All inspections: Princess Royal University Hospital

Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. They 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 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.
Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.

However:

Staffing levels were not always at the required level to meet patient care needs.
The service did not always manage infection control measures as well as expected.
The service did not always display patients dietary and feeding needs within bays.

The emergency department (ED) at The Princess Royal University Hospital (PRUH) is open 24 hours a day seven days a week and sees patients with serious and life threatening emergencies. There is a separate paediatric emergency department dealing with all attendances under the age of 18 years. Patients present to the department either by walking into the reception area or arrive by ambulance via a dedicated ambulance-only entrance. Patients transporting themselves to the department are initially seen by a nurse from the urgent care centre (UCC), which is next to the emergency department waiting area. If determined suitable to be treated the patient is then sent to the ED to await triage. The UCC is managed by a different provider and was not part of the inspection.

We carried out this focused inspection of the PRUH ED on 7 June 2021, to follow up on concerns and enforcement action we took at our previous inspection. We also followed the Resilience 5 Plus’ process. The ‘Resilience 5 Plus’ process is used to support focused inspections of urgent and emergency care services which may be under pressure due to winter demands or concerns in relation to patient flow and COVID-19.

We previously inspected this service in November 2019 and the service retained an overall rating of Inadequate. Focused inspections can result in an updated rating for any key questions that are inspected if we have inspected the key question in full across the service and/or we have identified a breach of regulation and issued a requirement notice, or taken action under our enforcement powers. In these cases, the ratings will be limited to requires improvement or inadequate. The focused inspection included a review of a previously issued requirement or warning notice that had resulted in the application of a ratings limiter, which can now be lifted.

We rated safe as requires improvement, caring as good, responsive as requires improvement and well led as requires improvement.

Our inspection had a short announcement (around 30 minutes) to enable staff to arrange to meet with us and for us to carry out our work safely and effectively.

During our inspection we found:

The design and use of some parts of the department/premises did not always keep patients and staff safe despite the efforts the department had made during the pandemic. We were concerned with crowding of the patient waiting area.
Not all paediatric early warning scores (PEWS) were completed in records we reviewed, and the department was not auditing to ensure staff were completing them correctly.
People could not always access the service and receive the right care promptly when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with national standards.
Incidents were not always dealt with in a timely manner.

However:

The service provided mandatory training in key skills including the highest level of life support training to all staff. Although the pandemic had hampered efforts for a better compliance rate with this training, the trust had a better system of monitoring mandatory training with staff.
In most aspects the service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
The mental health safe room was now ligature point free, and non-movable furniture had been installed. This was an improvement since our last inspection
Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it, however, medical staff relied on nursing staff to make safeguarding referrals.
The service had enough nursing staff and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix.
The service used systems and processes to store medicines safely.
The staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues. They were mostly visible and approachable in the service for patients and staff.
Leaders operated effective governance systems throughout the department, although there was recognition that some of these required further embedding into the service.

How we carried out the inspection

We spoke with approximately 21 staff across a range of disciplines, including nurses, senior nurses, health care assistants, ambulance crew, department consultants trust grade doctors, senior managers and executive leads.

As part of the inspection we observed care and treatment and spoke with five patients as well as looked at 12 care records. We analysed information about the service which was provided by the trust.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection

Whilst we recognise work had been undertaken by the service to correct the concerns raised during the previous inspection, we found that further work was required to demonstrate clear sustainable results.

Mandatory training rates were still variable for the staff groups and during the rolling year of the training schedule. Completion rates provided showed some the trust target being reached in May and June 2019 but falling under the target in October 2019.

The rotating and stock control of single use consumables still required work as we found a significant number of items which were past their use by date. Safe storage of medicines required further review.

The cubicle which was used as a mental health safe assessment room still had ligature points and was dirty in its appearance.

Issues relating to infection prevention and control remained a concern due to the doubling up of patients in cubicle designed for one patient.

Assess and flow within the department remain a concern but we recognised that work was being undertaken by the service to alleviate this situation where possible.

We witnessed apathy towards some patients who were being cared for within the major’s area and in the corridors.

The morale of the department remained low. Leadership issues had not been resolved.

