs of some patients into account when planning services. The admitted referral to treatment time (RTT) was consistently below the national standard of 90% for most specialties. The trust had failed to meet cancer waiting and treatment times.
The length of stay for non-elective surgery was worse than the national average offor trauma and orthopaedics, colo-rectal surgery and urology
The percentage of patients whose operations were cancelled and not treated within 28 days was consistently higher than the England average.
The percentage (31%) of admitted patients who moved wards during the night, (between 10 pm and 6 am).
Performance for out of hour’s discharges was variable and was connected to generally poor patient flow across the hospital.
There was room for improvement in the consistency of discharge protocols and documentation for patients who needed rehabilitation.

Well-Led
Staff in general reported a culture of bullying and harassment and a lack of equal opportunity. Staff survey results for the last two years supported this. Staff from BME and protected characteristics groups reported that bullying, harassment and discrimination was rife in the organisation with inequality of opportunity. Data from the workforce race equality standard supported this. Staff reported that inconsistent application of human resource policies and advice contributed to inequality and division within the workforce which led to a lack of performance and behaviour management.
The trust had a complex vision and strategy which staff did not feel engaged with. There was a lack of cohesive strategy for the medical services either within their separate directorates or within the trust as a whole. Whilst there were governance systems in place they were complex and operating in silos. There was little cross directorate working, few standard practices and ineffective leadership in bringing the many directorates together.
Staff told us there was a disconnection between staff and the executive board.
Department’s maintained risk registers; however it was unclear how this fed into the directorate risk and trust register. This was because we did not see evidence of information sharing among the multiple directorates.

The results of the most recent staff survey continued to raise concerns about staff welfare, moral and organisational culture at the trust.

In the 2014 staff survey over 50% of staff said their last experience of harassment or bullying was not reported by themselves.

Numerous members of staff told us they felt poor behaviour and poor performance of other staff members was tolerated and went unchallenged. Some nurses said they felt unsupported in their role as managers spent the majority of their time at RSCH. Staff told us that there was managerial support up to the level of matron, but there was a lack of support beyond that level.

There was evidence of a breakdown in communication between the executive team and the directorate teams, which resulted in the inability of local senior staff to obtain approval for urgent issues, such as nurse recruitment.

Staff were not able to obtain human resources support in a timely manner.

Outstanding Practice:

Brighton and Sussex University Hospitals NHS Trust was amongst Britain’s most dementia friendly trusts. The trust was one of five in the National Dementia Care Awards. The trust’s dementia team provided direct support to patients living with dementia in both the specialist dementia wards and in the trust in general.

Importantly, the trust must:

The provider must ensure that there are sufficient numbers of staff with the right competencies, knowledge, qualifications, skills and experience to meet the needs of patients using the service at all times. This includes ensuring that newly appointed overseas staff have the support and training to ensure their basic competencies before they care for and treat patients.
The provider must ensure that medicines are always supplied, stored and disposed of securely and appropriately. This includes ensuring that medicine cabinets and trollies are kept locked and only used for the purpose of storing medicines.
The provider must ensure its governance systems are embedded in practice to provide a robust and systematic approach to improving the quality of services. This includes improving learning from incidents, safeguarding and complaints across the directorates.
Facilitate and establish a line of communication between the clinical leadership team and the trust executive board.
Urgently review staff skill mix in the mixed/neuro ICU unit. This must include an analysis of competencies against patient acuity.
Implement an action plan to reduce further nurse sickness absence and attrition through a transparent, sustainable programme of engagement that must include a significant and urgent improvement in staff training.
Review funding for multidisciplinary specialties and ensure business cases submitted by specialists are considered appropriately. This specifically refers to pharmacy, occupational therapy and dietetics.
Adhere to RCN guidelines that the nurse coordinator remains supernumerary at all times.
Review and improve medical and nursing cover to meet relevant CEM and RCPCH standards and reflect/review activity rates relating to paediatric for the unit.
Review clinical training records for medical and nursing staff and rectify gaps in role specific resuscitation training such as ALS and PILS.
Complete mandatory training and performance appraisals for all staff.
Review the actual risk of the Alert computer system.
Ensure that resuscitation/emergency equipment is always checked according to the trust policy.
Ensure staff are working under appropriately approved Patient Group Directions (PGDs). Ensure PGDs are reviewed regularly and up to date.
Continue to ensure lessons learnt and actions taken from never events, incidents are shared across all staff groups.
Ensure the 18 week Referral to Treatment (RTT) is addressed so patients are treated in a timely manner and improve outcomes for patients.
Ensure safe and secure storage of medical records.
Monitor the turnaround time for biopsies for suspected cancer of all tumour sites.
Ensure that all staff complete mandatory training in line with trust targets, including conflict resolution training.
Ensure that all relevant staff have the necessary level of safeguarding training.

