This was a focussed, unannounced inspection of the emergency care service at Queen Alexandra Hospital. This inspection took place on 25 February 2019. We have not inspected all key lines of enquiry and so we have not issued any revised ratings of the urgent and emergency care service at this time. 

Our key findings were:

We found there to be very limited clinical leadership of the emergency department, and in particular, the pit-stop area and ambulance reception area until the departmental Clinical Lead assumed control at approximately 16:00.

At times,  we observed patients being handed between five different nurses with no clinical interventions occurring. These multiple handovers do introduce an element of risk for patients.

The nurse-in-charge was observed undertaking a range of task orientated activities including the physical movement of trolleys and patients; this distracted them from managing the emergency department and likely impacted on the poor flow across the emergency pathway.

Majors B lacked any noticeable senior clinical leadership; oversight of flow was by way of a band four associate practitioner (Nursing). Patients experienced delays in discharge because of a lack of suitably competent staff or the availability of equipment.

Flow through the pit-stop process was slow and at times became stagnated. There was confusion as to the purpose of the area with some patients receiving extended levels of care, again despite other patients waiting in the department for their treatment to commence. Again, there lacked any noticeable clinical leadership of the area which impacted on the smooth flow of patients through the emergency pathway.

The waiting room did not have sufficient seating to accommodate patients during peak times. Patients and visitors were observed standing for extended periods because of a lack of seats. We noted the streaming nurses to be competent at undertaking initial assessments. Patients did however experience delays in their care commencing, in part because of a congested emergency department. Patients also experienced delays in being initially assessed by the streaming nurse. There was a lack of robust assurance to support the effectiveness of the streaming pathway.

Hand hygiene practices and compliance remained poor with very limited hand decontamination taking place during the inspection.

There were occasions when the privacy and dignity of patients was not protected. During feedback we provided examples of occasions when nursing staff had failed to cover patients up; instead opting to half close cubicle curtains. Frail elderly patients were left for periods of time in Majors with no access to call bells, and left in unacceptable states of undress.

Patients were observed being moved through the department without being spoken to; staff routinely released the brakes on trolleys and started moving patients. Again, this was a common observation; it showed little in the way of positive communication between patients and staff.

However,

New bereavement facilities were a significant improvement on the facilities which had been found to be lacking at previous inspections.

The improvement board, located in the department, was observed to be well used with encouraging signs the views and voices of staff were being considered and heard respectively. There was a sense amongst staff we spoke with of improvements in relationships between the trust leadership team and staff working in the emergency department. Staff reported members of the executive team to be highly visible and supportive during times of surge.

The introduction of dedicated training time was welcomed by junior doctors across the department. The protected rostered non-clinical time for consultants to provide dedicated training on a weekly basis will be of great benefit to trainee doctors.

The use of the Hospital and Ambulance Liaison Officer (HALO) to oversee and co-ordinate the arrival of ambulances during times of surge, and the working relationships between the local NHS ambulance trust and Portsmouth Hospitals NHS Trust seemed robust. We observed good working relationships between ED staff and ambulance staff. There was clear prioritisation of patients who remained “On-board” ambulances due to limited capacity in the emergency department.

The service maintained a risk register which recorded known risks and rated them according to their potential impact. The risk register reflected the risks spoken about by staff in the department. The risk register further acknowledged the challenges inspectors identified during the inspection. There was a sense the leadership team were more aware of the challenges they faced than was the case in the previous inspection.

A range of staff including doctors, nurses, support workers, administrative staff and representatives from the local NHS ambulance trust reported they were able to raise concerns to local the management team without fear of retribution. Staff told us they felt supported and were encouraged to be open and transparent. There was an appetite among staff to improve the quality of care provided in the department.

Health professionals reported good multi-disciplinary working with positive relationships existing between doctors and nurses for example.

Many staff described their work colleagues as their second family and told us they would not want to work anywhere else. This continued to be the case at this inspection despite the department having experienced very busy periods over the preceding weeks.

