The Care Quality Commission
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Queen Victoria Hospital NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings

All Inspections

29 Jan to 27 Feb

During a routine inspection

We did not inspect all core services during this inspection, we inspected surgery (burns and plastics), outpatients and critical care. Overall, we rated the trust as good for safe, effective, responsive, well-led and outstanding in caring. All three core services we inspected were rated as good overall.

We rated safe, effective, responsive and well-led as good, and caring as outstanding. We rated all three of services as good. In rating the trust, we took into account the current ratings of the two services not inspected this time.

We rated the trust overall as good.

  • The trust had responded to concerns raised in our last inspection in critical care and improvements had been made. These included, for example, dedicated medical cover out of hours.
  • 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 kept themselves, equipment and the premises visibly clean. They used control measures to prevent the spread of infection.
  • The service followed best practice when prescribing, administering, recording and storing medicines. Patients received the right medication at the right dose at the right time.
  • 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. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the 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 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 preferences.
  • There was a strong, visible person-centred culture and the service truly respected and valued patients as individuals. Staff were highly motivated and inspired to offer care that was exceptionally kind and promoted people’s dignity.
  • Feedback from patients, those close to them and stakeholders was continually positive about the way staff treated people. The trust performed ‘much better than expected’ compared with other trusts in CQC’s 2017 Adult Inpatient Survey. NHS Friends and Family Test data displayed on the wards showed almost all patients would recommend the service to family and friends. There were consistently high recommendation rates, which reached 100% in nine out of 12 months in 2018 on the Burns Unit, and eight out of 12 months on Margaret Duncombe Ward.
  • Staff saw patients emotional and social needs as being as important as their physical needs. Staff provided emotional support to patients and those close to them to minimise their distress and help them in their recovery from traumatic events or major surgery.
  • Patient safety and the patient experience were the focus of the trust’s strategy and service delivery.
  • Staff were fully committed to working in partnership with people and making this a reality for each patient. The service always reflected patients’ individual preferences and needs in the delivery of care.
  • Advice and guidance for non-urgent GPs referrals were in place, this allowed GPs access to consultant advice prior to referring patients into specialist clinics.
  • Safety huddles were held every morning in each outpatient department. All staff working in the outpatient clinics met at the same time every day to discuss current safety issues relating to the premises, patient care and other relevant issues that could impact on patient safety.
  • The trust’s leadership team had the skills, knowledge, experience and integrity that they needed to lead the trust. Executives were given the support they needed. Where an individual board member was lacking in experience, they were supported to gain relevant expertise.
  • The trust’s existing strategy and projected ‘strategic direction’ were aligned to local plans in the wider health and social care economy and were planned to meet the needs of the relevant population. The trust worked closely with other trusts, clinical commissioning groups and sustainability and transformation partnerships to identify and meet regional patient’s needs.
  • The trust monitored their progress against delivery of the strategy and local plans. The strategic objectives, were outlined in the unique and exemplar Board Assurance Framework (BAF). The trusts BAF brought together the strategic objectives and used them to evaluate board work and risk. This ensured objectives were reviewed and acted against, in terms of current risks and long-term strategy.
  • The different levels of governance and management functioned effectively to provide assurance. The board had a structure of committees which were chaired by non-executive members and reported directly to the board. Each committee reviewed evidence to gain information and assurances and escalated to the board in line with their terms of reference.
  • The trust had arrangements for identifying, recording and managing risks, issues and had identified actions to reduce the impact of them. The trust used a risk register system to manage risks of all levels. Core service level risks were held on a departmental risk register. Risks that were strategic or affected multiple core services were held on the trust risk register. The board reviewed and managed the trust risk register.
  • The trust had positive and collaborative relationships with external partners. It worked closely with other trusts in the region, clinical commissioning groups and the regional sustainability and transformation partnership to build a shared understanding of systemic challenges and identify and meet patient’s needs.
  • The two highest rated risks on the risk register were both rated 20. One was referral to treatment time delivery and performance and one was financial performance.
  • The trust had a referral to treatment time recovery action plan to eliminate 52 week waits across the three affected areas of the trust, and reach performance compliance by September 2019. The trust was on trajectory to meet this target.
  • The trust was beginning its journey to address financial performance. The board recognised that system-wide working and collaboration could be key to its financial sustainability and that they needed to utilise support within the system and determine their position and the corresponding financial strategy aligning to this.
  • The trust used secure electronic systems with security safeguards. It had a clear technology infrastructure plan for the hospital hub (main) site and had implemented current cyber security systems.
  • The trust had a focus on learning. They supported research internally and as part of external research projects. Learning from and participation in internal and external reviews was used to lead improvement and innovation. The trust was able to identify numerous research-based initiatives it had adopted over the past 12 months to improve patient care.

