All inspections: Royal Preston Hospital

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.

A summary of CQC findings on urgent and emergency care services in Lancashire and South Cumbria.

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Lancashire and South Cumbria below:

Lancashire and South Cumbria.

Provision of urgent and emergency care in Lancashire and South Cumbria was supported by services, stakeholders, commissioners and the local authority.

We spoke with staff in services across primary care, integrated urgent care, acute, mental health, ambulance services and adult social care. Staff felt tired and continued to work under sustained pressure across health and social care. We found demand on urgent care services had increased. Whilst feedback on these services was mostly positive, we found patients were accessing these services instead of seeing their GP. Local stakeholders were aware that people were opting to attend urgent care services and were engaging with local communities to explore the reasons for this.

The NHS 111 service which covered the all of the North West area, including Lancashire and South Cumbria, were experiencing significant staffing challenges across the whole area. During the COVID-19 pandemic, the service had recruited people from the travel industry. As these staff members returned to their previous roles, turnover was high and recruitment was particularly challenging. Service leaders worked well with system partners to ensure the local Directory of Services was up to date and working effectively to signpost people to appropriate services. However, due to a combination of high demand and staffing issues people experienced significant delays in accessing the 111 service. Following initial assessment, and if further information or clinical advice was required, people would receive a call back by a clinician at the NHS 111 service or from the clinical assessment service, delivered by out-of-hours providers. The NHS 111 service would benefit from a wide range of clinicians to be available such as dental, GP and pharmacists to negate the need for onward referral to other service providers.
People who called 999 for an ambulance experienced significant delays.

Ambulance crews also experienced long handover delays at most Emergency Departments. Crews also found it challenging managing different handover arrangements. Some emergency departments in Lancashire and South Cumbria struggled to manage ambulance handover delays effectively which significantly impacted on the ambulance service’s ability to manage the risk in the community. The ambulance service proactively managed escalation processes which focused on a system wide response when services were under additional pressure.
We saw significant delays for people accessing care and treatment in emergency
departments. Delays in triage and initial treatment put people at risk of harm. We
visited mental health services delivered from the Emergency Department and found these to be well run and meeting people’s needs. However, patients experienced delays in the Emergency Department as accessing mental health inpatient services remained a significant challenge. This often resulted in people being cared for in out of area placements.

We found discharge wasn’t always planned from the point of admission which exacerbated in the poor patient flow seen across services. Discharge was also impacted on by capacity in social care services and the ability to meet people’s needs in the community. We also found some patients were admitted from the Emergency Department because they couldn’t get discharged back into their own home at night. Increased communication is needed between leaders in both health and social care, particularly during times of escalation when Local Authorities were not always engaged in action plans.

Royal Preston Hospital provided a full range of district general hospital services including an emergency department, critical care, general medicine including elderly care, general surgery, oral and maxillo-facial surgery, ear nose and throat surgery, anaesthetics, children’s services, neonatal care, women’s health and maternity, cardiac care, stroke care, cancer care, and care of the elderly. The urgent care service at this site was not provided by the trust

Additionally a range of general services are provided including ophthalmology, occupational therapy, pathology, physiotherapy, pharmacy, dietetics, outpatient services, diagnostic services, radiology and a range of specialist nursing services.

The hospital also provided several specialist regional services including for cancer, neurosurgery and neurology, renal, plastics and burns, rehabilitation, and was the major trauma centre for Lancashire and South Cumbria.

This inspection was focused on the emergency department and elements of the medical core service that included access and flow and patient experience.

Total attendances to the trust’s urgent and emergency care departments had risen from 131,396 between December 2019 and November 2020 to 160,594 between December 2020 and November 2021. This was an increase of 22%. For the same time period children’s attendances had risen from 24,831 to 34,702. This was an increase of 40%.

We spoke with staff of all grades including senior leaders, medical staff, nurses, domestics, practice educators, children’s nurses and pharmacists.

We spoke with 16 patients and their relatives.

We reviewed nine patient records.

We attended a range of meetings including, bed management meetings, ward handover meetings and senior leadership interviews.