However:

The use of the resus area had been reviewed and area was being used appropriately with appropriate step down of patients managed enabling the flow within the resus to be improved.

We saw improvement in the safety checking of resuscitation trolleys, the use of digital locked fridges for the storage of medicines. Patient group directions had been reviewed and were in date in line with trust policy.

Hand hygiene within the department had improved.

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

Although the mandatory training completion rates had improved since our previous inspection, some subjects including the safeguarding of vulnerable people had not been completed by all the required staff.
The environment in which people received treatment and care was not always suitably safe and risks had not been fully considered in some areas. The privacy of patients in some areas was less than expected.
Equipment was not always checked, and some consumable items were out of date.
Staffing in some areas was not always ideal, which impacted on the ability of staff to deliver timely holistic care. In some areas staff did not work effectively together and there were some variations in leadership style and department culture.
Medicine optimisation was not always achieved to a consistent level.
Infection prevention and control practices were less than expected in some areas.
Patient risk assessments and instructions were not completed with consistency, and treatment and care was not always provided in accordance with best practice guidance. The monitoring of effectiveness of treatment and care was not always reviewed.
Patients could not access care and treatment in a timely way. Waiting times for treatment and arrangements to admit, treat and discharge patients were worse than the England average and national standard.

However:
Staff were knowledgeable about the incident process and learning from incidents were discussed in departmental and governance meetings and action was taken to follow up on the results of investigations.
Staff understood their responsibilities to protect people from avoidable harm and were knowledgeable about safeguarding procedures. They were also aware of their responsibilities under the mental capacity act.
Staff had opportunities for professional development and were competent to perform the required treatment and care in their respective areas.
There had been improvements in palliative care provision with the introduction of a clinical nurse specialist seven-day service since April 2018.
Services were generally arranged and delivered considering the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances.

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

A number of ratings had improved at the PRUH. Of particular note was the work done in the urgent and emergency department care to bring the rating from inadequate to good for responsive. This service also improved the rating from requires improvement up to good for effective. All other domains remained unchanged, with requires improvement for safety and well-led and good for caring.

With respect to medicine services, ratings went up to good from requires improvement for safety, effective and responsive. Caring remained unchanged at good. However, there was a fall from good to requires improvement for well-led.

Surgery services increased the ratings in two domains previously found to require improvement to good. This included effective and well-led. Caring remained unchanged at good, and safe and responsive remained as requires improvement.

The critical care unit improved its ratings from requires improvement to good in safety and well-led. All other domains remained unchanged, with good ratings for effective and caring, and requires improvement for responsive.

The majority of domains in the outpatients remained unchanged with requires improvement for responsive and well-led, and good for caring. Safety improved from inadequate to requires improvement. We do not currently rate the effectiveness domain in this service.

Princess Royal University Hospital (PRUH) is part of King's College Hospital NHS Foundation trust. The Trust provides local services primarily for the people living in the London boroughs of Lambeth, Southwark, Bromley and Lewisham. The PRUH serves a population of approximately 300,000 in the borough of Bromley.

King's College Hospital NHS Foundation Trust employs around 11,723 whole time equivalent staff with approximately 2,572 staff working at the PRUH.

We carried out an announced inspection of the PRUH between 13- 17 April 201. We also undertook an unannounced visit to the hospital on 22 April 2015.

Overall, this hospital requires improvement. We found the maternity and gynaecology services and services for children and young people were good. Urgent and emergency care, surgery, medical care, critical care, end of life care outpatients and diagnostics and imaging required improvement.

Patients received effective care and they were positive about their interactions with staff. Action needs to be taken to improve the responsiveness and some aspects of the safety and leadership in order to meet the needs of patients.