However:

  • Mandatory training rates including safeguarding and Mental Capacity Act 2005 modules for all staff groups did not always meet the trust target of 95%. However, at the time of inspection compliance had improved. For example, the critical care unit had an aggregated compliance rate of 90%.
  • The service’s admissions policy for surgical and critical care patients relied heavily on the individual judgement of the on-call consultant as to whether a patient met the criteria for admission to the hospital. For example, there was no specific criteria for burns patients around the total body surface area affected by the burns. There were also no specific criteria for significant co-morbidities. However, the service had service-level agreements with a nearby large NHS acute teaching hospital trust for the provision of services such as general surgeons and geriatricians (specialist elderly medicine consultants) to support patients with existing co-morbidities.
  • There were high numbers of registered nurse vacancies predominantly in theatres and critical care and heavy reliance on temporary staff. However, the trust had systems and processes to mitigate the risk, for example, a limit to how many agency staff could be allocated to each theatre. These services used regular agency staff to provide consistency and continuity.
  • Nursing agency usage was higher than was recommended for a critical care unit. The Guidelines for the Provision of Intensive Care Services, 2015 recommended level was a maximum of 20% agency staff usage. There was a departmental policy of not having more than 50% agency on any one shift. This was an improvement which had been discussed and approved by senior clinical leads and the managers within the trust. Senior staff explained that due to the number of nurses, this would mean not more than two agency nurses per shift.
  • The critical care unit was not fully meeting the Guidelines for the Provision of Intensive Care Services 2015 but there had been an improvement since the last inspection. At the time of our last inspection critical care had no intensive care consultants but now had intensive care consultant cover Monday to Friday. However, the unit still lacked this cover out of hours and at weekends.
  • The trust had struggled to meet both the 18-week referral to treatment and cancer targets. Five specialties were below the England average for non-admitted pathways for referral to treatment times. The trust was acting to address this and was on a trajectory to meet the targets by April 2020.
  • The trust was not meeting its targets for cancellations of outpatient appointments in the seven days prior to the appointment. These rates varied within the reporting period, but neither the plastic surgery department, sleep disorder unit and ophthalmology met their target during the reporting period. On the day cancellations by the hospital had stayed the same for a period but also failed to reach their target.
  • The hospital did not meet the British Burn Association National Burn Care Standards. This was because, as a specialist trust, the hospital did not provide the usual range of hospital services such as general surgery, mental health liaison and paediatric medicine. To reduce these risks, the trust had service level agreements with a nearby acute NHS trust to provide these services in a timely way, 24 hours a day, seven days a week.
  • The trust was not expected to meet its financial plan in this year and the trust was projected to have a deficit of £5.9 million in 2018 to 2019. The trust was not used to operating within such a financially challenging environment. They were in the process of developing systems to manage the trust under these pressures.

November 11th and 12th 2015 unannounced 23rd November 2015

During a routine inspection

The Queen Victoria Hospital NHS Foundation Trust provides a specialist burns and plastic surgery service to both adults and children. The trust provides emergency, trauma and elective reconstructive surgery and rehabilitation for people who have been damaged or disfigured through accident or disease. Patients are admitted from the south east of England including south east London. The trust also provides ‘hub and spoke’ specialist services at other hospitals in the south east of England, bringing QVH staff with specialist skills to remote hospital locations.

