The Princess Alexandra Hospital NHS Trust Evidence Appendix Published 31 July 2019

The Princess Alexandra Hospital NHS
Trust
Evidence appendix
Princess Alexandra Hospital Date of inspection visit:
Hamstel Road 27 March to 24 April 2019
Harlow
Essex Date of publication:
CM20 1QX 31 July 2019
Tel: 01279 444455

Website: www.pah.nhs.uk
This evidence appendix provides the supporting evidence that enabled us to come to our
judgements of the quality of service provided by this trust. It is based on a combination of
information provided to us by the trust, nationally available data, what we found when we
inspected, and information given to us from patients, the public and other organisations. For a
summary of our inspection findings, see the inspection report for this trust.
Facts and data about this trust

The Princess Alexandra Hospital NHS Trust provides specialist and acute hospital services to a
population of approximately 350,000 people in east and north Hertfordshire and west Essex.
(Source: Trust website)
The Princess Alexandra Hospital NHS Trust (PAH) was established in 1995. It is a 508-bedded
hospital which provides a range of general acute services, including: a 24/7 accident and
emergency department, an intensive care unit, a maternity unit and a Level II neonatal intensive
care unit (NICU).
The trust currently employs approximately 3,000 whole time equivalent (WTE) staff and serves a
core population of around 350,000 in West Essex and East Hertfordshire. In addition to the
communities of Harlow and Epping, the trust serves the populations of Bishops Stortford and
Saffron Walden in the north, Loughton and Waltham Abbey in the south, Great Dunmow in the
east, and Hoddesdon and Broxbourne in the west. Its extended catchment (a radius of 11 to 13
miles) incorporates a population of up to 500,000.
The trust owns the main hospital site in Harlow, and also operates outpatient and diagnostic
services out of the Herts and Essex Hospital, Bishops Stortford, St Margaret’s Hospital, Epping
and the community hospital in Cheshunt. The operation of these facilities forms part of the
longer-term strategy of bringing patient services closer to where they live and making services,
where appropriate, more accessible and easily available to patients.
(Source: Routine Provider Information Request (RPIR) – Context acute tab)
Acute hospital sites at the trust
Evidence appendix The Princess Alexandra Hospital NHS Trust Page 1

A list of the acute hospitals at The Princess Alexandra Hospital NHS Trust is below.
Name of acute Details of any specialist services provided at

Address
hospital site the site
Hamstel Road
Princess
Harlow
Alexandra Acute hospital inpatient and outpatient services
Essex
Hospital
CM20 1QX
Outpatient clinics:
• Cardiology
• Dermatology
• Endocrinology
• Ear nose and throat
• Gastroenterology
• General surgery
• Gynaecology
• Haematology
• Medicine for the elderly
• Neurology
Heymeads Lane • Respiratory
Herts and Bishop's Stortford, • Rheumatology
Essex Hospital Hertfordshire • Therapies
CM23 5JH • Trauma and orthopaedics
Other services:
• Phlebotomy service
Outpatient clinics:
• Ante-natal
• Cardiology
• Dermatology
• Endocrinology
• Ear nose and throat
• Gastroenterology
• General surgery
• Gynaecology
• Haematology
The Plain • Neurology
St Margaret’s Epping • Paediatrics
Hospital Essex • Respiratory
CM16 6TN • Rheumatology
• Therapies
• Trauma and orthopaedics
• Urology (Oak unit)
Other services:
• Anticoagulation service
• Breast unit
• Chemical pathology
• Day case urology surgery (Oak unit)
• Phlebotomy service
(Source: Routine Provider Information Request (RPIR) – Sites tab)

Is this organisation well-led?
Leadership
The trust board, executives and senior leadership team had the skills, knowledge, integrity
and experience needed to provide high quality services on appointment and throughout
their employment.
To write this well-led report, and rate the organisation, we interviewed the members of the board,
both the executive and non-executive directors, and a range of senior staff across the hospital.
This included a wide group of clinical and non-clinical service and specialty directors. We met and
talked with a wide range of staff to ask their views on the leadership and governance of the trust.
We looked at a range of performance and quality reports, audits and action plans; board meeting
minutes and papers to the board, investigations, and feedback from patients, local people and
stakeholders.
We undertook checks to determine whether appropriate steps had been taken to complete
employment checks for executive staff in line with the Fit and Proper Persons Requirement
(FPPR) (Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014).
This regulation ensures that directors of NHS providers are fit and proper to carry out this
important role. A fit and proper persons (FPPR) procedure was in place.
Fit and Proper Person checks were in place. We reviewed the personnel files of four executive
directors and three non-executive directors to determine the necessary fit and proper person
checks had been undertaken. Our checks included the chief executive officer (CEO), chief nurse,
medical director and the chief operating officer. Board members completed annual self-declaration
forms to confirm they complied with the regulation. All files had an annual declaration within them
in line with FPPR. We found all files we reviewed were fully compliant with FPPR.
There was clear leadership of the trust to drive and improve the delivery of high-quality person-
centred care. Senior leaders were visible and were mindful of being accessible for staff across the
trust.
The board of directors managed the trust’s services and developed plans and strategies for the
future. The board included full-time executive directors who oversaw the day-to-day running of the
trust and part-time non-executive directors (NEDs) who brought with them a blend of knowledge,
experience and expertise from both the public and the private sector. They help to ensure the trust
is accountable to the people it serves.
Executive directors and non-voting directors were employed by and worked in the trust daily and
had management of set areas of the trust’s business. Non-executive directors were not full-time
employees of the trust. They were individuals who had shown an interest in the provision of health
services for the local people and brought with them specialist experience and independent
oversight of the board’s activities. NEDs helped ensure the trust remained accountable to the
people it served.
The trust board was made up from 11 voting members and four non-voting members, six NEDs,
including a chairperson and eight executive directors.
Since our last inspection, which took place in December 2017, there had been some changes to
the trust board. The longest standing member of the board was director of finance, who had been
appointed in 2013. The newest members of the trust board included a new director of nursing,
midwifery and allied healthcare professionals, who was appointed in October 2018 and a Director
of people, who was appointed in August 2018. The chief executive officer had been in position
since May 2017. The trust had put in place interim arrangements whereby the chairing of the
trust’s Audit Committee was shared between the trust’s Chair and the NED Chair of the trust’s
Performance and Finance Committee. The Trust’s Chair told us they were looking to bring in new
non-executives with a commercial and strategic background, to balance with the existing non-
executives experience, which is predominantly NHS based.
At the time of our inspection, the chair of the Audit Committee had taken up the role as Chair for
the trust, so there was a vacancy for the Chair of the Audit Committee. However, the trust was in
the process of recruiting two new NEDs, one of which was to Chair the Audit Committee, with the
expectation that a new Chair of the trust’s Audit Committee would be in place by summer 2019.
Leaders were clear about their portfolios and the portfolios of other members of the team; and they
recognised there was a need to keep these under review.
The chief medical officer was the executive lead for end of life care, clinical governance and risk
management and the director of nursing, midwifery and allied health professionals was
responsible for infection prevention and control, safeguarding, mental health and learning
disabilities.
The Trust had a stable finance team in place, which was led by the Chief Finance Officer (CFO),
who is also the trust’s Deputy Chief Executive Officer. Sitting beneath the CFO were two deputy
CFOs, one being responsible for operational finance and the other was responsible for income
and costing. Under the leadership of the existing CFO the trust had strengthened finance support
at divisional and Health Care Group (HCG) level, with senior finance staff embedded at divisional
level providing direct support to the associate medical directors (AMDs) and their senior
management teams. The AMDs were the budget holders and are accountable for the financial
performance of their divisions.
The board of directors was accountable to the non-executive directors for the running and
performance of the trust and was supported by the audit committee, performance and finance
committee, workforce committee, quality and safety committee and the remunerations and
nominations committee.
The board understood the challenges and priorities within the organisation and were able to
articulate these challenges and priorities clearly.
The trust board and senior leadership team displayed integrity on an ongoing basis. Throughout
our well-led inspection, we saw evidence of collective leadership from the trust board with a strong
focus on providing patient-centred care and on board and staff development. Without exception,
we found the board to be a cohesive unitary board who had a shared understanding of the trust’s
issues, challenges and priorities, and this was demonstrated by everyone we interviewed as part
of our well led inspection.
The trust’s senior leadership team had a comprehensive knowledge of the trust’s current priorities
and challenges and acted to address them. We attended a trust board meeting in February 2019,
and we studied the board minutes and associated papers throughout our inspection. The meetings
were well attended, and we observed a unitary board where there was appropriate challenge.
Prior to our inspection, we attended a board meeting. The meeting was appropriately chaired with
the chair promoting contributions from all members of the board. We observed trust and respect at
this meeting and it was apparent the board members were open and challenged each other in a
professional manner. Performance reports and important issues were discussed, and individuals
were well-sighted on the issues presented. The agenda for the meeting balanced time effectively
and an appropriate amount of time was given to each agenda item.

