The Princess Alexandra Hospital NewApproachFocused Report

162 Pages·2012·1.54 MB·English

The Princess Alexandra Hospital NHS Trust
TThhee PPrriinncceessss AAlleexxaannddrraa
HHoossppiittaall
Quality Report
PrincessAlexandraHospital
HamstelRoad
Harlow
Essex
CM201QX Dateofinspectionvisit:28and29June2016,2and6
Tel:[phone] July2016
Website:www.pah.nhs.uk Dateofpublication:19/10/2016
Thisreportdescribesourjudgementofthequalityofcareatthishospital.Itisbasedonacombinationofwhatwefound
whenweinspected,informationfromour‘IntelligentMonitoring’system,andinformationgiventousfrompatients,the
publicandotherorganisations.
Ratings
Overall rating for this hospital Inadequate –––
Urgent and emergency services Inadequate –––
Medical care (including older people’s care) Requiresimprovement –––
Surgery Requiresimprovement –––
Critical care Inadequate –––
–
Maternity and gynaecology Outstanding
Services for children and young people Requiresimprovement –––
End of life care Inadequate –––
Outpatients and diagnostic imaging Good –––
1 The Princess Alexandra Hospital Quality Report 19/10/2016
Summary of findings
LetterfromtheChiefInspectorofHospitals
Wecarriedoutacomprehensiveinspectionon28and29June2016aspartofourregularinspectionprogramme.This
inspectionwascarriedoutasacomprehensivefollowupinspectiontoassessifimprovementshavebeenmadeinall
coreservicesinceourlastinspectioninJuly2015.
ThePrincessAlexandraHospitalNHSTrustislocatedinHarlow,Essexandisa460beddeddistrictgeneralhospital
providingacomprehensiverangeofsafeandreliableacuteandspecialistservicestoalocalpopulationof350,000
people.Thetrusthasfivesites;ThePrincessAlexandraHospital,StMargaret’sHospital,HertsandEssexHospital,and
RectoryLaneClinic.Atourinspectionon28and29June2016,weinspectedThePrincessAlexandraHospital.Onour
unannouncedinspectionon2and5July2016,weinspectedThePrincessAlexandraHospital.Wereviewedtheservice
providedattheRectoryLaneClinicandfoundthatthislocationdidnotrequireregistration,thetrustwouldbeapplying
toremovethislocation.
Duringthisinspection,wefoundthattherehadbeendeteriorationinthequalityofsomeservicesprovidedsinceour
previousinspectionin2015.Duringthisinspection,wefoundthatthetrusthadsignificantcapacityissuesandwas
havingtoreassessbedcapacityatleastthreetimesaday.Thispressureonbedsmeantthatpatientswereallocatedthe
nextavailablebedratherthanbeingtreatedonawardspecificallyfortheircondition.Wefoundthatstaffshortages
meantthatwardswerestrugglingtocopewiththenumbersofpatientsandthatstaffweremovedfromonewardto
coverstaffshortagesonothers.Thetrustseesonaveragearound350patientsadayinitsemergencydepartment(ED).
WehaveratedThePrincessAlexandraHospitallocationasinadequateoverallduetosignificantconcernsinsafety,
responsivenessandleadership,withtheapparentdisconnectbetweenthetrustboardleadershiplevelandtheward
level.Itwasevidentthatthetrustleaderswerenotawareofmanyoftheconcernsweidentifiedthroughthisinspection.
Wefoundthatthestaffwereverycaringinallareas.Wehaveratedthematernityandgynaecologyserviceas
outstandingoverall.
Ourkeyfindingswereasfollows:
• Shortagesofstaffacrossdisciplinescoupledwithincreasedcapacitymeantthatservicesdidnotalwaysprotect
patientsfromavoidableharm,impacteduponsevendayprovisionofservicesandmeantthatpatientswerenot
alwaystreatedinwardsthatspecialisedinthecareofhealthissues.
• Thedisconnectbetweenwardstaffandthematronlevelhadimproved.However,someculturalissuesremainedat
thislevelwhichrequiredfurtherwork.