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

The hospital did not always have enough substantive staff with the right qualifications, skills, training and experience to meet national staffing standards and provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and were recruiting to vacancies at the time of our inspection.
Staff did not always support patients to make informed decisions about their care and treatment. Patients who lacked capacity were not always supported to make decisions around there care and treatment. In medical care we saw that where mental capacity assessments had been completed, the use of physical restrictions or restraint was indicated without rationale.
Patients could not always access services when they needed it. Patients waiting for emergency treatment had to wait longer than national standards and patients waiting for planned care had to wait longer than the England average. In surgery, there were regular theatre overruns and cancelled operations were above the England average.
In critical care, the design, maintenance and use of facilities and premises did not enable staff to always keep people safe. Not all of the doors from the unit were secure. Staff did not always use equipment and control measures to protect patients, themselves and others from infection. The trust was building new facilities at the time of the inspection.
In urgent and emergency care, patients at risk of deterioration within the waiting area were not always identified or acted.

In medical care, records were not always stored securely and patients’ consent was not always gained for bedside storage.
In surgery, risk assessments for blood clots, and for patients at risk of self-harm were not always completed. We found medicines management systems processes were not always being used effectively.
In medical care, the service had not improved in all of the areas we identified in the last inspection and did not always share good practice. Risk management processes could be improved within medical better identify and mitigate risks.
Services across the hospital had not always worked together to improve patient flow out of the emergency department at Royal Preston Hospital.

However,

Staff generally had training in key skills, understood how to protect patients from abuse, and managed safety well. In most areas the hospital controlled infection risk well. Staff in most areas assessed risks to patients, acted on them and kept good care records. They generally managed medicines well. The hospital managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Staff provided good care and treatment, gave patients enough to eat and drink, and generally 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 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 hospital 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 hospital engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

We carried out this announced inspection on 4, 5 and 28 December 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was carried out by two CQC inspectors and a team leader who were supported by a specialist professional advisor.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Our findings were:

Are services safe?

We found that this service was providing safe services in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

Background

In Lancashire, services for support and examination of people who have experienced sexual assault are commissioned by NHS England and Lancashire Constabulary. The SAFE Centre provides these services. The centre is based at the Royal Preston Hospital, Preston and provides services to adults and children from all over Lancashire.

The centre is a separate building within the hospital grounds and car parking is available outside the centre with level access for people who use wheelchairs and those with pushchairs. Most appointments are pre-booked at times to meet the needs of each patient. The entrance door is secure to safeguard staff and patients and a clear record is kept of all visitors to the centre.

The team consists a mix of permanent full-time staff and bank staff to provide a service day and night. Permanent staff include a centre manager and receptionist, one adult and one child independent sexual violence advisor and a part time clinical director. A new child and young person support worker commenced in post the week of our inspection. Doctors and crisis workers work an on-call rota, to cover daytime, nights and weekends. The service has two medical suites.

The service is provided by Lancashire Teaching Hospitals NHS Foundation Trust (LTH). The centre is included as part of the main services registered at the Royal Preston Hospital. The service is open from 8.30am until 4.30pm, with on call staff available outside of these hours.

During inspection we spoke with the centre manager, director, trust managers for governance and human resources, two independent sexual violence advisors, a crisis worker, the receptionist, and a doctor.

We looked at policies and procedures and other records about how the service is managed. We sampled 15 patients' records.

Our key findings were:

The clinical staff provided patient care and treatment which was in line with current guidelines.
Staff treated patients with dignity and respect.
Not all risks to patients had been identified but managers were developing systems to help identify and manage risk.
The service appeared clean and well maintained.
Staff knew how to deal with emergencies. Appropriate medicines and emergency equipment were available.
The appointment/referral system met patients’ needs.
The service had effective leadership and culture of continuous improvement.
Staff felt involved and supported and worked well as a team.
The service asked staff and patients for feedback.

We identified an area of good practice. The manager and clinical director had agreed that all bank staff would be treated as permanent staff for the purposes of training, appraisal and supervision due to the nature of the work they carried out at the centre. In addition, the centre had developed an accredited two-day sexual assault referral centre training course for staff. This ensured staff were appropriately trained and supported in providing the best possible patient care for patients attending the centre and their families.

There are also areas where the provider SHOULD make improvements. They should:

Ensure that governance arrangements are fully embedded into the service including risk assessment, incident reporting and learning, record keeping and audit procedures.

Ensure referral arrangements to and from partner health services are formalised.