Leaders welcomed new and improved ways of organising and providing care through the findings
of external reviews. The most recent having taken place prior to our inspection throughout urology
and maternity services.
Leadership development opportunities were available, including opportunities for staff below team
manager level. The executive team were clearly sighted on the development needs of senior staff
within the organisation and recognised leadership development and succession planning to
empower staff was instrumental to further shaping the culture within the organisation and to
ensure the trust continued to develop effective leaders.
Throughout our core service inspection and focus groups undertaken with staff, feedback about
the senior leadership team was positive. Staff told us the senior leadership team, including the
board were engaging, visible and approachable.
The trust had an operational structure, which sat across four clinical divisions known as health
care groups. These were:
• Surgery health care group
• Family and women’s services
• Medicine and patient@home
• Cancer, cardiology and clinical services
Triumvirate leadership was provided at health care group level by an associate medical director, a
director of operations and an associate director of nursing. Each health care group also had a
specialty leadership team. Local leadership was provided by ward/departmental managers and
matrons.
Pharmacy services were led by a chief pharmacist, who also formed part of the triumvirate
leadership team for cancer, cardiology and clinical services.
Board Members
Of the executive board members at the trust, 12.5% were black and minority ethnic (BME) and
37.5% were female.
Of the non-executive board members 0% were BME and 50% were female.
Staff group BME % Female %

Executive directors 12.5% 37.5%
Non-executive directors 0% 50%
All board members 7.1% 42.9%
(Source: Routine Provider Information Request (RPIR) – Board Diversity tab)
Vision and strategy

The trust had a vision for what it wanted to achieve and workable plans to turn it into action
developed with involvement from staff, patients, and key groups representing the local
community.
There was a clear vision and credible strategy to deliver high quality sustainable care.
The trust’s vision title ‘Your future, our hospital’ was voted for and chosen by staff and was
launched at a staff ‘event in a tent’ in September 2017. This underpinned the trust’s vision to be an
excellent provider of integrated acute care services and the trust’s mission to put quality in

everything the trust does. The aim of the vision was to continually improve and develop so that
they could consistently provide outstanding services to the local population whilst working
seamlessly with partners.
To meet their ‘your future, our hospital’ vision, the trust had developed a five-year strategy. This
was holistic in its approach and centred around a five ‘P’ plan. The five ‘P’ plan involved five
strategic objectives:
• Our Patients - continue to improve the quality of care we provide our patients, improving
our CQC rating and exiting special measures.
• Our People – support our people to deliver high quality care within a culture that improves,
engagement, recruitment and retention and improvements in our staff survey results.
• Our Places – maintain the safety of and improve the quality and look of our places and
work with our partners to develop an OBC for a new build, aligned with the development of
a West Essex and East Hertfordshire Accountable Care Partnership.
• Our Performance - meet and achieve our performance targets, covering national and local
operational, quality and workforce indicators.
• Our Pounds – manage our pounds effectively to achieve our agreed financial targets and
control totals.
The trust had a clear set of values. These values formed the foundations of behaviours that all
staff were expected to follow.
• Value 1: Respectful - treating others as we would wish to be treated. We are be
welcoming and polite, valuing and supporting our colleagues and celebrating our
achievements. We maintain patients' dignity and recognise and respect our differences.
• Value 2: Caring - always putting patients first. We are kind and compassionate, making
sure patient safety is at the centre of everything we do. We show empathy, caring for every
patient as an individual and listening and responding to the views of patients and their
carers.
• Value 3 - Responsible - doing what we say we're going to do. We are professional, and
maintain the highest standards of behaviours and accountability, working as a team and
communicating openly and honestly. We lead by example, speaking up when we see that
our values are not being displayed.
• Value 4 - Committed - striving to be the best. We strive for excellence, constantly
challenging the status quo and seeking to improve quality and efficiency. We innovate and
adopt best practice in our day-to-day activities to achieve our goals and improve our skills
and knowledge.
Without exception, all staff we spoke with throughout the trust knew and understood the trust’s
vision, values and strategy and how these applied to them and the work of their health care group.
Work was on-going to ensure the trust vision, values and strategy were embedded throughout the
trust.
During our inspection, the trust told us its financial strategy was to achieve its control total for
2019/20 which would result in a £6.2m deficit inclusive of funding incentives, and the following
year 2020/21, to deliver a reported breakeven position, which was inclusive of incentive funding
which would then be incorporated into tariff. Part of the trust’s financial strategy was to achieve
this by working more closely with the system to drive out inefficiencies within specific services
across the system, by taking responsibility for the overall service, re-designing the pathways of
care to improve quality and reduce inefficiencies. An example of this was the musculoskeletal
service.
In addition to the trust wide strategy, the trust had a number of other strategies in place, for
example the trust had:
• a five-year people strategy 2019 to 2024, which set out the steps the trust was taking to
develop a diverse and inclusive culture where staff felt engaged, had scope to grow and
develop, were empowered to transform how services were provided.
• A quality improvement strategy 2019 to 2022, which had been launched in February 2019
and recognised quality improvement as working together in partnership to make sustainable
changes that would lead to excellence against the trust’s five ‘P’s.
• a medicines optimisation strategy, which involved collaborative working across the
sustainability and transformation plan (STP) and accountable care partnership (ACP)
board.
Culture
Managers at all levels at the trust were committed to promoting a positive culture that
supported and valued staff, created a sense of common purpose based on shared values. Staff
felt supported, respected, and valued.
Throughout this inspection and our observations of the trust, we saw cooperative, supportive and
appreciative relationships among the executive and non-executive team. The senior leadership
team worked collaboratively, shared responsibility and resolved conflict quickly and constructively.
Since our last inspection, the executive team had given up their individual offices to create more
clinical space and had decided to move to an open plan office, where they shared an open space.
Without exception, members of the executive team told us this was a positive move and the open
office was working well and enabled more open discussions.
Without exception, throughout our interviews with the trust executives and senior leadership team,
they described a positive change within the organisation’s culture under the leadership of the
current chief executive officer (CEO). The CEO had introduced a 360-degree appraisal process for
the executive team, which had opened out the opportunity for them to receive rounded feedback
from their peers. In addition to this, under the leadership of the CEO, the executives undertook an
exercise on the five dysfunctions of a team, to assist in building a cohesive senior management
team. This was followed up with a second session, facilitated by an external human resources
expert, focusing on what a good team looks like.
Throughout our interviews with the trust executives and senior leadership team, there was a
consensus that the culture within the organisation has changed from being one that was internally
focused to being more externally focused. It was expressed that the investments made within
some of the services and the hospital’s front entrance had contributed to the cultural change seen
over the last 18 months and following the appointment of the current Chief Executive Officer
(CEO). Throughout our interviews with trust staff, they told us they felt more engaged and able to
approach the executive team members to discuss issues and raise their views.
The culture of working amongst the executives at the trust had led to an improvement in senior
management team meetings, with a greater focus on delivering quality services for patients,
improving performance whilst being mindful of and managing finances. Members of the executive
team told us this had led to improvements in clinical care at the trust. The trust’s non-executive
directors told us the executives were now more transparent as a result of a change in culture at
senior management team level following the appointment of the current CEO.
The trust’s strategy, vision and values also underpinned a culture that was patient focused and
centred and every conversation we had with members of the senior leadership team focused
around what was right for patients and for staff.
The triumvirate leadership teams told us the culture within the trust was positive and that they
found the executive team extremely supportive of ideas they and their teams may have. We heard
the healthcare groups were supportive of each other and where appropriate, they also worked in
collaboration.
Managers across the trust promoted a positive culture that supported and valued staff and created
a sense of common purpose based on shared values. Leaders at every level of the organisation
encouraged pride and positivity within the organisation to empower staff to make decisions and to
put patients at the centre of their care.
We met with different grades of staff throughout our core service inspection, and prior to our
inspection we held staff focus groups. Most staff we spoke with described a positive culture and
told us they felt equally respected, supported and valued. Most staff felt positive and proud about
working for the trust and their team and were encouraged to instigate change through a quality
improvement process. Our interviews with staff at all levels demonstrated that the culture of the
organisation was patient-centred and focused on the needs of people using the services.
Candour, openness and honesty were the norm for the board and without exception, all the
leaders we interviewed spoke about empowering staff to drive improvement.
The trust had a whistleblowing policy and had appointed two freedom to speak up guardians.
Freedom to speak-up guardians were introduced following Sir Robert Francis’s Freedom to
Speak-up Review (2015). Their role was to work alongside the trust’s executive and senior
leadership teams to help support the organisation in becoming more open and transparent place
to work, where staff were actively encouraged to speak up safely without fear of repercussions.
The trust had a named executive director and named non-executive director who was responsible
for speaking up and both were clear about their responsibilities.
The freedom to speak up guardians were promoted though the trust’s information technology
system through pop up banners and screens on the trust’s intranet. There was a dedicated email
address by which staff could contact the freedom to speak up guardians in confidence. However,
staff also approached the freedom to speak up guardians’ face to face.
The freedom to speak up guardians produced quarterly reports identifying the work they had
undertaken including any emerging themes. This was reviewed by the trust’s workforce
committee.
The trust submitted information to the National Guardian’s Office on the cases that had been
raised with the trusts freedom to speak up guardians. From information submitted to the national
Guardian’s office, between 1 April 2018 and 31 December 2018 we could see there had been 45
issues raised with the freedom to speak up guardians. Nine of these were raised anonymously,
five related to some element of patient safety or quality and 39 included issues with an element of
bullying or harassment.
There is a clear correlation between a trust having effective speaking up arrangements and
showing evidence of being a well-led trust. As a result, NHS Improvement and the National
Guardian’s Office published a guide in 2018 setting out expectations of boards in relation to
freedom to speak up to help them create a culture that was responsive to feedback and focused
on learning and continual improvement. To accompany this, they produced a self-review tool for all
boards to use as an assessment of their current position with regards to speaking up as well as to
inform areas for development.

Key trust board members worked with the freedom to speak up guardians to use this review tool to
assess the trust’s current position and where the trust had met, partially met or not met the
expectations along with supporting evidence and actions.
The board demonstrated commitment to providing staff at every level with the development they
needed, including appraisal. ‘Our People’ was one of the trust’s objectives and reflected the trust’s
acknowledgement that the organisation was full of talented people committed to delivering the
best healthcare. The trust’s people vision was to be a place where people love coming to work and
were productive on a daily basis. The trust’s aim was to make work exciting, rewarding, stimulating
and enjoyable. Collective leadership and devolution as at the heart of what the trust wanted to
achieve.
Within their people strategy, the trust pledged to take a strategic approach to talent management
and the way in which staff were developed, engaged and retained within the trust. The senior
leaders within the trust wanted to ensure staff were involved in decision making and having the
freedom to voice their ideas and were given opportunities to develop their services.
The trust had launched a health and wellbeing programme for staff. The programme was called
‘working well together’ and was aimed at improving the health of staff in the workplace by
promoting a healthy and engaged workforce. Working well together was run by several health
champions and offered a range of services for staff to get involved with.
Staff Diversity
The trust provided the following breakdowns of medical and dental and nursing and midwifery staff
by ethnic group.
Medical and Nursing and

Ethnic group dental staff midwifery staff
(%) (%)
White British/Irish/Any other white background 32% 61%
BME 59% 35%
Not stated 10% 4%
(Source: Routine Provider Information Request (RPIR) – Staff Diversity tab)
NHS Staff Survey 2018 results – summary scores
The following illustration shows how this provider compares with other similar providers on ten key
themes from the survey. Possible scores range from one to ten – a higher score indicates a better
result.