• Therelationshipbetweenstaffandthesitemanagementteamhadimproved,thoughthiswasstillworkinprogress
andthetrustacknowledgedfurtherworkwasrequiredhere.
• Agencystaffdidnotalwaysreceiveappropriateorientation,orhavetheircompetencychecksundertakenfor
intravenous(IV)careforpatientsonindividualwards.Thishadimprovedbythetimeourunannouncedinspection
concluded.
• Thestorage,administrationandsafetyofmedicationwasnotalwaysmonitoredandeffective.
• Informationflowsandhowinformationwassharedtotruststaffwerenotrobust.Thismeantthatstaffwerenot
alwayscommunicatedtointhemosteffectiveways.
• Thestaffprovidedgoodcaredespitenursingshortages.
• Therewerepoorculturalbehavioursnotedinsomeareas,withsomewardsnotdeclaringhowmanystafforbeds
theyhadovernighttotryandeasetheworkloads.Thiswasaresultofconstantpressureontheserviceactivities.
• Themortuaryfridgeshaddeterioratedsinceourlastinspectionandsomewerenolongerfitforpurpose.Thesewere
repairedandsealedduringourunannouncedinspectiontoensuretheyprovidedanappropriateenvironmentfor
patients.
2 The Princess Alexandra Hospital Quality Report 19/10/2016
Summary of findings
• Acrosssurgery,therewerenotabledelaysinansweringcallbellsonsurgicalwardsincludingKingsmoorand
Saundersward.
• Gynaecologyinpatientcarehadnotimproved,butdeclined,sinceourpreviousinspection.Theinpatient
gynaecologyservice,whichwasoperatedthroughsurgery,wasnotresponsivetotheneedsofwomen.
Wesawseveralareasofoutstandingpracticeincluding:
• ThewardmanagerfortheDolphinchildren’swardhadsignificantlyimprovedthewardandperformanceofchildren’s
servicessinceourlastinspection
• Thetissueviabilitynurseintheatresproducedmodelsofpressureulcerstosupporttheeducationandpreventionof
pressureulcerdevelopmentintheatres.Thisalsohelpedtoincreasereporting.
• Theimprovementanddedicationtoresolvethebacklogandissueswithinoutpatientswasoutstanding.
• Theadvancednursepractitionergroupswithintheemergencydepartmentwereanoutstandingteam,whoworked
todevelopthemselvestoimprovecarefortheirpatients.
• Thegynaecologyearlypregnancyunitandterminationserviceswasoutstandingandprovidedaveryresponsive
servicewhichmettheneedsofwomen.
• Theoutcomesforwomeninthematernityservicewereexcellentandcomparablewithunitsinthetopquartileofall
Englandtrusts.
• MSSAratesreportedatthetrustplacedtheminthetopquartileofthecountry.
• Thepermanentstaffwhoworkedwithinwomen’sserviceswerepassionate,dedicatedanddeterminedtodeliverthe
bestcarepossibleforwomenandwereoutstandingindividuals.
• Theleadnursefordementiawasinnovativeintheirstrategytoimprovethecareforpeoplelivingwithdementia.
However,therewerealsoareasofpoorpracticewherethetrustneedstomakeimprovements.
Importantly,thetrustmust:
• Ensurethatsafeguardingchildren’sprocesses,reportingandinvestigationsforthesafeguardingofchildrenare
improved.
• Ensurethatstaffcaringforchildrenandyoungpeoplehaveappropriatelevelsoflifesupporttraininginlinewiththe
RoyalCollegeofNursing‘Healthcareservicestandardsincaringforneonates,childrenandyoungpeople’.
• Ensurethatstaffareprovidedwithappraisals,thatarevaluableandbenefitstaffdevelopment.
• Improvemandatorytrainingrates,particularlyaround(butnotexclusiveto)safeguardingchildrenlevelthree,
movingandhandling,andhospitallifesupport.