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

The hospital had made improvements to compliance with mandatory training, life support training and safeguarding training in some areas but compliance in other areas such as urgent and emergency services were still not meeting the trust’s targets.
The access and flow of patients was an issue for the hospital which was demonstrated by the hospital not meeting national performance targets or performing worse than the England average. There were also a high number of bed moves at night.
Some of the areas used for escalation, at times of high demand, were unsuitable for patient use.
The hospital did not always have enough staffing in every area. While there had been improvements since the last inspection some areas such as some medical wards and the neo natal unit did not always have enough staff on duty.
The hospital was not always managing medicines well. There were different issues with medicines management in areas of the hospital such as patient group directions and to take home medicines.
While the number of staff who had received an annual appraisal had improved since the last inspection, in areas it was not at the trust target.
Staff lacked understanding and awareness of the Mental Capacity Act and the Deprivation of Liberty safeguards in areas of the hospital.
Patient records were not always completed in line with best practice.
Risks were not always recorded accurately, with timely action to mitigate risks. Some of the governance processes have recently been developed so were not yet embedded.
Policies in a number of areas were not reviewed to ensure that they were up-to-date and in line with best practice.

However:

The hospital was managing safety incidents well in most areas. The environment and equipment was kept clean and on the whole used appropriately for the services provided.
While policies were not up-to-date, services were provided in line with national guidelines and best practice and services were participating and carrying out local audits to improve practice.
Staff throughout the hospital were kind, compassion and caring to patients, their carers and family members. Patients were involved in decisions about their care and given emotional support.
Services were planned to meet the needs of people using the hospital and services were in general responsive to the individual needs of patients. The hospital engaged well with patients and members of the local community.
Staff were positive about their leaders across the hospital. There was a positive culture and staff were proud to work at the hospital.
Staff were committed to making improvements, although some of these processes were yet to be embedded. Staff were positive about the focus on continuous improvement and initiatives such as the safety triangulation accreditation review process.

Royal Preston Hospital provides a full range of district general hospital services including Emergency Department, critical care, general medicine including elderly care, general surgery, oral and maxillo-facial surgery, ear nose and throat surgery, anaesthetics, children’s services, women’s health and maternity, and several specialist regional services including cancer, neurosurgery and neurology, renal, plastics and burns, rehabilitation, and the major trauma centre for Lancashire and South Cumbria.

The hospital has around 700 beds, operating theatre complex, outpatient suites, and education facilities.

We inspected the hospital as a follow up to the inspection in July 2014 where the hospital was found to require improvement in the safe, responsive and well led domains and good in the effective and caring domains. We visited Royal Preston Hospital between 27 and 30 September 2016.

Following this inspection we have rated the hospital as requires improvement overall and the trust needs to make improvements. Staff were noted to be caring and patient focused and the caring domain was rated as good in all service areas.

We saw several areas of outstanding practice including:

In Outpatients and diagnostic imaging the introduction in dermatology of a computerised diary colour codes patients by procedure enabling the service to plan a block of 12 week care in one go to suit the requirements of each patient. It also flags and calculates potential breeches giving better patient flow, facilitating comprehensive audit of care provision and outcome of treatment.

In Critical Care the trust had launched the Sleep Improvement in Adult Critical Care Programme. Disturbed sleep in critical care patients is associated with delirium, in which patients become confused, restless and experience hallucinations. This can delay their recovery from critical illness. The trust recognised this and identified the potential disturbances to sleep. To minimise disruption to patients during the night, they offered eye masks and earplugs, dimmed lights, anticipated empty infusion alarms, turned down the volume on medical equipment and phones and encouraged staff to talk away from the bedside. Staff were also reminded to check regularly for signs of delirium. The project and associated resources were shared with neighbouring critical care networks and at national meetings. An initial research study showed that making small changes caused a 50% reduction in patient delirium and significantly improved the quality of sleep experienced by patients. The study had won an initiative award at the National Nursing Times Awards.

However there were areas for improvement. Importantly, the hospital must:

In Urgent and Emergency Care services ;

Ensure access to the main entrance paediatric waiting area is limited to reduce the risk of children exiting the area through the automatic doorway.
Ensure intravenous fluids are stored securely and daily checks are completed with actions to address issues identified, completed.
Ensure mandatory training, including safeguarding, compliance reaches and consistently achieves the trust target.
Ensure clinical staff are aware of and adhering to the requirement for senior review of specific patient groups prior to discharge from the ED
Ensure appropriate signage is displayed in areas where close circuit television cameras are used.
Ensure action plans following CEM audits target areas of poor performance and improve practice.
Improve performance, particularly in relation to the department of health four hour target; wait times following a decision to admit, ambulance handovers.
Ensure version control for policies, procedures and guidance is robust and that these are kept up to date and reviewed regularly.
Ensure the department has a dedicated risk register with start dates, timelines, mitigating action and responsible person with review dates included.