(Source: NHS Staff Survey 2018)
The trust’s response rate of 40% for the 2018 NHS staff survey was below the national average of
44%. However, the trust’s score in the 2018 staff survey was significantly better than average for
the benchmark group in relation to the quality of appraisals. The scores for the remaining nine
themes were better than the averages.
The trust had introduced freedom to speak up guardians and was planning a programme of work
to address pockets of bullying and harassment, such as the ‘am I a bully’ programme and planned
to roll out training to address unconscious bias. Whilst much work had been undertaken to
improve the culture at the trust the senior leadership team recognised that there was more to do
and viewed this as a cultural journey, with further improvements being supported by these
programmes and a behaviour charter, which had been developed with staff.
Workforce race equality standard
The Workforce Race Equality Standard (WRES) became compulsory for all NHS trusts in April 2015.
Trusts must show progress against nine measures of equality in the workforce.
The scores presented below are indicators relating to the comparative experiences of white and
black and minority ethnic (BME) staff, as required for the Workforce Race Equality Standard.
The data for indicators 1 to 4 and indicator 9 is supplied to CQC by NHS England, based on data
from the Electronic Staff Record (ESR) or supplied by trusts to the NHS England WRES team,
while indicators 5 to 8 are included in the NHS Staff Survey.
Notes relating to the scores:

• These scores are un-weighted, or not adjusted.

• There are nine WRES metrics which we display as 10 indicators. However, not all indicators
are available for all trusts; for example, if the trust has less than 11 responses for a staff survey
question, then the score would not be published.
• Note that the questions are not all oriented the same way: for 1a, 1b, 2, 4 and 7, a higher
percentage is better while for indicators 3, 5, 6 and 8 a higher percentage is worse.
• The presence of a statistically significant difference between the experiences of BME and
White staff may be caused by a variety of factors. Whether such differences are of regulatory
significance will depend on individual trusts' circumstances.
As of March 2018, two of the ESR staffing indicators shown above (indicators 1a to 4) showed a
statistically significant difference in score between White and BME staff:
1a. In 2018, BME candidates were significantly less likely than White candidates to hold senior
(band 8+) clinical roles (3.5% of BME staff compared to 7.9% of White staff). This increased
by 0.2% compared to the previous year, 2017.
1b. In 2018, BME candidates were significantly more likely than White candidates to hold senior
(band 8+) non-clinical roles (14.9% of BME staff compared to 8.0% of White staff). This
increased by 1.4% compared to the previous year, 2017.
2. In 2018, BME candidates were significantly less likely than White candidates to get jobs for
which they had been shortlisted (10.3% of BME staff compared to 15.7% of White staff). This
has decreased by 0.7% compared to the previous year, 2017.
Of the four indicators from the NHS staff survey 2018 shown above (indicator 5 to 8), the
following indicators showed a statistically significant difference in score between White and BME
staff:
5. 35.1% of BME staff experienced harassment, bullying or abuse from patients, relatives and the
public in the past year (2018 NHS staff survey) which was significantly higher when compared
to 26.8% of White staff. This was also significantly different when compared to the trust’s peer
group. The score had increased by 6.6% when compared to the previous year, 2017.
6. 71.7% of BME staff believed that the trust provided equal opportunities for career progression
and promotion (2018 NHS staff survey) which was significantly lower when compared to 86.8%
of White staff. The score had increased by 1.0% when compared to the previous year, 2017.
7. 12.5% of BME staff experienced discrimination from a colleague or manager in the past year
(2018 NHS staff survey) which was significantly higher when compared to 6.5% of White staff.
The score had decreased by 3.8% when compared to the previous year, 2017.
There were no BME Voting Board Members at the trust, which was significantly different to the
number expected, based on the overall percentage of BME staff.
The trust had introduced champions for all protected characteristics throughout the trust.
(Source: NHS Staff Survey 2018; NHS England)
Friends and Family test
The Friends and Family Test was launched in April 2013. It asks people who use services
whether they would recommend the services they have used, giving the opportunity to feedback
on their experiences of care and treatment.
The trust scored above the England average for recommending the trust as a place to receive
care in 11 of the 12 months from February 2018 to January 2019. The trust scored about the
same as the England average in the remaining month, April 2018.
(Source: Friends and Family Test)

Sickness absence rates
The trust’s sickness absence levels from November 2017 to October 2018 were generally slightly
lower than the England average. The trend at the trust was similar to that seen nationally, with a
spike in sickness in the winter period, centred on January 2018.
(Source: NHS Digital)
General Medical Council – National Training Scheme Survey
In the 2018 General Medical Council Survey the trust performed worse than expected for two
indicators (educational supervision and feedback) and the same as expected for the remaining
11 indicators.
Survey area RAG

Overall satisfaction
Clinical Supervision
Clinical Supervision out of hours
Handover
Induction
Adequate Experience
Supportive environment
Work Load
Educational Supervision
Feedback
Local Teaching
Regional Teaching
Study Leave
(Source: General Medical Council National Training Scheme Survey)

Governance
The trust had effective governance structures, systems and processes in place to support
the delivery of its strategy including sub-board committees, divisional committees and
team meetings. However there had been running themes of lapses of basic governance at
core service level which suggested governance processes had not been fully embedded
throughout the trust.
The trust had an established board of directors and a board reporting and accountability structure
in place, which meant that information, escalation and reporting lines were clear from ward to
board.
The board was supported by four board assurance sub-committees that met regularly to ensure
trust services and systems were performing to required expectations. These included the:
• Performance and finance Committee

• Quality and safety Committee
• Audit Committee
• Workforce Committee
The performance and finance committee met monthly and was chaired by a non-executive
director. The executive lead for this committee was the trust’s chief financial officer. The purpose
of this committee was to assure the board of directors that the trust had robust processes in place
to prioritise its finance and resources and make decisions about their deployment to ensure they
met the needs of patients and delivered best value for money.
The quality and safety committee met monthly and functioned as the trust’s governance
committee, with the aim of assuring the trust board that high levels of care were being provided
by the trust and that adequate governance structures, processes and controls were in place
throughout the trust to enable it to a quality service. This committee was chaired by a non-
executive director and the executive leads were the director of nursing and midwifery, chief
medical officer and the chief operating officer.
Groups that fed into the quality and safety committee included the trust’s infection control group,
mortality improvement board, medicines management group, end of life care group and the
patient safety and quality group.
The audit committee met four times per year and additional meetings were undertaken as
necessary. The meeting was chaired by a non-executive director, however, at the time of our
inspection, the chair of the audit committee had taken up the role as chair for the trust, so there
was a vacancy for the chair of the audit committee. However, the trust was in the process of
recruiting two new NEDs, one of which was to Chair the Audit Committee, with the expectation
that a new Chair of the trust’s Audit Committee would be in place by summer 2019. The purpose
of the audit committee was to provide the trust’s board with an independent and objective review
of financial and corporate governance, assurance processes and risk management across the
trust’s activities.
The workforce committee was chaired by a non-executive director and the executive lead was the
director of people OD and communications. The committee met bi-monthly and provided
assurance to the board on all aspects of workforce and organisational development issues that
supported the trust’s annual objectives.
In addition to the sub-committees there was a ‘Senior Management Team’ (SMT) group. This
group was not a sub-committee but was accountable to the trust board and was chaired by the
chief executive officer and attended by the executive team, executive deputies, associate medical

directors, director of operations and associate directors of nursing from the health care groups.
This group met every two weeks. This group monitored the trust’s quality improvement plan, risk,
reviewed business cases and received reports from the trust wide groups that required
escalation. This group reported directly to the trust board.
Groups that fed into the senior management team included the ICT programme Board, risk
management group, access board, information governance steering group, hospital transfusion
committee, capital planning group, trust policy group, health care group boards and the people
board.
In addition to the groups and committees mentioned above, the trust also had a strategy
committee, charitable funds committee and a remuneration and nomination committee.
The board of directors was responsible collectively for the success of the trust and the
achievement of its objectives. Accordingly, all members of the board had joint responsibility for
the operational and financial management of the trust on a day-to-day basis, regardless of their
individual skills or status.
At core service level, we found that although processes for governance were in place, and risk
had been identified, there had been times when some services did not have robust systems in
place to improve safety and quality of care, despite monitoring the quality and standards of its
services and care. There had been basic lapses of governance, which suggested systems were
not fully embedded at core service level. For example, we found safety concerns in the core
services of medical care, surgery and maternity services.
During our core service inspection, we identified some concerns and reported to the trust that
some policies and guidance were due for review and some had not been reviewed in a timely
manner. Information received following our core service inspection assured us discussions were
taking place with nominated people within the directorates to ensure all polices were brought up
to date as soon as was practicable.
Within surgery and maternity services, we found the service did not always manage patient safety
incidents in a timely way, and whilst staff recognised incidents and reported them appropriately,
we were concerned about the length of time the trust took to implement patient safety actions and
apply duty of candour when things went wrong.
At the time of our inspection, the trust had identified a backlog of incidents that remained open
trust wide on the trust’s electronic reporting system. This had been reported at the March 2019
patient safety and quality committee. At this time there were 343 incidents waiting to be reviewed
and 1,140 incidents that were being reviewed but had not been closed. These had recently been
identified by the trust, and the trust was taking appropriate action to deal with the backlog of
incidents, but none of the senior leadership team could tell us how this backlog had been allowed
to happen. The trust provided us regular updates following our inspection to provide assurance
that appropriate action was being taken to enable the incidents to be reviewed and where
appropriate, closed.
The trust had effective structures, systems and processes in place to support the delivery of its
strategy and provide safe and good quality patient care, including sub-board committees, health
care group board meetings and team meetings. The trust board met regularly and provided an
opportunity for scrutiny to members of the public as well as internally. Papers for board meetings
and other committees were of a good standard and contained appropriate information. We
reviewed several papers as part of our inspection including for example, minutes from board
meetings and subcommittee meetings. Minutes were found to be clear and well presented with
clear actions identified.