• Ensurethattherearesafeandefficientstaffinglevelsatalltimes.
• Ensurethatresuscitationtrolleysanddifficultairwaytrolleysareroutinelychecked,stockedandkeptinasafe
conditionforemergencyuse.
• Ensurethatfridgetemperaturesaremonitored,andacteduponwhenconcernsareidentified.
• Ensurethatwomenundergoingelectivegynaecologyprocedures,includingbutnotexclusivetoterminationof
pregnancy(TOP)procedures,arecaredforbystafftrainedintheclinical,holisticandsocialneedsofwomen.
• Ensurethatrapiddischargeofpatientsattheendoftheirlifeismonitored,targetedandmanagedappropriately.
• EnsurethattruststaffareknowledgeableandprovidecareandtreatmentthatfollowstherequirementsoftheMental
CapacityAct2005.
• Ensurethatgovernancearrangements,includingtheriskregisterandboardassuranceframeworkareembedded,
robust,andactivelyreflecttheriskswithintheorganisation.
• Ensurethatthequalityofrecordkeepingoncriticalcareimproves.
• Reducetheimpactorlikelihoodofmixedsexaccommodationbreachesonthehighdependencyunit(HDU).
• Ensurethatcomplaintsarelearntfrom,andlearningissharedthroughoutthetrust.
• EnsurethatpatientsarrivingbyambulanceintotheEDareappropriatelyassessedandtriagedinatimelymannerin
accordancewithTheRoyalCollegeofEmergencyMedicine(RCEM)guidelines.
3 The Princess Alexandra Hospital Quality Report 19/10/2016
Summary of findings
AsaresultofthefindingsfromthisinspectionIhaverecommendedtoNHSImprovementthatthetrustbeplacedinto
specialmeasures.Itishopedthatthetrustwillmakesignificantimprovementsthroughreceiptofsupportfromthe
specialmeasuresregimepriortoournextinspection.
ProfessorSirMikeRichards
ChiefInspectorofHospitals
4 The Princess Alexandra Hospital Quality Report 19/10/2016
Summaryoffindings
Summary of findings
Ourjudgementsabouteachofthemainservices
Service Rating Why have we given this rating?
Urgent and Overallweratedtheemergencydepartment(ED)at
Inadequate –––
emergency ThePrincessAlexandraHospitalasinadequate.
services Safetyandresponsivenessofserviceswasratedas
inadequate,howeffectiveandwell-ledtheservice
washasbeenratedasrequiresimprovement,and
caringwasratedasgood.
Patientsarrivingbyambulancewerenotroutinely
beinginitiallyassessedwithin15minutesas
required.Manypatientswereintheambulance
waitingareaforprolongedperiods,withpatients
notbeingassessedorhandedovertothetrust
teams.Levelsofnursestaffingintheresuscitation
roomwereunsafe.Therewasnoclinicaloversight
orviewofthewaitingroom.Regularcheckingof
equipment,includingresuscitationtrolleysand
defibrillators,wasnottakingplace.Fridge
temperatureswerenotroutinelymonitoredto
ensuresafestorageofmedicines.Mandatory
trainingcomplianceforthedepartmentwaslow,
especiallyonpaediatriclifesupport.
Theservicewasmostlyfollowingguidelinesknown
tothemfromtheRoyalCollegeofEmergency
Medicine(RCEM)andNationalInstituteforHealth
andCareExcellence(NICE).However,staffwerenot
familiarwithallrecentguidelineupdates.Staffhad
notreceivedregularappraisals.Theunplanned
patientre-attendanceratewasconsistentlyhigher
thantheEnglandaverage.Concernswereraised
abouthowstaffweretrained,developedand
progressedintheirroleswithintheED.Therewasa
lackofclinicalaudittakingplace.
Theservicehadnotachievedthefourhour
performancestandardsinceAugust2014.The
percentageofpatientswaitingfourto12hoursfrom
thedecisiontoadmituntilbeingadmittedhasbeen
longerthantheEnglandaveragesinceMay2015.