In Medicine;

Ensure that all staff receive appraisals and complete mandatory training to enable them to carry out the duties they are employed to perform.
Ensure that records are kept secure at all times, so that they are only accessed by authorised people.
Ensure procedures in place around medicine management are robust and that policies are followed.
Ensure the risk registers are consistent and demonstrate mitigating actions and review dates

In Surgery;

Take appropriate actions to improve staff training compliance in areas such as safeguarding training and life support training.
Take appropriate actions to ensure that patients requiring escalation, as part of the national early warning score system (NEWS), are appropriately escalated by staff.
Take appropriate actions to improve compliance against 18 week referral to treatment standards.
Take appropriate actions to reduce the number of cancelled operations and the number of patients whose operations were cancelled and were not treated within the 28 days.

In Maternity and Gynaecology;

Ensure midwifery and support staffing levels and skill mix are sufficient in order for staff to carry out all the tasks required for them to work within their code of practice and meet the needs of the patient.
Ensure there is a safe system for protecting babies from abduction.
Ensure all necessary staff completes mandatory training, including Level 3 safeguarding training and annual appraisals.
Ensure that the assessment and mitigation of risk and the delivery of safe patient care is in the most appropriate place.
Complete risk assessments for midwives carrying medical gases in their cars and develop a Standing Operating Procedure (SOP) or protocol for carrying medical gases by car.
Ensure that all staff receive medical devices training to ensure all equipment is used in a safe way.

In Critical Care;

Ensure that escalation procedures are followed appropriately across the hospital where patients’ National Early Warning Scores (NEWS) are greater than five and the patient may need to be assessed for admittance to the critical care unit.
Ensure that any patients admitted to Ward 2A, who are assessed as Level 2 high dependency patients, receive nursing care at a ratio of 1:2 in accordance with national standards.
Address action points on a gap analysis that showed that there was no availability for endoscopy for urgent gastro intestinal bleeds 24 hours a day.

In Children and Young People’s services;

Ensure that staffing levels in neonatal and children’s services are maintained in accordance with national guidelines.
Ensure that all relevant staff having regular contact with children, as defined by intercollegiate guidance, complete level three safeguarding training.
Ensure that indicators for managing the changing condition of ill children are consistently used and responded to appropriately on the children’s ward.
Ensure that the isolation room used on the children’s ward is free from access to ligature points
Ensure that patient records are kept securely in the children’s out patients department.
Ensure that checks on emergency resuscitation equipment, are completed and accurately recorded on the neonatal unit.
Ensure that secure access to the neonatal unit and children’s ward is maintained at all times by staff, parents and visitors.

In Outpatients and Diagnostic Imaging;

Ensure that clear processes and structures are in place for the management and reviewing of governance, quality and risks.
Review the processes for managing access and flow for outpatient services to ensure patients are not put at risk.
Ensure staff complete mandatory training as per the trust policy.

In addition the trust should:

Urgent and Emergency Services

The service should work to embed the forthcoming escalation process to support staff when capacity issues arise.
The service should have access to information in languages other than English
The service should improve attendance at monthly ED safeguarding meetings

Medical Care (including older peoples care)

The service should ensure that patients are discharged as soon as they are fit to do so.

The service should ensure that patients are not moved ward more than is necessary during their admission and are cared for on a ward suited to meet their needs.
The service should consider improving the environment of the discharge lounge to maintain patient’s privacy and dignity.
The service should ensure that patients have access to pressure relieving equipment at all times.
Consider implementing formal procedures for the supervision of staff to enable them to carry out the duties they are employed to perform.

Surgery

The service should take appropriate actions to maintain safe nurse staffing levels across the surgical wards.
The service should take appropriate actions to improve the general environment in the theatre areas.
The service should take appropriate actions to improve staff appraisal completion rates.
The service should take appropriate actions to improve infection rates following knee replacement surgery.

Critical Care

The trust should ensure intravenous fluids are stored appropriately and are not accessible to patients or visitors on the critical care unit.
The trust should make every effort to secure funding to expand the critical care unit in order to bring bed spaces within the recommended guidelines, make the flooring safe and to reduce the level of bed occupancy.
The Critical Care Governance Team should follow up the request for a review of the risk rating of the lack of a specialist critical care trained pharmacist on a weekend.
The trust should ensure that all staff in critical care receive mandatory training so that trust mandatory training targets are met.
The trust should ensure that all staff in critical care (especially nursing staff) receive an annual appraisal, in line with trust targets.
The service should ensure that action plans arising from audits are kept up to date until complete or actions should be removed.
The service should ensure that GPICS guidelines for 50% of nursing staff to have undertaken a post qualification course in critical care nursing is achieved as soon as possible.
The trust should for any mitigating actions that could reduce the number of delayed discharges from critical care.
The trust should look for ways that Speech and Language therapy (SALT) assessments can be carried out in a more timely manner.