The Chair of the trust’s Performance and Finance Committee was also Vice Chair of the board, as
well as being a member of the Audit Committee and was a Chartered Accountant by profession,
with over 35 years of experience working within both the private and public sector.
Since our last inspection, the trust had introduced a new performance management review
process, known as progress review meetings (PRMs) under a business partner model. These
were used to hold divisional performance to account, including finance, and a flexible approach
was used so that specific areas could be targeted as required, an example given being
assurances over temporary issues with surgery capacity. Performance review escalation meetings
were held as required in addition to the PRMs. These were chaired by the Director of Finance or
Chief Operating Officer and attended by the Chief Medical Officer, Director of Human Resources
and Director of Quality Improvement, Estates and Facilities.
Papers for board meetings and other committees were of a reasonable standard and contained
appropriate information. The trust board was focused on the key priorities for the trust. The trust
board considered reports from several committees including the performance and finance
committee, quality and safety committee and the audit committee. A workforce committee had
been established in 2017 and an additional workforce focused meeting, the People Board, was
established six months prior to the inspection to focus on recruitment, retention and vacancies
throughout the trust.
There was a risk management group, which fed into the senior management team, and in turn fed
into the trust board. A serious incident group (SIG) fed into the quality and safety committee, which
was chaired by the chief medical officer and the chief nurse and was held daily. In addition, the
quality first board and the oversight group fed into the trust board.
Health care groups within the trust had monthly meetings to discuss performance, risk, safety and
quality metrics. The appropriate committee then considered the outcomes of the divisional
meetings. Triumvirate leaders we spoke with throughout our inspection could describe the
escalation of information from the health care group through board sub committees to the board.
Without exception, the risks identified by members of staff at all levels and across the health care
groups matched those that were on the trust’s risk register. The top four risks were workforce
capacity, estates and infrastructure, failure to achieve the four-hour emergency department
constitutional standard and finance.
Board Assurance Framework
The trust’s head of corporate affairs supported the executive and non-executive directors in risk
management and took the lead for maintaining the board assurance framework (BAF). The board
was sighted on risk within the organisation. The BAF was being used to track strategic risks and
these were overseen at a strategic board level.
The trust provided their BAF, which detailed five strategic objectives. A summary of these is
below.
• Patients - continue to improve the quality of care it provides its patients, improving its CQC
rating.
• People - support our people to deliver high quality care within a culture that improves,
engagement, recruitment and retention and improvements in its staff survey results.
• Performance - meet and achieve its performance targets, covering national and local
operational, quality and workforce indicators.

• Places - maintain the safety of and improve the quality and look of our places and work with
our partners to develop an outline business case for a new build, aligned with the
development of a local Integrated Care Alliance.
• Pounds - manage our pounds effectively to achieve its agreed financial control total for
2018/19.
(Source: Trust Board Assurance Framework – November 2018; trust website)
The trust’s BAF detailed their highest profile risks. Of these there were nine risks with a risk
score of 15 or higher as of November 2018. These are shown in the table below.
Risk score Risk score

ID Description
(current) (target)
Outcomes: Inconsistent outcomes in clinical quality, safety,
1.1 16 12
patient experience and ‘higher than expected' mortality.
Electronic Patient Record: concerns around availability of
1.2 functionality for innovative operational processes together 16 12
with data quality and compliance with system processes.
Coding risk: coding issues (including clinical) within the trust
1.3 impacting on patient safety, finance, performance and 16 12
operational delivery.
Workforce capacity: concerns around staffing capacity in
2.1 some areas to manage work load, deliver services of high 16 12
quality and maintain national performance requirements.
Estates and infrastructure: concerns about potential failure of
3.1 the trust's estate and infrastructure and consequences for 20 8
service delivery.
Financial and clinical sustainability across health and social
care system: capacity and capability to deliver long term
3.3 16 12
financial and clinical `sustainability across the health and
social care system.
Sustainability of local services: failure to ensure sustainable
3.5 local services whilst the new hospital plans are in 16 12
development.
Four hour emergency department constitutional standard:
4.2 20 12
failure to achieve emergency department standard.
Finance: concerns around failure to meet financial plan
5.1 15 10
including cash shortfall.
(Source: Trust Board assurance framework, November 2018)
Each risk on the BAF had a named executive lead. Risks on the BAF were also allocated to trust
board committees hose responsibility was to review and challenge the management of risk as
well as the effectiveness and assurances on control for each risk on behalf of the board.
Assurances on this review were provided to the board at its bi-monthly review of the BAF along
with any changes to the BAF since its last review. The risks on the BAF are reviewed regularly by
the lead Executive Directors (usually monthly), at the relevant Trust Board Committees (bi-
monthly) and by the Board (bi-monthly). Changes to the BAF are also presented to the trust risk
management Group by exception. The BAF was available to all trust staff through the trust’s
intranet.
The trust viewed its BAF as a good example of governance but recognised that it was still on a
journey and the BAF required further refinement. Our review of the BAF found that each BAF risk

had a named executive lead who held responsibility for the risk and identified the assurance
committee responsible for providing assurance to the board. Each designated committee and
outcome of committee review was also documented for each risk. However, from reviewing the
BAF, it was not always clear what the assurances were for each principle risk. This was because
the trust’s BAF tended to sight towards where assurances could be found, such as the papers
from various meetings, rather than more precisely identifying and summarising the assurances
received at these meetings, or from other sources, such as internal audit.
The trust’s internal auditors reviewed the effectiveness of the Risk Management Strategy
(including Policy & Procedure) and BAF annually and had received substantial assurance for
2018/19.
Senior leaders were clear about their roles and understood what they were accountable for, and to
whom.
During the period of special measures, oversight meetings were convened and attended by
several stakeholders to monitor progress against issues that had been reported at our previous
inspection. The trust had engaged well with this programme of monitoring. They encouraged
teams to present at these meetings areas of challenge and how they had addressed our concerns.
We saw that our concerns had been taken on board by the trust and its staff and heard staff speak
passionately about the improvements they had made to services to improve patient care.
Stakeholders were able to constructively challenge the staff groups making these changes at
ground level and hear about the impact these changes were having to teams and patients. This
had been a positive driver for the trust in empowering staff to make quality improvements in their
area.
The trust had a Quality First Programme, which was led by an Associate Clinical Director,
Associate Medical Director and a Deputy Director of Quality Improvements. It was a
multidisciplinary team with a focus on developing the workforce, systems and ways of working to
prepare for transfer to a new hospital environment. The aim of the programme was to put quality
first in everything they did and give local teams the tools and the ownerships to make this happen.
The team described wanting to start a ‘revolution’ within the trust. There were several quality
improvement projects in place, which supported the trusts overarching quality improvement plan.
There was an accountability framework in place for the quality first programme.
The Trust had embedded a business partner model at divisional level, with each division having
the support of a cost accountant as a financial advisor to the clinical groups. All budgets were
signed off at the beginning of the year by the divisions, and monthly integrated progress review
meetings were in place to discuss performance. For key areas of spend there were weekly
meetings in place, for example to discuss issues such as high agency spending, the requirements
for these meetings being flexed to accommodate any issues and additional needs. The divisions
had signed up to these new governance arrangements and the divisional accountants were
operating out of the clinical sites they were supporting.
On review of the trust’s internal audit progress report dated March 2019, several improvements
had been identified within finance related audits, demonstrating that progress had been made
within these areas since 2017/18. Examples included recruitment and payroll, which had gone
from limited assurance in 2017/18 to substantial assurance in 2018. In addition, key finance
systems had gone from reasonable assurance to substantial assurance over the same period. The
Trust had also achieved substantial assurance for financial reporting.

Management of risk, issues and performance
The trust had effective systems for identifying risks, planning to eliminate or reduce them,
and coping with both the expected and unexpected.
Finances Overview
Historically the trust had delivered or improved upon its planned pre-sustainability fund deficit,
except for 2017/18, which it believed was in part due to the national decision to suspend elective
activity during a period of the winter. This had an adverse impact on trust’s income and
subsequent planned delivery. Historically the trust has relied on a proportion of non-recurrent
efficiencies to deliver plan, c. £4m in 2017/18 and c. £3.8m in 2018/19 but has recognised this and
is planning for only c. £0.8m of its £10m 2019/20 CIP to be delivered non-recurrently.
Historical data Projections

