THE report by the Care Quality Commission (CQC) into Princess Alexandra Hospital is a damning indictment into the quality of care in a number of areas in the hospital.

Here are some of the criticisms. We will highlight the good aspects in a separate piece.

Overview

During this inspection, we found that there had been deterioration in the quality of some services provided since our previous inspection in 2015. During this inspection, we found that the trust had significant capacity issues and was having to reassess bed capacity at least three times a day. This pressure on beds meant that patients were allocated the next available bed rather than being treated on a ward specifically for their condition. We found that staff shortages meant that wards were struggling to cope with the numbers of patients and that staff were moved from one ward to cover staff shortages on others. The trust sees on average around 350 patients a day in its emergency department (ED).

Shortages of staff across disciplines coupled with increased capacity meant that services did not always protect patients from avoidable harm, impacted upon seven day provision of services and meant that patients were not always treated in wards that specialised in the care of health issues.

• The disconnect between ward staff and the matron level had improved. However, some cultural issues remained at this level which required further work.
• The relationship between staff and the site management team had improved, though this was still work in progress and the trust acknowledged further work was required here.
• Agency staff did not always receive appropriate orientation, or have their competency checks undertaken for intravenous (IV) care for patients on individual wards. This had improved by the time our unannounced inspection concluded.
• The storage, administration and safety of medication was not always monitored and effective.
• Information flows and how information was shared to trust staff were not robust. This meant that staff were not
always communicated to in the most effective ways.
• The staff provided good care despite nursing shortages.
• There were poor cultural behaviours noted in some areas, with some wards not declaring how many staff or beds
they had overnight to try and ease the workloads. This was a result of constant pressure on the service activities.
• The mortuary fridges had deteriorated since our last inspection and some were no longer fit for purpose. These were
repaired and sealed during our unannounced inspection to ensure they provided an appropriate environment for patients.

Across surgery, there were notable delays in answering call bells on surgical wards including Kingsmoor and Saunders ward.
• Gynaecology inpatient care had not improved, but declined, since our previous inspection. The inpatient gynaecology service, which was operated through surgery, was not responsive to the needs of women.

There were areas of poor practice where the trust needs to make improvements. Importantly, the trust must:

• Ensure that safeguarding children’s processes, reporting and investigations for the safeguarding of children are improved.
• Ensure that staff caring for children and young people have appropriate levels of life support training in line with the Royal College of Nursing ‘Health care service standards in caring for neonates, children and young people’.
• Ensure that staff are provided with appraisals, that are valuable and benefit staff development.
• Improve mandatory training rates, particularly around (but not exclusive to) safeguarding children level three,
moving and handling, and hospital life support.
• Ensure that there are safe and efficient staffing levels at all times.
• Ensure that resuscitation trolleys and difficult airway trolleys are routinely checked, stocked and kept in a safe
condition for emergency use.
• Ensure that fridge temperatures are monitored, and acted upon when concerns are identified.
• Ensure that women undergoing elective gynaecology procedures, including but not exclusive to termination of
pregnancy (TOP) procedures, are cared for by sta trained in the clinical, holistic and social needs of women.
• Ensure that rapid discharge of patients at the end of their life is monitored, targeted and managed appropriately.
• Ensure that trust staff are knowledgeable ad provide care and treatment that follows the requirements of the Mental
Capacity Act 2005.
• Ensure that governance arrangements, including the risk register and board assurance framework are embedded,
robust, and actively reflect the risks within the organisation.
• Ensure that the quality of record keeping on critical care improves.
• Reduce the impact or likelihood of mixed sex accommodation breaches on the high dependency unit (HDU).
• Ensure that complaints are learnt from, and learning is shared throughout the trust.
• Ensure that patients arriving by ambulance into the ED are appropriately assessed and triaged in a timely manner in
accordance with The Royal College of Emergency Medicine (RCEM) guidelines.

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Emergency Department

Overall we rated the emergency department (ED) at The Princess Alexandra Hospital as inadequate. Safety and responsiveness of services was rated as inadequate, how eff ective and well-led the service was has been rated as requires improvement, and caring was rated as good.

Patients arriving by ambulance were not routinely being initially assessed within 15 minutes as required. Many patients were in the ambulance waiting area for prolonged periods, with patients not being assessed or handed over to the trust teams. Levels of nurse staffing in the resuscitation room were unsafe. There was no clinical oversight or view of the waiting room. Regular checking of equipment, including resuscitation trolleys and defibrillators, was not taking place. Fridge temperatures were not routinely monitored to ensure safe storage of medicines. Mandatory training compliance for the department was low, especially on paediatric life support.

The service was mostly following guidelines known to them from the Royal College of Emergency Medicine (RCEM) and National Institute for Health and Care Excellence (NICE). However, sta were not familiar with all recent guideline updates. Sta had not received regular appraisals. The unplanned patient re-attendance rate was consistently higher than the England average. Concerns were raised about how sta were trained, developed and progressed in their roles within the ED. There was a lack of clinical audit taking place.