Maternity and Gynaecology

The service should improve the recording of the review dates and version control of all policies and procedures.
The service should strengthen the risk registers to support the management of risk.
The service should improve attendance at governance meetings.
The service should consider the safe storage of patient’s notes on the gynaecology wards.
The service should consider the safe storage of expressed breast milk on the postnatal ward.
The service should consider the dignity and privacy of patients within the clinical areas, especially where curtains are used between bed areas and waiting areas that are positioned near procedure rooms.
The service should continue to monitor consultant labour ward presence with an aim of extending weekday and weekend cover.
The service should ensure that the capacity within the obstetrics and gynaecology theatres prevent delays in patient procedures.
The service should continue to ensure that processes for the storage, recording and traceability of fetal pregnancy remains on the gynaecology wards are robust.
The service should improve staff annual appraisal rates.
The service should increase staff training uptake for Female Genital Mutilation (FGM) training.
The service should work to better understand the variation in unplanned home birth rates to ensure safety of patients and babies.

Services for Children and Young People

The service should use an evidence-based dependency tool to manage appropriate staffing ratios for nursing care on the children’s ward.
The service should appropriately meet the continuing needs of patients who are admitted for child and adolescent mental health services, with adequate support and training for nursing staff where this is required.
The service should accurately record the completed temperature checks for breastmilk fridges and stores on the neonatal unit.
The service should maintain appropriate environmental temperatures on the children’s ward.
The service should maintain neonatal guidelines in an up to date and accessible format for staff to use on the neonatal unit.
The service should that complete and maintain appropriate records for staff supervision and appraisals on children’s and neonatal wards
The service should collect patient feedback responses on the children’s ward using the NHS Friends and Family Test

End of Life services

The service should improve compliance for mandatory training particularly safeguarding, life support and care of the dying education.
SPC staff appraisal rate should meet the trust target of 85%.
The service should address the low numbers of registered nurses who were trained in delivery of end of life care, particularly surgical staff.
The service should create a system for monitoring numbers of staff trained in syringe driver use to assure competency.
The service should consider they take steps to meet the needs of patients by providing a seven day specialist palliative care service.
The service should review staffing levels to ensure they are adequate to maintain the excellent results of the donor retrieval team.

Outpatient and diagnostic imaging services

The service should continue to monitor and review the procedures for caring for vulnerable patients attending for cancer therapy.
The service should consider improving the environment in the Outpatients department to ensure privacy and dignity is maintained.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Royal Preston Hospital is one of two hospitals providing care as part of Lancashire Teaching Hospitals NHS Foundation Trust. It provides a full range of hospital services, including emergency department, critical care, coronary care, general medicine including elderly care, general surgery, orthopaedics, anaesthetics, stroke rehabilitation, paediatrics and midwifery-led maternity care.

Lancashire Teaching Hospitals NHS Foundation Trust as a whole provides services to 390,000 people in Preston and Chorley, and specialist care to 1.5 million people across Lancashire and South Cumbria.

We carried out this inspection as part of our comprehensive inspection programme.

We undertook an announced inspection of the hospital between 9 and 11 July 2014, and an unannounced inspection between 6pm and 8pm on 21 July 2014 at Royal Preston Hospital only. We looked at the management of medical admissions out of hours.

Our key findings were:

Access and flow

The hospital had a high number of medical emergency admissions that was resulting in high numbers of medical outliers (patients placed in areas not best suited to their needs). There were times when there were more than 35 patient outliers.
Patients sometimes remained in the Emergency Department overnight.
There were also occasions when patients were moved from ward to ward many times, sometimes at night.
The number of medical outliers placed in surgical beds led to unused theatre capacity.
Issues with bed capacity were also made worse by the number of delayed discharges.
The management of patient access and flow across the hospital was of immediate concern and remained a significant challenge for managers. The hospital had made arrangements to ensure timely medical review of patients placed in a clinical setting that did not best suit their needs. However, the number of moves across wards and being placed in less appropriate clinical settings was far from ideal and was having a negative effect on patient experience.

Mortality rates

Mortality rates were within expected limits.

Never events

There had been five reported potential surgical never events during the period April 2013 to April 2014. However, three had been declassified, and the trust had taken appropriate steps to reduce the risk of further occurrences.