Previous
Last Financial This Financial Next Financial
Financial metrics Financial Year
Year (2017/18) Year (2018/19) Year (2019/20)
(2016/17)
Income £209.9m £213.3m £236.8m £252.9m
Surplus (deficit) (£26.7m) (£28.4m) (£16.5m) (£6.2m)
Full Costs £236.6m £241.7m £253.3m £259.0m
Budget (or budget
(£29.7m) (£29.1m) (£28.5m) (26.9m)
deficit)
* Budget = Trust's control total (excluding sustainability, financial recovery and MRET funding) as
set by NHSI/E.
NHS Improvement's Single Oversight Framework provides the framework for overseeing
providers and identifying potential support needs. The framework looks at five themes:
• Quality of care
• Finance and use of resources
• Operational performance
• Strategic change
• Leadership and improvement capability (well-led)
Based on information from these themes, providers are segmented from 1 to 4, where '4' reflects
providers receiving the most support, and '1' reflects providers with maximum autonomy. The
trust was in segment three of the framework. This meant the trust was receiving mandated
support for significant concerns.
NHS Improvement are currently assessing all non-specialist acute NHS trusts and foundation
trusts for their Use of Resources assessments. The aim of the assessment is to improve
understanding of how productively trusts are using their resources to provide high quality and
sustainable care for patients. The assessment includes an analysis of trust performance against
a selection of initial metrics, using local intelligence, and other evidence. This analysis is followed
by a qualitative assessment by a team from NHS Improvement during a one-day site visit to the
trust.
Please see the separate use of resources report for details of the assessment.
Over the last two years, the trust had introduced controls over medical agency spending which
were introduced by the trust’s Chief Medical Officer, following concerns over escalating medical
agency pay costs. A ten-point plan was issued to senior trust leaders, which set out the process
for the approval of medical agency spend and was issued alongside a new process for the
booking of medical agency staffing. This change contributed to the trust making significant savings
on agency run rate spend of £5.4m over that two-year period.
The Trust used a Quality Impact Assessment (QIA) approach when assessing the risks associated
with the delivery of its cost improvement plans (CIPs). The approach taken was to primarily review
these at divisional level. If signed off at divisional level, they were then passed to the Director of
Nursing and Chief Medical Officer for review and final sign off. If the Director of Nursing or Chief
Medical officer had any concerns they were returned to the division unapproved. Once CIPs had
been approved and were in delivery phase, quality impact during delivery was also assessed by
the senior management team.
The trust had a risk management strategy in place. The strategy included processes for
identification, assessment, management and escalation of risks and processes for maintenance
of the trust’s risk registers and the Board Assurance Framework (BAF). The risk management
strategy (including Policy and Procedure) was supported by relevant policies, such as the trust’s
incident management policy and procedure.
The risk management strategy defined the relevant roles and responsibilities for risk
management as follows:
• Chief Executive is the Accountable Officer with overall responsibility for risk management
in the Trust. The Chief Executive has responsibility for ensuring that it meets its statutory
and legal requirements.
• Chief Medical Officer (CMO) is the trust’s Executive Director with delegated responsibility
for risk management, ensuring that all risk policies are updated and in line with best
practice and/or legislation and that staff are supported in the implementation of the
organisation’s risk policies and processes.
• Chief Nurse has executive responsibility for Infection prevention & control and
Safeguarding.
• Associate Director of Governance & Quality provides the lead and expertise on risk
management and risk related issues.
• Head of Corporate Affairs supports the Chief Executive and the Chair, monitors and co-
ordinates the implementation of the statutory and legal provisions required within the trust,
including appropriate stewardship and board governance processes and advises on action
required.
• Health care group Associate Medical Directors/Associate Director of Nursing and
Associate Directors of Operations. The Health care group Associate Medical Directors are
responsible for ensuring that risks are appropriately managed within their health care
group according to the trust’s Strategy.
There were three types of risk that the trust expected to be identified and managed. These were:
• Strategic risks – Risks that directly threaten the organisation’s principal objectives. These
were recorded on the BAF and overseen at a strategic board level.
• Tactical/project risks - Short range risks, usually less than a year or those related to
specific projects that the trust might undertake within a defined period.
• Operational risks - Risks that arise from the day to day running of the trust across all
services and at the frontline. These are usually managed at service or health care group
level but where an operational risk or a combination of risks threatens achievement of a
strategic objective, its effect becomes strategic and is then escalated upwards as a
significant risk.
Trust corporate risk register

Whilst each health care group held a risk register, the trust held a significant risk register. This was
a snap shot in time of all risks scoring 15 or above across all risk registers held in the trust. It was
populated from risks identified across the health care groups and consisted of risks that had
breached the risk appetite trigger point and were being considered for board escalation.
The significant risk register was reviewed primarily by the trust’s risk management group.
Recommendations and suggested next steps were then presented to the senior management
team. The senior management team senior reviewed the risks bi-monthly prior to presenting them
to the board. Where there was a common theme from significant risks that had been escalated
from the health care groups onto the significant risk register, these were summarised and
escalated as a single significant risk to the board.
As part of our inspection, we reviewed the significant risk register and saw there were no risks
scoring 25. However, there were 74 significant risks with a score of 15 or more on the trust’s
significant risk register. There were 18 risks with a score of 20, 23 risks with a score of 16 and 33
risks with a score of 15.
We reviewed the report that was presented to the trust board on 4 April 2019 and found the report
had an executive summary, which included a comparison with the number and level of risk that
had been presented to the board in February 2019. The report indicated the number of risks with a
score of 20 had decreased from 20 to 18; whilst the number of risks with a score of 16 had
increased to 23 from 22 and the number of risks with a score of 5 had decreased from 37 to 33.
The report also detailed the key areas from the risks with a score of 20. This meant the board
were sighted on the most significant risks throughout the trust.
Information management
The trust had processes in place to ensure that the information used to manage, monitor and
report on performance and quality was accurate, reliable and validated. This included internal
and external processes.
The trust had a Senior Information Risk Owner (SIRO) who had overall responsibility for the
organisation's information risk policy. The SIRO was accountable and responsible for information
risk across the organisation.
The trust recognised the importance of protecting personal and confidential information and was
committed to ensuring that patient identifiable information was protected and as such had an
information governance strategy.
The law determines how organisations can use personal information. This is covered within the
General Data Protection Regulation (GDPR), UK Data Protection Law, the Human Rights Act,
Common Law Duty of Confidentiality and other Health Service legislation. In accordance with NHS
guidance, the trust had the relevant roles in place to effectively manage information. This included
a director of ICT/IMT, a data protection officer, a Caldicott guardian, a senior independent risk
owner (SIRO) and a chief nursing information officer, which was a new role since the acquisition.
The Caldicott guardian was also the chief medical director.
The Information Governance (IG) Toolkit is a self-assessment audit completed by every NHS
Trust and submitted to NHS Digital on 31 March each year. The purpose of the IG Toolkit is to
provide assurance of an organisation’s information governance practices. Level 2 compliance is
the minimum expected level within the toolkit. NHS Digital anticipates that trusts should be striving
for level 3 compliance where possible.
The Trust’s IG Toolkit publication score for 2017/18 was 82%, with no requirements showing
below level 2. The trust received an overall assessment of ‘satisfactory’ and continued to be rated
green.

The Trust had a clinically led electronic prescribing team who had rolled out a new electronic
medicines management, prescribing and administration systems across the trust to promote
patient safety in line with the Carter report.
The non-executive directors had access to the trust’s ‘Diligent Tool’ where they could access and
review trust reports and meeting information and papers. The non-executive directors told us they
felt supported with briefings being provided on important areas, such as the 10-year plan.
However, there was a general view that there was a need to strengthen and establish Key
Performance indicators (KPIs) for reporting within certain areas, such as on mortality, and a
general feeling that this information had to be requested by the non-executive directors on
occasion, rather than being provided automatically by the executive team.
Incidents, including serious incidents, were reported as required to the NHS National Reporting
and Learning System or the NHS Strategic Executive Information System in a timely manner.
Where required, the trust submitted notifications to the Care Quality Commission in line with their
statutory responsibilities.
Engagement
There was a high level of engagement with patients, staff, members of the public and local
organisations to plan and manage appropriate services. The trust also collaborated with
partner organisations effectively.
Managers at all levels shared leadership responsibilities to improve communication and coordinate
engagement activities between staff, patients and external stakeholders.
The trust was committed to ensuring that patients’ views and experiences were collected. A variety
of methods were used that included CQC national surveys, Friends and family test (FFT) and
patient led assessments of the care environment (PLACE).
Patient stories were presented at trust board and we saw evidence that changes to practice and
processes had been implemented as a direct result of patients sharing experiences at board
meetings.
The trust visited local secondary schools and sixth form colleges to introduce young people to
career opportunities in health and care. The approach was very much aligned with individual well-
being; raising aspirations and widening participation particularly for young people from a lower
socio-economic background. Each academic year the trust hosted around 180 work experience
students who had expressed an interest in a healthcare career.
The trust held staff recognition award ceremonies for positive contributions to services. Staff were
recognised for their contribution through the ‘employee of the month’ and ‘superstar of the month’
scheme.
The trust’s staff engagement score for the 2018 NHS staff survey was 3.82, which was a
significant increased from 3.27 in 2017. Staff we spoke with throughout our core service inspection
and prior to our inspection, through our core service groups told us they felt communication was
good throughout the trust. Staff were extremely positive about the open lines of communication
with senior leaders and the board, and we saw many examples of where improvements had been
maintained to ensure staff engagement.
Every Tuesday morning the executive team held an executive brief in the staff restaurant. This
was open to all staff. The briefing lasted approximately half an hour and gave the executive team
the opportunity to update staff with any significant news, make any special announcements and to
acknowledge any challenges across the trust. It also gave staff the opportunity to ask questions of
the executive team. The briefing was well attended by staff of all grades and all areas of the trust.