Our key findings were as follows:

Safe

Since our last inspection a lot work had been done to improve the reporting and investigating of incidents. Many staff we spoke with told us they were was an open culture and they were encouraged to report incidents.
One of the key problems facing the hospital was the recruitment of substantive staff. Although the hospital was actively recruiting staff and there had been some improvement since our last inspection in December 2013, recruiting substantive staff was still a problem across most services.
Staff were aware of the policies for infection prevention and control and adhered to them. The clinical areas we visited were clean and tidy.
There was good pharmacy support for clinical areas. However on some areas, including medical wards and theatres medicines were not always stored safely. For example r was unlocked when theatre lists were running and on medical wards rooms storing medicines were not always locked and medicine trolleys were not always secured to the wall.
Access to and availability of equipment had improved since our last inspection. However equipment was not always cleaned and checked in line with trust policy.
In some services the environment needed to be improved. The environment in the surgical assessment unit was cramped and afforded patients little privacy. Confidential information could be heard when staff went through the theatre checklist with patients. A recent reconfiguration to the main waiting area of the imaging department meant that people with limited mobility had to negotiate two sets of manual doors. The amount of chairs in the waiting area of the imaging clinic had also been significantly reduced which had resulted in patients standing and waiting for their appointment most of the time.
The hospital used paper records and on some medical wards and critical care we found omissions in patients notes. For example there were omissions in risk assessments or assessments by a physiotherapist or occupational therapist.
The availability of medical records in the outpatients department was a significant issue at our last inspection in December 2013. At this inspection, we found some improvements had been made, including a new medical records library at Orpington Hospital site which meant that records were delivered to the clinics more quickly. However, problems still remained in outpatients departments, day surgery unit and medical wards.
The introduction of a new IT system had caused significant problems. There were problems with how the new system interfaced with existing IT systems which resulted in some patients having five or six hospital numbers. Some clinic dates did not migrate accurately which meant that many people attended for an appointment on the wrong day. The hospital was working to resolve the issues
Attendance at mandatory training had improved along with the system for recording and monitoring attendance.

Effective

Most of the services we inspected provided effective care. National guidance was used to inform the care and treatment of patients and services participated in national and local audits.
There was good multidisciplinary working in many of the services except for some of the medical wards where staff felt the focus was on discharging patients quickly. They felt that little attention was paid to concerns raised by other healthcare professionals. Some of the therapists felt their opinion was not always valued by certain members of the nursing and medical team.
Staff appraisal had been identified as an issue at our last inspection and there had been some improvement. In some areas all staff had had an appraisal whereas in others, they were still working towards this. In theatres, the number of staff who had had an appraisal was low, with at least ten staff who had not had an appraisal since 2012.
Patients received timely effective pain relief and the nutritional needs of patients were being met.
Understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards was variable: in some areas it was very good, but in others such as in medical care, more work was required. In surgery we found some of the consent forms did not include all the risks and benefits of a procedure.
Documenting of do not attempt cardio pulmonary resuscitation (DNACPR) orders required more work The trust policy was not embedded and there was a variation in completion of orders.
Average length of stay was higher than the England average for most of the elective and non-elective procedures at the Princess Royal University Hospital. length of stay was higher than the England average for most of the elective and non -elective procedures at the Princess Royal University Hospital
The risk of readmission for elective general medicine was noticeably worse w o r s e than the England average at the Princess Royal University Hospital In surgery the relative risk of re-admission to the PRUH following surgery was reported to be less than the England average for the top three elective and non-elective surgical specialities.

Caring

Patients we spoke with were positive about how staff cared for and engaged with them. They told us staff treated them with dignity and respect and maintained their privacy.
We observed staff being friendly towards patients and treating them and visitors with understanding and patience.
Patients felt they were listened to and were involved in discussions about their care and treatment.
Parents felt involved in the care of their child and participated in the decisions regarding their child’s treatment.

Responsive

The hospital continued to experience severe difficulties managing patient movement ("flow") around the hospital. There were difficulties in managing bed capacity. Both of these issues impacted on several core services. Bed capacity had consistently been above 90% since April 2013. This had been identified at the previous inspections and although some action had been taken, particularly in the emergency department (ED), the problem persisted.
The ED was not achieving the four hour standard to see, treat and discharge patients within four hours and once a decision to admit a patient was made they often had to wait more than 12 hours for a bed to become available.
In surgery, operations were cancelled, and not always rescheduled and undertaken within 28 days. Critical care had experienced over 100% capacity in the four months preceding the inspection with over 40% of discharges being delayed by more than four hours between January and March 2015.
The hospital referral-to-treatment times had been deteriorating since October 2013. It was below the England average but above the 90% standard.
There were regular delays in outpatient clinics, with patients waiting from a few minutes to over an hour. Staff were aware of the delays along with over booking of appointments but no systematic action had been taken to address the situation.
In medical care the pressures on beds meant that that medical patients were sometimes admitted to non- medical wards and moved several times during their stay.
Services, such as translation services, were available to meet the needs of individual patients. Specialist nurses were available and patients were referred to the falls team or tissue visibility nurses if they sustained a fall or developed a pressure ulcer. There was a learning disability nurse attached to the safeguarding team.
There was good staff awareness about caring for patients who were living with dementia and how to meet their needs.
Staff were aware of the complaints process and received feedback through governance meetings and newsletters.