Dr. Nigel Acheson

Deputy Chief Inspector of Hospitals

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

• Within medical care, surgery, maternity and urgent and emergency services records of patients care and treatment did not always contain updated risk assessments and appropriate individualised care plans. Up to date records were therefore not always available to all staff that provided care.
• Medicines were not managed safely in many of the core services we inspected. Medicines were not always stored securely, and medicine fridges were not consistently monitored to ensure medication was kept at required temperatures.
• There were insufficient numbers of staff with the right qualifications, skills, training and experience to keep people safe and provide the right care and treatment in the medical care, children and young peoples and urgent and emergency services.
• The design and layout of the emergency department (ED) did not keep people safe. The emergency department was frequently crowded and patients were queued in a corridor which became congested, sometimes hampering the movement of patients and equipment. People waited too long for initial assessment in ED and the flow through the department often impacted on the movement of patients into the hospital.
• Within ED and surgical services infection prevention and control was not robust in some areas and some equipment and premises were not sufficiently clean. Within the surgical high dependency unit there was no facility to isolate patients and therefore there was a risk of the spread of infection.
• Mandatory training rates in some areas fell short of the trust’s target meaning staff did not have the minimum training deemed essential for their roles.
• Staff who worked in the surgery, urgent and emergency and medical care services did not fully understand their roles and responsibilities with regards to the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards (DoLS). Where appropriate, people’s mental capacity and DoLS were not consistently assessed and recorded in line with legal requirements. This had been identified at previous inspections and the trust had not given sufficient priority to ensure staff were suitably trained, competent and fully understood their requirements under the legislation.
• Within the maternity service, guidelines had not been reviewed and updated in line with current best practice or national guidance. There was no robust practice that ensured completed audits were acted upon to improve practices.
• Staff did not always provide patients with compassionate or respectful care in the emergency department. We observed a number of nursing staff who did not behave in a way which was consistent with the trust’s stated values or desired practice. Staff did not always provide emotional support to patients and relatives to minimise their distress.
• In both medical and urgent and emergency care staff did not always involve patients and those close to them in decisions about their care and treatment. Some patients and relatives told us there was little communication from staff and they were not kept well informed about what was happening
• Within maternity, medical and urgent care, services were not consistently planned or delivered to meet the needs of the local population.
• In urgent and emergency services patients were not always able to access care and treatment in a timely way and in the right setting. The trust was consistently failing to meet national standards in relation to the time patients spent in the emergency department, the time they waited for treatment to begin and the time they waited for an inpatient bed. Patients waited too long for their treatment to begin. Facilities and premises were not wholly appropriate for the services delivered and we observed patients queuing in non-clinical areas such as corridors where there was a lack of comfort and privacy. Patients sometimes waited on ambulances outside of the emergency department due to congestion.
• Within maternity, services were not routinely planned to ensure women could always deliver their baby in the preferred place of birth.
• There were shortfalls in how the needs and preferences of different patients were met in medical and urgent care. Staff did not fully consider the needs of individual patients living with dementia or who had a learning disability.
• Although the medical service treated concerns and complaints seriously and investigated them, there was lack of process to ensure learning from complaints was communicated and shared across all staff groups.
• During our inspection the trust was in the processes of re-designing both their risk and governance structures. While some new processes were in place these had not been fully embedded. There were systems in place to identify, manage and mitigate risks however risks had not been fully identified and risk registers had not been fully completed within the urgent and emergency, maternity, medical and surgery services.
• Governance processes did not consistently provide an effective systematic approach which identified areas for improvements and there was no overarching governance structure in the outpatients service.
• The trust had identified improvements were required to address some poor cultures across the hospital. On the whole staff told us managers promoted a positive culture that supported and valued staff creating a sense of common purpose. Managers had the skills and abilities to run a service which provided high quality sustainable care However we observed some poor behaviours exhibited by senior nurses within the urgent and emergency service. In the outpatients department there was a poor culture where staff concerns were not always taken seriously and there was low staff morale in some areas.
• Information systems within urgent and emergency services, maternity and medical services did not support effective sharing of patient information or support comprehensive recording or analysis of data.

