Royal Preston Hospital

Updated 24 November 2023

Lancashire Teaching Hospitals NHS Foundation Trust is an acute trust providing services to the Preston and Chorley areas and a range of specialist services to people in Lancashire and South Cumbria. The trust delivers services from three core sites, Royal Preston Hospital, Chorley & South Ribble Hospital and the Specialist Mobility and Rehabilitation Centre. It is also a major trauma centre. The trust serves a population of 395,000 people and provides regional specialist care to 1.8 million people.

The trust is situated in an area where 20% of the population are 10% most deprived nationally, up to 25% of children and 20% of over 65s are living in poverty. There are high levels of long-term conditions including mental health, cardiovascular disease, asthma, and dementia. By 2035 the over 75s will double. 17% of people in Pennine Lancashire are from a black minority ethnic background.

The trust employs over 8,800 staff and has 900 beds across 2 sites. It has an income of 738 million.

We carried out this unannounced inspection as part of our continual checks on the safety and quality of healthcare services at the trust. We inspected urgent and emergency care at Royal Preston Hospital and Chorley and South Ribble Hospital, and medicine, and surgery at Royal Preston Hospital.

A focussed inspection of maternity services was also undertaken as part of the CQC national maternity inspection programme which looked at the safe and well led questions.

We also inspected the well-led key question for the trust overall.

Where we did not inspect services, using our rating principles the ratings for these services have been aggregated from the inspection in 2019.

No Use of Resources review was undertaken as part of the 2023 inspection.

Our rating of services stayed the same. We rated them as requires improvement because:

• We rated safe, effective, responsive and well led as requires improvement and caring as good.
• We rated surgery at Preston and urgent and emergency care and maternity at Chorley as good. We rated urgent and emergency care, medicine and maternity at Preston as requires improvement. In rating the trust, we took into account the current ratings of the 9 services not inspected this time.

Urgent and Emergency Care

At the Royal Preston Hospital, the urgent and emergency service operates 24 hours a day, seven days a week. The emergency department is also a major trauma centre, accepting adult patients with more serious injuries. The service also has a separate children’s emergency department for children in need of urgent care. Patients are triaged in designated assessment areas and in cubicles or rooms for more seriously unwell patients. An urgent care centre was co-located in the department, with services delivered by an independent healthcare provider for adults and children, 24 hours a day, seven days a week. Following triage, patients are treated in one of four main areas: the minor injury/illness unit, the ambulatory care unit, A&E majors, or A&E resuscitation.

We visited the service as part of our unannounced inspection on 31 May & 1 June 2023. We inspected the urgent and emergency care services at the hospital as part of a trust inspection. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

The inspection was carried out by two CQC hospital inspectors, a medicines inspector, and two specialist advisors. We observed care, spoke with ten patients and their relatives, reviewed care records for 13 patients. We spoke with 26 staff of all grades including senior leaders, medical staff, nurses, domestics, allied health professionals, practice educators, children’s nurses, and pharmacists. We attended a range of meetings including, bed management meetings, ward handover meetings and senior leadership interviews.

Our rating of this location stayed the same. We rated it as requires improvement because:

• Compliance for some areas of mandatory training was low for medical staff; the design, of the department made it difficult to keep people safe; Staff did not always assess risks to patients, act on them or keep care records updated. Staff did not always complete medicines records accurately or kept them up to date although they managed medicines well.
• Staff did not always know how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. Staff did not always follow up if patients had enough food and drink whilst waiting for treatment.
• People could not always access the service when they needed it and patients often had long waiting times for treatment.
• The service did not always take account of patients’ individual needs.

However:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and helped them understand their conditions. They provided emotional support to patients, families, and carers.
• The service planned care to meet the needs of local people, and made it easy for people to give feedback.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Medical Care

Medical care services at Preston Royal Hospital are provided by Lancashire Teaching Hospitals NHS Trust.

We visited Royal Preston Hospital as part of our unannounced inspection from 31 May to 1 June 2023. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

Medical care services are part of the division of specialist medicine at Lancashire Teaching Hospital.