Infection control

The hospital was clean throughout. Staff adhered to good practice guidance in the prevention and control of infection. There was a good rate of compliance with hygiene audits.

Food and hydration

Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs were supported by dieticians and the speech and language therapy team.
There was a period over mealtimes when all activities on the wards stopped, if it was safe for them to do so. This meant that staff were available to help serve food and assist those patients who needed help. We also saw that a coloured tray system was in place to highlight the patients who needed assistance with eating and drinking.

Medicines management

Medicines were provided, stored and administered in a safe and timely way. Some concerns were raised regarding the completeness of prescription charts in outpatients and the timely provision of medicines for patients to take home.

Nurse staffing

Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services. However, nurse staffing levels, although improved, remained of concern. The trust was actively recruiting nursing staff using innovative methods of recruitment. These included a number of efforts to improve recruitment and retention through wider access schemes with local universities and dedicated ring-fenced funding to support this. They had also linked into international universities to support this recruitment. However, we found that required staffing levels were not consistently achieved in all core services at the time of the inspection.

Medical staffing

Medical treatment was delivered by committed medical staff, however:
Medical staffing was not sufficient to provide appropriate and timely treatment and review of patients at all times within the medical division and to maintain timely clinics in outpatients to meet targets. Many of the middle grade vacancies were due to national shortages of trainees and the full allocation not being sent from the regional training schools. It was noted that the North West had historical difficulty in recruiting and retaining doctors and there had been a number of efforts to improve recruitment and retention through wider access schemes with local universities and dedicated ring-fenced funding to support this.
Medical staffing was not always appropriate at the location, including medical trainees, long-term locums, middle-grade doctors and consultants.

We saw several areas of good practice, including:

Data from the College of Emergency Medicine (CEM) consultant sign-off audit showed that 100% of patients at Preston Emergency Department were seen by an emergency department doctor, compared with a national average of 92%. Also 25% of patients were seen by a consultant, which is well above the national average of 13% in 2012/13.
Ultrasound-guided blocks for patients with neck of femur injuries in the Emergency Department.
Children’s safeguarding review meeting in the Emergency Department.
Chaplaincy service engagement with patients in the Emergency Department.
Consistently rapid handover times for patients arriving by ambulance to the Emergency Department.
Responsive and flexible training using ‘simulation man’ to deliver trauma training within the Emergency Department at quiet times.
The trust was committed to becoming a dementia-friendly environment. An older people’s programme was developing this work and we saw several excellent examples of how this was being put into practice during our inspection. The proactive elderly care team helped staff to identify and assess the needs of older people. The team worked proactively with intermediate care services to ensure the safe discharge of older people and people living with dementia. Activity boxes had been introduced throughout the division to promote and maintain cognitive and physical function and help reduce the unwanted effects of being in a hospital environment.
The trust had won the Clinical Innovation category at the North West Excellence in Supply Awards for developing a disposable female urinal.
The alcohol liaison service had been nominated for a national Nursing Standards award. Staff spoke highly of the service and the positive contributions they had made in supporting patients with alcohol-related conditions.
Our specialist adviser assessed that speech and language therapy input for neonatal babies was likely to improve the long-term outcomes for these children and considered this to be outstanding practice.
The end of life team coordinated rapid response for discharge to the preferred place of care. Staff told us there was a multidisciplinary approach to discharge planning, which involved the hospital and the community staff working towards a rapid but safe discharge for patients.

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

Importantly, the trust must:

Staffing

Ensure that there are enough suitably qualified, skilled and experienced nurses to meet the needs of medical patients at all times.
Ensure that there are enough suitably qualified, skilled and experienced midwives to meet the needs of patients at all times.
Ensure that medical staffing is sufficient to provide appropriate and timely treatment and review of patients at all times within the medical division and outpatients.
Ensure that medical staffing is appropriate at the location, including medical trainees, long-term locums, middle-grade doctors and consultants.

Supporting staff

Ensure that relevant staff receive advanced paediatric life support and moving and handling training.
Take steps to enable the trust to confirm the status of mandatory training that staff have completed in the child health directorate, so that staff have received information about the actions required to maintain and promote safety.
Improve patient flow throughout the hospital to reduce the number of bed moves and length of stay – particularly in the medical division.
Prevent the cancellation of outpatients clinics at short notice and ensure that clinics run to time, particularly within ophthalmology outpatients.

In addition the trust should:

In the Emergency Department:

Improve mechanisms to achieve and maintain performance to meet the four-hour target set by the government for emergency departments.
Address the reasons why patients wait for up to nine hours in the department before being admitted to an inpatient area.