However

• In critical care, diagnostic imaging, outpatients and children and young people staff kept clear, up to date, detailed records of patients care and treatment.
• Overall in critical care, children’s and young people, end of life, outpatients and diagnostic imaging services people were protected from abuse and avoidable harm.
• We identified comprehensive systems where in place to keep people safe and risks were regularly assessed and updated.

• The services controlled infection risk well and staff kept themselves and equipment clean.
• Within critical care, end of life, outpatients and diagnostic imaging there were sufficient numbers of suitably trained and competent staff available to care for patients safely.
• Staff in urgent and emergency, services for children and young people, end of life care, diagnostic imaging and critical care provided care and treatment based on national guidance. Managers checked to make sure staff followed guidance and audits were undertaken and acted upon to improve services. Staff, teams and services worked well together to provide effective care for patients.
• We observed exceptional care in both children’s and young people’s services and critical care. We observed staff going ‘above and beyond’ to ensure patients and their relatives were supported and involved in treatment plans.
• Overall in the services other than patients were treated with care and compassion. Patients and their relatives were complimentary about the care and treatment they received.
• Staff involved patients and those close to them in decisions about their care and treatment.
• Staff offered emotional support to patients and their relatives.
• In most services we inspected we found people were able to access the service when they needed them. The services had been planned and provided in a way that met the needs of local people.
• The services mostly took account of people’s needs and were flexible to encompass individual needs and preferences.
• In critical care there was a proactive approach to understanding the needs and preferences of different groups of people and to delivering care in a way that met those needs, which was accessible and promoted equality.
• Effective governance processes which monitored the quality of services provided were evident some services
• Within critical care there was a fully embedded systematic approach to improvement. The service was forward looking, promoted training and clinical research and encouraged innovations. The service made effective use of internal and external reviews and learning was shared effectively and used to make improvements. There was a record of shared working locally, nationally and internationally.
• Some services engaged well with patients, staff, and the public and local organisations to plan and manage appropriate services

The Care Quality Commission (CQC) carried out an unannounced inspection at Queen Alexandra Hospital on 19 July 2017. The purpose was to look at specific aspects of the care provided by the diagnostic imaging department.

Concerns were initially raised by a member of the public, and the trust was given the opportunity to respond to these. When satisfactory assurances were not received from the trust, the local inspection team decided to conduct an unannounced inspection.

In particular we looked at the reporting of chest x-rays, and the governance processes in place to ensure that any backlog in reporting was managed, escalated and resolved.

We did not inspect other diagnostic imaging services or any outpatient services at the hospital on this occasion. Because of this we have not provided ratings for this inspection.

Our key findings in the diagnostic imaging department were:

• An increasing problem with staffing capacity in radiology meant reporting of chest x-rays was not always undertaken by appropriately trained members of staff

• There have been three serious incidents causing significant harm to patients which was caused by the failure of reporting of chest x-rays by radiologists.

• At the time of inspection there had been no trust wide risk assessment or up to date audit of the potential harm caused by the failure to report chest and abdomen images

• There was insufficient audit undertaken to ensure that every examination undertaken had sufficient clinical review.

• During the junior doctor focus group, we were informed that staff that had been delegated responsibilities for reviewing chest and abdomen x-rays were not always appropriately trained and felt that they were not competent or confident to undertake such duties.

• Reporting on some plain film and cross sectional diagnostic imaging tests were not completed in a timely manner.

• Chest and abdomen x-rays from the emergency department did not always receive a formal report

• There was no effective governance framework to support the delivery of good quality care around reporting times.

• There was insufficient assurance that the risk was appropriately managed and mitigated to ensure that patients are protected from harm.

• During the inspection we were told the risk was “being tolerated”.

However:

• We saw good evidence of learning from radiation incidents which had meant that the department had good framework around radiation protection.

• We saw some evidence that scope of practise had been and was continuing to be extended for radiographers.

