Portsmouth Hospit Hospitals als NHS Trust Inspection report Trust Headquarters, F Level Queen Alexandra Hospital Portsmouth Hampshire PO6 3LY Tel: 02392286000 www.porthosp.nhs.uk Date of inspection visit: 15 to 17 Oct 2019 12 to 14 Nov 2019 Date of publication: This is auto-populated when the report is published We plan our next inspections based on everything we know about services, including whether they appear to be getting better or worse. Each report explains the reason for the inspection. This report describes our judgement of the quality of care provided by this trust. We based it on a combination of what we found when we inspected and other information available to us. It included information given to us from people who use the service, the public and other organisations. This report is a summary of our inspection findings. You can find more detailed information about the service and what we found during our inspection in the related Evidence appendix. Ratings Overall trust quality rating Are services safe? Good ––– Requires improvement ––– Are services effective? Good ––– Are services caring? Good ––– Are services responsive? Good ––– Are services well-led? Good ––– Are resources used productively? Good ––– Combined quality and resource rating Good ––– 1 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings We rated well-led (leadership) from our inspection of trust management, taking into account what we found about leadership in individual services. We rated other key questions by combining the service ratings and using our professional judgement. Background to the trust Portsmouth Hospital NHS Trust is a 997 bedded District General Hospital which is located in Cosham, Portsmouth. The trust provides a comprehensive range of acute and specialist services to a local population of approximately 675,000 people across Portsmouth and South East Hampshire. The trust provides specialist renal services to a population of 2,2 million across Wessex. It employs about 7,300 staff members and has over 700 volunteers. The trust holds contracts with three clinical commissioning groups, Fareham and Gosport, Southeast Hampshire and Portsmouth. Other stakeholders include Portsmouth City Council, Hampshire County Council, NHSI, NHSE, Healthwatch and other system providers. It works closely with the local university and military to support the local population. Overall summary Our rating of this trust improved since our last inspection. We rated it as Good ––– What this trust does The main work is located at the Queen Alexandra Hospital where the trust provides urgent and emergency care, medical care, surgery, critical care, gynaecology, maternity, services for children and young people, end of life care, diagnostics and outpatients. The trust offers outpatients clinics at the other locations. The Trust has four registered locations: • Queen Alexandra Hospital • Gosport War Memorial Hospital • St Mary’s Hospital • Petersfield Hospital. Key questions and ratings We inspect and regulate healthcare service providers in England. To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so, we rate the quality of services against each key question as outstanding, good, requires improvement or inadequate. Where necessary, we take action against service providers that break the regulations and help them to improve the quality of their services. What we inspected and why We plan our inspections based on everything we know about services, including whether they appear to be getting better or worse. We use information from previous inspections, engagement, notifications and information from staff, patients, stakeholders and the trust to decide what areas of the trust to inspect. 2 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings During this inspection we inspected five core services, the trust’s use of resources and the trust’s leadership. The core services we inspected were, urgent and emergency services, medical care (including older people’s care), surgery, maternity and outpatients. What we found Overall trust Our rating of the trust improved. We rated it as good because: Are services safe? Our rating of safe stayed the same. We rated it as requires improvement because: • Overall there was some improvement with regards to safety across the trust. However there were still significant concerns about safety in some areas that we inspected. • The services provided mandatory training in key skills to all staff but did not make sure everyone completed it. Some areas met the mandatory training targets but there were still significant deficiencies in compliance throughout the trust. Medical staff compliance with mandatory training targets was particularly poor. • Some services did not always control infection risk well. Staff did not always use control measures effectively to protect patients, themselves and others from infection. • The design, maintenance and use of facilities, equipment and premises did not keep all people safe. There were areas throughout the hospital that did not have capacity for the patients it served. The hospital was often close to its bed capacity causing flow issues and outliers and some spaces were cramped. • The emergency department was frequently crowded. Lack of capacity within the department led to patients being accommodated in non-clinical areas, including in corridors, and being held for long periods in ambulances outside the emergency department. • There were no side rooms for isolation of infectious patients on the Surgical High Care Unit. • Staff did not always use or check emergency equipment according to guidance or the trust’s policy. • It was not always clear that all staff recognised and reported all incidents and near misses and there were delays to incident reviews in some areas. • The triage processes were not always managed safely and effectively and in line with guidance. • There were significant numbers of patients waiting in ambulances over an hour before being handed over to the emergency department staff. However, • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. • Some services did control infection risk well. In these areas, staff used control measures effectively to protect patients, themselves and others from infection. • The services had 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 and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction. • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care. 3 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings • The services used systems and processes to safely prescribe, administer, record and store medicines. Are services effective? Our rating of effective improved. We rated it as good because: • The services provided care and treatment based on national guidance and evidence-based practice. • Staff generally gave patients food and drinks and considered the needs of patients who needed special feeding and hydration techniques. • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. • The services made sure staff were competent for their roles. • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. • Key services were available seven days a week to support timely patient care. • Staff gave patients support and advice to lead healthier lives. • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. However, • Some departments did not have regular team meetings and there was no consistent approach to sharing information across teams. • Not all staff had a recent appraisal recorded. The trust was meeting its overall target appraisal rate, but there were areas which were not meeting the target. • Some services were outliers for some national audits. Are services caring? Our rating of caring stayed the same. We rated it as good because: • Staff generally treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. • Staff generally provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs. • Staff generally supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Are services responsive? Our rating of responsive improved. We rated it as good because: • The services planned and provided care to meet the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers. 4 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings • People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards. • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint. However, • Patients were not always able to access care and treatment in a timely way and in the right setting, particularly in the emergency department. • Patients were still waiting extended periods for appointments in some clinics. • The trust only met its target to respond to complaints within 30 days in 47% of cases. • There was not a consistent approach to providing patients with accessible information, for instance letters in large print. • Signage in the hospital could be confusing. We observed, and patients reported, that they were not always able to navigate the hospital easily. Are services well-led? Our rating of well-led improved. We rated it as good because: • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the services faced. They were visible and approachable and supported staff to develop their skills and take on more senior roles. • The culture across the trust had improved since out last visits. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The trust promoted equality and diversity in daily work and provided opportunities for career development. It had an open culture where patients, their families and staff could raise concerns without fear. • Leaders operated effective governance processes. Staff at all levels had regular opportunities to meet, discuss and learn from the performance of the service. • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. They used a systematic approach to improve the quality of the service. Managers we spoke with at all levels understood the risks to the services and could describe action to reduce risks. • The services collected reliable data and analysed it to understand performance and make decisions and improvements. • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients. Staff were committed to continually learning and improving services. Leaders encouraged innovation and participation in research. However, • IT systems did not support comprehensive recording and analysis of data and not all services had the information to monitor performance in all areas. 5 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings • Not all risks were identified, or there was not assurance that all risk was identified, and included in the risk management process. • There was no vision and strategy for some services. • There was lack of pace with plans to improve performance of the service. Use of resources We award the Use of Resources rating based on an assessment carried out by NHS Improvement. Our combined rating for Quality and Use of Resources summarises the performance of the trust taking into account the quality of services as well as the trust’s productivity and sustainability. This rating combines our five trust-level quality ratings of safe, effective, caring, responsive and well-led with the Use of Resources rating. Combined quality and resources Our rating of use of resources was good because: • The trust had a past record of delivering financial deficits but had strengthened its financial governance, was delivering against its financial recovery plan and was on track to improve its financial position in 2019/20. The trust benchmarked overall well on workforce productivity, clinical support services, corporate services and clinical services metrics. It had a total cost per weighted activity unit which benchmarked in the second-best quartile nationally for 2017/18. • However, we noted a few areas where the trust could improve particularly around operational performance, agency staff spend, delivery of financial efficiencies and specific areas in clinical support services, estates and procurement. Ratings tables The ratings tables show the ratings overall and for each key question, for each service, hospital and service type, and for the whole trust. They also show the current ratings for services or parts of them not inspected this time. We took all ratings into account in deciding overall ratings. Our decisions on overall ratings also took into account factors including the relative size of services and we used our professional judgement to reach fair and balanced ratings. Outstanding practice We found examples of outstanding practice across the trust. For more information, see the Outstanding practice section of this report, below. Areas for improvement We found areas for improvement including 17 breaches of legal requirements that the trust must put right. We found 40 things that the trust should improve to comply with a minor breach that did not justify regulatory action, to prevent breaching a legal requirement, or to improve service quality. Action we have taken We issued requirement notices to the trust. What happens next We will check that the trust takes the necessary action to improve its services. We will continue to monitor the safety and quality of services through our continuing relationship with the trust and our regular inspections. 