Well-led

At the last inspection we found significant problems with clinical governance at all levels in the hospital. Since our last inspection the leadership, governance and culture of the hospital has improved.
Most of the services either had or were developing a local or trust wide strategy.
Unlike the End of Life service at Denmark Hill site the service at the Princess Royal University Hospital was not commissioned which impacted on resources and long term planning. A business case had been submitted to the local clinical commissioning group but it had not been approved.
Systems for clinical governance had been developed and were being embedded across services. Compared with the last inspection staff were able to tell us about how they monitored the quality of care they provided.
Leadership had been strengthened and improved since our last inspection with additional staff being appointed clear management structures. The improvement was evident in improvements in service delivery, training for staff and monitoring the quality and safety of care provided. Many staff were positive about the local leadership and felt supported by their immediate line managers.
There was an open culture and staff were encouraged to report incidents and concerns. Staff told us they were encouraged to share their ideas and felt they were listened to and treated with respect. They also commented on the good teamwork.
Many services and staff had embraced the changes being part of Kings College Hospital NHS Foundation Trust had brought. A small number of staff felt the good work being done at the PRUH did not always get the recognition it deserved and that it was the "Kings way or no way".
Work had been undertaken to improve engagement with staff and this was evident in discussions with staff, although more work was required with some senior medical staff. .
Staff surveys had been undertaken to examine the cultural differences across the trust and a three year plan developed to address the differences identified. The most recent survey had found some improvements at the Princess Royal University Hospital.
At the last inspection we commented on the commitment and motivation of staff and although not all of the problems had been resolved staff remained positive and motivated about working at the hospital.

We saw several areas of outstanding practice including:

Recent data from the Royal College of Physicians' Sentinel Stroke National Audit Programme (SSNAP) had given the PRUH stroke service a Level A ranking. This is the highest possible rank and only eight per cent of stroke units in the country currently achieve it. This is a significant improvement as the hospital was previously rated as Level D and has risen to Level A in 18 months, making it one of the most improved stroke services in the country. Recent data from the Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP), had given the Princess Royal University Hospital stroke service a Level A ranking. This is the highest possible rank and only eight per cent of stroke units in the country currently achieve it. This is a significant achievement as the hospital was previously rated as Level D and has risen to level A in just 18 months, making it one of the most improved stroke services in the country.
Pets As Therapy (PAT) dogs is an initiative to help patients who may be feeling low after suffering a disability following a stroke, or who may have been in hospital for a long period of time. The stroke ward had introduced pet therapy and a dog and their owner visited the ward weekly. They visited patients who were unable to communicate and found they often made huge efforts to communicate with the dog. The stroke ward had introduced pet therapy and a dog and their owner visited the ward weekly. They visited patients who were unable to communicate and found they often made huge efforts to communicate with the dog.

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

Importantly, the trust must:

Continue to work to improve the availability of medical records in the outpatients department and medical care wards.
Work with key stakeholders to improve patient flow throughout the hospital to reduce waiting times in the ED, cancellation of operations and delayed discharges.
Improve the system for booking and managing waiting times in outpatient clinics to reduce delays for patients and clinics running over time.
Improve the environment in the surgical assessment unit.
Review and improve record documentation to ensure it is fully completed and in line with national guidance including DNACPR orders.