• The department did reach the department’s key performance indicator for turnaround times for reporting cancer waits.

• Local leadership was good. The radiology service manager had kept oversight of the risk and had attempted to influence change as best to their ability.

• The clinical director for radiology was new in post, and was highly regarded. They had already made several efforts to improve the service’s risk.

Based on the findings of this inspection CQC took urgent enforcement action and imposed conditions on the trust’s registration, as a service provider. CQC believed patients would be exposed to the risk of harm if these conditions were not urgently imposed. These conditions are;

1. The Registered Provider must take evidenced based appropriate steps to resolve the backlog of radiology reporting using appropriately trained members of staff. This must include a clinical review, audit and prioritisation of the current backlog of unreported images, (including those taken before January 2017); assess impact of harm to patients, and apply Duty of Candour to any patient adversely affected.

2. The Registered Provider must ensure that they have robust processes to ensure any images taken are reported and risk assessed in line with Trust policy.

3. The Registered Provider must submit their evidenced based decision-making on how the backlog will be addressed to the Commission by the 21 August 2017.

4. From 6 September 2017, and on the Wednesday of each week after, the Registered Provider must report to the Care Quality Commission, NHS Improvementand the NHS England Local Area Team:

• The total number of images remaining in the backlog (including unreported images pre-January 2017) shown by year of image taken.

• The current trajectory date of when the backlog (including unreported images pre-January 2017) will be cleared.

• The proportion of patients waiting less than the trusts KPI for x-rays, CT and MRI.

• The average waiting time (in days and hours) for a reported plain film (excluding GP requests).

• The average waiting time (in days and hours) for chest and abdominal films (excluding GP requests).

• Number of plain film requests (excluding GP requests).

• Longest waiting time for a reported radiology plain film request.

Professor Edward Baker

Chief Inspector of Hospitals

During this inspection we visited 15 wards and other areas where patient's received care within the hospital.

We looked at the quality of care provided to support patients who were living with a diagnosis of dementia. We looked at the support they received to maintain their physical and mental well-being as part of a themed inspection programme. This programme looked at how providers worked together to provide care to patients with dementia, how the needs of patients in relation to their dementia were assessed, planned and delivered and how the trust monitored the quality of the care, treatment and support provided to patients with dementia during their hospital stay.

We spoke with 13 patients with dementia during this inspection. We also spoke with five relatives and approximately 40 staff, including the chief executive officer, acting director of nursing and deputy director of nursing.

For all the patients we saw and records we reviewed dementia was the secondary diagnosis and not the main reason for admission to hospital.

We were provided with information from the trust that told us that all areas within the hospital had an appointed, "dementia champion". We were told that these staff had undertaken additional training about dementia and were responsible for cascading any new developments through to their teams. We were told this was working well in some areas although others had only just received the training. We saw that in all the areas we visited a member of staff had been designated as a dementia champion.

Nursing staff we spoke with told us that they are required to undertake annual essential skills days and that these have included sessions about dementia. They also told us that they are required to undertake a competency assessment, which included questions about dementia and the care people would require.

This inspection focused on the discharge process because the public had raised concerns to us. In order to assess the discharge process we spent time in the discharge lounge, on ward F4, the pharmacy and the various wards within the Medical Assessment Unit (MAU). One member of the inspection team spent the day with the hospital's lead in Discharge Liaison. This included spending time with other professional's from external organisations and attending a multidisciplinary meeting where discharges were discussed and arranged. Over the course of the day we spoke to 33 patients, five relatives/friends of patients, three doctors, twenty two nurses, eleven support workers, three pharmacists, a pharmacy technician, a ward clerk and at least nine professionals from other organisations.

We met and observed a variety of other staff such as porters and physiotherapists. On the wards and units we observed that people were spoken to in a friendly manner and their wishes were respected. The majority of people we spoke to were happy with their treatment and their plans for discharge. Records showed they were consulted on the decision making and their relatives and other professionals were also consulted if necessary. We found that the provider had robust systems for discharge and worked well with other providers to ensure safe and successful discharges took place. Sometimes those systems fell short of ensuring this for every patient in particular those admitted for short periods.