The service had not achieved the four hour performance standard since August 2014. The percentage of patients waiting four to 12 hours from the decision to admit until being admitted has been longer than the England average since May 2015. Ambulance delays over 30 minutes were some of the worst in England. Black breach rates were high. Calls bells went unanswered for prolonged periods of time when the emergency department was busy. Sta we spoke with were unaware of the trust’s values. There was a business plan, vision and strategy for the service with some basic objectives

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Critical Care

Overall we rated critical care services at The Princess Alexandra Hospital as inadequate. Safe, responsive and well-led were rated as inadequate. E ective was rated as requires improvement, and caring was rated as good.

There was evidence of poor medicines management practices, which posed potential serious risks to safety. Concerns included unsafe practices with morphine, carelessness in the storage and transfer of potassium chloride, and access to controlled drugs by non-registered staff .

There was poor and inconsistent documenting of patient records. There was little evidence of learning from incidents and sharing feedback among sta , meaning there was an increased potential risk of incidents reoccurring. The di icult airway trolley was disorganised, incomplete and had items on it that were not part of the trolley.

We saw that the last check carried out on the trolley was five months prior to the inspection. Daily checks were not being carried out on resuscitation trolleys. We were concerned about the competencies and induction processes for agency sta as the unit was not conducting internal competency checks. The quality of mortality and morbidity meetings was poor.

There was a lack of effective multidisciplinary (MDT) working. Physiotherapists did not have sufficient input to maximise patient outcomes and physiotherapy staffing did not meet national standards, which could have an impact on patient rehabilitation needs. Documentation of MDT working in patient records and handovers was poor. Ward rounds did not routinely involve MDT input. Staff gave negative feedback about the training they received to maintain competencies. Appraisal rates were the lowest in the trust at 23%.

Bed occupancy was consistently at 100% or over. There were mixed-sex accommodation breaches on the unit owing to the lack of capacity, and no evidence of action taken to mitigate this. Critical care patients regularly had to be treated in the post

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Children and Young People

Children and young people’s services were rated as requires improvement overall, with the safe domain rated as inadequate, well-led rated as requires improvement, and the remaining domains rated as good.

The service was rated as requiring improvement for safety because root cause analysis investigations and three day investigation reports were not always completed to a good standard. Processes for safeguarding children were not robust, as reflected by five serious safeguarding incidents. This was a long standing issue from our previous inspection. Mandatory training levels were below the trust target across the service, and were at their lowest for medical staff .

Daily safety checks for emergency trolleys, controlled drugs and drug fridge temperatures were not consistently completed. This was reflective of a poor culture on Dolphin ward and the neonatal unit around daily checks. An audit into antibiotics usage on the neonatal unit showed that babies waited over double the time recommended to receive antibiotics when required.

The service was not in line with Royal College of Nursing guidelines relating to staff training levels for life support training. The transition service was disjointed for long term conditions and the service did not have a transition nurse, with provision in place for diabetic children but not epileptic children. Staff were not trained in supporting children with mental health problems despite mentally unwell children regularly being admitted to the ward.

Response rates for the Friends and Family Test were very low and did not give any context to the results of the survey. Parents and carers on the neonatal unit felt that communication was lacking. Arrangement of the environment in the day surgery unit and recovery areas meant that children had to walk past adult areas to get to the anaesthetic room, and adults in recovery would o en directly face the children’s bay.

We were concerned that there was a lack of grip from the leaders of this service in regards to management monitoring and actions regarding the safeguarding of children. There were significant risks for safeguarding children that were thematic and were similar to themes from the last inspection that had not been addressed.

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End of life care

End of life care at The Princess Alexandra NHS Trust was rated inadequate overall. Safe and e ective have been rated requires improvement, with caring rated as good. Well-led and responsive have been rated as inadequate.

The mortuary environment was not fit for purpose, with damage and ine iciencies in the workings of the fridges and freezers. Medical sta ing was not in line with national guidance, with the equivalent of 0.4 whole time equivalent palliative care consultants. Medical sta ing was being provided on a service level agreement from two local hospices. Safeguarding was not included within the anticipated last days of life care plan. There was a risk nursing sta may not consider safeguarding when undertaking care planning. Medication was being prescribed and administered without documenting times on medication charts.

Patient outcomes were not routinely or robustly being monitored. The trust had a decrease in the number of clinical outcomes achieved within the End of Life Care Audit, published in March 2016. There were no end of life care champions in clinical areas. Multidisciplinary team meetings were attended by palliative care nurses and a palliative care consultant. However, no other professions attended, for example physiotherapy, occupational therapy or social workers. There was inconsistent knowledge amongst sta around the Mental Capacity Act.

No formal counselling or emotional support was available for patients at the end of life or their families. One patient stated they felt no member of sta was taking the lead on their care.

The trust did not routinely monitor patients preferred place of care or preferred place of death. The fast track discharge process was not being monitored or audited for patients at the end of life. Patients were at risk of waiting extended periods of time to be discharged.

There was no vision or strategy in place for end of life care. A non-executive director had been appointed to lead end of life care. However, this was in May 2016 and they were not yet fully established in post. There was a disconnect between clinical sta and the executive lead for end of life care. The executive and non-executive leads showed limited oversight of the service. There was no risk register which collated risks for end of life care that could be monitored. The risks identified by the specialist palliative care team and the executive team did not match the risks that had been documented. There was a decline in compliance with ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) form completion, despite executive oversight. The trust had limited improvement plans in place at the time of inspection.