6 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings Outstanding practice • We observed improvements in culture across the trust. Staff and leaders throughout the core service and well led inspections reflected the significant changes which had improved staff experience and care they provided. • The trust used innovative methods to implement their overseas nurses program to recruit, train and settle nurses to increase staffing numbers, particularly in hard to resource areas such as the ED. • The trust had developed a proprietary Bedview system to give a trust wide view of patient information to improve decision making and patient safety and a proprietary Minestrone system linked to Bedview to maintain patient records. • The trust’s multidisciplinary simulation for emergency and non-emergency clinical situations was an area of outstanding practice. The hospital’s simulation centre provided a dedicated training environment with scenariobased learning using actors from a variety of clinical settings. • The trust had developed a multi birth facility which offered women one stop clinic and continuity in their care. The trust had developed the role of midwives’ sonographers which impacted positively on care women were receiving. • The service’s multidisciplinary ‘surgery school’ initiative, which helped patients adopt healthier lifestyles before surgery. • The rheumatology service’s helpline initiative supported anxious patients. The success of this service meant that the trust was planning to fund a clinical psychologist to support the most anxious callers. • The surgical and ear, nose and throat outpatients service’s use of coloured cards to make it easier for patients to identify clinic rooms as an area. • A ‘meet and greet’ staff member in the blood testing department helped to improve the flow and experience of patients. Areas for improvement Action the trust MUST take is necessary to comply with its legal obligations. Action a trust SHOULD take is to comply with a minor breach that did not justify regulatory action, to prevent it failing to comply with legal requirements in future, or to improve services. Action the trust MUST take to improve We told the trust that it must take action to bring services into line with four legal requirements. This action related to three services. In the urgent and emergency services: • The trust must ensure that all staff in the emergency department complete regular mandatory training to ensure they have up to date knowledge relating to safe systems and processes. (Regulation 18(1)(2)(a)) • The trust must take steps to ensure patients who attend the emergency department are able to access care and treatment in a timely way in the right setting. The trust must continue to take actions to improve flow through the department and meeting the government targets and the RCEM standards. (Regulation 17(1)(2)(a)) • The trust must ensure that patients are not accommodated in non-clinical areas which are not appropriate to meet their needs and that their comfort, privacy and dignity are maintained. (Regulation 12(1)(2)(d)) 7 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings • The trust must ensure that staff check all emergency equipment according to the trust policy. (Regulation 12(1)(2)(e)) • The trust must ensure that systems to ensure the ongoing monitoring of patients and to identify patients at risk of harm, or deteriorating patients, are consistently complied with. (Regulation 12 (1)(2)(a)(b)) • The trust must assess patients for risk of development of pressure ulcers in a timely manner. (Regulation 12 (1)(2)(a)) • The trust must ensure that the safety of self-presenting patients in the reception waiting area is considered. This includes, but is not restricted to, ensuring patients are assessed in a timely manner and ensuring there is oversight of the wellbeing of patients to identify patients that might be deteriorating. (Regulation 12 (1)(2)(a)(b)) • The trust must ensure that staff recognise and report all incidents. (Regulation 17(1)(2)(b)) • Nursing staff must treat patients with dignity and respect. This includes protecting the dignity of patients cared for in corridor areas and those waiting in the reception waiting area. (Regulation 10(1)(2)(a)) • The trust must ensure staff in the emergency department consistently comply with processes for preventing the spread of infection, including staff use of personal protective equipment. (Regulation 12 (1)(2)(h)) • The trust must develop a comprehensive audit system to provide assurance that patients’ records are appropriately completed. (Regulation 17(1)(2)(a)(c)) • The trust must ensure that all patient safety risks are captured on an appropriate risk register, which must describe planned and completed mitigating actions. (Regulation 17(1)(2)(b)) In Surgery: • The provider must ensure all patients with airborne infections are isolated effectively in side rooms to prevent the spread of infections. (Regulation 15(1) (c)) In Maternity: • Ensure that women attending the maternity assessment unit have timely assessments and care to meet their needs. (Regulation 12(2)(a)) • Ensure care and treatment is provided in a safe way. Processes for the control of infection including cleaning must be developed to prevent and control the risks of infection. (Regulation 12(2)(a)(h)) • Ensure staff have training in the use of the hoist for the pool and emergency evacuation of women from the pool. (Regulation 12(c)) • Ensure that incidents are reviewed in a timely way and risks are mitigated. (Regulation 12(2)(a)(b)) Action the trust SHOULD take to improve In the urgent and emergency services: • The trust must ensure that all staff in the emergency department complete regular mandatory training to ensure they have up to date knowledge relating to safe systems and processes. (Regulation 18(1)(2)(a)) • The trust must take steps to ensure patients who attend the emergency department are able to access care and treatment in a timely way in the right setting. The trust must continue to take actions to improve flow through the department and meeting the government targets and the RCEM standards. (Regulation 17(1)(2)(a)) • The trust must ensure that patients are not accommodated in non-clinical areas which are not appropriate to meet their needs and that their comfort, privacy and dignity are maintained. (Regulation 12(1)(2)(d)) • The trust must ensure that staff check all emergency equipment according to the trust policy. (Regulation 12(1)(2)(e)) 8 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings • The trust must ensure that systems to ensure the ongoing monitoring of patients and to identify patients at risk of harm, or deteriorating patients, are consistently complied with. (Regulation 12 (1)(2)(a)(b)) • The trust must assess patients for risk of development of pressure ulcers in a timely manner. (Regulation 12 (1)(2)(a)) • The trust must ensure that the safety of self-presenting patients in the reception waiting area is considered. This includes, but is not restricted to, ensuring patients are assessed in a timely manner and ensuring there is oversight of the wellbeing of patients to identify patients that might be deteriorating. (Regulation 12 (1)(2)(a)(b)) • The trust must ensure that staff recognise and report all incidents. (Regulation 17(1)(2)(b)) • Nursing staff must treat patients with dignity and respect. This includes protecting the dignity of patients cared for in corridor areas and those waiting in the reception waiting area. (Regulation 10(1)(2)(a)) • The trust must ensure staff in the emergency department consistently comply with processes for preventing the spread of infection, including staff use of personal protective equipment. (Regulation 12 (1)(2)(h)) • The trust must develop a comprehensive audit system to provide assurance that patients’ records are appropriately completed. (Regulation 17(1)(2)(a)(c)) • The trust must ensure that all patient safety risks are captured on an appropriate risk register, which must describe planned and completed mitigating actions. (Regulation 17(1)(2)(b)) In Surgery: • The provider must ensure all patients with airborne infections are isolated effectively in side rooms to prevent the spread of infections. (Regulation 15(1) (c)) In Maternity: • Ensure that women attending the maternity assessment unit have timely assessments and care to meet their needs. (Regulation 12(2)(a)) • Ensure care and treatment is provided in a safe way. Processes for the control of infection including cleaning must be developed to prevent and control the risks of infection. (Regulation 12(2)(a)(h)) • Ensure staff have training in the use of the hoist for the pool and emergency evacuation of women from the pool. (Regulation 12(c)) • Ensure that incidents are reviewed in a timely way and risks are mitigated. (Regulation 12(2)(a)(b)) Action the trust SHOULD take to improve In the urgent and emergency service: • The trust should continue to embed and develop governance systems to provide assurance of the efficiency and effectiveness of systems to ensure patient flow and patient safety. • The trust should continue to ensure that staff in the emergency department receive regular supervision and performance appraisal to provide assurance of their continuing competence in their role. • The trust should consider the need to have a record of food and fluid intake of patients. • The trust should accurately monitor the time of arrival to time of assessment for all patients self-presenting to the department. • The trust should consider providing training to reception staff about identifying ‘red flag’ conditions that require immediate escalation to a clinical professional. 9 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings • The trust should continue to embed the process and completion of staff appraisals according to trust policy. In Surgery: • The provider should review the provision of patient toilet facilities on the Surgical High Care Unit. • The provider should take action to improve mandatory training compliance for medical staff. • The provider should consider adding version numbers and review dates to forms used by staff. • The provider should take action to meet the trust target of 85% for appraisals in all staff groups. • The provider should take action to improve the completion of patients’ fluid balance charts. • The provider should work to meet the trust’s 30-day target for responding to complaints. The service should consider describing medical or clinical terminology in plain English in complaints response letters to aid patient and relatives’ understanding. In Medical care: • The service should look at ways to enable improvements in compliance for medical mandatory training and aspects of safeguarding training. • The service needs to improve sepsis management to avoid unnecessary care failings. • The service should consider equipment replacement in some areas to avoid delays to patient treatment due to equipment failure. • The service had embarked on a work program to improve falls risk assessment and care, this should be continued to improve sustained good practice. • The service should monitor storage of medicines more closely to avoid errors in administration. • Improvement in patient outcomes needs to be sustained in all areas where the service is participating in national audit programmes. • The service should continue to ensure staff appraisals are completed in order to be assured that staff remain competent for their roles. • The service needs to investigate complaints and report back to complainants according to the trust guidelines. In Maternity: • Review the facility for women in the maternity assessment unit including adequate seating. • Develop system to capture mandatory training data for medical staff. • Women’s records should be maintained bound and filed securely to mitigate the risks of these being mislaid. • Develop an effective process for sharing information with staff including lessons learnt. • Review the facility in the bereavement suite. • Review the use of whiteboard and management of women’s personal information. • Develop a vison and strategy specific to maternity services. • Develop measures to collect and submit data in a timely way to monitor performances. In Outpatients: 10 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings • The service should take action to improve mandatory training compliance for medical staff. • The service should take action so all departments meet the trust risk assessment for the storage of cleaning solutions in locked cupboards. • The service should consider a routine inspection and audit for cleaning and replacing cubicle curtains in all departments. • The service should take action to meet the trust target of 85% for appraisals in all staff groups. • The service should take action to service and correctly label all medical equipment in use in the outpatient departments . • The service should take action to develop the understanding and use of LOCSSIPS throughout the departments that may use them. • The service should take action to meet the Accessible Information Standards in a consistent manner across all outpatient departments. Trust wide: • The trust should implement succession planning for the senior leadership team. • The trust should take steps to meet its duty of candour in all cases where it is required with timely information and proportionate engagement. • The trust should implement a framework, that applies to the new context of the trust, with transparent role expectations and clear accountability for roles at all levels. • The trust should continue to work towards IT that meets the trust’s and individual services’ needs • The trust should take steps to increase the pace of improvement to meet patients’ and services’ demands of across the trust. Is this organisation well-led? Our comprehensive inspections of NHS trusts have shown a strong link between the quality of overall management of a trust and the quality of its services. For that reason, we look at the quality of leadership at every level. We also look at how well a trust manages the governance of its services – in other words, how well leaders continually improve the quality of services and safeguard high standards of care by creating an environment for excellence in clinical care to flourish. Our rating of well-led at the trust improved. We rated well-led as good because: Leadership • The leadership team was providing the trust stable leadership which had improved since our 2017 and 2018 inspections. Leaders had the experience, capacity, capability and integrity to ensure that the strategy could be delivered and risks to performance addressed. • The leadership was knowledgeable about issues and priorities for the quality and sustainability of services, understood what the challenges were and acted to address them. Vision and Strategy 11 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings • There was a clear statement of vision and values, driven by quality and sustainability. It was translated into a strategy and well-defined, achievable and relevant objectives. The vision, values and strategy were developed through a structured planning process in collaboration with people who used the service, staff and external partners. They were aligned to local plans in the wider health and social care economy and services were planned to meet the needs of the relevant population. Progress against delivery of the strategy was monitored and reviewed. • The challenges to achieving the strategy, including relevant local health economy factors, were understood and the trust was taking actions to address these. Culture • Leaders modelled and encouraged compassionate, inclusive and supportive relationships among staff so that they feel respected, valued and supported. There were processes to support staff and promote their positive wellbeing. • We observed improvements in culture across the trust. Leaders at every level shared values, prioritised high-quality, sustainable and compassionate care, and promoted equality and diversity. They encouraged pride and positivity in the organisation and generally focused attention on the needs and experiences of people who use services. Behaviour and performance inconsistent with the vision and values was identified and dealt with regardless of seniority. • Among staff, candour, openness, honesty, transparency and challenges to poor practice were the norm. The leadership promoted staff empowerment to drive improvement, and raising concerns was encouraged and valued. • There was a culture of collective responsibility between teams and services. There were processes for providing all staff at every level with the development they needed, including high-quality appraisal and career development conversations and appraisal rates were improving, although the trust as a whole had not met its appraisal target rate. However, • We still found there were areas where culture was not centred on the needs and experience of people who used the service. For instance, in the emergency department some non-patient centred care had been normalised, waiting rooms could be challenging to navigate or a risk for a unwell or vulnerable patient. • The hospital was not well signposted and we observed patients regularly becoming lost and confused. • We saw both at core service level and leadership level that the spirit of the duty of candour was not always followed. The response was not always timely and in some more serious cases the trust did not proactively attempt to contact patients other than to send a letter. • All staff did not always feel they were treated equally. Governance • The board and other levels of governance in the organisation functioned effectively and interacted well