In addition the trust should:

Continue to recruit to substantive posts and ensure that there is always an appropriate skill mix of staff on duty
Continue to embed the processes for monitoring and improving the quality and safety of care provided including incident reporting and learning from incidents
Continue to improve the rate of staff appraisal and attendance at mandatory training
Ensure all medicines are stored and secured in line with trust policy
Improve the monitoring of hand hygiene in services for children and young people
Ensure all equipment (including resuscitation trolleys) is cleaned, maintained, checked and secured in line with trust and national policies
Continue to work to resolve the problems with IT system to ensure patient information is managed effectively and safely.
Improve multidisciplinary working in medical care and services for children and young people.
Improve staff awareness and understanding of their role and responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards
Continue to work with commissioners to ensure there is adequate funding and resources for the End of Life service

Professor Sir Mike Richards

Chief Inspector of Hospitals

King’s College Hospital NHS Foundation Trust is one of London's largest and busiest teaching hospital trusts, with a strong profile of local services primarily serving the boroughs of Lambeth, Southwark and Lewisham. Its specialist services are available to patients across a wider catchment area, providing nationally and internationally recognised work in liver disease and transplantation, neurosciences, haemato-oncology and foetal medicine. The trust is one of four founder partners of King’s Health Partners, one of England’s five academic health science centres for research collaboration.

The trust provides general and specialist services to patients in South London, and also coordinates, or is a part of, various regional centres for trauma, breast screening, diabetes, cystic fibrosis, stroke and liver disease.

The Princess Royal University Hospital (PRUH) was acquired by King’s College Hospital NHS Foundation Trust on 1 October 2013. Before this it was part of the South London Healthcare Trust, which was placed into administration by the Secretary of State in July 2012.

This report relates to the acute services provided by the Princess Royal University Hospital. The hospital has over 500 beds and serves a population of approximately 300,000 in the borough of Bromley of which 91.6% are White and 8.4% are Black or minority ethnic people.”

Prior to being dissolved, the South London Healthcare Trust experienced severe financial challenges, which impacted on many areas of care and systems for monitoring the quality of care provided. The due diligence reports carried out by King’s College Hospital NHS Foundation Trust, dated June 2013, identified a number of significant problems, including the processes for managing risk, complaints and clinical effectiveness, which were perceived to be weak and understaffed. They highlighted the urgent need for clinical governance systems to be put into place at all levels of the PRUH. The current trust is aware of the issues and has developed action plans and started to address the problems.

The scale, number and longstanding history of many of the problems the current trust has inherited should not be underestimated. They include long waiting times in the accident and emergency (A&E) department and significant problems with the availability of medical records. Poor management of patient movement (“flow”) around the hospital means some patients are having their elective surgery cancelled and some patients cannot be transferred from the critical care unit. Systems for monitoring the quality of care had also been much reduced.

Along with (until recently) a lack of resources and support, staff were working in very difficult circumstances and under enormous pressure to provide safe care. Despite the history of problems morale amongst the majority of staff was good and staff were motivated and keen to improve care and services. They are to be commended for maintaining their commitment while working in difficult circumstances for a long period of time. The current trust has recognised that it needs to invest and support staff and has started to do this by increasing staffing levels, and providing a clear management structure for each of the divisions and a dedicated site management team.

During the inspection we were concerned about the degree of urgency in responding to the long waiting times that patients were experiencing in A&E and the lack of capacity within the hospital. To mitigate some of the risk, more staff were being brought in to care for patients. Although senior managers/executives reassured us that they were taking prompt action, this was not supported by what the inspection team saw during the inspection. Some staff working in clinical areas appeared to have become resigned to the situation and worked around the problems rather than addressing them. This attitude was evident in some interviews with staff and during our observations of clinical areas. The plans of senior managers had not yet had enough visible impact on the delivery of care.

At the time of the inspection, the trust was implementing its escalation plan which is now in place, although there has been no improvement in the A&E waiting times.

There was also a significant lack of data available about the quality and effectiveness of the care and treatment provided to patients.

We also identified a number of areas where we felt the trust could and should be taking more prompt action – for example, improving the waiting times in the A&E department.

Some action has been taken to improve the availability of medical records in the outpatients department, but this has yet to have an impact on the service. More action is in process but a lack of records meant that at times patients were undergoing complex medical procedures without clinicians having access to complete set of notes. We reported these areas to the trust and, since the inspection, we have received a letter outlining the immediate action the trust intends to take.