The inspection was carried out by 2 CQC hospital inspectors, a medicines inspector and 2 specialist advisors. We observed care, spoke with 15 patients and their relatives and reviewed care records for 15 patients. We spoke with staff of all grades including senior leaders, medical staff, nurses, allied health professionals and practice educators. We attended a range of meetings including, bed management meetings, ward handover meetings and senior leadership interviews.

During our inspection we visited and inspected the acute assessment unit, the acute medical unit, the frailty assessment unit, respiratory, the coronary care unit, the discharge lounge, Fell View, a general medical ward, and the stroke unit. We visited Finney House to review how patients move from the hospital to the step-down rehabilitation centre .

We previously inspected the medical division at Preston Royal Hospital in 2019.

Our rating of this location stayed the same. We rated it as requires improvement because:

• The service did not always control infection risk well. The environment did not always keep people safe. Staff did not always identify and quickly act upon patients at risk of deterioration and did not always have the resources available to them to support patient’s needs. The service did not have enough established medical staff to keep patients safe from avoidable harm.
• The service did not always achieve good outcomes for patients. Not all services were available 7 days a week.
• The services facilities and premises were not always appropriate for the services being delivered.
• The service did not always meet the needs of local people and the communities served.
• People could not always access the service when they needed it and sometimes had to wait longer than national targets for treatment.

However:

• Staff completed their mandatory training in a timely manner. Staff understood how to protect patients from abuse, and managed safety well. The service had enough nursing staff to keep patients safe from avoidable harm. Staff kept good care records. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and supported patients to make informed decisions about their care.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families, and carers.
• The service took account of patients’ individual needs and made it easy for people to give feedback.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported, and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service identified relevant risks and issues and implemented timely actions to reduce their impact. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Surgery

We inspected the service with two inspectors, a medicines inspector and a specialist advisor.

During our inspection we visited the main theatres; a specialist plastics theatre; pre-operative assessments; the surgical assessment unit and 13 wards, including those with specialities in major trauma, vascular surgery, orthopaedics, general surgery and neurosurgery.

We spoke with 68 staff from a range of roles, including nurses, support workers, medical staff, ward managers, matrons, governance staff and senior leaders. A further interview with the senior leadership team was conducted off site following the inspection.

We also spoke with 9 patients and 2 relatives. We reviewed 5 patient records and attended a team handover/safety huddle and a bed meeting.

We reviewed policies and procedures and a range of data and other documents.

We previously inspected the surgery division at Preston Royal Hospital in 2019.

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

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They mainly managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• The service did not always ensure that medicines with a minimum dosage interval were administered as prescribed.
• People could not always access the service when they needed it and waiting times for treatment were above the England average.

Maternity

We inspected the maternity service at Royal Preston Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions. We last carried out a comprehensive inspection of the maternity service in October 2018.

Royal Preston Hospital provides maternity services to the population of central Lancashire.

Royal Preston Hospital is 1 of 2 sites for maternity services for the trust. On site there was both an obstetric led unit as well as a midwifery led birthing unit. The obstetric led service had a delivery suite and two wards, ward A (antenatal care) and ward B (postnatal care), maternity theatres, antenatal clinic, maternity assessment suite which incorporated maternity triage and maternity day unit. The trust had approximately 4,125 deliveries per year across both sites.

Following our inspection and a review of trust data, we issued a letter of intent under section 31 of the Health and Social care Act 2008 to the trust. The letter of intent requested further information around waiting times and staffing within the maternity triage, delays within the induction of labour, as well as delays within reporting incidents and the grading of incidents. The trust responded quickly to the concerns raised and provided the required assurances.

We also inspected 1 other Maternity service run by Lancashire Teaching Hospitals NHS Foundation Trust. Our report is here:

Chorley and South Ribble District General Hospital - https://www.cqc.org.uk/location/RXN01

The team that inspected the service comprised a CQC lead inspector, 2 other CQC inspectors and 4 specialist advisors including midwives and an obstetrician. The inspection team was overseen by Carolyn Jenkinson, Deputy Director of Secondary and Specialist Care.

We provided the service with 2 working days’ notice of our inspection.

We visited the delivery suite, midwifery led birthing unit, maternity theatres, antenatal ward, postnatal ward and maternity assessment unit.