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.

The patients we spoke with were generally happy with the care provided at the hospital. They said that staff were kind and helpful and responded to calls for assistance, although they were very busy. They told us that staff maintained their dignity and privacy at all times by ensuring that the screens were always pulled around the bed when care and treatment was provided. Patients told us that staff provided them with sufficient information about their care.

The patients who were admitted for elective surgery told us that the system worked very well and they were provided with information prior to admission. One patient said that they also received the information in writing on admission which made it easier to remember what was happening.

Four relatives told us that information was very good on the current ward, but this had not been their experience in the medical assessment unit (MAU). Two patients told us that both they and their families had been involved in discussion about them going home.

Some people said that they were advised when their relative had moved to another part of the ward into a side room. Three people said that they were not kept informed when their relative had moved to another ward following deterioration in their conditions. They only found out when they arrived on the ward and found that their relative had been moved during the night. One person said that they ‘nearly pulled open the curtain’ to another patient as they thought it was their relative.

The patients we spoke to were mainly positive about the care and treatment that they were receiving. People told us that they were treated with respect and their privacy and dignity had been respected when receiving personal care. Patients were asked if the staff used their preferred names when speaking to them. Most of them said that the staff had asked how they liked to be called.

Patients told us that they were asked about medical procedures that needed to be carried out and said the staff had kept them informed about investigations such as taking a blood sample from them. We asked the patients whether they had been asked how they would like to be treated and some said they had been.

Patients we spoke to said that they received an adequate amount of food. A visitor also commented that their relative received adequate amounts of food. They said that the staff always provided them with water jugs and ensured they had enough water. People we spoke to told us that they were supported by the staff to eat.

Patients commented that the staff had not asked them about what they liked to eat and whether they needed support, but they said that they received a menu card to complete. One patient said they were helped with the menu as they had poor eyesight and staff were aware that they required a special diet. People told us that meal times were nice and quiet but they said that they were not always offered the opportunity to wash their hands before or after eating.

We undertook this unannounced focussed inspection in response to concerns about the safety and quality of patient care during the winter months, when the trust has been under extreme pressure. Increased demand for services, a high incidence of flu, and poor outflow from the hospital had resulted in high bed occupancy and insufficient inpatient capacity in the hospital. This has led to crowding and extended waits for patients in the emergency department and has resulted in inpatients being cared for in outlying ‘escalation’ areas, not designed for inpatient care.

We did not rate this service due to the limited focus of our inspection. We looked at specific key lines of enquiry under three of our five key questions; Is the service safe, responsive and well led?

We found:

• The trust’s escalation status during the months of December 2017, January and February 2018 indicated that they experienced significant and extreme operational pressures, due to insufficient capacity to meet demand for services, for much of this time. This put patients at risk.

• The emergency department was frequently crowded; patients were cared for in corridors and in ambulances outside the emergency department. Patients experienced delays in their assessment, treatment and admission to a hospital bed. When there was insufficient inpatient capacity, patients were cared for in unsuitable outlying and escalation areas, some of which were not designed for inpatient care.

• There were frequent delays in ambulance staff handing over care of patients to emergency department staff. This included a significant number of delays of over one hour, known as black breaches, and ambulance staff being unable to offload their patients. This not only delayed patients’ assessments in the emergency department, but also delayed ambulance staff who were not available to respond to further calls.

• Patients were not always promptly assessed on arrival in the emergency department to identify or eliminate any serious or life threatening illness or injury. Processes to stream and triage patients on their arrival in the emergency department were not operating efficiently or effectively.

• Staff in the emergency department did not consistently complete safety checklists so we could not be assured that patients were regularly monitored to ensure their on going safety and comfort.