Ambulancedelaysover30minutesweresomeof
theworstinEngland.Blackbreachrateswerehigh.
Callsbellswentunansweredforprolongedperiods
oftimewhentheemergencydepartmentwasbusy.
Staffwespokewithwereunawareofthetrust’s
values.Therewasabusinessplan,visionand
strategyfortheservicewithsomebasicobjectives
5 The Princess Alexandra Hospital Quality Report 19/10/2016
Summaryoffindings
Summary of findings
fortheEDtoimprovearoundfourhour
performance.However,itwaslimitedtofourhour
performanceandfinancialpenalties,ratherthan
linkingittopatientsafetyandoutcomes.
Caringwasgoodbecausethetrusthadsystemsin
placetooffermulti-faithsupportandbereavement
services.Careprovidedbystafftopatientswasseen
askindandcompassionate.
Medical care WehaveratedmedicalcareatThePrincess
Requiresimprovement –––
(including AlexandraHospitalasrequiresimprovement
older overall,withsafetyandresponsivenessratedas
people’s requiresimprovementandtheotherdomainsrated
asgood.
care)
Nursestaffinglevelsdidnotalwaysmeetthe
expectedestablishedstaffingrequirementsonthe
wards.Agencynurseswereadministering
intravenousmedicationswithoutproviding
evidenceoftrainingcompetencies,whichplaced
patientsatrisk.However,thetrusttookimmediate
actiontoresolvethis.Thereweregapsinthe
checkingoftheresuscitationequipmentand
medicinesfridges.Thereweregapsintherecords
forthecontrolleddrugsregisterchecks.Staffwere
notalwaysawareofoutcomesfromlocalaudits.
Appraisalrateshadreducedsinceourlast
inspection.
Therewerehighnumbersofoutofhoursdischarges
reported.Thetrustacknowledgedthattherewere
issueswithspecialityinputandbedavailabilityas
patientscouldnotalwaysbeplacedonthe
appropriatespecialistward.
Therewasaclearleadershipstructureacrossthe
service.Staffshowedacommitmenttotheservice
anddemonstratedpocketsofinnovationintheir
areaofwork.However,wealsoidentifiedrisksto
theservicethathadnotbeenidentifiedontherisk
register.Wewereconcernedaboutsomeofthepoor
culturalpracticesofthenursingstaffinthemedical
careservices.
Staffdemonstratedakind,compassionateand
caringapproachtopatients. However,wealso
foundthattherewasathemeincomplaintsrelating
tostaffcommunicationissueswithpatientsand
theirrelatives.
6 The Princess Alexandra Hospital Quality Report 19/10/2016
Summaryoffindings
Summary of findings
Surgery Surgeryservicesrequiredimprovementoverall.
Requiresimprovement –––
Safewasratedasinadequate,witheffective,caring,
responsiveandwell-ledratedasrequires
improvement.
Thereductioninnursestaffinghaddirectimpacton
patientsafetyonKingsmoorandSaundersward
withdelayedcare.Establishmentnursingnumbers
didnotmatchpatientacuityconsistently.
Managementofincidentreportingwasnotrobust.
Monitoringofstaffcompetencieswaspoor.
Mandatorytrainingrateswerelowacrosssurgery.
Storageofintravenous(IV)fluidsonSaundersward
wasnotsecure.Medicationprescriptionand
administrationwasnottimespecific.Thedifficult
intubationtrolleyintheatreswasnotappropriately
storedorregularlychecked.Thequalityofmortality
andmorbiditymeetingswaspoor.
Notallguidelineswereupdatedinlinewith
nationalguidance.ThetrustresultsintheNational
EmergencyLaparotomyAuditindicatedfouroutof
11measuresreportedwereratedamber.Appraisal
rateswerepoor.Consentonthedaymeantthere
wasaverylimitedopportunityforpatientsto
consideralltheinformationpriortotheprocedure
takingplace.
