A team of 56 inspectors descended on Queen Alexandra Hospital, in Cosham, to check services and care over a four-day period. The Care Quality Commission report has been published today and shows how the hospital did against five inspection categories.
Health reporter PRIYA MISTRY goes through the report and speaks to Peter Mellor, director of corporate affairs and business development at the hospital, to find out what it means for patients.
What is working at QA
THE inspection report highlighted exemplary care and innovative ideas at QA.
- A coffee and conversation group held for patients in the stroke wards. This gave patients an opportunity to share experiences, and provide peer support and education.
- In the intensive care unit, innovative electronic recording systems supported the effective assessment and monitoring of patients.
- The clever use of grab packs meant staff had instant guidance about what to do in the event of utility failure, emergency telephone breakdown and major incidents.
- A maternity phone app provides information on the choices of places to give birth and was being improved to include additional information.
- The trust had introduced a volunteer programme for people who wanted to work as a chaplain’s assistant.
Volunteers are also being trained to support patients.
What needs improvement
THE report also picked out actions that must be taken immediately by the hospital trust.
- Patients should be appropriately assessed and monitored in A&E to ensure they receive appropriate care and treatment.
- Ambulance patients must be received and triaged in A&E by a qualified healthcare professional.
- There has to be an adequate supply of basic equipment and timely provision of pressure-relieving mattresses.
- The cardiac arrest call bell system in E level theatres must be able to identify the location of the emergency.
- Medication must be prescribed appropriately in surgery and be administered as prescribed in gynaecology.
- Appropriate standards of care must be maintained on ward E3 and the acute medical unit.
- Nurse staffing levels must comply with safer staffing levels guidance.
- There ought to be enough medical staff at all times.
Is the trust well led?
THE trust received a ‘requires improvement’ in this category.
The A&E and surgery departments were rated as ‘requires improvement’, while medical care, maternity and gynaecology, children and young people, end-of-life care and outpatients all got a rating of ‘good’.
Critical care shone with an ‘outstanding’ ranking.
The report noted plus points, and said: ‘Staff were positive about working for the trust and the quality of care they provided.
‘The trust was similar to other trusts for staff engagement, but its staff survey had demonstrated year-on-year improvement.
‘The trust Listening into Action programme had demonstrated changes and improvements to services based on staff innovations.
‘The staff had a strong sense of identify that was focused on care.’
Mr Mellor says: ‘It’s great to hear staff enjoy working for the trust and that this was reflected in the report.
‘We encourage all staff to talk to us about both the good and the bad, and we’re pleased to see this has been picked up on.’
Some of the criticisms given in this inspection category centred around ongoing problems in A&E.
The report says that during the visit inspectors: ‘Served two warning notices for the trust’s failure to respond to patient safety issues, and the failure to effectively assess and manage the risks to patients in the emergency department.’
Mr Mellor said: ‘During the inspection it was noted that in the evening and into the night, there was not enough consultant cover in the emergency department.
‘The majors [area] department in A&E was moved into a bigger space, but it meant it was moved away from the resuscitation room.
‘This means in the night if a consultant is needed in the resuscitation area, they will have to walk all the way around from majors, and that meant there was no senior member there.
‘However we rectified that immediately and have added another consultant on to the rota to avoid that.
‘The other warning was to do with the skill-mix of nurses in the emergency department.
‘We did not have as many top-qualified nurses there to access needs, however we have now added to this team as well.’
Are services safe?
THIS category received an overall rating of requires improvement.
It’s in this category where the hospital trust was given its only rating of inadequate and this was for A&E.
The medical care, surgery and end-of-life departments were all assessed as ‘requires improvement’.
Maternity and gynaecology, children and young people and outpatients all came out as ‘good’.
And critical care was the sole department to get an ‘outstanding’.
Positives in the report include: ‘The wards were visibly clean, and infection control practices were followed.
‘The trust infection rates for MRSA and clostridium difficile were within an expected range and the trust had not had a norovirus outbreak for five years.’
Mr Mellor says: ‘That’s quite remarkable and really good.
‘It’s unusual to perform so well on that when we hear about so many other hospitals struggling to keep such cases down.
‘To have such a great record on this is unusual for the NHS as a whole.’
Negative aspects picked up in the report include:
- Patients were sometimes assessed according to the time that they arrived in A&E and not according to clinical need, with some patients waiting more than an hour to be seen.
- Many patients waited in corridors and in temporary bay areas. Patients in these areas and in the majors queue area were not adequately observed or monitored.
- The environment in A&E did not enhance patient safety. A&E had been extended and its majors treatment area and children’s treatment area
were now a considerable distance from the resuscitation room.
Mr Mellor adds: ‘We do need to re-think the layout of the A&E department, but of course that would be a big project financially and would also need to be so the service could still run.
‘In hindsight when we designed the new hospital we should have included A&E in that.
‘But at the time it was working well and it didn’t see as many people as it does now, that’s something we must deal with now.