with each other. Structures, processes and systems of accountability, including the governance and management of partnerships, joint working arrangements and shared services, were clearly set out, understood and effective. However, • Staff were not always clear about their roles and what they were accountable for. Management of risk, issues and performance 12 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings • The organisation had the processes to manage current and future performance. There were processes to identify, understand, monitor and address current and future risks. Performance issues were escalated to the appropriate committees and the board through clear structures and processes. Clinical and internal audit processes functioned well and had a positive impact on quality governance, with clear evidence of action to resolve concerns. • Financial pressures were managed so that they did not compromise the quality of care. Service developments and efficiency changes were developed and assessed with input from clinicians so that their impact on the quality of care was understood. However, • Risks, issues and poor performance were not always identified or dealt with quickly enough. We continued to have serious concerns around the Emergency Department and the senior leadership team’s oversight of risk management and pace of change within the department. Information management • Integrated reporting supported effective decision making. There was a holistic understanding of performance, which integrated the views of people with quality, operational and financial information. Quality and sustainability both received sufficient coverage in relevant meetings at all levels. Performance information was used to hold management and staff to account. The information used in reporting, performance management and delivering quality care was usually accurate, valid, reliable, timely and relevant, with plans to address any weaknesses. • There were arrangements for the availability, integrity and confidentiality of patient identifiable data, records and data management systems. New information technology systems were used effectively to monitor and improve the quality of care. • However, the trust’s data maturity remained low, systems were not always effective and information used in some areas was not always accurate, valid, reliable, timely or relevant. Engagement • The trust encouraged a full and diverse range of people’s views and concerns. The service proactively engaged and involved staff, public and stakeholders (including those with protected equality characteristics) and ensured their voices were considered to shape services and culture. • The service was transparent, collaborative and open with stakeholders about performance, to build a shared understanding of challenges to the system and the needs of the population and to design improvements to meet them. Learning, continuous improvement and innovation • There was a strong focus on continuous learning and improvement at all levels of the organisation, including through external accreditation and participation in research. • There was knowledge of improvement methods and systems and staff had the skills to use them at all levels of the organisation. These supported improvement and innovation work. • The service made effective use of internal and external reviews, including review of deaths and incidents, and learning was shared effectively and used to make improvements. • The service had a strong research department which engaged in research that benefited patients and the trust directly. 13 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Ratings tables Key to tables Ratings Rating change since last inspection Not rated Inadequate Requires improvement Same Up one rating Up two ratings Good Outstanding Down one rating Down two ratings same-rating ––– Symbol * Month Year = Date last rating published * Where there is no symbol showing how a rating has changed, it means either that: • we have not inspected this aspect of the service before or • we have not inspected it this time or • changes to how we inspect make comparisons with a previous inspection unreliable. Ratings for the whole trust Safe Requires improvement upone-rating Feb 2020 Effective Caring Responsive Well-led Overall Good Good Good Good Good Feb 2020 Feb 2020 Feb 2020 Feb 2020 Feb 2020 The rating for well-led is based on our inspection at trust level, taking into account what we found in individual services. Ratings for other key questions are from combining ratings for services and using our professional judgement. 14 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published g g g g Ratings for Queen Alexandra Hospital Safe Urgent and emergency services same-rating ––– Medical care (including older people’s care) upone-rating Surgery upone-rating Critical same-rating ––– care Maternity same-rating ––– Services for children and young people same-rating ––– End of life care upone-rating Outpatients same-rating ––– Diagnostic imaging same-rating ––– Overall* upone-rating Effective Caring Responsive Well-led Overall Requires Requires Requires Requires Requires Requires improvement improvement improvement improvement improvement improvement Feb 2020 Requires improvement Feb 2020 Feb 2020 Feb 2020 Feb 2020 Feb 2020 Good Good Good Good Good Feb 2020 Feb 2020 Feb 2020 Feb 2020 Feb 2020 Good Good Good Good Good Feb 2020 Outstanding Feb 2020 Outstanding Feb 2020 Outstanding Feb 2020 Outstanding Feb 2020 Outstanding Feb 2020 Outstanding Aug 2018 Requires improvement Aug 2018 Aug 2018 Aug 2018 Good Good Good Feb 2020 Feb 2020 Feb 2020 Good Outstanding Aug 2018 Feb 2020 Good Feb 2020 Requires improvement Aug 2018 Good Aug 2018 Good Feb 2020 Good Aug 2018 Requires improvement Feb 2020 Aug 2018 Aug 2018 Requires Requires improvement improvement Feb 2020 Feb 2020 Good Good Good Aug 2018 Aug 2018 Aug 2018 Aug 2018 Good Good Good Good Good Aug 2018 Aug 2018 Good Aug 2018 Good Aug 2018 Good Aug 2018 Good Good Feb 2020 Good Feb 2020 Good Feb 2020 Good Feb 2020 Good Aug 2018 Aug 2018 Aug 2018 Aug 2018 Aug 2018 Good Good Good Good Good Feb 2020 Feb 2020 Feb 2020 Feb 2018 Feb 2018 N/A *Overall ratings for this hospital are from combining ratings for services. Our decisions on overall ratings take into account the relative size of services. We use our professional judgement to reach fair and balanced ratings. 15 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Queen Alex Alexandr andraa Hospit Hospital al Southwick Hill Road Cosham Portsmouth Hampshire PO6 3LY Tel: 02392286000 www.porthosp.nhs.uk Key facts and figures Queen Alexandra Hospital is located in Cosham, Portsmouth. It is a large District General Hospital providing a comprehensive range of acute and specialist services. The hospital serves local, regional and military communities. The local population is approximately 675,000 people and the hospital provides specialist renal services to a population of 2.2 million people across Wessex. The trust’s main site is the Queen Alexandra Hospital. The hospital provides services including: urgent and emergency care, medical care, surgery, outpatients, diagnostic imaging, critical care, services for children and young people and end of life care. It has 977 beds, 28 theatres, and two interventional radiology suites. It employs over 7000 staff and has more than 700 volunteers. Summary of services at Queen Alexandra Hospital Good ––– Our rating of services improved. We rated them overall as good because: • Our rating of safe stayed the same. We rated it requires improvement because there were still significant concerns about safety in urgent and emergency care, medical care and maternity. However, there was improvement with regards to safety across the hospital. • Our rating of effective improved. We rated it as good because the hospital provided evidence based care, treatment and support to achieve good outcomes and promote a good quality of life. However, there were some inconsistencies between teams regarding information sharing, not all staff had appraisals and some services were outliers for some national audits. • Our rating of caring improved. We rated it as good because the hospital involved patients in their care and treated them with compassion kindness dignity and respect. We saw an improvement to caring treatment throughout much of the hospital including some examples of outstanding care. However, there were still some concerns about care provided and privacy and dignity in the urgent and emergency service. • Our rating of responsive improved. We rated it as good because the service provided care that met the needs of individual patients and the community. However, patients could not always access care and treatment in a timely way or in the right setting and there were delays to responding to more than 50% of complaints. 16 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Summary of findings • Our rating of well-led improved. We rated it as good because leadership, management and governance of the organisation had improved, enhancing the trust’s ability to deliver high-quality care, supporting learning and innovation, and promoting an open and fair culture. However, IT systems did not always support good care, not all risks were identified and there was a lack of pace regarding some improvements. 17 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Urgent and emergency services Requires improvement ––– Key facts and figures Urgent and emergency services are provided by the trust at Queen Alexandra Hospital. The department is open 24 hours a day, seven days a week, with consultant-led emergency care and treatment provided from 8am to 12 midnight, seven days a week to people across the city of Portsmouth and south east Hampshire. The trust has a Minor Injuries Unit based at Gosport War Memorial Hospital and a GP-led Urgent Care Centre. At the time of the inspection the GP – led Urgent Care Service was being reconfigured and was not available during our inspection. The emergency department is a recognised trauma unit. Major trauma patients are transported directly to the nearest major trauma unit. The department has a four-bay resuscitation area, with one bay designated for children. There are two major treatment areas; majors A has 18 bays and three cubicles, majors B has 12 chairs, two bays and an additional bay for clinical examinations. There is a separate ‘pit stop’ assessment area with six trolleys and four chairs. If the pit stop area is full, up to six patients are accommodated in the corridor while they wait for assessment. One further corridor area is used when the department reaches capacity. There is a nine-bed emergency decision unit (EDU). This area comprises of two four-bed bays and a single-bed sideroom. The area is used for patients who are unlikely to require admission but who require short term observation or are waiting for test results. The unit is regularly used to accommodate patients with acute mental health problems who are waiting for assessment by a mental health practitioner or waiting for a mental health bed. There is a side room designated for mental health practitioners to undertake mental health assessments. The minor treatment area has six treatment cubicles and two consultation rooms used by general practitioners to provide an urgent care service. This service operates from 8am to 11pm, seven days a week and sees patients who present with a condition which requires immediate treatment, but which can be carried out by a GP. The emergency department has a separate children’s treatment area with its own secure waiting room. This consists of an observed play area, a high dependency cubicle, an isolation room, five majors cubicles and four minors cubicles. This area is open from 8am until midnight, seven days a week. Outside of these hours, children are seen in the main (adult) area of the emergency department or they are taken directly to the children’s assessment unit, located elsewhere in the hospital. From March 2018 to February 2019 there were 156,347 attendances at the trust’s urgent and emergency care services. We undertook an announced inspection of the urgent and emergency care services between 15 and 17 October 2019 and carried out further observations of the service on 12 November 2019. We spoke with 10 patients and six relatives and carers. We spoke with approximately 30 members of staff including nurses, managers, health care support workers, doctors and reception staff. We observed care in the service and looked at 10 sets of patients’ records We previously inspected this service in April 2018. At that time the service was rated requires improvement overall, with safe, effective caring and well led rated as inadequate and responsive as inadequate. We completed a focused inspection in February 2019 in response to concerns about how the trust was managing with the increased pressures of the winter period. As that was a focused inspection and we did not look at all five key questions, the rating for the service was not reviewed at that time. 18 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Urgent and emergency services Urgent and emergency services are provided by the trust at Queen Alexandra Hospital. The department is open 24 hours a day, seven days a week, with consultant-led emergency care and treatment provided from 8am to 12 midnight, seven days a week to people across the city of Portsmouth and south east Hampshire. The trust has a Minor Injuries Unit based at Gosport War Memorial Hospital and a GP-led Urgent Care Centre. At the time of the inspection the GP – led Urgent Care Service was being reconfigured and was not available during our inspection. The emergency department is a recognised trauma unit. Major trauma patients are transported directly to the nearest major trauma unit. The department has a four-bay resuscitation area, with one bay designated for children. There are two major treatment areas; majors A has 18 bays and three cubicles, majors B has 12 chairs, two bays and an additional bay for clinical examinations. There is a separate ‘pit stop’ assessment area with six trolleys and four chairs. If the pit stop area is full, up to six patients are accommodated in the corridor while they wait for assessment. One further corridor area is used when the department reaches capacity. There is a nine-bed emergency decision unit (EDU). This area comprises of two four-bed bays and a single-bed sideroom. The area is used for patients who are unlikely to require admission but who require short term observation or are waiting for test results. The unit is regularly used to accommodate patients with acute mental health problems who are waiting for assessment by a mental health practitioner or waiting for a mental health bed. There is a side room designated for mental health practitioners to undertake mental health assessments. The minor treatment area has six treatment cubicles and two consultation rooms used by general practitioners to provide an urgent care service. This service operates from 8am to 11pm, seven days a week and sees patients who present with a condition which requires immediate treatment, but which can be carried out by a GP. The emergency department has a separate children’s treatment area with its own secure waiting room. This consists of an observed play area, a high dependency cubicle, an isolation room, five majors cubicles and four minors cubicles. This area is open from 8am until midnight, seven days