Staff we spoke with throughout our core service inspection told us the briefing session was useful
and was well attended.
The chief executive officer (CEO) sent out a weekly email update, which all staff had access to
and had a separate email address called ‘Ask Lance’ for any staff member to email them with any
query or concern. Staff consistently reported a quick response to any concerns raised.
The senior leadership team welcomed patient stories at the trust board meetings and welcomed
this as a way of sharing and learning from patient experiences.
The trust had a feedback Friday newsletter that was sent to staff weekly that had a message from
the trust’s chief executive officer, patient compliments, incidents and complaint information.
Although visibility and engagement were reported to be good at the Princess Alexandra Hospital,
the senior leadership team recognised that it needed to be improved to ensure they were more
visible to staff working across the other sites at the trust.
Recruitment and retention continued to be a concern throughout the trust and the trust had a
comprehensive retention improvement plan. In addition, the trust had introduced an initiative called
‘itchy feet’, which enabled staff who were thinking of leaving the trust to email a ‘stay@pah.nhs.uk’
email address to identify themselves to access a personal conversation about what might help
them to stay at the trust. In addition, the trust was also starting to run career clinics to identify
career opportunities for staff.
Throughout our well led inspection, the trust shared with us that they were undertaking some
market testing on the benchmarking of cost of domestic and cleaning services which had created
some concerns and anxiety amongst the trust staff employed within those areas. The trust had
recognised this and set up workshops to address these staff concerns and were working with the
unions, holding meetings every two weeks, to help ‘bust the myths’ which had developed following
this market testing work.
The Trust engaged with the local health economy and was part of the west Essex STP. The trust
worked closely with commissioners and partners to progress key pieces of strategic work to help
resolve the trust’s sustainability challenges. The trust realised it would struggle to resolve its
financial, demand and service needs on its own and that a system wide approach was required.
As set out in the STP called ‘A healthier future: Improving health and care in Herts & West Essex’,
the focus of collaborative working was on three key areas:
• Prevention - supporting communities to make the right lifestyle choices and helping people
with long term conditions to live as well as possible for as long as possible
• Integrated Primary and Community Care - supporting people to maintain their
independence by locating frequently used services close to where people live
• Acute Hospital Service - partnerships between the STP hospitals in order to support
improved patient care, clinical and financial sustainability and delivery of services more
efficiently
Within the West Essex system work had continued on developing an Integrated Care Partnership
(ICP) bringing together key elements of primary, community, secondary, social and mental health
services.
The Integrated care partnership (ICP) has identified a number of priorities to manage future
demand for the trust but also in developing a more integrated care model. Early transformational
changes were being focused on improving respiratory care, Musculoskeletal (MSK) and urgent
care services across the system. In addition, the trust continued to be actively involved in:
• Developing multi-professional neighbourhood teams and build Population Health

• Management infrastructure
• Managing demand and improve patient access to services moving care closer to home
where possible
• Improving service navigation and care transition across settings
• Reducing variation in care delivery and optimise the care management of complex patients
with long term conditions
• Strengthening the focus on community activation, well-being and prevention and supporting
people to lead healthier lives.
To support these ambitious plans, the trust recognised there was a need to address key
infrastructure requirements. The hospital estate within the West Essex and East Hertfordshire
health system had been a source of significant concern for several years. This was due to a
combination of the condition and capacity of the existing estate, the needs of the local population
over the next 20 years, and the plans of health leaders to transform the model of care provided to
patients under an ICP. The STP was actively supporting the trust to find a long-term sustainable
solution to their estates challenge and supported the submission of their strategic outline case to
build a new hospital.
Whilst the trust planned for a new hospital in the future, they continued to invest in the current
infrastructure and estate to support their people in the provision of high-quality care for their
patients and had invested a significant amount of capital money in their highest risk clinical areas,
including:
• A new paediatric emergency department

• Reshaping, resizing and refurbishing the adult emergency department
• Creating medical and surgical assessment facilities
• Creating an ultra-clean ward for elective orthopaedic surgery
• Improving outpatient facilities and waiting room facilities
• Adding a second maternity theatre
Learning, continuous improvement and innovation

The trust was committed to improving services by learning from when things went well and
when they went wrong, promoting training, research and innovation.
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that
measures whether the number of deaths in hospital is higher or lower than you would expect. For
the 12-month period from October 2017 to September 2018, HSMR was higher than expected with
a value of 123.15 (compared to 100 for England) and 1,052 deaths compared to an expected 854
deaths. HSMR has remained within the higher than expected banding since 2016. Weekend
HSMR was higher than expected for this time period.
At the time of our inspection, the trust had two active mortality alerts. One was for septicaemia
(except in labour) and the other was fractured neck of femur.
Because of concerns around mortality, the trust launched a mortality strategy and mortality
improvement board in December 2018.
In March 2017, the National Quality Board introduced new guidance for NHS providers on how
they should learn from the deaths of people in their care. This trust had put in place all the key
mandated requirements from the national guidance, with a learning from deaths policy being put in
place by June 2017 and data provided to the Board from December 2017. The executive lead for
learning from deaths was the trust’s chief medical officer.

The trust had a process in place for reviewing inpatient deaths in line with the National Quality
Board’s learning from deaths guidance. Mortality meetings happened monthly and were attended
by multidisciplinary staff to ensure that any learning was shared, and to improve practice. The trust
had a mortality improvement board with oversight of mortality across the trust. We saw effective
participation in and learning from internal reviews relating to mortality, the learning was shared and
used to make improvements within the service.
Complaints
The trust had a policy and procedure for responding to complaints and concerns, that set out the
responsibilities of all staff for dealing with complaints throughout the trust. The trust board was
accountable for ensuring that effective controls were in place to support the management of
complaints. The chief executive officer was the ‘accountable officer’ and the designated board
member responsible for ensuring compliance with the NHS Regulations 2009. The director of
nursing, midwifery and allied health professionals had board level responsibility for patient
experience, which included concerns and complaints management. This person was responsible
for reporting to the trust’s executives on the trust’s performance on complaints handling and
ensuring that, where lessons need to be learned and changes in practice were required, these
were implemented, evaluated and reviewed within stated timescales.
The trust had an associate director of patient experience and engagement who was responsible
for managing the trust’s complaints policy.
The trust had a complaints reference group. This was a subgroup of the patient panel, which had
been established to be the independent external scrutiny body for complaints made to the trust
by patients and their families. The complaints reference group reviewed a random selection of
anonymised and recently closed complaints provided to them by the patient engagement and
experience team to ensure that each complaint had been appropriately handled, within the
timescale laid down and that any faults that had been found had been corrected.
The governance of complaints was overseen through the quality and safety committee and at the
trust board meetings. A quarterly report and recommendations were made to the trust’s quality
and safety committee.
Complaints process overview
The trust was asked to comment on their targets for responding to complaints and current
performance against these targets for the last 12 months (December 2017 to November 2018).
Current
Question In days
performance
Three working
What is your internal target for responding to complaints? 95.9%
days
What is your target for completing a complaint? See below*
If you have a slightly longer target for complex complaints 99.6%
180 days
please indicate what that is here
Number of complaints resolved without formal process in the 2,835 (December 2017 to
last 12 months? November 2018)
*The trust noted that all deadlines for completion were agreed with their individual complainants.
However, they worked towards a target of 180 working days.
(Source: Routine Provider Information Request (RPIR) – Complaints Process Overview tab)

Number of complaints made to the trust
The trust received 241 complaints from December 2017 to November 2018. Medical care
received the most complaints with 30.3% of the overall complaints received by the trust.
Four core services accounted for 75.9% of complaints made to the trust: medical care, surgery,
urgent and emergency care and maternity. In addition, 1.7% of complaints could not be mapped
to a specific core service.
Number of Percentage
Core service
complaints of total
Medical care 73 30.3%
Surgery 52 21.6%
Urgent and emergency services 37 15.4%
Maternity 21 8.7%
Outpatients 20 8.3%
Gynaecology 14 5.8%
End of life care 9 3.7%
Services for children and young people 8 3.3%
Not core service specific 4 1.7%
Diagnostics 2 0.8%
Critical care 1 0.4%
(Source: Routine Provider Information Request (RPIR) – Complaints tab)
Compliments
From December 2017 to November 2018, the trust received a total of 2,691 compliments. Of
these 41.4% concerned surgery.
A breakdown by core service can be seen in the table below:
Core Service
compliments of total
Surgery 1,115 41.4%
Outpatients 466 17.3%
Medical care (including older people's care) 317 11.8%
Urgent and emergency services 277 10.3%
Services for children and young people 213 7.9%
Gynaecology 121 4.5%
Maternity 94 3.5%
Not core service specific 55 2.0%
Diagnostics 30 1.1%
Critical care 3 0.1%
(Source: Routine Provider Information Request (RPIR) – Compliments)
We reviewed complaints as part of our monitoring phase of this inspection and found the
processes were effective in dealing with complaints. The trust took complaints seriously, the
quality of complaint responses was good and there was a good oversight of complaints. The trust
had a genuine desire to learn from complaints.
Accreditations

NHS trusts participate in a number of accreditation schemes whereby the services they provide
are reviewed and a decision is made whether or not to award the service with an accreditation. A
service will be accredited if they are able to demonstrate that they meet a certain standard of best
practice in the given area. An accreditation usually carries an end date (or review date) whereby
the service will need to be re-assessed to continue to be accredited.
The table below shows which of the trust’s services have been awarded an accreditation.
Accreditation scheme name Service accredited

All pathology services had achieved UK
Clinical Pathology Accreditation and its
Accreditation Service (UKAS) accreditation as of
successor Medical Laboratories ISO 15189
April 2018
Joint Advisory Group on Endoscopy (JAG) Endoscopy unit – April 2018
(Source: Routine Provider Information Request (RPIR) – Accreditations tab)

Under the current trust leadership, several improvements had been made throughout the trust,
including investments in key clinical services such as a second operating theatre in maternity
services, changes to the emergency department and a new front entrance, which provided
additional facilities and services for patients, visitors and staff.
The pharmacy department had introduced specialist roles in critical care, gastroenterology and
rheumatology to support patient care. Pharmacists attended daily consultant ward rounds in
critical care to provided expert advice on medications, ensure correct choice and dose for critically
ill patients, in addition to bedside teaching of staff regarding medication matters.
The trust won the 2018 FabChange70 award for the second year in a row which was awarded to
the trust in relation to being an organisation whose energy, leadership and vision had empowered
staff to put their ideas into action and had embedded Quality Improvement (QI) as ‘the norm’
throughout their organisation.