Additionally the hospital provides a minor injuries unit and services for the treatment of common conditions of the hands, eyes, skin and teeth for people living in and around East Grinstead, as well as out patient and therapy services’

There are two surgical wards with 47 beds where trauma and plastics patients are cared for together with a dedicated burns unit with 12 beds. The hospital has 10 operating theatres with associated areas for anaesthetics and recovery within the main theatre suite. Two further theatres are used for plastic surgery (Rowntree; day care 1 and 2). There is also one theatre attached to the burns unit where patients who arrived by ambulance are assessed and treated before being transferred either to the burns unit or to critical care.

There are 9 beds on Peanut Ward for the care of Children and Young people.

The Hospital was inspected as part of our Comprehensive Inspection programme for the NHS Trusts in England. It was inspected on the 11th and 12th November 2015, with an unannounced visit on 23rd November 2015.

Our key findings were as follows:

Safe

There were effective and robust systems and protocols in place to protect patients from harm, and staff contributed to an incident-reporting culture. There were opportunities for learning from results of investigations.

A culture of openness was found in the Hospital. We found examples where the organisation had carried out its Duty of Candour and generally staff we talked to were aware of the requirements.

The Hospital was clean, and the environment was found to be conducive to safe care although some areas, required some redecoration and minor maintenance.

Medicines management was good. Regular medicines audits took place. Controlled drugs were regularly checked with entries double signed. The pharmacy staff worked closely with colleagues in the trust to ensure best practice in prescribing was undertaken.

We found nurse staff levels to be appropriate and safe to provide the care given.

However there is a lack of resident medical cover out of hours after 22:00hrs when there is only 2 doctors on duty, this could lead to patients having to wait for urgent care the doctor is attending to someone else, however there is consultants in all specialities on call. 

Effective

Throughout our inspection we observed patient care carried out in accordance with national guidelines and best practice recommendations.

However the trust did not meet national guidance on managing burns patients as the hospital did not have the on-site facilities that a large district general hospital would provide; such as specialist renal, haematology and intensive care facilities. Substantial work had been undertaken to ensure that the hospital was able to care safely for the patients that were admitted.

Consultants and nursing staff from a range of specialties were engaged in the development of national and international treatment guidelines for burns and plastics, as well as engaging in international research programmes.

We found that food was available to patients as required and people were able to access drinking water in all areas. There were 3 refreshment areas where visitors could get food and hot drinks.

Staff caring for patients had undertaken training relevant to their roles and completed competence assessments to ensure safe and effective patient outcomes. Staff received an annual performance review and had opportunities to discuss and identify learning and development needs through this.

Caring

Throughout the hospital and in all specialties we saw examples of compassionate and considerate care being delivered.

Patients were treated with respect and dignity and all the patients and their families who we spoke with, both before and during the inspection told us that they were treated with dignity and respect and had their care needs met by caring and compassionate staff. This positive feedback was reflected in the Family and Friends feedback and patient survey results, where the hospital consistently achieved scores of over 95%.

Parents felt involved in the care of their child and participated in the decisions regarding their child’s treatment, and that staff were aware of the need for emotional support to help children and families cope with their care and treatment.

Responsive

Services for local people were responsive to their needs and offered a minor injuries unit, out patient services as well as access to therapies.

The specialist services undertaken by the trust were responsive because the needs of patients throughout the south east of England, the local people, commissioners and stakeholders were taken into consideration when planning services. The trust operated a ‘Hub and spoke’ system so that patients who lived a great distance from the trust could benefit from the QVH staffs skills and experience.

Interpreting services were available for people whose first language was not English and we saw patients with a learning disability or living with dementia were well supported.

Complaints were acknowledged, investigated and responded to. Information was shared to promote learning and prevent reoccurrence

Well led

At the inspection we spoke with positive and loyal teams, many of whom at worked at QVH for a considerable time. Staff told us that they felt valued and felt able to deliver individual and compassionate care to people using their services. Staff described an open culture, where they were encouraged to report incidents, concerns and complaints to their manager. Staff we spoke with told us they felt able to raise concerns and felt that the organisation was transparent with a “non judgemental, no blame” culture.

