Princess Royal University Hospital Also known as Farnborough Hospital

Updated 23 December 2022

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

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

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

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

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

During our inspection we found:

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

However:

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

How we carried out the inspection

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

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

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

Updated 31 January 2018

• There was a shortage of permanent employed staff throughout the service; nursing and medical.

• Ward staff were not aware of the need for more frequent observations on patients who had been given rapid tranquillisation.

Updated 30 September 2015

There had been significant progress in how the trust delivered services to neonates, children and young people since our last inspection. Some improvements were still required to ensure that nursing levels were aligned to national standards and  that all staff complied with trust-wide policies regarding infection prevention and control practices including the screening of patients for MRSA.

The majority of care and treatment was provided in line with evidence based practice but some improvements were required in areas such as the management of children presenting with asthma. Clinical outcomes for children with diabetes was better than the national average in a number of areas.

Staff had fully embraced the concept of family centred care. All members of the family played pivotal roles in the care and treatment of neonates and children. Children and parents spoke positively about the care they received.

Access into children’s services was generally good. There had been a reduction in the number of surgical cases being cancelled and children and young people who presented to the hospital requiring surgical intervention were appropriately managed in a safe and effective way.

Local leadership at ward level was considered to be good. Staff were complimentary about their direct ward leaders who were seen to be working at ward level, supporting staff.

The service had a specific child health strategy that was aligned with the trust-wide strategy. The strategy was driven by quality and safety, and took into account the requirement for the service to be fiscally responsible.

Governance arrangements were in place for which a range of healthcare professionals assumed ownership. There was evidence that risks were managed and escalated accordingly. However, there were a small number of examples where risks that might have an impact on the clinical effectiveness of the service were not recorded on the divisional risk register.

Since our previous inspection in December 2013, the service had introduced a quality measurement scorecard; however, there was a lack of information for some metrics, which meant that the scorecard was not being used to its optimum.

Updated 31 January 2018

Our rating of this service improved. We rated it as good because:

• Following our inspection in 2015, there had been improvements to the critical care unit. The trust had approved a business plan to expand the unit. Patient records were now comprehensive, with all appropriate risk assessments completed. Medicines were generally stored safely and securely. The unit had purchased new equipment and mitigating plans were in place to alleviate the lack of technical support on site. A larger visitor’s room had been created in the CCU following feedback from patients. The room was spacious and relatives had access to a toilet close to the visitor’s room.

• There were effective systems in place to protect patients from harm and a good incident reporting culture. The iMobile (critical care outreach) team provided rapid response and stabilisation to patients who needed immediate attention and transfer.

• Patients received effective, evidence-based care and patient mortality outcomes were within the expected range.

• Appropriately qualified staff cared for patients. The percentage of nursing staff with post registration qualification was higher than recommended guidelines.

• Patient feedback for the services inspected were mostly positive. Staff respected confidentiality, dignity and privacy of patients. Patients were engaged through surveys and feedback forms and the response showed high satisfaction with the service.

• Services were developed to meet the needs of patients. Feedback from patients were taken into consideration in creating a more spacious visitor’s room.

• There was good local leadership on the CCU. Staff felt valued, were supported in their roles and had opportunities for learning and development. Staff were positive about working on the critical care unit.

However:

• The unit was very busy and occupancy on the critical care unit consistently ran above 100%.

• Out of hours, medical staffing was stretched and did not comply with recommended guidelines.

• Therapy staffing levels were below the recommended guidelines.

Updated 12 June 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

• The service did not always provide care and treatment based on national guidance or evidence its effectiveness.
• Staff did not always complete and update risk assessments for each patient or have an action plan to address any identified risk. We found little evidence of individualised planning or regular review of the dying patient in place.
• The end of life care plan was not integrated into the electronic patient record and we were not assured there was an identified date by which this would be available.
• There was incomplete documentation of discussions with relatives when recoding ‘do not attempt cardio pulmonary resuscitation’ status on patient treatment escalation plans (TEP).
• There was no on-site consultant presence at weekends.
• It was not always clear whether all patients were offered the opportunity to meet with a member of the chaplaincy.