Urgent and emergency care
Facts and data about this service
Details of emergency departments and other urgent and emergency care services
• Princess Alexandra Hospital emergency department

• Princess Alexandra Hospital paediatric emergency department
Urgent and emergency care services at the trust are provided 24 hours per day, 365 days per
year. The trust has a level 1 consultant led department with approximately 101,000 attendances
per year, of which approximately 25,000 are children. Last year, the department was refurbished
to support changes in patient flow, assessment and increase resuscitation capacity.
A separate paediatric emergency department facility is adjacent to the main department. This is
staffed by registered children’s nurses and treats children under the age of 16 years.
(Source: Acute Routine Provider Information Request (RPIR) – Context Acute tab)
Activity and patient throughput
From November 2017 to October 2018 there were 102,857 attendances at the trust’s urgent and
emergency care services as indicated in the chart below.
Total number of urgent and emergency care attendances at The Princess Alexandra
Hospital NHS Trust compared to all acute trusts in England, November 2017 to October
2018
(Source: Hospital Episode Statistics)

Urgent and emergency care attendances resulting in an admission
The percentage of accident and emergency (ED) attendances at this trust that resulted in an
admission remained similar in 2017/18 compared to 2016/17. In both years, the proportions
were slightly higher than the England averages.
(Source: NHS England)
Urgent and emergency care attendances by disposal method from November 2017 to
October 2018
* Discharged includes: no follow-up needed and follow-up treatment by GP

^ Referred includes: to ED clinic, fracture clinic, another OP, other professional
# Left department includes: left before treatment or having refused treatment
During our inspection we spoke with 46 members of staff including matrons, nurses, health care
assistants, doctors, junior doctors and consultants. We also spoke with housekeeping staff,
reception staff, the safeguarding lead for children, safeguarding adult nurse, advanced nurse
practitioners, psychiatric liaison staff, occupational therapists, physiotherapists, ward managers,
practice development nurse and ambulance staff from a local NHS Trust
We inspected the resuscitation areas, majors and minors, rapid assessment and treatment
(RAT), the clinical decisions unit (CDU), the paediatric emergency department and paediatric
ambulatory care area, the general practitioners (GP) minor treatment areas and reception areas.
We spoke with nine patients and relatives to ask about their experience of care.
We reviewed 35 sets of patient records in relation to their care, treatment and medication. We
also reviewed policies, procedures and guidelines within the emergency department and
reviewed equipment to ensure it was clean and serviced in line with manufacturer guidance.
Following our previous inspection in December 2017, we issued the trust with Requirement
Notices and told the trust it must make improvements in relation to:
• The trust must ensure that medication fridge temperatures are consistently monitored and
acted upon when concerns are identified.
• Medical records must contain a complete and contemporaneous record in respect of each
patient and that appropriate risk assessments are completed and documented.
• Staff must receive training to ensure competence in their role. In particular, but not limited
to; fire, safeguarding and infection prevention and control.
• The trust must ensure that patients arriving by ambulance to the emergency department
are appropriately assessed and triaged in a timely manner in accordance with Royal
College of Emergency Medicine (RCEM) guidelines.
We also told the trust that it should ensure staff undertake regular care rounds and emergency
care safety checklists are completed.
At our recent inspection in March 2019, we found the trust had addressed most of the points
within our requirement notices, however concerns remained regarding the completion of patient
records and risk assessments and staff training compliance.
Is the service safe?

By safe, we mean people are protected from abuse* and avoidable harm.
*Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or

discriminatory abuse.
Mandatory training
The service provided mandatory training in key skills to staff but did not ensure everyone
completed it.
Mandatory training completion rates
Princess Alexandra Hospital
The trust set a target of 90% for completion of mandatory training.
A breakdown of compliance for mandatory training courses as of October 2018 for qualified
nursing staff in Princess Alexandra Hospital’s emergency department is shown below:

As of October 2018
Training module name Staff Eligible Completion Trust Met
trained staff rate target (Yes/No)
Values & behaviours 62 62 100% 90% Yes
Adults & paediatrics basic life support 1 1 100% 90% Yes
Introduction to information governance 74 74 100% 90% Yes
Dementia awareness 62 62 100% 90% Yes
Learning disabilities awareness level 1 62 62 100% 90% Yes
Equality, diversity and human rights 62 62 100% 90% Yes
Conflict resolution 61 62 98.4% 90% Yes
Blood training for registered staff 59 62 95.2% 90% Yes
Fire - general awareness 59 62 95.2% 90% Yes
Moving & handling level 2 clinical 58 62 93.5% 90% Yes
Infection prevention & control level 2 57 62 91.9% 90% Yes
Immediate life support level 3 43 50 86% 90% No
Paediatric immediate life support 42 50 84% 90% No
In Princess Alexandra Hospital’s emergency department, the 90% target was met for 11 of the
13 mandatory training modules for which qualified nursing staff were eligible.
(Source: Routine Provider Information Request (RPIR) – Training tab)
Following the inspection, the trust provided updated data as of March 2019 showing the
following compliance for nursing and midwifery staff in Princess Alexandra Hospital’s
emergency department on the mandatory training modules by department:
Training module Paediatric A&E A&E Nursing ENP Service A&E Medical
Adults & paediatrics basic
life support n/a n/a n/a 100.0%
Blood training for
registered staff 78.6% 100.0% 100.0% 100.0%
Conflict resolution 92.9% 100.0% 100.0% 100.0%
Dementia awareness 92.9% 100.0% 100.0% 100.0%
Equality, diversity and
human rights 100.0% 100.0% 100.0% 100.0%
Fire - general awareness 85.7% 100.0% 100.0% 100.0%
Immediate life support -
level 3 n/a 78.0% 100.0% n/a
Infection prevention &
control - level 2 85.7% 97.6% 100.0% 100.0%
Introduction to information
governance 78.6% 100.0% 100.0% 100.0%
Learning disabilities
awareness level 1 92.9% 100.0% 100.0% 100.0%
Manual handling - level 1 n/a n/a n/a n/a
Moving & handling - level 2
clinical 92.9% 95.1% 100.0% 100.0%
Paediatric immediate life
support 92.9% 75.6% n/a n/a
Values & behaviours 100.0% 100.0% 100.0% 100.0%

(Source: Inspection data request DR040)
A breakdown of compliance for mandatory training courses as of October 2018 for medical staff
in Princess Alexandra Hospital’s emergency department is shown below:
As of October 2018
Manual handling level 1 1 1 100% 90% Yes
Fire - general awareness 34 39 87.2% 90% No
Conflict resolution 29 35 82.9% 90% No
Equality, diversity and human rights 32 39 82.1% 90% No
Blood training for registered staff 25 31 80.6% 90% No
Dementia awareness 28 35 80% 90% No
Values & behaviours 31 39 79.5% 90% No
Learning disabilities awareness level 1 25 34 73.5% 90% No
Adults & paediatrics basic life support 22 31 71% 90% No
Moving & handling level 2 clinical 23 33 69.7% 90% No
Introduction to information governance 24 40 60% 90% No
Infection prevention & control level 2 17 39 43.6% 90% No
In Princess Alexandra Hospital’s emergency department, the 90% target was met for one of the
12 mandatory training modules for which medical staff were eligible. The completion rate for
infection prevention and control level 2 was particularly low.
Following the inspection, the trust provided updated data as of March 2019 showing the
following compliance for medical staff in Princess Alexandra Hospital’s emergency department
on the mandatory training modules:
Training module Completion Trust Met Yes/No

rate Target
Manual handling - level 1 100.0% 90% Yes
Blood training for registered staff 87.1% 90% No
Conflict resolution 86.8% 90% No
Adults & paediatrics basic life support 85.3% 90% No
Values & behaviours 84.6% 90% No
Dementia awareness 81.6% 90% No
Learning disabilities awareness level 1 81.1% 90% No
Fire - general awareness 76.9% 90% No
Equality, diversity and human rights 76.9% 90% No
Introduction to information governance 71.8% 90% No
Moving & handling - level 2 clinical 67.6% 90% No
Infection prevention & control - level 2 48.7% 90% No
Data provided by the trust following our inspection showed the trust had made improvements in
staff training compliance since our inspection in December 2017. However, data showed that
medical staff were still not meeting the trust’s compliance target in 11 of the 12 mandatory
training fields.

Staff received training through on line learning, face to face training sessions and during mentor
sessions with nominated experienced staff. Most staff we spoke with were positive about the
trust’s training programme and could demonstrate how they could access a wide range of
learning materials on the trust’s intranet system. Some staff told us staff shortages had limited
their access to some training activities.
The service had one full time clinical educator working in the emergency department (ED) who
worked alongside staff to improve compliance with mandatory training and offer opportunities for
staff development. Staff told us this was beneficial in providing ongoing support and access to
learning.
All staff we spoke with understood the trust’s sepsis management process, when to implement
this and how to use the sepsis screening tool. The ED had a nurse sepsis champion who offer
additional advice and support to staff in recognising and treating suspected sepsis.
Medical staff we spoke with told us that teaching and training for doctors was positive at the trust.
Teaching sessions were delivered on set days and they were released from duty to attend
various clinical updates, and other core skills. Managers were responsive to requests for
additional training and staff valued the mentor days, which they felt added to their core skills and
provided opportunities to discuss any areas of interest and seek feedback on their current
competencies.
Safeguarding
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.
Safeguarding training completion rates
The trust set a target of 95% for completion of safeguarding training modules, apart from prevent
health WRAP training, where the target was 90%.
The tables below include prevent training as a safeguarding course. Prevent works to stop
individuals from getting involved in or supporting terrorism or extremist activity.
A breakdown of compliance for safeguarding training courses as of October 2018 for qualified
nursing staff in Princess Alexandra Hospital’s emergency department is shown below:
As of October 2018
Safeguarding children level 2 3 3 100% 95% Yes
Safeguarding adults level 2 60 62 96.8% 95% Yes
Prevent/health WRAP 59 62 95.2% 90% Yes
Safeguarding children level 3 55 59 93.2% 95% No