a week. Outside of these hours, children are seen in the main (adult) area of the emergency department or they are taken directly to the children’s assessment unit, located elsewhere in the hospital. From March 2018 to February 2019 there were 156,347 attendances at the trust’s urgent and emergency care services. We undertook an announced inspection of the urgent and emergency care services between 15 and 17 October 2019 and carried out further observations of the service on 12 November 2019. We spoke with 10 patients and six relatives and carers. We spoke with approximately 30 members of staff including nurses, managers, health care support workers, doctors and reception staff. We observed care in the service and looked at 10 sets of patients’ records We previously inspected this service in April 2018. At that time the service was rated requires improvement overall, with safe, effective caring and well led rated as inadequate and responsive as inadequate. We completed a focused inspection in February 2019 in response to concerns about how the trust was managing with the increased pressures of the winter period. As that was a focused inspection and we did not look at all five key questions, the rating for the service was not reviewed at that time. Summary of this service Our rating of this service stayed the same. We rated it as requires improvement because: 19 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Urgent and emergency services • Staff did not assess risks to patients in a timely manner. Arrangements for patients self-presenting at the department increased the risk of delays to assessment of their conditions and risk of deteriorating patients not being identified. Staff did not always carry out clinical observation of patients in line with the hourly requirement set by the department. There was no assurance that staff completed patient records fully and accurately. It was not clear that staff recognised and reported all incidents and near misses. The service did not consistently control infection risk well. • There were significant numbers of patients waiting in ambulances over an hour before being handed over the emergency department staff and delays with the timeliness of assessments and start of treatment. • Staff did not have assurance that patients had enough food and drink to meet their needs and improve their health, as staff did not record whether patients had eaten or drunk the food and drink provided. Annual appraisal rates still did not meet the trust’s target. • Staff did not always respect the privacy and dignity of patients. • Facilities and premises did not meet the needs of the number of patients attending the department. Demand for services frequently outstripped the availability of appropriate clinical spaces to assess, treat and care for patients. Patients were frequently cared for in non-clinical spaces and there were regular occurrences of patients being held in ambulances outside the department due to lack of capacity to accommodate them. Patients were not always able to access care and treatment in a timely way and in the right setting. • Not all service risks were identified and included in the risk management process. However, • The service had enough staff to care for patients and keep them safe. Most staff had training in key skills and understood how to protect patients from abuse. They managed medicines well. The service managed safety incidents and learned lessons from them. • Staff provided patients pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives and supported them to make decisions about their care. Key services were available seven days a week. • Staff helped patients to understand their conditions. They provided emotional support to patients, families and carers. • Staff took account of patients’ individual needs, and treated concerns and complaints seriously. The service was making changes to try to improve patient flow. Although not meeting most of the national targets for patient flow, there were some improvements with performance against some of the targets. • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged with patients and the community to plan and manage services and all staff were committed to improving services continually. Is the service safe? Requires improvement ––– Our rating of safe stayed the same. We rated it as requires improvement because: • The service did not make sure all staff completed the mandatory training, including safeguarding training. 20 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Urgent and emergency services • The service did not always control infection risk well. Staff did not always use control measures effectively to protect patients, themselves and others from infection. We observed staff handling used linen, emptying bins and attending to patients’ elimination needs without using personal protective equipment such as gloves and aprons. The condition of seating in some areas meant it was not possible to carry out effective cleaning. There were used paper cups and used tissues on the floor of the reception area where self-presenting patients waited to be attended to. • The design, maintenance and use of facilities, equipment and premises did not keep people safe. The emergency department was frequently crowded. Crowding in emergency departments is associated with an increase in mortality and impacts on patients’ experience. Lack of capacity within the department led to patients being accommodated in non-clinical areas, including in corridors, and being held for long periods in ambulances outside the emergency department. Crowding in the department, meant the sicker patients self-presenting who needed to be cared for in the major treatment areas had a longer wait to be allocated a care space than those waiting to be seen in the minor treatment area. Staff did not always check emergency equipment according to the trust’s policy. • Staff did not complete assessments for each patient in a timely manner. The service consistently performed poorly against the Royal College of Emergency Medicine recommendation that all patients should be assessed by a healthcare professional within 15 minutes of arrival at the emergency department. Arrangements for patients selfpresenting at the department and lack of oversight of patients in the reception waiting area increased the risk of delays to assessment of their conditions and risk of deteriorating patients not being identified. Reception staff had not received any training about how to identify red flag signs and symptoms that may indicate a patient needed urgent medical assistance. The department’s own audits showed that staff did not always carry out clinical observation of patients in line with the hourly requirement set by the department. • There were significant numbers of patients waiting in ambulances over an hour before being handed over to the emergency department staff. • There was heavy reliance on bank and agency nursing staff to maintain safe staffing numbers. • The service relied on consultant medical staff working additional hours to deliver a safe service. • Staff did not always keep detailed and up-to-date records of patients’ care and treatment. There was no process to monitor staff completion of patient records. • It was not clear that staff recognised and reported all incidents and near misses. Overcrowding, relatives having to sit on the floor, delays of patients being clinically assessed and patient queue jumping for the navigator nurse were not reported as incidents, suggesting that staff considered these as normal practices. Staff had not recognised incidents as being a Never Event. Managers had not ensured that actions from patient safety alerts were implemented and monitored. The service reported three Never Events, all relating to patients being administered air rather than oxygen. This had been a subject of a safety alert in October 2016, but the service had failed to ensure the appropriate actions were taken to support the safety of patients. However, • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. • Staff were trained to use equipment. Staff managed clinical waste well. • The service had enough nursing 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 and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction. • The service had enough medical 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 and adjusted staffing levels and skill mix, and gave locum staff a full induction. 21 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Urgent and emergency services • Records were clear, stored securely and easily available to all staff providing care. • The service used systems and processes to safely prescribe, administer, record and store medicines. • Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Our rating of safe stayed the same. We rated it as requires improvement because: • The service did not make sure all staff completed the mandatory training, including safeguarding training. • The service did not always control infection risk well. Staff did not always use control measures effectively to protect patients, themselves and others from infection. We observed staff handling used linen, emptying bins and attending to patients’ elimination needs without using personal protective equipment such as gloves and aprons. The condition of seating in some areas meant it was not possible to carry out effective cleaning. There were used paper cups and used tissues on the floor of the reception area where self-presenting patients waited to be attended to. • The design, maintenance and use of facilities, equipment and premises did not keep people safe. The emergency department was frequently crowded. Crowding in emergency departments is associated with an increase in mortality and impacts on patients’ experience. Lack of capacity within the department led to patients being accommodated in non-clinical areas, including in corridors, and being held for long periods in ambulances outside the emergency department. Crowding in the department, meant the sicker patients self-presenting who needed to be cared for in the major treatment areas had a longer wait to be allocated a care space than those waiting to be seen in the minor treatment area. Staff did not always check emergency equipment according to the trust’s policy. • Staff did not complete assessments for each patient in a timely manner. The service consistently performed poorly against the Royal College of Emergency Medicine recommendation that all patients should be assessed by a healthcare professional within 15 minutes of arrival at the emergency department. Arrangements for patients selfpresenting at the department and lack of oversight of patients in the reception waiting area increased the risk of delays to assessment of their conditions and risk of deteriorating patients not being identified. Reception staff had not received any training about how to identify red flag signs and symptoms that may indicate a patient needed urgent medical assistance. The department’s own audits showed that staff did not always carry out clinical observation of patients in line with the hourly requirement set by the department. • There were significant numbers of patients waiting in ambulances over an hour before being handed over to the emergency department staff. • There was heavy reliance on bank and agency nursing staff to maintain safe staffing numbers. • The service relied on consultant medical staff working additional hours to deliver a safe service. • Staff did not always keep detailed and up-to-date records of patients’ care and treatment. There was no process to monitor staff completion of patient records. • It was not clear that staff recognised and reported all incidents and near misses. Overcrowding, relatives having to sit on the floor, delays of patients being clinically assessed and patient queue jumping for the navigator nurse were not reported as incidents, suggesting that staff considered these as normal practices. Staff had not recognised incidents as being a Never Event. Managers had not ensured that actions from patient safety alerts were implemented and monitored. The service reported three Never Events, all relating to patients being administered air rather than oxygen. This had been a subject of a safety alert in October 2016, but the service had failed to ensure the appropriate actions were taken to support the safety of patients. However: • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. 22 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Urgent and emergency services • Staff were trained to use equipment. Staff managed clinical waste well. • The service had enough nursing 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 and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction. • The service had enough medical 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 and adjusted staffing levels and skill mix, and gave locum staff a full induction. • Records were clear, stored securely and easily available to all staff providing care. • The service used systems and processes to safely prescribe, administer, record and store medicines. • Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Is the service effective? Requires improvement ––– Our rating of effective stayed the same. We rated it as requires improvement because: • Staff did not have assurance that patients had enough food and drink to meet their needs and improve their health, as staff did not record whether patients had eaten or drunk the food and drink provided. • Annual appraisal rates still did not meet the trust’s target. • There was lack of assurance that managers and staff used audit results to improve patient outcomes. National audit results showed areas of clinical management that did not meet the national standards. This included consultant sign off, management of moderate and acute severe asthma, the time from arrival to CT scan of the head for patients with traumatic brain injury and proportion of patients with severe open lower limb fracture receiving appropriately timed urgent and emergency care. More recent national audits showed management of pain for both adults and children did not fully meet the national standards. • The service had a higher (worse) than expected risk of re attendance within seven days of initial attendance than the national standard, but had performed better than the England average. However, • The service provided care and treatment based on national guidance and evidence-based practice. • Staff gave patients food and drinks and considered the needs of patients who needed special feeding and hydration techniques. • The service made sure staff were competent for their roles. • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care • Key services were available seven days a week to support timely patient care. • Staff gave patients some support and advice to lead healthier lives. 