In addition the trust should:

The provider should ensure there is a cohesive vision and strategic plan for the directorates which engages staff and provides an effective guide in the development of services.
The provider should continue to prioritise patient flow through the hospital as this impacted on length of stay, timely discharge and capacity.
The provider should ensure there is documentary evidence available to support recording that staff mandatory training is in line with trust targets.
The provider should ensure that there are sufficient staff available to offer a full seven-day service across all directorates and support services.
The provider should review the HR policies and ensure they are fit for purpose.
The provider should ensure that effective HR resources are available that support staff. In particular the provider should continue to address the culture of bullying and intimidation found in some areas of the service.
Ensure all staff are included in communications relating to the outcomes of incident investigations.
Implement a sepsis audit programme.
Review the workload of the nurse practice educators and assess the impact on their availability for bedside learning and teaching.
Make adjustments to the rehabilitation pathway to ensure it is fully compliant with NICE CG83.
Harmonize computerised patient information and management software between trust sites.
Review and improve major incident storage facilities and replenish stock.
Review analgesia authorisation for Band 5 nursing staff (PGD).
Ensure equipment and medicines required in an emergency are stored in tamper evident containers.
Review the provision of pharmacy services across the seven day week and improve pharmacy. support.
Review the nurse staffing levels to ensure all areas are adequately staffed.
Ensure all staff have had an annual appraisal.
Review the consent policy and process to ensure confirmation of consent is sought and clearly documented.
Review the provision of the pain service in order to provide a seven day service including the provision of the management of chronic pain services.
Continue in embedding its governance systems to ensure a more consistent approach to governance processes.
Have a defined regular audit programme for the end of life care service.
Provide a seven day service from the palliative care team as per national guidelines.
Record evidence of discussion of an end of life care patient’s spiritual needs.
Ensure all DNACPR, ceilings of care and Mental Capacity assessments are completed and documented appropriately as per guidelines.
Ensure that all staff receive annual appraisals.
Have a non-executive director for end of life care services.
Implement a formal feedback process to capture bereaved relatives views of delivery of care.

On the basis of this inspection, I have recommended that the trust be placed into special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Princess Royal Hospital is an acute hospital in the Brighton and Sussex University Hospitals NHS Trust, which provides acute services to the population of people across the Haywards Heath area. The hospital provides maternity, a special care baby unit, outpatient services, medical care and it is the trust’s centre for elective surgical services. The campus also houses the Hurstwood Park Neurosciences Centre and The Sussex Orthopaedic Treatment Centre.

We carried out this comprehensive inspection because the Brighton and Sussex University Hospitals NHS Trust was an aspirant foundation trust. The inspection of Princess Royal Hospital took place between 21 and 23 May 2014.

Overall, this hospital requires improvement. We rated it ‘good’ for being caring and effective, but it required improvement in providing safe care, being responsive to patients’ needs and being well-led.

Our key findings were as follows:

Staffing levels in medicine and surgery and the high use of bank or agency staff placed pressure on staff and meant there was a risk that patients’ care needs may not be appropriately met.
There was a lack of consultant cover at weekends and out of hours.
Staff were not always able to attend training as required.
Lack of beds in some services had an impact on poor flow and patients were cared for in wards which were not for their required speciality.
The outpatient Hub was not operating efficiently and effectively to ensure patients had access to outpatient review and follow-up as required.

We saw several areas of good practice including:

Support for the provision of care for stroke pathway.
Team working and commitment in the critical care units.

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

Importantly, the trust must:

Ensure that there are sufficient numbers of staff for critical care and medical wards.
Review the provision and skills mix of staff to ensure they are suitably trained to meet the needs of children who use the service.
Ensure that patient flow does not impact on access to services and treatment.
Ensure that equipment allocated to manage sick children or newborn babies is routinely checked to ensure it is safe for use.
Ensure that planning and delivery of care on the obstetrics and gynaecology units meets patients’ individual needs.
Address the culture between staff groups to prevent potential harm to patients.
Review and monitor all aspects of the Hub, in particular for high-risk patients who are unable to access urgent referrals for treatment through the Hub.