‘If the pressure continues as it is now then this is something we will definitely need to address.’
Are services effective?
THIS inspection category was given an overall rating of ‘good’.
The A&E, medical care, surgery, maternity and gynaecology and children and young people departments were all said to be ‘good’.
End-of-life care was rated as ‘requires improvement’ and critical care was deemed ‘outstanding’.
The outpatients ward – like all other hospital trusts in the country – was inspected but the rating has not been given.
Positives picked up by the report include:
- Services provided care and treatment in line with national best practice guidelines, and outcomes for patients were often better than average or improving.
- The trust’s mortality rates were within the expected range.
- Patients received good pain relief, in particular after surgery, in critical care and in end-of-life care.
- Seven-day consultant-led services were developed in all areas, with the exception of outpatient services.
Mr Mellor says: ‘Providing seven-day NHS care is a major driver at the moment and I’m pleased this trust is providing that.
‘We have been building this up for quite some time and it’s working.
‘Sadly other hospitals will see more deaths at the weekend because there aren’t as many staff around.
‘You can see our mortality rate is in the expected range and that’s helped by a seven-day week.’
One of the biggest criticisms highlighted in the report was around discharge letters being sent to GPs.
The report said: ‘Discharge summaries giving GPs information on patient care were delayed.
‘The trust was not meeting Department of Health standards for letters to be sent within 48 hours and there could be delays of up to two weeks.
‘Renal outpatient letters were taking 35 days to be typed and sent to the patients’ GP because the renal department had a separate IT system from the rest of the trust.
‘This had caused significant delay in GPs receiving updated information regarding their patients’ treatment.’
Mr Mellor adds: ‘We recognised there was a delay in getting letters out and we are now working on an electric discharge summary system so GPs get information quickly.’
Are services caring?
THE hospital received the highest rating the inspection report gives in this category overall – outstanding.
While surgery got a ‘requires improvement’, A&E, medical care, end-of-life care and outpatients were given a rating of ‘good’.
Critical care, maternity and gynaecology, and children and young people, are all ‘outstanding’.
The report picked out the following:
- The trust had a culture of compassionate care. Staff were caring and compassionate, and treated patients with dignity and respect.
- Many patients and relatives told us that although staff were very busy, they were supported with compassion, patience, dignity and respect, with time being given to the delivery of personalised care.
- Staff were responsive to patients’ emotional care needs. Emotional care was also provided by the chaplaincy department and patients and relatives told us how much they valued this service, which had supported them at difficult times.
- We observed outstanding care and compassion in critical care, maternity and gynaecology and children and young people’s services.
Staff were person-centred and supportive, and worked to ensure that patients and their relatives were involved in their care.
- Data from the NHS Friends and Family Test demonstrated that patients were satisfied with the care they received.
- Overall results were above the England average and the trust was in the top quarter of all trusts. Results were clearly displayed in ward areas.
The report did pick up on criticism of care and attention provided in E3.
Mr Mellor says: ‘It’s quite contradictory when we are told we’re giving an outstanding performance in providing care, but marked down on other areas.
‘Above all patients and their families and friends want to be cared for in hospital, and it’s no surprise we have come out on top.
‘I am glad this has been reflected and recognised in the report.
‘The NHS is facing all sorts of challenges, but here you can see our staff take the time out to make sure patients are cared-for and looked after.
‘Of course if one ward at one time did give care short of that during the inspection then it will be picked up on.’
Are services responsive?
THIS category received an overall rating of ‘requires improvement’.
A&E, medical care, surgery and children and young people, were all rated as ‘requires improvement’.
Critical care, maternity and gynaecology, end-of-life care and outpatients, were all found to give a good service.
The report found:
- Patients were not always admitted to wards according to their clinical needs and were being placed where beds became available.
This meant that the necessary level of specialist expertise and experience may not always have been available to them.
- Patients could be moved several times during their admission. This happened at night and for non-clinical reasons.
- The trust identified that older patients, patients with high dependency and acuity needs and end-of-life care patients should not be moved.
However, older patients, including patients who were confused, or living with dementia and who may have had complex conditions, were being moved.
- Patient moves were tracked but the information was not used effectively at ward level.
Some medical staff told us they did not always know where to find them and this could lead to a delay in treatment.
Patients’ relatives also told us that they had difficulty finding patients.
- Capacity issues within the hospital resulted in elective procedures being cancelled. Some patients told us their operations had been cancelled several times; although the majority did go on to have their surgery within 28 days.
Mr Mellor says: ‘We are facing pressure on bed-space available in the hospital and that can affect patients.
‘But what options do we have? If a heart patient needs a hospital bed for the night and the cardio ward is full, then we can’t turn them away.
‘It’s better for the patient to be in hospital with easy access to the care they need.
‘We don’t enjoy doing it, but bed availability can be a problem.
‘We always move patients safely and use a clinical judgement to make sure that if we are moving someone then it’s done correctly.
‘Sometimes it’s in the patient’s interest because they need different type of care and other times it’s due to necessity.’