23 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Urgent and emergency services Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. Is the service caring? Requires improvement ––– Our rating of caring stayed the same. We rated it as requires improvement because: • Staff did not always treat patients with compassion and kindness or respect their privacy and dignity. • Staff did not always support the privacy and dignity of patients accommodated in the corridor cohort area. However, • Staff provided emotional support to patients, families and carers to minimise their distress. • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment Is the service responsive? Requires improvement ––– Our rating of responsive improved. We rated it as requires improvement because: • Facilities and premises did not meet the needs of the number of patients attending the department. Demand for services frequently outstripped the availability of appropriate clinical spaces to assess, treat and care for patients. Patients were frequently cared for in non-clinical spaces and there were regular occurrences of patients being held in ambulances outside the department due to lack of capacity to accommodate them. • Patients were not always able to access care and treatment in a timely way and in the right setting. The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. From July 2018 to April 2019 the trust failed to meet the standard and performed worse than the England average. From August 2018 to July 2019 the trust’s monthly percentage of patients waiting more than four hours from the decision to admit until being admitted was consistently higher (worse) than the England average. From January 2019 to June 2019, the trust’s median total time for patients in the department in A&E was higher (worse) than the England average. However, • The service was inclusive and took account of patients’ individual needs. Staff coordinated care with other services and providers. • The service had made recent changes to try to improve patient flow. The major treatment B area had been transformed to an ambulatory major treatment area, where more patients were accommodated on chairs. Although the service performed worse than the England average for patients waiting more than four hours from the decision to admit until being admitted, the numbers of patients experiencing this was less than it had been at the previous inspection. There were improvements from the last inspection with the number of patients waiting more than 12 hours from the decision to admit until being admitted. There had been one patient waiting more than 12 hours from the decision to admit until being admitted between August 2018 to July 2019 and none in October 2019. 24 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Urgent and emergency services • The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. Is the service well-led? Requires improvement ––– Our rating of well-led stayed the same. We rated it as requires improvement because: • The service did not have a developed vision and purpose for the Emergency Department and Urgent Care Group. • Not all risks were identified and included in the risk management process. • There was lack of pace with plans to improve performance of the service. • The service did not have the information to monitor performance in all areas of the service. However, • Leaders had the integrity, skills and abilities to run the service. They understood the priorities and issues the service faced and supported staff to develop their skills and take on more senior roles. • The service was developing, with relevant stakeholders, a vision for what it wanted to achieve and a strategy to turn it into action. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. • Leaders operated governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities. Leaders had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care. • Leaders and staff engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients. All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Areas for improvement Action the trust MUST take to improve The trust must ensure that all staff in the emergency department complete regular mandatory training to ensure they have up to date knowledge relating to safe systems and processes. (Regulation 18(1)(2)(a)) The trust must take steps to ensure patients who attend the emergency department are able to access care and treatment in a timely way in the right setting. The trust must continue to take actions to improve flow through the department and meeting the government targets and the RCEM standards. (Regulation 17(1)(2)(a)) The trust must ensure that patients are not accommodated in non-clinical areas which are not appropriate to meet their needs and that their comfort, privacy and dignity are maintained. (Regulation 12(1)(2)(d)) The trust must ensure that staff check all emergency equipment according to the trust policy. (Regulation 12(1)(2)(e)) The trust must ensure that systems to ensure the ongoing monitoring of patients and to identify patients at risk of harm, or deteriorating patients, are consistently complied with. (Regulation 12 (1)(2)(a)(b)) The trust must assess patients for risk of development of pressure ulcers in a timely manner. (Regulation 12 (1)(2)(a)) 25 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Urgent and emergency services The trust must ensure that the safety of self-presenting patients in the reception waiting area is considered. This includes, but is not restricted to, ensuring patients are assessed in a timely manner and ensuring there is oversight of the wellbeing of patients to identify patients that might be deteriorating. (Regulation 12 (1)(2)(a)(b)) The trust must ensure that staff recognise and report all incidents. (Regulation 17(1)(2)(b)) Nursing staff must treat patients with dignity and respect. This includes protecting the dignity of patients cared for in corridor areas and those waiting in the reception waiting area. (Regulation 10(1)(2)(a)) The trust must ensure staff in the emergency department consistently comply with processes for preventing the spread of infection, including staff use of personal protective equipment. (Regulation 12 (1)(2)(h)) The trust must develop a comprehensive audit system to provide assurance that patients’ records are appropriately completed. (Regulation 17(1)(2)(a)(c)) The trust must ensure that all patient safety risks are captured on an appropriate risk register, which must describe planned and completed mitigating actions. (Regulation 17(1)(2)(b)) Action the trust SHOULD take to improve The trust should continue to embed and develop governance systems to provide assurance of the efficiency and effectiveness of systems to ensure patient flow and patient safety. The trust should continue to ensure that staff in the emergency department receive regular supervision and performance appraisal to provide assurance of their continuing competence in their role. The trust should consider the need to have a record of food and fluid intake of patients. The trust should accurately monitor the time of arrival to time of assessment for all patients self-presenting to the department. The trust should consider providing training to reception staff about identifying ‘red flag’ conditions that require immediate escalation to a clinical professional. The trust should continue to embed the process and completion of staff appraisals according to trust policy. 26 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Medical care (including older people’s care) Good ––– Key facts and figures Medical care (including older people’s care) at Portsmouth Hospitals NHS Trust includes a broad range of specialities. The service sits within the Medicine and Urgent Care Division, specialist care groups in Queen Alexandra Hospital include the following: Gastroenterology & Hepatology Endocrinology & Diabetes Respiratory Cardiology Neurology Endoscopy General Medicine The older people’s medicine includes: Stroke – hyper acute and acute, Neurology rehabilitation Acute Neurology Team Hospital Palliative Care The Acute Medical Unit which provides diagnostic assessment for adult patients admitted as emergencies. We also visited the haematology / oncology wards which formed part of the Networked Services division. The Queen Alexandra Hospital site has 997 beds and serves a population of around 675,000 Portsmouth and south east Hampshire residents. Approximately 580 beds are provided to patients admitted under the care of the Medicine and Urgent Care Division. The trust had 61,557 medical admissions from March 2018 to February 2019. Emergency admissions accounted for 27,851 (45.2 %), 1,314 (2.1 %) were elective, and the remaining 32,412 (52.7 %) were day case. Admissions for the top three medical specialties were: • General Medicine – 20,374 • Gastroenterology – 15,131 • Rheumatology – 6,409 During this inspection, we visited a selection of wards across the division, the acute medical unit (AMU), the ambulatory care unit, cardiac catheterisation laboratories and the endoscopy suite. We spoke with 58 members of staff including service leads, doctors, nursing staff, healthcare assistants, housekeeping staff, and administrative staff and attended medical and nursing handover meetings. We also spoke with 10 patients, reviewed 15 sets of medical records and observed interactions between staff and patients. 27 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Medical care (including older people’s care) During and after the inspection, we reviewed a wide range of documents including policies, standard operating procedures, meeting minutes, action plans, risk assessments and audit results. Before our inspection, we reviewed performance information from, and about, the trust. We last completed a comprehensive inspection of medical care services in this hospital in April 2018 and rated the medical care as requires improvement for all five domains. Summary of this service Our rating of this service improved. We rated it as good because: • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week. • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers. • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment. • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually. However • The service did not always have staff with the correct skills available to them to care for patients and keep them safe. Is the service safe? Requires improvement ––– Our rating of safe stayed the same. We rated it as requires improvement because: • The service provided mandatory training in key skills to all staff but did not make sure everyone completed it. Medical staff compliance with mandatory training targets was poor. • Staff had training on how to recognise and report abuse, but compliance for prevent awareness was not achieved for nursing staff and was poor for medical staff. 28 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Medical care (including older people’s care) • Sustained management of sepsis was below the national average. • Some equipment in use was old and past its expected lifespan and some areas lacked enough storage space, resulting in cluttered corridors. • Staff completed and updated risk assessments for each patient and removed or minimised risks, but completion of clinical records was inconsistent and some areas in falls risk assessments were poorly assessed. • The service used systems and processes to safely prescribe, administer, and record medicines. Storage and monitoring of medicines wasn’t consistent throughout the medical wards. However: • On the whole staff understood how to protect patients from abuse and the service worked well with other agencies to do so. • 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. Staff managed clinical waste well. • Staff identified and quickly acted upon patients at risk of deterioration. • The design, maintenance and use of facilities, premises and equipment kept people safe. • The service did not always have enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment, but managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction. • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored. • The service used monitoring results well to improve safety. Staff collected safety information and shared it with staff, patients and visitors. Our rating of safe stayed the same. We rated it as requires improvement because: • The service provided mandatory training in key skills to all staff but did not make sure everyone completed it. Medical staff compliance with mandatory training targets was poor. • Staff had training on how to recognise and report abuse, but compliance for prevent awareness was not achieved for nursing staff and was poor for medical staff. • Sustained management of sepsis was below the national average. • Some equipment in use was old and past its’ expected lifespan and some areas lacked enough storage space, resulting in cluttered corridors. • Staff completed and updated risk assessments for each patient and removed or minimised risks, but completion of clinical records was inconsistent and some areas in falls risk assessments were poorly assessed. • The service used systems and processes to safely prescribe, administer, and record medicines. Storage and monitoring of medicines weren’t consistent throughout the medical wards. However: • On the whole staff understood how to protect patients from abuse and the service worked well with other agencies to do so. 29 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Medical care (including older people’s care) • 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. Staff managed clinical waste well. • Staff identified and quickly acted upon patients at risk of deterioration. • The design, maintenance and use of facilities, premises and equipment kept people safe. • The service did not always have enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment, butt managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction. • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored. • The service used monitoring results well to improve safety. Staff collected safety information and shared it with staff, patients and visitors. Is the service effective? Good ––– Our rating of effective improved. We rated it as good because: • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983. • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other needs • Staff assessed and monitored patients regularly to see if they were in pain, and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain. • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development. • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. • Key services were available seven days a week to support timely patient care. • Staff gave patients practical support and advice to lead healthier lives. • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. They used agreed personalised measures that limit patients' liberty. • Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update. 