However:

• There was an improved palliative care clinical nurse specialist seven-day service introduced in April 2018. Referrals to the SPCT were responded to in a timely manner with 91% of referrals seen within one day of referral and 98% within three days.
• The specialist palliative care team (SPCT) now included a palliative care social worker who provided emotional support for patients and their families.
• There was improved weekday on-site provision of palliative care medical staff with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment.
• Patients and their family members told us staff treated them with dignity, respect and compassion. They said staff explained what was happening and were caring. There were no visiting time restrictions for family and friends in the last days or hours of a person’s life.
• End of life care had a clear governance framework. This ensured responsibilities for end of life care went right up to trust board level. End of life priorities had been identified and there was an action plan for the service based on these priorities.

Updated 23 December 2022

Updated 12 June 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated outpatients as requires improvement because:

• The service did not take steps to ensure all staff completed the required mandatory training. Compliance rates for required safety related training amongst medical staff was poor.

• The service did not always have suitable premises or equipment and did not always look after them well.

• Patient’s privacy and dignity was not always maintained due to the environments staff were working in, although staff tried their best to maintain standards where possible.

• Outpatient services showed generally poor performance in referral to treatment (RTT) and cancer waiting times. The trust was performing worse than the England average and national standard for both the RTT incomplete pathway, where patients should be seen within 18 weeks, and for urgent cancer referrals, where patients should be seen within two weeks. This meant the service was not always responsive and could not always meet patient urgent clinical needs in a timely manner.

• Services did not always provide the right information to service users prior to their appointments. Incorrect telephone numbers were often printed on appointment letters.

• Morale amongst administrative staff across most services was low.

• Not all risks on the risk register for OPD had not been reviewed recently, and it was not clear if all risks were being addressed.

• There were some additional plans for the long-term future of the OPD, but these were not an immediate priority due to the current challenges faced by the department. Plans did not always have clear timescales, and staff could not give examples of being involved in such plans.

However:

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.

• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.

• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

• Services were delivered and co-ordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances.

• The trust used a mostly systematic approach to continually improving the quality of its service, with clear escalation and reporting structures.

Updated 12 June 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

• There had been no improvements in mandatory training completion rates for medical staff since our last inspection. The 80% target was not met for any of the 22 mandatory training modules for which medical staff were eligible.

• Safeguarding training completion rates for medical staff were below the trust target with completion rates as low as 12% for level 3 safeguarding children training.

• The endoscopy unit was not suitable and there were insufficient procedure rooms to meet the demands for the service. Endoscopy decontamination took place in theatres due to space constraints. Decontamination of endoscopes was carried out in a room used for both clean and dirty equipment.

• Plans to improve endoscopy services had not been implemented since our last inspection.

• Medicine audit results showed the service performed below trust standards for a number of indicators.

• Vacancy rates for medical staff were worse than the trust’s target.

• Staff felt there was a disparity in the way resources were allocated across trust sites.

• The trust did not always provide services in a way that met the needs of local people. There was a significant number of medical outliers in surgical wards. Mixed specialities were admitted on surgical wards due to bed pressures.

• Waiting times from referral to treatment were not always in line with good practice.

However:

• Nurse staffing had improved since our last inspection. The service had enough nursing staff with the right mix of qualifications and skills, to keep patients safe and provide the right care and treatment.

• Staff kept records of patients’ care and treatment. Staff completed risk assessments and followed escalation protocols for deteriorating patients.

• There were effective systems to protect people from avoidable harm. Learning from incidents were discussed in departmental and governance meetings and action was taken to follow up on the results of investigations.

• Staff provided evidence-based care and treatment in line with national guidelines and local policies. There was a program of local audits to improve patient care.

• The service made sure staff were competent for their roles. Managers appraised staff’s work performance.

• Staff were aware of their responsibilities under the mental capacity act.

• There was effective multidisciplinary working, including liaison with community teams, to facilitate timely discharge planning.

• Feedback for the services inspected were positive. Staff respected confidentiality, dignity and privacy of patients.

• There was good local leadership on surgical units. Staff felt valued and they were supported in their role. There was a good governance structure, both within surgical care and within the directorate.

Updated 11 August 2021