Staffdeliveredcareinacompassionate,supportive
andconsideratemanner.Patientsprovided
consistentlypositivefeedbackabouttheircareand
treatment.FriendsandFamilyTestdata(FFT)
showedanaverageof97.8%ofpatientsonsurgical
wardssaidthattheywouldrecommendtheservice.
Callbellswerenotansweredinatimelymanner.
Patientswerenotalwaysawareofwhichwardthey
wouldbeadmittedtoaftersurgery.Referralto
treatmenttimes(RTT)standardof92%wasmetin
onlyfourof11specialties.Theatreutilisationwas
impactingonservicedelivery.Dischargeplanning
wasnotconsistent.Outofhourstransfersbetween
10pmand7amwerehigh.Thenumberofpatients
beingheldinthepostanaestheticcareunit(PACU)
formorethan12hourswashigh.
Therewasinstabilitywithintheseniormanagement
team.Oversighttoriskandqualitymanagement
waslimited.Staffatalocallevelwerenot
7 The Princess Alexandra Hospital Quality Report 19/10/2016
Summaryoffindings
Summary of findings
supportedtoensurethatriskswereidentified,
reportedandmanagedinatimelymanner. Failure
toretainandrecruitstaffwasimpactingonstaff
morale.
Critical care OverallweratedcriticalcareservicesatThe
Inadequate –––
PrincessAlexandraHospitalasinadequate.Safe,
responsiveandwell-ledwereratedasinadequate.
Effectivewasratedasrequiresimprovement,and
caringwasratedasgood.
Therewasevidenceofpoormedicines
managementpractices,whichposedpotential
seriousriskstosafety.Concernsincludedunsafe
practiceswithmorphine,carelessnessinthe
storageandtransferofpotassiumchloride,and
accesstocontrolleddrugsbynon-registeredstaff.
Therewaspoorandinconsistentdocumentingof
patientrecords.Therewaslittleevidenceof
learningfromincidentsandsharingfeedback
amongstaff,meaningtherewasanincreased
potentialriskofincidentsreoccurring.Thedifficult
airwaytrolleywasdisorganised,incompleteand
haditemsonitthatwerenotpartofthetrolley.We
sawthatthelastcheckcarriedoutonthetrolley
wasfivemonthspriortotheinspection.Daily
checkswerenotbeingcarriedoutonresuscitation
trolleys.Wewereconcernedaboutthe
competenciesandinductionprocessesforagency
staffastheunitwasnotconductinginternal
competencychecks.Thequalityofmortalityand
morbiditymeetingswaspoor.
Therewasalackofeffectivemultidisciplinary(MDT)
working.Physiotherapistsdidnothavesufficient
inputtomaximisepatientoutcomesand
physiotherapystaffingdidnotmeetnational
standards,whichcouldhaveanimpactonpatient
rehabilitationneeds.DocumentationofMDT
workinginpatientrecordsandhandoverswaspoor.
WardroundsdidnotroutinelyinvolveMDTinput.
Staffgavenegativefeedbackaboutthetraining
theyreceivedtomaintaincompetencies.Appraisal
rateswerethelowestinthetrustat23%.
Bedoccupancywasconsistentlyat100%orover.
Thereweremixed-sexaccommodationbreacheson
theunitowingtothelackofcapacity,andno
evidenceofactiontakentomitigatethis.Critical
carepatientsregularlyhadtobetreatedinthepost
8 The Princess Alexandra Hospital Quality Report 19/10/2016
Summaryoffindings
Summary of findings
anaestheticcareunit(PACU)becauseofthelackof
bedspace.ThelongestlengthofstayinthePACU
wasover72hours.Delayeddischargeswerea
significantriskowingtotheproblemswithaccess
andflowontheunit.Therewasahighrateofoutof
hoursdischargesatovertwicetherateonaverage
forsimilarunitsnationally.Therewasnoclear
formalsysteminplaceforlearningfromcomplaints
andconcernsinordertoimprovetheservicefor
patients.