In addition the hospital should

Ensure that the Princess Royal Hospital emergency department is fully integrated into the governance structure within the medicine directorate.

Ensure that learning from incidents, accidents and complaints is disseminated among staff to ensure changes to practice are fully embedded.
Ensure that consultants are available to support members of the medical team at all times when on call.
Continue the work to introduce more midwife-led pathways to help normalise birth and reduce the rates of caesarean sections.
Ensure equipment in all of the departments is checked, as required, and the outcomes recorded.
Ensure IT connectivity across all clinical bases is at a level where all community midwives can review essential information.
Ensure cover is in place for specialist services as part of the workforce planning.
Ensure that senior staff for outpatient services receive the necessary performance data for referral to treatment targets and non-attendances (DNAs) to enable them to more effectively manage the outpatient services at the Princess Royal Hospital.
Maintain the security of patient records at all times.
Ensure that the senior staff for outpatient services are part of a wider clinical governance framework for outpatient services, across the trust.
Ensure that staff are able to access mandatory training.
Ensure the secure storage of medicines in critical care.
Develop and use care plans for patients for whom restraint has been necessary.
Maintain the privacy and dignity of patients on the neurological unit.
Ensure the trust-wide profile for end of life care is reviewed in line with the recommendations of the End of Life Care Strategy (2008).
Communicate changes to service configuration in a timely manner to relevant staff.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The inspection team included an advisor with specialist knowledge of infection control, and five inspectors. During the inspection we spoke with 16 staff, in a range of roles, including matrons, maintenance engineers, healthcare support workers, housekeepers, nursing staff, consultants, doctors, directors and managers. We also observed care and spoke with 17 patients and visitors. We visited a sample of elderly care and rehabilitation wards, orthopaedic, surgical and maternity wards and the neurosciences department. We inspected operating theatres and the sterile services department where surgical equipment was decontaminated.

On the day of our inspection we found that the hospital was clean and procedures were in place to prevent and control the spread of infections. We spoke with many patients who were generally very positive about the standards of cleanliness. Most commented that they had observed staff wash their hands frequently, and made use of gloves and aprons when necessary. For example one patient told us," 'I keep an eye on this kind of thing; they change their gloves patient to patient and job to job'.

We found some areas of the hospital where the fabric of the building had become compromised and although intermediate solutions had been instigated these were found to be unsuitable and inappropriate in a healthcare setting. We had concerns that security measures in some areas of the hospital were unsuitable and presented a risk to people's safety. This included areas that housed electrical and computer communications equipment and for the safe storage for clinical waste.

During our visit we took the opportunity to speak with many women and found that they were generally very complementary about the care and dedication of the staff looking after them. We were told that communication was good, staff referred to individual birth plans and women felt supported and listened to. Whilst the women were clearly aware that there were staffing issues everyone that we spoke with said the care was 'superb' and staff were committed and dedicated to 'providing the highest standards'.

Staff were pleased to talk to us and told us 'Our care of the women and babies is really good and we get lots of comments about how nice and helpful the staff are". 'We get compliments from people on how well we look after the women despite staff shortages'.

Although staff told us they were supported by managers who were dedicated and approachable, there was genuine concern that current staffing levels impacted directly on the quality of care. Staff talked about not being able to take breaks and working longer hours than they were paid for. All felt they could not allow women to receive a lesser service due to staffing shortages. One member of staff we spoke with told us 'staffing levels need to improve, there are not enough qualified staff on the ward. Staffing needs to be sorted out or something bad could happen'. Another member of staff told us 'It is a lovely place to work, but we need more staffing support, we are so understaffed'.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records and spoke with staff. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Archived: Princess Royal Hospital

All Inspections

25 September 26 September

During a routine inspection

25 - 27 April 2017

During a routine inspection

Professor Sir Mike Richards

4th-8th April 2016

During a routine inspection

21-23 May 2014

During a routine inspection

Professor Sir Mike Richards

7 May 2013

During an inspection looking at part of the service

8 November 2012

During an inspection in response to concerns

20 March 2012

During a themed inspection looking at Termination of Pregnancy Services