The inspection was carried out using a pre-inspection data submission and an on-site inspection where we observed the environment, observed care, conducted interviews with patients and staff, reviewed policies, care records, medicines charts and documentation.

During the inspection we spoke with staff including the divisional nursing and midwifery director, deputy director, and midwives. We reviewed records and spoke with women, birthing people and their families.

We received over 100 give feedback on care forms through our website. Feedback received indicated women and birthing people had mixed views about their experience. Feedback included about concerns about communication.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

Our rating of this service ​went down​. We rated it as ​requires improvement​ because:

• Staff training compliance for life support, compliance with life support training was below trust targets and medical staff was below the trust target for all training other than Cardiotocography (CTG) training.
• The service did not consistently report incidents to the National Learning and Reporting System (NRLS) in a timely manner.
• Not all staff felt that were listened to by senior leaders when highlighting concerns around staffing.
• The service reported women had experience long delays in the induction of labour and not all reasons for the delays were documented.
• Audits showed compliance with hourly CTG reviews continued to not meet the trust target of 85%.
• From November 2022 to May 2023 data showed there was a declining performance in relation to the time taken from making the decision to carry out a category 1 (urgent) caesarean section to delivery in line with clinical guidance.

However:

• Staff had training in key skills and worked well together for the benefit of women and birthing people, understood how to protect women and birthing people from abuse, and managed safety well. The service-controlled infection risk well. Staff assessed risks to women and birthing people, acted on them and kept good care records. They managed medicines well.
• Leaders ran services well using reliable information systems and supported staff to develop their skills.
• Staff understood the service’s vision and values, and how to apply them in their work. Managers monitored the effectiveness of the service and made sure staff were competent. Staff felt respected, supported and valued. They were focused on the needs of women and birthing people receiving care.
• Staff were clear about their roles and accountabilities. The service engaged well with women and birthing people and the community to plan and manage services.
• People could access the service when they needed it and did not have to wait too long for treatment. and all staff were committed to improving services continually.

Updated 24 November 2023

Updated 17 October 2018

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

• The trust had made improvements since the last inspection to safeguarding training levels. Safeguarding training levels had improved significantly since the last inspection, although were still lower than the trust target.
• The service was taking action to assess and respond to patient risks. The service was using early warning scores more consistently to monitor deteriorating patients which was an improvement from the last inspection.
• The service kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care. Although signatures were not always clearly identifiable. Records in outpatients were kept securely which was an improvement from the last inspection.
• The service had suitable premises and equipment and controlled infection risk. This was an improvement since the last inspection. The trust had improved the security in all areas and was checking resuscitation equipment daily.
• The service had improved nurse staffing on the paediatric ward since the last inspection.
• Staff were competent in their roles and mandatory training was close to the trust’s target.
• The service managed patient safety incidents well, as staff recognised incidents and reported them appropriately using the trust’s reporting system.
• The service monitored the effectiveness of care and treatment and used the findings to improve them.
• The service gave patients enough food and drink to meet their needs and pain relief when it was required.
• Staff were caring, involved patients and those close to them in decisions about their care and treatment and provided emotional support to patients who needed it.
• Services were planned to meet the needs of patients and patient’s individual needs were met.
• While a number of the leaders were new in post, staff were positive about the leadership team. The leaders promoted a positive culture that supported and valued staff. Staff were open, honest and proud to work within the service.
• There was a clear governance structure and clear lines of accountability for staff at all levels and effective systems for identifying and mitigating risks.
• The service engaged well with children, their parents and carer, staff, the public and local organisations and was committed to improving services.

However:

• While the service prescribed, gave and recorded medicines well, all the hard copies of the patient group directives, were out of date and that there were lots of dates for different fridges where the temperature had either not been checked, or not recorded.
• In our previous inspection we reported that staffing levels in the neonatal unit needed to be maintained in accordance with national guidelines. We found that the neonatal unit, they were still not compliant with British Association of Perinatal Medicine (BAPM) although had taken action to mitigate the risks. There were still some issues with medical staffing levels.
• Policies were not all within their review dates.
• The decorations of the paediatric ward were not all child friendly.
• There were gaps in the information the service collected, analysed, managed and used to support all its activities, such as information about timeliness of medical reviews.