Therewasalackofinformationsharingbetween
theserviceleadsandthestaffontheunit.Therisk
registerdidnotincludeseveraloftherisksto
patientsafetyweobservedduringourinspection
suchasthepoorculturesurroundingmedicines
managementandcontrolleddrugs,andthe
inconsistentdocumentationofpatientrecords.We
wereconcernedaboutsomeaspectsoftheculture
assomemembersofstafftoldusleadershipwas
notvisibleorapproachable,andfeltunsupported.
Maternity – Overallweratedmaternityservicesasoutstanding.
Outstanding
and Withcaringandwell-ledoutstandingandsafety,
gynaecology effectiveandresponsivenessbeingratedasgood.
Incidentreportingandlearningfromincidentswas
embeddedwithintheservice.Theenvironment
withintheunitwassecure.Theservicewas
consistentlyproviding60hours,ormore,of
consultanttimetothelabourwardperweek.
Staffinglevelsweremonitoredandmanaged
effectively.
Outcomesforwomenwhousedserviceswere
generallybetterthanexpectedwhencompared
withothersimilarsizedservices.However
caesareansectionrateswerehigherthanthe
nationalaverage.Breastfeedingrateswerebetter
thantheEnglandaverageandnaturalvaginal
deliveryrateswerethebestintheEastofEngland
andcomparablewiththenationalaveragefor
England.Theservicehadanoutstandingprocess
forauditing,learningfromnationalreportsand
recommendationsaswellkeepinguptodatewith
currentguidelines.Theterminationofpregnancy
servicewasoutstandingandfollowedallelements
ofnationalguidelinesandlegislation.
Thematernityservicewasratedasoutstandingfor
beingcaringbecausestaffprovidingbothmaternity
9 The Princess Alexandra Hospital Quality Report 19/10/2016
Summaryoffindings
Summary of findings
andgynaecologycarewerededicated,
compassionate,caringandtheyconsistentlywent
beyondthecallofdutytodeliverthebest
experiencepossibleforthewomen.
Theservicesweredeliveredworkinginpartnership
withcommissionteamsandcommunityservices
withinEssexandacrosstheborders.However,we
alsofoundthatthelackofagynaecologyin-patient
wardmeantthatwomendidnotalwaysreceive
timelycarewhilstaccommodatedinvariouswards
acrossthetrust.
Thegovernanceandriskmanagementsystems
withinmaternityandgynaecologyserviceswere
robustandwellestablished.Themedical,
midwiferyandoperationalleadershipteamwere
respectedandstaffspokehighlyoftheclinicalleads
fortheserviceandhowinvolvedandapproachable
theywere,whichcreatedanopenculture.
Services for Childrenandyoungpeople’sserviceswereratedas
Requiresimprovement –––
children and requiresimprovementoverall,withthesafedomain
young ratedasinadequate,well-ledratedasrequires
people improvement,andtheremainingdomainsratedas
good.
Theservicewasratedasrequiringimprovementfor
safetybecauserootcauseanalysisinvestigations
andthreedayinvestigationreportswerenotalways
completedtoagoodstandard.Processesfor
safeguardingchildrenwerenotrobust,asreflected
byfiveserioussafeguardingincidents.Thiswasa
longstandingissuefromourpreviousinspection.
Mandatorytraininglevelswerebelowthetrust
targetacrosstheservice,andwereattheirlowest
formedicalstaff.
Dailysafetychecksforemergencytrolleys,
controlleddrugsanddrugfridgetemperatureswere
notconsistentlycompleted.Thiswasreflectiveofa
poorcultureonDolphinwardandtheneonatalunit
arounddailychecks.Anauditintoantibioticsusage
ontheneonatalunitshowedthatbabieswaited
overdoublethetimerecommendedtoreceive
antibioticswhenrequired.
TheservicewasnotinlinewithRoyalCollegeof
Nursingguidelinesrelatingtostafftraininglevels
forlifesupporttraining.Thetransitionservicewas
disjointedforlongtermconditionsandtheservice
didnothaveatransitionnurse,withprovisionin
10 The Princess Alexandra Hospital Quality Report 19/10/2016