Address the appropriateness of the environment for the children’s treatment area in the Emergency Department with regard to visual or audible separation.

Address the appropriateness of the environment for the delivery of modern emergency medicine.
Review how the constraints of the environment would negatively affect plans to increase services within the department.
Review privacy and dignity for patients being handed over by ambulance crews in the corridor area.
Address the effectiveness of how services for acute gastrointestinal bleeds are provided out of hours.
Review mechanisms for supporting and recording clinical supervision within the Emergency Department.

In the medical division

Improve the management of people with diabetes and stroke in line with national guidance.
Improve the consistency of access to emergency upper gastrointestinal endoscopy and interventional radiology.

In the surgical division

Consider reviewing the overnight provision for ophthalmology patients who require unplanned overnight stays.
Consider reviewing unused theatre capacity within the surgical division.
Ensure that checklists for daily cleaning jobs within the surgical division are completed and current.

In critical care

Ensure that the use of critical care beds is factored into any trust-wide discussions and solutions for improving patient access and flow. This should include continuing to monitor and report on delayed discharges, cancelled elective procedures and the use of theatre recovery at times of peak demand.
The trust is not currently providing a critical care outreach service 24/7. In the absence of this 24/7 service, the trust should ensure that all staff employed within the hospital at night team are suitably qualified and competent to cover the critical care support role.
Consider the impact of not having a weekend pharmacy service in the intensive care unit (ICU). Appropriate care of critically ill patients requires frequent review and re-assessment of therapies, including medication.

In maternity services

Continue to review patient flow with regard to managing induction of labour and transfer of mothers to the delivery suite.

In children’s services

Ensure that all incidents are described in a consistent manner so that details and the action taken can always be easily reviewed.
Ensure that the information in the audits is accurate so that the trust can be confident that appropriate steps are taken to promote safety.
Consider the security and safety of how expressed milk is stored, as the kitchen and fridge were accessible to anyone on the unit.
Be able to provide a comprehensive training record for each member of staff.
Review the décor and furnishings in the children’s day surgery waiting room and pre-operative area.
Ensure that the Child Health directorate completes a comprehensive audit of the Day Case Unit that includes feedback from all stakeholders to ensure plans incorporate all aspects of the services strengths and weaknesses.
Ensure that all opportunities are used to alert staff about the risks identified in relation to safety.
Ensure that staff always report all incidents that are concerned with child safety.
Ensure that information provided about the safety of children’s services is accurate and consistent.
Take more robust action to prevent parents from taking children to Chorley and South Ribble Hospital Accident and Emergency (A&E) department, as there are no children’s A&E services at that site.

Regarding end of life care

Review the processes in place for the return of syringe drivers from the community to ensure availability.
Ensure that audits are carried out on pain management and pain relief for end of life care.

In outpatients

Ensure that the trust receives feedback from patients within the outpatients departments to monitor and measure quality and identify areas for improvement.
Ensure that appropriate checks are in place to provide assurance that medicines prescriptions are correctly completed.
Ensure that members of staff have the opportunity to discuss any issues or concerns they may have on a regular basis within clinical supervision.

Professor Sir Mike Richards

Chief Inspector of Hospitals

This was an unannounced inspection carried out over several days. During the inspection we visited a variety of areas including the hospital’s accident and emergency (A&E) department, the medical assessment unit (MAU), rapid assessment unit (RAU) and a number of medical wards.

We spoke to 31 people who were either using the service at the time of our inspection or had recent experience of it. We also spoke with over 40 staff members who included domestic assistants, nurses, health care assistants, doctors and senior managers.

The vast majority of discussions we held were very positive. Most people who were using or who had recently used the service, expressed satisfaction with their care and treatment. However, we did receive a small number of negative comments. The things people told us included:

‘’I have had absolutely first class care. They have all been brilliant!’’

‘’The staff have been very kind and caring.’’

‘’I cannot thank them enough. They have been wonderful.’’

‘’The doctors have been fine and the nurses have been very friendly.’’

‘’The bay in A & E wasn’t very private, people can hear everything!’’

‘’They need to improve the way they communicate with patients!’’

‘’I felt forgotten about while I was waiting but when I did see the consultant he was brilliant.’’

During the inspection we looked at the care people received and how their welfare was promoted. We found that the vast majority of patients received safe and effective care that met their needs. However, we also found people’s experiences were variable in relation to having a lot of ward moves or not being on the correct ward to meet their needs.