Most staff we spoke to could describe the Hospitals vision and strategies, and had been consulted on the future of services at the QVH.

The Trust is currently developing a strategy for the future of the services provided by the QVH, particularly the sustainability of providing acute burns care.

Additionally there is consideration being given to developing more services for local people, including more primary and community care.

Clinical governance structures were stronger in some areas than others. For example in burns and plastics there was a robust structure, records of meetings and risk register which was current and regularly reviewed. In MIU the structure appeared less clear and risk issues were discussed in routine team meetings and the risk register did not capture known risks.

Leaders in the organisation were available to staff and had a high profile across the hospital and staff gave examples of senior staff attending, wards and departments and taking part meetings.

We saw several areas of outstanding practice including:

  • Staff were taking exceptional steps to improve the hospital experience for patients living with dementia. Allowing extra time during assessment, facilitation families in supporting the patient, awareness of the environment and equipment in relation to vulnerable patients and the use of distraction accessories such as ‘twiddle muffs’ demonstrated that the needs of vulnerable patients were taken into consideration and steps taken to personalise their care and treatment.
  • The burns outreach nurse post was an innovative solution to the problems of dealing with burns in the community. Patients were able to be discharged quicker with continuity of care and treatment.
  • The hospital’s audit office undertook the task of monitoring and auditing the quality of care and treatment across the trust. The staff demonstrated passion and enthusiasm for improving patient experience through the use of data and audit.
  • The trust developed and actively uses a Telemedicine Referral Image Portal System which has been developed in collaboration with the London and South East of England Burns Network. Telemedicine is the use of telecommunication and information technologies in order to provide clinical health care at a distance. Telemedicine was chosen as the SE Coast Regional Winner in the 2008 Health & Social Care Awards in the category of “Innovative Information & Communications Technology” and went on to be a runner up at the National awards. This Innovative use of telemedicine allows trained staff to view a burn injury at a distance either in another hospital or via ambulance staff photos and give appropriate advice, assessment and advise transfer to most appropriate location.
  • Staff within the paediatric service had been instrumental in developing unique aftercare opportunities for patients. One such initiative was called the CREW camp. This stands for challenging, recreational, educational weekend for burns patients which is funded by local businesses and provides educational activity weekends for up to 30 ex patients. A committee of eight staff have been established to run the event which selects nominated children who they consider would get the most benefit from the activities
  • The prosthetics department was cutting edge and provided a patient focussed individualised service. Clinicians worked with patients to ensure the best outcomes were achieved. Staff were enthusiastic, dedicated and were committed to continual professional development publishing regularly in professional journals. This meant that patients received the most up to date advancements in prosthetic development.
  • The patient pathway for head and neck patients was comprehensive. Patients attended a pre-assessment appointment, were allocated a named nurse and visited other departments in the hospital that would be part of the treatment intervention. There was a separate waiting area in outpatients so that patients had privacy whilst waiting to be and seen and a psychology service was available to support the emotional needs of patients coming to terms with life changing body image issues.

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

Importantly, the trust must:

  • The provider must ensure that all medication in theatre is stored appropriately.
  • The provider must ensure that medical cover out of hours is sufficient to meet the needs of patients.

In addition the trust should:

  • Ensure that all COSHH (Control of substances hazardous to health) products should be stored appropriately
  • Continue to review how it benchmarks itself against national quality standards
  • Review how patients pain is managed specifically when carrying out dressing changes.
  • Continue its review of governance arrangements so that critical care has its own individual agenda
  • Ensure that departmental risks are identified, recorded and regularly reviewed.
  • Ensure there are mechanisms in place for staff and patients to raise an alert in an emergency situation in the therapies department.
  • Ensure all incidents are reported in a timely manner in therapies and critical care.
  • The trust should ensure the décor is refreshed and updated in outpatient department 1
  • Ensure there are adequate facilities for patients attending the hand therapy clinic and that privacy is maintained
  • Ensure that staff in MIU have attended all mandatory training.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.