30 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Medical care (including older people’s care) However; • The service was an outlier for some national audits. • Some documents available on the intranet were not current. • Not all staff received timely appraisals. • A lack of speech and language therapists resulted in a decrease in timely assessments for stroke patients. Is the service caring? Good ––– Our rating of caring improved. We rated it as good because: • Staff generally treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs. • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Is the service responsive? Good ––– Our rating of responsive improved. We rated it as good because: • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers. • People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards. • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint. However; • Response to complaints was outside of the trust’s 30 day target. Is the service well-led? Good ––– Our rating of well-led improved. We rated it as good because: 31 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Medical care (including older people’s care) • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles. • The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress. • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work, and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear. • Leaders operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. • Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care. • The service collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required. • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients. • All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research. Areas for improvement • The service should look at ways to enable improvements in compliance for medical mandatory training and aspects of safeguarding training. • The service needs to improve sepsis management to avoid unnecessary care failings. • The service should consider equipment replacement in some areas to avoid delays to patient treatment due to equipment failure. • The service has embarked on a work program to improve falls risk assessment and care, this should be continued to improve sustained good practice. • The service should monitor storage of medicines more closely to avoid errors in administration. • Improvement in patient outcomes needs to be sustained in all areas where the service is participating in national audit programmes. • The service should continue to ensure staff appraisals are completed in order to be assured that staff remain competent for their roles. • The service needs to investigate complaints and report back to complainants according to the trust guidelines. 32 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Surgery Good ––– Key facts and figures Portsmouth Hospitals NHS Trust provides district general hospital surgical services at the Queen Alexandra Hospital. The surgical specialties offered at the hospital are colorectal, urology, breast and plastics, lower and upper gastrointestinal, vascular surgery, bariatric and general surgery. The trust is an orthopaedic centre, providing elective and emergency trauma surgery, with the head and neck clinical service centre at the trust also providing ophthalmic (eye) surgery, dental, maxillo-facial and oral surgery. The service had 46,216 surgical admissions from March 2018 to February 2019. Emergency admissions accounted for 13,744 of these (29.7%), 26,369 (57.1 %) were day case, and the remaining 6,103 (13.2 %) were elective. The service had 28 operating theatres and 279 surgical beds. During our inspection, we spoke with six patients and 44 staff, including nurses, doctors, service managers, healthcare assistants and therapists. We reviewed 14 sets of patient records relating to the surgical core service. We reviewed a variety of documents, including policies, training records, audits and performance data. Summary of this service Following improvements since the last inspection in record keeping, risk assessment, infection prevention and control, medicines management, theatre safety culture, leadership, Mental Capacity Act (2005) and Deprivation of Liberty Safeguards, our rating of this service improved. We rated it as good because: • The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. • The service provided mandatory training in key skills to all staff. Nursing staff received and kept up-to-date with their mandatory training. • 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. • 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 design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment and carried out daily safety checks of specialist equipment. • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration. • The service had enough 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 and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction. • Staff kept records of patients’ care and treatment. Records were clear, up-to-date, and available to all staff providing care. 33 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Surgery • The service used systems and processes to safely prescribe, administer, record and store medicines. Staff stored and managed medicines and prescribing documents in line with the provider’s policy. • The service used monitoring results well to improve safety. Staff collected safety information and shared it with staff, patients and visitors. • The service provided care and treatment based on national guidance and best practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983. • Staff gave patients practical support and advice to lead healthier lives. The service had relevant information promoting healthy lifestyles and support on the wards. Staff assessed each patient’s health when admitted and provided support for any individual needs to live a healthier lifestyle. • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Staff assessed patients’ pain using a recognised tool and gave pain relief in line with individual needs and best practice. Patients received pain relief soon after requesting it. • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. • The service made sure staff were competent for their roles. Managers appraised staff work performance and held supervision meetings with them to provide support and development. • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. • Key services were available seven days a week to support timely patient care. Staff could call for support from doctors and other disciplines, including mental health services and diagnostic tests, 24 hours a day, seven days a week. • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Patients said staff treated them well and with kindness. • Staff provided emotional support to patients, families and carers to minimise their distress. Staff gave patients and those close to them help, emotional support and advice when they needed it. They supported patients who became distressed. • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. The service actively involved patients’ relatives as partners in their care. • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers. • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. • People could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were generally in line with national averages. Managers and staff worked to make sure that they started discharge planning as early as possible. 34 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Surgery • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with staff. • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. • Leaders operated effective governance processes. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. It used a systematic approach to continually improve the quality of the service. Managers we spoke with at all levels understood the risks to the service and could describe action to reduce risks. • The service collected reliable data and analysed it to understand performance, make decisions and improvements. • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients. • Staff were committed to continually learning and improving services. Leaders encouraged innovation and participation in research. However: • Medical staff received, but did not always keep up-to-date, with their mandatory training. Medical staff met the trust target of 85% for five out of 14 mandatory training modules. • Although policies included version control information, some forms used by staff did not include version numbers or review dates. This meant staff might not know whether they were using the most up-to-date version of the document. • Staff did not always fully complete fluid balance charts. This meant it was difficult for colleagues reviewing the chart to see a patient’s fluid balance at a glance. • Staff appraisal rates for the reporting period June 2018 to May 2019 were 81%, which did not meet the trust target of 85%. • The service did not meet the trust’s 30-day target for responding to complaints. In the reporting period June 2018 to May 2019, the service took an average of 45.5 days to respond and close complaints. This was not in line with the trust’s complaints policy. Complaints responses we reviewed sometimes included clinical language without explanations in plain English, which might have been difficult for some complainants to understand. • There were no side rooms for isolation of infectious patients on the Surgical High Care Unit. Is the service safe? Good ––– Following improvements since the last inspection in record keeping, risk assessment, infection prevention and control and medicines management, our rating of safe improved. We rated it as good because: 35 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Surgery • The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored. • The service provided mandatory training in key skills to all staff. Nursing staff received and kept up-to-date with their mandatory training. Nursing staff met the trust target for 13 of the 14 mandatory training modules. The only module where nursing staff did not meet the trust target of 85% was adult basic life support, where the compliance rate was 81%. • 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. Staff knew how to identify patients at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff knew how to make a safeguarding referral and who to inform if they had concerns. • 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. Staff followed infection control principles including the use of personal protective equipment (PPE). Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. The service used systems to identify and prevent surgical site infections. • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment and carried out daily safety checks of specialist equipment. The service had enough suitable equipment to help them to safely care for patients. Staff managed clinical waste well. • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration. Staff used a nationally recognised tool to identify deteriorating patients and escalated correctly in line with national guidance. Staff completed risk assessments for each patient on admission (and pre-admission for elective surgery). They updated assessments when necessary and used recognised tools. This was an improvement from our previous inspection in April 2018, when staff did not always complete comprehensive risk assessments or develop risk management plans in line with national guidance. • The service had enough 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 and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction. • Staff kept records of patients’ care and treatment. Records were clear, up-to-date, and available to all staff providing care. • The service used systems and processes to safely prescribe, administer, record and store medicines. Staff stored and managed medicines and prescribing documents in line with the provider’s policy. • The service used monitoring results well to improve safety. Staff collected safety information and shared it with staff, patients and visitors. Safety thermometer data was displayed on wards for staff and patients to see. The safety thermometer data showed the service achieved harm free care within the reporting period. However: • Medical staff received, but did not always keep up-to-date, with their mandatory training. Medical staff met the trust target of 85% for five out of 14 mandatory training modules. • There were no side rooms for isolation of infectious patients on the Surgical High Care Unit. The service mitigated this risk by using screens designed to achieve isolation and control measures such as personal protective equipment and 36 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Surgery handwashing, deep cleaning, and closely working with the infection prevention and control team. However, the service cared for six patients with airborne infections on the Surgical High Care Unit in the year before our visit. This was not in line with their acceptance policy to only accept patients with non-airborne infections due to the lack of side rooms on the unit. Is the service effective? Good ––– Following improvements since the last inspection in Mental Capacity Act (2005) and Deprivation of Liberty Safeguards, our rating of effective improved. We rated it as good because: • The service provided care and treatment based on national guidance and best practice. Managers checked to make sure staff followed guidance. Staff protected the rights of patients’ subject to the Mental Health Act 1983. Staff followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance. • Staff gave patients practical support and advice to lead healthier lives. The wards had relevant information promoting healthy lifestyles and support. Staff assessed each patient’s health on admission and provided support for any individual needs to live a healthier lifestyle. The service’s multidisciplinary ‘surgery school’ initiative helped patients adopt healthier lifestyles before surgery. Feedback showed 90% of patients who attended, changed their lifestyles, and 100% said they would recommend it to other patients. • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other needs. Staff followed national guidelines to make sure patients fasting before surgery were not without food for long periods. • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Staff assessed patients’ pain using a recognised tool and gave pain relief in line with individual needs and best practice. Patients received pain relief soon after requesting it. • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. The service had been accredited under relevant clinical accreditation schemes, such as International Organisation for Standardisation (ISO) 13485 accreditation for sterile services. The service participated in relevant national clinical audits. Outcomes for patients were positive, consistent with results nationally, and mostly met expectations such as national standards. • The service made sure staff were competent for their roles. Managers appraised staff work performance and held supervision meetings with them to provide support and development. Managers gave all new staff a full induction tailored to their role before they started work. They made sure staff received any ongoing specialist training for their role. Managers supported staff to attend multidisciplinary simulation training for non-emergency as well as emergency scenarios led by actors at the trust’s dedicated simulation centre. • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Staff worked across health care disciplines and with other agencies when required to care for patients. • Key services were available seven days a week to support timely patient care. Staff could call for support from doctors and other disciplines, including mental health services and diagnostic tests, 24 hours a day, seven days a week. Where the trust did not have 24-hour services on site, such as MRI scanning, the service had a service-level agreement with neighbouring organisations to ensure patients received urgent imaging out-of-hours if needed. 