Updated 7 November 2019

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

• The service had enough registered nurse and medical staff to meet the needs of patients. The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse. Staff completed and updated risk assessments for each patient and took action to remove or minimise risks. They managed medicines well. The service managed safety incidents well and learned lessons from them. Records were clear, up-to-date, easily available to all staff providing care and stored securely.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. staff made reasonable adjustments to help patients access services. The service admitted, treated and discharges patients in line with national standards. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
• The service had managers at all levels with the right skills and abilities. Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The service collected, analysed, managed and used information well to support all it’s activities, using secure electronic systems with security safeguards. The service engaged well with staff and local organisation to plan and manage appropriate services. The service was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

However:

• The design, maintenance and use of facilities and premises did not enable staff to always keep people safe. The design of the environment was not in line with national guidance and the flooring was in a poor condition. Not all of the doors from the unit were secure.
• Staff did not always use personal protective equipment, such as aprons and gloves when disposing of waste.
• The service did not have enough allied health professionals with the right qualifications, skills, training and experience to provide the right care and treatment.
• Not all staff were aware of the vision or strategy for the unit.

Updated 21 April 2017

At the previous inspection in July 2014 we rated this service as good overall at both hospitals. At this inspection we will only report on End of Life services within the Royal Preston Hospital report as the service delivered is by the same team across both hospital sites, however we did inspect both hospital sites. Following this inspection we have maintained this good rating because:

• There was good use of the individualised plan of care document throughout the hospital. All health care records were completed to a high standard to ensure patient safety. There was evidence of comprehensive risk assessments regularly performed and patients’ goals and wishes were recorded.
• There was evidence of changes and improvements made as a result of feedback from patients and other staff.
• The palliative care team delivered training to all levels of staff, using a variety of teaching methods to capture the maximum staff available. Online guidance was provided via the trust intranet that ensured all staff had access to the most current information at all times.
• The end of life care (EOLC) team demonstrated excellent management of patients in their last days/hours of life. The team had used the National Institute for Health and Care Excellence (NICE) Care of the Dying guidance to develop a ‘Think CLEAR’ policy for all staff to follow. The team had performed on or better the national average on 11 out of 13 of the key performance indicators on the 2016 Dying in Hospital Audit.
• The team attended daily multidisciplinary team meetings across the hospital specialities in order to provide knowledge and input into patients’ end of life care. The hospital team also participated in local and national groups to share information and learn from peers.
• Staff respected patients and their relatives and valued them as individuals. The care provided by the palliative care team was person centred and the culture within the team reflected this. All interactions between staff that we witnessed were patient centred and displayed compassion and respect.

However:

• The team were not providing a seven-day palliative care service that meant rapid discharge between Friday and Monday could not always be facilitated. This meant that some patients may not die in their preferred place.
• Due to staffing difficulties, the number of eye retrievals had decreased in recent months.
• The educational facilitator was having difficulties ensuring an end of life link nurse was available on every ward, due to staff movement within the hospital.
• Staff compliance with mandatory training and appraisal was below the trust target.

Updated 24 November 2023

Updated 17 October 2018

We previously inspected outpatients jointly with diagnostic imaging in September 2016, so we cannot compare our new ratings directly with previous ratings.

We rated the service as good because:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Care and treatment was delivered in line with best practice guidance. Patient outcomes were reviewed during clinic appointments to make sure patients were receiving appropriate care and treatment.
• Staff demonstrated a consistently caring attitude to supporting patients that was compassionate and kind. Patients’ dignity was always maintained.
• 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 had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
• Patients could access care and treatment in a timely manner.
• Staffing numbers and skills were flexibly managed to make sure there was sufficient staff to support the clinics as needed.
• There was a clear strategy based on best practice and values that assisted the service in developing quality care and treatment.
• The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However:

• The assessment and recording of a patient’s mental capacity and staff understanding of the Mental Capacity Act 2005 was not always consistent.
• Systems designed to flag patients needing extra support were not consistently used.
• Information for patients was not always available in formats that met their needs
• Appropriate records of patients’ care and treatment were not being kept in all outpatient clinics. Some records were not clear, up to date and available to all staff providing care.

Updated 24 November 2023

Updated 24 November 2023