We inspected the area of cleanliness and infection control and found the Trust had good arrangements in place to help ensure that people were cared for in a clean, hygienic environment and were protected from the risk of infection.

We assessed staffing levels. We found there were safe staffing levels in most areas and that the Trust had implemented a number of positive measures to maintain safe staffing levels. However, we did find that not all areas of the service used procedures for responding to unexpected, short notice requirements effectively.

Arrangements for the monitoring of quality and safety were assessed. We saw there were good processes in place that enabled managers to monitor standards, identify risk and respond appropriately to adverse incidents.

We looked at how the Trust enabled people to raise concerns and their processes for responding. We found this area was in need of improvement.

We spoke with four patients about their medicines. Everyone we spoke with was positive about their stay. One patient we spoke with about medication handling told us, 'they're really, really good, they explained how everything worked'. Documents for assessing and supporting patients to self-administer medication were available and in use. Patients choosing to do so were; where possible, supported to look after their own medicines. Patients told us that they had enough information about the medicines they were taking and about any changes to their medicines.

During this inspection we looked specifically at the maternity services provided at the hospital. The hospital provides a full range of maternity services including a 52 bed ward and 12 labour rooms.

We spoke with 12 patients who were receiving care and 18 staff members including midwives, health care assistants and managers.

We received very positive feedback from the majority of patients we spoke with. Patients told us that they were happy with the care they had received and the way they had been treated.

Comments included;

'We are very pleased with everything. The staff have been brilliant.''

'They seem very competent and professional, but they are nice with it.'

'I was really pleased with the way they looked after me in labour. They were lovely.'

'I have no complaints. I've found everything really good.'

We looked at six areas during the inspection including the ways in which patients were enabled to make decisions about their care, the quality of care provided and the way in which patients' medicines were managed. Other areas included arrangements for the safeguarding of patients from abuse and staff training. We also looked at how the Trust monitored the safety and quality of the service.

The Trust were able to provide evidence of compliance with the majority of areas we inspected. However, some concerns were identified in relation to the management of medication. We have asked the Trust to take action to address this.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. 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.

During our visit we were able to speak with a number of patients and in some cases, their relatives. People that we spoke with were very complimentary about the care and treatment they had received at the hospital and spoke highly of staff providing their care.

Comments from patients included;

'We have such a laugh with them (the staff), it passes the time away.'

'So far, everyone I have had looking after me has been great.'

'They can't do enough for you ' whatever you ask for they will try to sort out.'

One patient commented, 'They are so very kind and attentive. I will be sad to be going home.'

Visiting relatives also expressed satisfaction with the care their loved ones were receiving and told us that they had felt fully involved at all times. One relative said, 'You can tell they really care about the patients here. They always seem to have time for people.'

Other relatives' comments included;

'The staff here are so good. I come in every day and see everything going on and I can tell you this is a good place.'

'They are great and they make you feel so comfortable.'

No person that we spoke with during our visit expressed concerns about any aspect of the care they or their loved one had received. People told us that staff took time to understand their individual needs and that their requests for assistance were always answered promptly.

The majority of people we spoke with were very complimentary about the care they were receiving and spoke highly of staff. Comments included;

'I feel lucky to be here, they are absolutely brilliant with me.'

'I felt scared when I came but they soon put my mind at rest.'

'We are treated very well, if the younger generation are treated as well as us then this is a very good place.'

Most people felt that their care needs were met well and that they were cared for in a way that they wanted.

People told us that they felt their dignity and privacy was respected and everyone we spoke with told us that they had never been made to feel embarrassed during their stay.

Whilst people were generally very positive about their care, some did express concerns. Some people commented that, at times, they had to wait a long time to get assistance and generally felt that this was due to staffing levels sometimes being low.

We received generally positive feedback about the quality and variety of meals available. People told us that they thought there was a good choice of food made available. However, several people told us that they didn't always get the meals they had ordered.

People said that they were confident that staff understood their nutritional needs. One patient told us that she had been very underweight on her admission but had managed to achieve a steady weight gain throughout her stay.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

All Inspections

However there were areas for improvement. Importantly, the hospital must:

In addition the trust should:

Professor Sir Mike Richards

Access and flow

Mortality rates

Never events

Infection control

Food and hydration

Medicines management

Nurse staffing

Medical staffing

We saw several areas of good practice, including:

Staffing

Supporting staff

In the Emergency Department:

In the medical division

In the surgical division

In critical care

In maternity services

In children’s services

Regarding end of life care

In outpatients

Professor Sir Mike Richards