37 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Surgery • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Health Act 1983 and the Mental Capacity Act 2005. However: • Although policies included version control information, some forms used by staff did not include version numbers of review dates. This created a risk staff might not know whether they were using the most up-to-date version of the document. • Staff did not always fully complete fluid balance charts. This meant it was difficult for colleagues reviewing the chart to see a patient’s fluid balance at a glance. • Staff appraisal rates for the reporting period June 2018 to May 2019 were 81%, which did not meet the trust target of 85%. Is the service caring? Good ––– Our rating of caring stayed the same. We rated it as good because: • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Patients said staff treated them well and with kindness. Staff understood and respected the individual needs of each patient and showed understanding and a non-judgmental attitude when caring for or discussing patients with mental health needs. • Staff provided emotional support to patients, families and carers to minimise their distress. Staff gave patients and those close to them help, emotional support and advice when they needed it. They supported patients who became distressed. Staff understood the emotional and social impact that a person’s care, treatment or condition had on their wellbeing. • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. The service actively involved patients’ relatives as partners in their care. The service had implemented the national #EndPJparalysis campaign and encouraged patients to wear daytime clothes rather than pyjamas to help them feel more like themselves. Is the service responsive? Good ––– Our rating of responsive stayed the same. We rated it as good because: • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers. • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. 38 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Surgery • People could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were generally in line with national averages. Managers and staff worked together to make sure that they started discharge planning as early as possible. They worked to make sure patients did not stay longer than they needed to. When patients had their operations cancelled at the last minute, managers made sure they were rearranged as soon as possible and within national targets and guidance. • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with staff. However: • The service did not meet the trust’s 30-day target for responding to complaints. In the period June 2018 to May 2019, the service took an average of 45.5 days to respond and close complaints. This was not in line with the trust’s complaints policy. Complaints responses we reviewed sometimes included clinical language without explanations in plain English, which might have been difficult for some complainants to understand. • The Surgical High Care Unit did not have patient toilet facilities. Staff escorted patients to the toilet on the adjacent ward or provided commodes for patients Is the service well-led? Good ––– Following improvements since the last inspection in leadership and safety culture in theatres, our rating of well-led improved. We rated it as good because: • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles. • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear. Safety culture and staff morale had improved in theatres since our last inspection following the appointment of two new managers. • Leaders operated effective governance processes. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. It used a systematic approach to continually improve the quality of the service. Managers we spoke with at all levels understood the risks to the service and could describe action to reduce risks. • The service collected reliable data and analysed it to understand performance, make decisions and improvements. • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients. • Staff were committed to continually learning and improving services. Leaders encouraged innovation and participation in research. The service had introduced innovations with robotic surgery and had also been shortlisted for a British Medical Journal award for an anaesthetic project. 39 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Surgery Outstanding practice We found areas of outstanding practice in this service: • We identified the service’s multidisciplinary ‘surgery school’ initiative, which helped patients adopt healthier lifestyles before surgery, as an area of outstanding practice. • We identified the trust’s multidisciplinary simulation for emergency and non-emergency clinical situations as an area of outstanding practice. The hospital’s simulation centre provided a dedicated training environment with scenariobased learning using actors from a variety of clinical settings. Areas for improvement We found areas for improvement in this service. See the Areas for Improvement section above Action the provider must take to improve: • The provider must ensure all patients with airborne infections are isolated effectively in side rooms to prevent the spread of infections. (Regulation 15(1) (c): Premises and Equipment) Action the provider should take to improve: • The provider should review the provision of patient toilet facilities on the Surgical High Care Unit. • The provider should take action to improve mandatory training compliance for medical staff. • The provider should consider adding version numbers and review dates to forms used by staff. • The provider should take action to meet the trust target of 85% for appraisals in all staff groups. • The provider should take action to improve the completion of patients’ fluid balance charts. • The provider should work to meet the trust’s 30-day target for responding to complaints. The service should consider describing medical or clinical terminology in plain English in complaints response letters to aid patient and relatives’ understanding. 40 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Maternity Requires improvement ––– Key facts and figures The maternity services at Queen Alexandra Hospital in Portsmouth is consultant led providing care and treatment for women with high risk pregnancy or medical complications. The trust also offers a home birth service. The Mary Rose unit also known as (B5) is a co located midwife led unit with two birthing pool offering maternity services to low risk women. The maternity services provide care and treatment to women living in Portsmouth and the surrounding areas. The maternity services include hospital and community settings ensuring that women receive care across the antenatal, labour and post-natal periods. The service comprises of the pre–natal diagnostic service such as foetal medicine, ante-natal screening facilities and the Ultrasound Sonography (USS) service. The trust has three standalone maternity centres as well as a co-located maternity centre at Queen Alexandra Hospital; • Blake maternity centre based at Gosport War Memorial Hospital • Grange maternity centre based in Petersfield Community Hospital • Portsmouth maternity centre based in St Mary’s Community health campus. • Ward B5 co-located maternity unit. The trust has a foetal medicine sub-specialty. From January 2018 to December 2018 there were 5,065 deliveries at the trust. Summary of this service We undertook an announced inspection of the maternity services between 15 and 17 October 2019. We last inspected Portsmouth Hospital NHS Foundation Trust maternity services in April 2018 as part of a joint maternity and gynaecology inspection. The purpose of this inspection was to see if maternity services performance had been maintained or if any improvements had been made by the service in the interim. We spoke with 13 patients, relatives and carers. We spoke with approximately 18 members of staff including midwives, managers, maternity support workers, doctors, reception and medical records staff, and healthcare assistants. We observed care in outpatient clinics and looked at 16 sets of patients’ records. We received comments from the staff and from patients and the public directly. We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated maternity as requires improvement because: We undertook an announced inspection of the maternity services between 15 and 17 October 2019. We last inspected Portsmouth Hospital NHS Foundation Trust maternity services in April 2018 as part of a joint maternity and gynaecology inspection. The purpose of this inspection was to see if maternity services performance had been maintained or if any improvements had been made by the service in the interim. 41 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Maternity We spoke with 13 patients, relatives and carers. We spoke with approximately 18 members of staff including midwives, managers, maternity support workers, doctors, reception and medical records staff, and healthcare assistants. We observed care in outpatient clinics and looked at 16 sets of patients’ records. We received comments from the staff and from patients and the public directly. We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated maternity as requires improvement because: • Women were not assessed in a timely way when they were referred to the maternity assessment unit. • Infection control practices for the birthing pool may pose safety risks to women and babies. • Emergency evacuation of women from the pool and the use of the hoist was not effectively managed. • There was a backlog of incidents which had not been reviewed in a timely way in order to mitigate risks. • The facilities in the bereavement suite was not homely and clinical in appearance which did not meet the needs of women and their families. • Although some women’s records were fully completed, there were some inconsistencies in the recording of assessments of women. • The maternity IT system did not support comprehensive recording and analysis of data. • There was a lack of oversight and monitoring of mandatory training for medical staff including safeguarding. • Women’s personal information was not managed effectively and could be viewed by visitors and other people in the unit. • The trust’s data submission to the maternity services dataset was inconsistent and they could not be assured that outcome data was used to effectively improve the service provision. • Although there were some plans to reduce risks these were not fully developed and embedded in practice. • There was no vision and strategy specific for maternity services and the trust had recognised this needed to be developed. However; • The maternity unit was well maintained, and the accommodation was spacious and well equipped to meet the needs of women. • Emergency equipment was checked regularly in line with the trust policy, well maintained and available to the staff. • Maternity services had a clearly defined accountability structure. The midwifery matron and community matron were accountable to the head of midwifery. • Medical staff and midwives received practical obstetric multi-professional (PROMPT) emergency training • There were a range of structured governance meetings to provide oversight of risks and quality assurance. • The maternity unit employed infant feeding specialists and provided breastfeeding clinics and drop-in sessions. • The trust had developed a multi birth facility which offered women one stop clinic and continuity in their care. • The trust had developed the role of midwives’ sonographers which impacted positively on care women were receiving. 42 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Maternity • Maternity staff understood how to protect women and babies from abuse and the service worked well with other agencies to do so. Midwives had completed training on how to recognise and report abuse, and they knew how to apply it. • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. • Doctors, midwives and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Is the service safe? Requires improvement ––– Our rating of safe stayed the same. We rated it as requires improvement because: • Infection control processes and practices for managing the birthing pool were not adequate and may put women at risk of infection. • There was a lack of understanding among the staff about the use of the appropriate equipment for the emergency retrieval of women from the pool. There was no evidence of regular drills and the trust could not be assured this would be carried out safely. • The triage process for women attending the maternity assessment unit was at times not managed safely and effectively and in line with the pathway. • There was no data available on mandatory and safeguarding training for medical staff. The trust could not be assured staff had the skills and competence to undertake their role. • The gestational recording for the trust was 77.5% incomplete compared to England average of 18%. • The process for reviewing incidents reported was not always effectively managed to minimise risks. However; • The service provided mandatory training in key skills to all maternity staff and made sure everyone completed it. Most midwives and nursing staff had completed the required mandatory training relevant to their role. • Maternity staff understood how to protect women and babies from abuse and the service worked well with other agencies to do so. Midwives had completed training on how to recognise and report abuse, and they knew how to apply it. • The service used systems and processes to safely prescribe, administer, record and store medicines. Staff regularly reviewed the effects of medications on each patient’s physical health. • The maternity unit was clean, well equipped and well maintained. • The emergency equipment was checked regularly and available to staff. Is the service effective? Good ––– Our rating of effective improved. We rated it as good because: 43 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Maternity • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. • Staff gave women enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. • Staff provided information and supported women to manage their pain. Women were assessed and received pain relief in a timely way. • Doctors, midwives and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. • The maternity service offered key services seven days a week to support timely care for women and babies. • The maternity service used their dashboard to monitor their performance. • Staff gave women practical support and advice to lead healthier lives such as healthy diets and weight management in pregnancy and offered breast feeding support. However; • The maternity service was not meeting its appraisal rates in line with the trust target for staff and to provide support and development. • There were areas of the maternity red, amber, green (RAG) traffic light dashboard that were not always meeting the trust’s key performance indicators (KPI). Is the service caring? Good ––– Our rating of caring stayed the same. We rated it as good because: • Staff treated women with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. • Staff provided emotional support to women, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs. • Staff supported and involved women, families and carers to understand their condition and make decisions about their care and treatment. • The perinatal team supported women in a compassionate way. Women were supported to make informed choices about available birth settings according to their needs and risks. Is the service responsive? Good ––– Our rating of responsive improved. We rated it as good because: 44 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Maternity • Staff assessed the physical and mental health of all patients on admission. They developed individual care plans. • Staff took complaints seriously and responded to women a sensitive way and offered an apology. Complaints were managed in line with trust policy. • Patients had access to information leaflets and staff could request translation services or interpreters for people with communication or language difficulties. • Staff liaised well with the community team ensuring women and babies continue to receive care and support in a consistent way. Is the service well-led? Requires improvement ––– Our rating of well-led stayed the same. We rated it as requires improvement because: • The service was working to improve its approach to audit, reporting and improvement to support good governance. • The trust had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. These were not fully integrated in practices such as sharing outcomes of investigations and lessons learnt. • The maternity IT system did not support comprehensive recording and analysis of data. Although some data was available, this had been recently developed. • There was a backlog of incidents needing reviews which may impact on care, as the trust could not be assured that these were investigated in a timely manner and actions taken to eliminate any risks. • There was no vision and strategy specific for maternity services and staff told us this needed to be developed. They were working with the acute trust vision and strategy. However; • Leaders had the integrity, skills and abilities to run the service. They were visible and approachable in the service for patients and staff. • Staff spoke positively of the changing culture and the inclusive leadership style of the head of midwifery. • Managers understood and managed the priorities and recognised areas that needed to be developed and had plans to achieve this. • The maternity service engaged well with women, staff the public and local organisations to plan and manage appropriate services and worked effectively with partner organisations. • The maternity service undertook work streams, working with other providers across Hampshire and Commissioners. • Midwives and support staff benefitted from an open culture where staff were encouraged to raise concerns and they worked well together. Outstanding practice • The trust had developed a multi birth facility which offered women one stop clinic and continuity in their care. 45 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Maternity • The trust had developed the role of midwives’ sonographers which impacted positively on care women were receiving. Areas for improvement Actions the provider must take • Ensure that women attending the maternity assessment unit have timely assessments and care to meet their needs.(Regulation 12) • Ensure care and treatment is provided in a safe way. Processes for the control of infection including cleaning must be developed to prevent and control the risks of infection. (Regulation 12) • Ensure staff have training in the use of the hoist for the birthing pool and emergency evacuation of women from the pool.(Regulation 12) • Ensure that incidents are reviewed in a timely way and risks are mitigated. (Regulation 12) Actions the provider SHOULD take to improve • Review the facility for women in the maternity assessment unit including adequate seating. • Women’s records should be maintained bound and filed securely to mitigate the risks of these being mislaid. • Develop system to capture mandatory training data for medical staff. • Develop an effective process for sharing information with staff including lessons learnt. • Review the facility in the bereavement suite. • Review the use of whiteboard and management of women’s personal information. • Develop a vison and strategy specific to maternity services. • Develop measures to collect and submit data in a timely way to monitor performances. 46 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Outpatients Good ––– Key facts and figures The trust provides outpatients services from its Queen Alexandra Hospital site and at local community hospitals. The specialties covered include cardiology, dermatology, endocrinology, gastroenterology, haematology, neurology, ophthalmology, oncology, oral surgery, plastic surgery, respiratory, rheumatology and urology. The trust provides a number of multidisciplinary ‘one stop’ clinics, where patients see a clinician along with other members of the multidisciplinary team(for example, allied health professionals). During our inspection a team of two inspectors visited the main outpatients area, rheumatology, urology, cardiology, ophthalmology, audiology, ENT, surgical outpatients, haematology and oncology, trauma and orthopaedics, plastic surgery, phlebotomy, and staff in the medical records team. We also spoke to staff from the booking centre. The departments were open between 8.30am to 5pm although some units remained open until 6pm. Services were available from Monday to Friday, with the emergency eye clinic open on a Saturday. We spoke with seven patients, relatives and carers. We spoke with approximately 40 members of staff including managers, nursing staff of all grades, doctors, therapists, reception and medical records staff, and healthcare assistants. We observed care in outpatient clinics and looked at four sets of patient records. We received comments from our staff and from patients and the public directly. In addition, we reviewed national data and performance information about the trust and read a range of policies, procedures and other documents relating to the operation of the outpatient department (OPD). Summary of this service Our rating of this service stayed the same. We rated it as good because: • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers. • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it. 47 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Outpatients • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services. However • Patients in some departments were waiting for lengthy periods before they were given a follow-up appointment. Is the service safe? Good ––– Our rating of this service stayed the same. We rated it as good because: • The service provided mandatory training in key skills to all staff and made sure everyone completed it. • 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. • 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 design, maintenance and use of most facilities, premises and equipment kept people safe. Staff were trained to use equipment. Staff managed clinical waste well. • Staff identified and quickly acted upon patients at risk of deterioration. Some departments had developed guidance for patients on when and how to seek help with symptom control. • The service had 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 and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction. • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care. • The service used systems and processes to safely prescribe, administer, record and store medicines. • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses within the clinical area. Managers investigated incidents and shared lessons learned with the team. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored. However • Compliance in mandatory training for medical staff was below trust target of 85% in seven of the 13 modules required. • Premises in the eye clinic and emergency eye clinic were cramped. Staff had to triage patients in the same room as staff taking telephone calls. Curtains were in use in some rooms and did not provide privacy for conversations. The waiting area in eye clinic was full at times with patients standing. • Some accessible toilets required painting and refurbishment. 48 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Outpatients • Resuscitation trolleys were not tamper proof although they were in line with the trust policy. • PGDs had been completed but the version date on the paperwork for three medicines had expired in June 2019. • Staff in outpatients, where invasive procedures took place, were not able to describe a LocSSIP and its use in their department. Is the service effective? We do not rate effective but found the following areas of good practice: • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. • Staff made sure patients had access to food and drink while waiting in clinics. • Staff accessed pain relief within outpatient clinics in line with individual needs. • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. Services had been accredited under several accreditation schemes. • The service made sure staff were competent for their roles. They held supervision meetings with them to provide support and development. • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. • Some services were available six days a week to support timely patient care. • Staff gave patients practical support and advice to lead healthier lives. • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. However • Some departments did not have regular team meetings and there was no consistent approach to sharing information across teams. • Managers had a system to appraise staff’s work performance however, not all staff had a recent appraisal recorded. Is the service caring? Good ––– Our rating of this service stayed the same. We rated it as good because: • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs. Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. 49 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Outpatients Is the service responsive? Good ––– Our rating of this service stayed the same. We rated it as good because: • The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers. • People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to treat and discharge patients were in line with national standards for most speciality clinics. • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint. However • There was no consistent approach to providing patients with accessible information in the form of appointment letters in large print. • Check in processes were different in some clinics. Patients reported that they were not always able to find clinics easily. • Patients were still waiting extended periods for follow-up appointments in some clinics for example audiology. Is the service well-led? Good ––– Our rating of this service improved. We rated it as good because: • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles. • The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress. • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work, and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear. • Leaders operated effective governance processes, throughout the service and with partner organisations. Most staff at each level were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. 50 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Outpatients • Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. • The service collected reliable data and analysed it to understand performance, make decisions and improvements. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care. • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients. • All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research. However • Staff told us that the recent change in divisional structures meant they did not yet recognise the leadership team. • Staff were not clear on the overarching divisional strategy for outpatients. • There was no consistent approach to audits in the outpatient departments, with each department auditing different things and using their own paperwork. • Staff felt that the impact of staff shortages on team morale was not always recognised by consultants and managers. Outstanding practice We found examples of outstanding practice in this service. • We identified the rheumatology service’s helpline initiative, which supported anxious patients as an area of outstanding practice. We were told that the success of this service meant that the trust was planning to fund a clinical psychologist to support the most anxious callers. • We identified the surgical and ear, nose and throat outpatients service’s use of coloured cards to make it easier for patients to identify clinic rooms as an area of outstanding practice. • We identified the development of a ‘meet and greet’ staff member in the blood testing department to improve the flow and experience of patients to be an area of outstanding practice. Areas for improvement We found areas for improvement in this service. • The service should take action to improve mandatory training compliance for medical staff. • The service should take action so all departments meet the trust risk assessment for the storage of cleaning solutions in locked cupboards. • The service should consider a routine inspection and audit for cleaning and replacing cubicle curtains in all departments. • The service should take action to meet the trust target of 90% for appraisals in all staff groups. • The service should take action to service and correctly label all medical equipment in use in the outpatient departments . • The service should take action to develop the understanding and use of LOCSSIPS throughout the departments that may use them. 51 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Outpatients • The service should take action to meet the Accessible Information Standards in a consistent manner across all outpatient departments. 52 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published This section is primarily information for the provider Requirement notices Action we have told the provider to take The table below shows the legal requirements that the service provider was not meeting. The provider must send CQC a report that says what action it is going to take to meet these requirements. For more information on things the provider must improve, see the Areas for improvement section above. Please note: Regulatory action relating to primary medical services and adult social care services we inspected appears in the separate reports on individual services (available on our website www.cqc.org.uk) This guidance (see goo.gl/Y1dLhz) describes how providers and managers can meet the regulations. These include the fundamental standards – the standards below which care must never fall. Regulated activity Surgical procedures Treatment of disease, disorder or injury Regulated activity Treatment of disease, disorder or injury Regulated activity Treatment of disease, disorder or injury Regulated activity Maternity and midwifery services Treatment of disease, disorder or injury Regulation Regulation 15 HSCA (RA) Regulations 2014 Premises and equipment Regulation Regulation 17 HSCA (RA) Regulations 2014 Good governance Regulation Regulation 18 HSCA (RA) Regulations 2014 Staffing Regulation Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment 53 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published Our inspection team Catherine Campbell, Head of Hospitals South East, led the inspection. The team included three inspection managers, one medicines manager, eleven inspectors including specialist mental health and medicines inspectors, eleven specialist advisers, one assistant inspector, one analyst and one inspection planner. Specialist advisers are experts in their field who we do not directly employ. 54 Portsmouth Hospitals NHS Trust Inspection report This is auto-populated when the report is published