• Patients experienced lengthy delays in the emergency department. The trust was consistently failing to meet the national standard which requires that 95% of patients are admitted transferred or discharged within four hours. A significant number of patients waited up to12 hours in the emergency department from the time a decision was made to admit them to the time they were admitted. The trust’s performance was significantly worse than the England average.

• The emergency department was not adequately staffed at night. The department had assessed that two middle grade doctors were required at night but currently night time cover was provided by only one. Junior medical staff felt unsupported and vulnerable at night and consultant staff were frequently working additional hours to support their junior colleagues. It was felt that this was not sustainable.

• Patients were frequently accommodated in corridor areas of the emergency department, when all assessment and treatment areas were full. These areas were not suitably equipped and did not facilitate easy monitoring of patients held there. Queuing caused congestion, which hampered the movement of patients, staff and equipment in these areas. Despite the efforts of staff, patients’ comfort, privacy and dignity needs could not be met.

• Inpatients were frequently cared for in unsuitable outlying areas of the hospital. This meant they were admitted to a ward in a speciality other than that which they were assigned to. We could not be assured that staff caring for these patients had the necessary skills and experience to meet these patients’ needs.

• Patients were frequently cared for in departments (designated as escalation areas) which were not designed, equipped or staffed for inpatient care.

• There was a lack of effective governance to provide assurance that escalation areas were being used in a safe and appropriate way.

• The regular and frequent use of day case departments as escalation areas impacted on their ‘business as usual’ activity, their ability to function efficiently, and resulted in some elective day case procedures being cancelled.

• Patients experienced frequent bed moves, often at night, which impacted on their comfort and wellbeing.

• The trust did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The trust’s winter resilience plan had not been effective and had not yielded the required capacity and flow to manage the significant pressures the trust faced during the winter months. We questioned the effectiveness of the plan, the apparent lack of robust challenge and review in the face of failing systems, and whether planning for winter had begun soon enough.

• Although the risks associated with poor flow and capacity were understood at a senior level in the trust, the corporate risk register did not accurately or fully reflect the serious risks to patient safety and quality.

• Appropriate and accurate information was not always available or used effectively to monitor, manage and report on quality and safety. The trust was unable to provide us with key data, which could be used to provide assurance of quality and safety and inform and drive improvements.

• There was a lack of assurance in regard to the effectiveness of safety systems in the emergency department.

However:

• There was commitment to deliver improvement at a senior level in the trust. There were many streams of work on going to change internal processes to improve patient flow and operational performance. Alongside this there was a system-wide capacity and demand review led by commissioners to establish the level of capacity required to improve flow across the health and social care system.

• There was evidence that staff in the emergency department consistently used a screening tool to identify suspected sepsis and followed guidance to ensure prompt treatment.

• Patients attending the emergency department with acute mental illness were assessed using a recognised mental health risk assessment. The trust monitored compliance with this and had performed at above 90% since November 2017.

• There was a dedicated discharge ambulance, which had been funded from December 2017 through to March 2018, which staff told us was very helpful in facilitating patient discharges and improving patient flow.

Importantly, the trust must:

• Review the effectiveness of the winter resilience plan and its failure to yield sufficient capacity to improve patient flow and reduce crowding in the emergency department.

• Review the corporate risk register to ensure the risks associated with capacity are fully captured and actions to mitigate risk are regularly reviewed by the board.

• Set clear targets and milestones, review progress and challenge failure.

• Improve monitoring systems; use timely and appropriate data to provide assurance of quality and safety and drive improvement.

• Continue to drive initiatives to reduce length of inpatient stay and improve patient flow.

• Fully embed new systems in the emergency department used to assess and monitor risks to patients, and audit their effectiveness.

• Take steps to ensure the emergency department is adequately staffed at night.

• Review the governance systems in relation to the use of escalation areas, to provide assurance that they are appropriately used, and appropriately staffed and equipped.

We have written to the trust outlining our concerns and asked that they respond to these urgently. We will follow up on these concerns at our scheduled comprehensive inspection of trust services in April 2018.

Professor Edward Baker

Chief Inspector of Hospitals