Royal Preston Hospital Scheduled Report
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Lancashire Teaching Hospitals NHS Foundation Trust Royal Preston Hospital Quality Report Sharoe Green Lane Fulwood Preston Lancashire PR2 9HT Tel:01772 716565 Date of inspection visit: 9, 10, 11 July 2014 Website: www.lancsteachinghospitals.nhs.uk Date of publication: 14/11/2014 This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the public and other organisations. Ratings Overall rating for this hospital Requires improvement ––– Urgent and emergency services Good ––– Medical care Requires improvement ––– Surgery Requires improvement ––– Critical care Good ––– Maternity and gynaecology Good ––– Services for children and young people Good ––– End of life care Good ––– Outpatients and diagnostic imaging Requires improvement ––– 1 Royal Preston Hospital Quality Report 14/11/2014 Summary of findings Letter from the Chief Inspector of Hospitals Royal Preston Hospital is one of two hospitals providing care as part of Lancashire Teaching Hospitals NHS Foundation Trust. It provides a full range of hospital services, including emergency department, critical care, coronary care, general medicine including elderly care, general surgery, orthopaedics, anaesthetics, stroke rehabilitation, paediatrics and midwifery-led maternity care. Lancashire Teaching Hospitals NHS Foundation Trust as a whole provides services to 390,000 people in Preston and Chorley, and specialist care to 1.5 million people across Lancashire and South Cumbria. We carried out this inspection as part of our comprehensive inspection programme. We undertook an announced inspection of the hospital between 9 and 11 July 2014, and an unannounced inspection between 6pm and 8pm on 21 July 2014 at Royal Preston Hospital only. We looked at the management of medical admissions out of hours. Our key findings were: Access and flow • The hospital had a high number of medical emergency admissions that was resulting in high numbers of medical outliers (patients placed in areas not best suited to their needs). There were times when there were more than 35 patient outliers. • Patients sometimes remained in the Emergency Department overnight. • There were also occasions when patients were moved from ward to ward many times, sometimes at night. • The number of medical outliers placed in surgical beds led to unused theatre capacity. • Issues with bed capacity were also made worse by the number of delayed discharges. • The management of patient access and flow across the hospital was of immediate concern and remained a significant challenge for managers. The hospital had made arrangements to ensure timely medical review of patients placed in a clinical setting that did not best suit their needs. However, the number of moves across wards and being placed in less appropriate clinical settings was far from ideal and was having a negative effect on patient experience. Mortality rates • Mortality rates were within expected limits. Never events • There had been five reported potential surgical never events during the period April 2013 to April 2014. However, three had been declassified, and the trust had taken appropriate steps to reduce the risk of further occurrences. Infection control • The hospital was clean throughout. Staff adhered to good practice guidance in the prevention and control of infection. There was a good rate of compliance with hygiene audits. Food and hydration • Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs were supported by dieticians and the speech and language therapy team. • There was a period over mealtimes when all activities on the wards stopped, if it was safe for them to do so. This meant that staff were available to help serve food and assist those patients who needed help. We also saw that a coloured tray system was in place to highlight the patients who needed assistance with eating and drinking. 2 Royal Preston Hospital Quality Report 14/11/2014 Summary of findings Medicines management • Medicines were provided, stored and administered in a safe and timely way. Some concerns were raised regarding the completeness of prescription charts in outpatients and the timely provision of medicines for patients to take home. Nurse staffing • Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services. However, nurse staffing levels, although improved, remained of concern. The trust was actively recruiting nursing staff using innovative methods of recruitment. These included a number of efforts to improve recruitment and retention through wider access schemes with local universities and dedicated ring-fenced funding to support this. They had also linked into international universities to support this recruitment. However, we found that required staffing levels were not consistently achieved in all core services at the time of the inspection. Medical staffing • Medical treatment was delivered by committed medical staff, however: • Medical staffing was not sufficient to provide appropriate and timely treatment and review of patients at all times within the medical division and to maintain timely clinics in outpatients to meet targets. Many of the middle grade vacancies were due to national shortages of trainees and the full allocation not being sent from the regional training schools. It was noted that the North West had historical difficulty in recruiting and retaining doctors and there had been a number of efforts to improve recruitment and retention through wider access schemes with local universities and dedicated ring-fenced funding to support this. • Medical staffing was not always appropriate at the location, including medical trainees, long-term locums, middle-grade doctors and consultants. We saw several areas of good practice, including: • Data from the College of Emergency Medicine (CEM) consultant sign-off audit showed that 100% of patients at Preston Emergency Department were seen by an emergency department doctor, compared with a national average of 92%. Also 25% of patients were seen by a consultant, which is well above the national average of 13% in 2012/13. • Ultrasound-guided blocks for patients with neck of femur injuries in the Emergency Department. • Children’s safeguarding review meeting in the Emergency Department. • Chaplaincy service engagement with patients in the Emergency Department. • Consistently rapid handover times for patients arriving by ambulance to the Emergency Department. • Responsive and flexible training using ‘simulation man’ to deliver trauma training within the Emergency Department at quiet times. • The trust was committed to becoming a dementia-friendly environment. An older people’s programme was developing this work and we saw several excellent examples of how this was being put into practice during our inspection. The proactive elderly care team helped staff to identify and assess the needs of older people. The team worked proactively with intermediate care services to ensure the safe discharge of older people and people living with dementia. Activity boxes had been introduced throughout the division to promote and maintain cognitive and physical function and help reduce the unwanted effects of being in a hospital environment. • The trust had won the Clinical Innovation category at the North West Excellence in Supply Awards for developing a disposable female urinal. • The alcohol liaison service had been nominated for a national Nursing Standards award. Staff spoke highly of the service and the positive contributions they had made in supporting patients with alcohol-related conditions. • Our specialist adviser assessed that speech and language therapy input for neonatal babies was likely to improve the long-term outcomes for these children and considered this to be outstanding practice. • The end of life team coordinated rapid response for discharge to the preferred place of care. Staff told us there was a multidisciplinary approach to discharge planning, which involved the hospital and the community staff working towards a rapid but safe discharge for patients. 3 Royal Preston Hospital Quality Report 14/11/2014 Summary of findings However, there were also areas of poor practice, where the trust needs to make improvements. Importantly, the trust must: Staffing • Ensure that there are enough suitably qualified, skilled and experienced nurses to meet the needs of medical patients at all times. • Ensure that there are enough suitably qualified, skilled and experienced midwives to meet the needs of patients at all times. • Ensure that medical staffing is sufficient to provide appropriate and timely treatment and review of patients at all times within the medical division and outpatients. • Ensure that medical staffing is appropriate at the location, including medical trainees, long-term locums, middle-grade doctors and consultants. Supporting staff • Ensure that relevant staff receive advanced paediatric life support and moving and handling training. • Take steps to enable the trust to confirm the status of mandatory training that staff have completed in the child health directorate, so that staff have received information about the actions required to maintain and promote safety. • Improve patient flow throughout the hospital to reduce the number of bed moves and length of stay – particularly in the