In Princess Alexandra Hospital’s emergency department the trust’s training targets were met for
three of the four safeguarding training modules for which qualified nursing staff were eligible.
Following the inspection, the trust provided updated safeguarding training data as of March
2019 for qualified nursing staff in Princess Alexandra Hospital’s emergency department:
As of March 2019
Safeguarding children level 2 3 3 100.0% 90% Yes
In Princess Alexandra Hospital’s emergency department, the 90% target was met for all four
safeguarding training modules for which qualified nursing staff were eligible. The completion
rates for the individual modules were similar to those in the previous time period.
(Source: Inspection data request)
A breakdown of compliance for safeguarding training courses as of October 2018 for medical
staff in Princess Alexandra Hospital’s emergency department is shown below:
As of October 2018
Training module name Staff Staff Completion Trust Met
trained eligible rate target (Yes/No)
Safeguarding adults level 2 23 39 59% 95% No
Prevent/health WRAP 19 35 54.3% 90% No
In Princess Alexandra Hospital’s emergency department the trust’s training targets were met for
one of the four safeguarding training modules for which medical staff were eligible.
2019 for medical staff in Princess Alexandra Hospital’s emergency department:
As of March 2018
Safeguarding adults level 2 25 39 64.1% 90% No
In Princess Alexandra Hospital’s emergency department, the 90% target was not met for any of
the four safeguarding training modules for which medical staff were eligible. However, with the
exception of the safeguarding children level 2 module, the rates had increased when compared

to the previous time period.
All five of the trust’s named professionals for safeguarding had completed level 4 training in
safeguarding.
Between October 2018 and March 2019, the trust had 156 adults and 28 children’s safeguarding
alerts in the ED.
Staff received training on how to recognise and report different forms of abuse, including domestic
violence, female genital mutilation (FGM), modern slavery, child sexual abuse and fabricated
illness amongst other key areas.
All staff knew and could explain to us their responsibilities in relation to FGM, how to contact the
safeguarding teams and make a safeguarding referral. Key guidance on safeguarding displayed
around the ED including posters advising patients on safer spaces to go, how to call the police
or speak members of staff. Safeguarding folders and information was available on the trusts
intranet site.
Staff used a paper-based referral system to record safeguarding concerns, completed an

electronic incident record and notified the local authority. Safeguarding concerns were flagged on
the trusts electronic patient record system. All staff we spoke with were clear on how to use the
safeguarding referral system.
All the staff we spoke with knew of the “Daisy Project” within the hospital, and its focus on
supporting victims of domestic violence and abuse. The Daisy project delivered training and
support to staff aimed at improving the health, wellbeing and safety outcomes of people attending
the department and their children. Posters were displayed throughout the department, advising of
the Daisy Project and safer spaces, encouraging anyone with concerns on domestic violence or
abuse to speak to a member of staff.
We reviewed the safeguarding teams annual audit plan for the 2019/20 which included the ED.
The safeguarding team did not complete any audits in 2018; all safeguarding reviews were local
to the department and discussed at safety huddles.
Staff could identify patients who attended the ED more frequently, as each ED attendance was
recorded within the patient electronic record. Children who attended the ED more than five times
in a 12-month period were automatically highlighted for a safeguarding review by staff and the
trust policies gave clear guidance to staff on how to follow up on any frequent attenders.
If staff were concerned about a possible non-accidental injury to a child, they immediately
referred this to a senior consultant and completed a referral form to the internal safeguarding
team. Staff policies also considered the needs of patients during pregnancy, and the unborn
child, as well as looking for patients who may have a mental health need and if these may place
a child or other family members at risk.
Staff we spoke with described the safeguarding team as engaged in ED day to day work, visible
within the department and always willing to offer advice or guidance. Safeguarding staff reviewed
patient records daily to look for any concerns and liaised with external agencies where
appropriate. For example, contacting the Police for a domestic violence issue.
Staff could download an NHS app to their mobile phone, which gave up to date details in relation
to safeguarding adults and children, including guidance on the types and recognition of abuse.
This meant that staff had access to guidance on safeguarding remotely through their mobile
phones.
Cleanliness, infection control and hygiene
The service controlled infection risk well. Equipment and premises were clean. Staff used
control measures to prevent the spread of infection.
Housekeeping staff were visible in the department throughout our inspection, engaged in cleaning
activities and emptying waste bins frequently during the day. We checked cleaning schedules and
noted records were up to date and reflected the various areas of the ED that required cleaning.
We also reviewed additional cleaning rotas supplied by the trust which showed staff completed
cleaning schedules in line with daily cleaning schedules. Staff used I am clean stickers to indicate
that cleaning had taken place, we noted these were in date and easily visible to staff.
Data supplied by the trust following our inspection showed hand hygiene compliance in the ED
was 91% in January 74% In February and 93% in March 2019. The trust aimed for an expected
compliance of between 95% and 100%. Staff explained that the compliance rate was affected by
the way the audit was carried out, and they had approached the infection control team to change
the audit process.
ED staffed carried out routine meticillin-resistant Staphylococcus aureus (MRSA) swabbing on
patients entering the ED. Data supplied by the trust post inspection showed compliance rates
routinely above 97%.
C.Difficile is a bacterium affecting the digestive system; it often affects people who have been
given antibiotics and has the capability of causing harm to patients. All patients were tested on
admission to the ED, none of the patients had been an inpatient at the trust in the six weeks prior
to ED admission. There were zero cases for ED and 21 cases attributed to the community.
Samples for analysis and diagnosis were either taken whilst the patient was in the ED or once they
arrived on a ward (within 3 days of admission).
Staff were aware of and practiced infection prevention and control in line with national guidance.
Handwashing facilities and hand sanitiser stations were readily available throughout the
department and the “Five Moments of Hand Hygiene” guidance was displayed at all hand washing
stations. Five Moments for Hand Hygiene defines the key moments for hand hygiene, overcoming
misleading language and complicated descriptions.
Hand washing facilities, alcohol gel and hand conditioner were available throughout the
department. We observed staff following hand hygiene, ‘Bare below the Elbow’ guidance, and
wearing personal protective equipment (PPE) such as gloves and aprons whilst delivering care in
line with the trust’s policy. The department had a plentiful supply of PPE and we observed staff
restocking this as required.
Clean linen was accessible and stored on covered trolleys. Staff told us that even in busy times
they could replenish their linen stock. All the store rooms we observed were clean, tidy and well
ordered.
Staff cleaned equipment thoroughly between patients to reduce the risk of cross contamination
and restocked equipment where appropriate.
The department had dedicated cubicles for patients with a possible infection. All patients were
screened as part of their initial assessment to assess whether they had any infections or had
visited any overseas locations. The trust had protocols in place to manage patients who may likely
pose a risk to others, including radiological, nuclear and biological
Staff we spoke with could explain the protocol for isolating patients with a possible infectious
disease. We observed appropriate signs for an infective patient being nursed in the ED and
reminding staff of the actions they must follow to minimise the risk of cross contamination.
All the disposable cubicle curtains we checked were clean and in date for renewal and disposal.

Environment and equipment
The service had systems, processes and practices in place to manage the environment and
equipment to keep people safe.
Since our last inspection, the trust had invested significantly in improving the physical environment
and creating clinical areas to deal with the increased demand in patients access the department.
This included completion of the paediatric ED and ambulatory care area, clinical decision unit
(CDU) and moving the GP service to an alternative location. This had helped to minimise
overcrowding within the ED and created additional space for patients waiting to be seen. The rapid
assessment treatment (RAT) team had dedicated escalation bays identified within the corridor
area adjacent to the RAT areas to guide ambulance staff on where to allocate patients waiting to
be seen at times of increased patient demand, this was an improvement on our last inspection.
There was a dedicated entrance for ambulance and air ambulance arrivals which led to the
resuscitation and RAT areas that enabled critically ill patients to be triaged and transferred to the
correct area. Patients self-presenting used the main reception areas for the ED. The main ED
entrance was staffed by the reception team 24 hours a day, seven days per week. Staff within
reception knew how to escalate concerns if a patient presented as seriously unwell.
Some areas of the ED were monitored by internal and external closed-circuit television (CCTV)
and access into the ED clinical areas was by swipe card to protect patient and staff safety.
The paediatric ED had its own dedicated entrance, this had CCTV and swipe card access.
Throughout our inspection we found the environment to be free from clutter. The layout of the
departments was appropriate for supporting easy access to diagnostic and imaging services. It
provided portable X-rays for adults and children. Staff were confident that access to computerised
tomography (CT) or magnetic resonance imaging (MRI) scans was not delayed when required for
urgent investigations. Staff told us that children using these facilities used the same entrance as
adult patients. However, patients were always escorted by a member of hospital staff when
requiring imaging services.
There was a dedicated room within the ED for patients requiring a mental health assessment This
room met the Royal College of Emergency Medicine (RCEM) mental health tool kit guidance for
improving care in emergency departments. The room also met the requirements of Health Building
Note Building Note 15-01: accident & emergency departments 17.9 (2013) which states an
interview room should be considered for use by staff for talking to disturbed and distressed
patients and relatives. The RCEM tool kit states any assessment area needs to be safe for staff,
and conducive to valid mental health assessment and importantly, the assessment room must be
safe for both the patient and staff. However, the trust was unable to demonstrate that any areas of
the ED had up to date environmental risk assessments for ligature points. This meant we were not
assured that patients likely to cause harm through use of a ligature would be safe if left unattended
within the department.
At the time of our announced inspection, the ED had one f ligature cutter for all the ED areas, this
was kept under lock and key and staff had to break a glass to retrieve the key and get the cutters.
We raised this as a concern because this would take additional time in an emergency. Normally
ligature cutters are either carried by staff or on resuscitation trolleys so that staff can easily find
them and use them quickly. The trust had a process for staff to follow in a ligature event, however
we did raise the location and access to ligature cutters with the trust during our inspection. At our
unannounced inspection on 9 April 2019, the trust had allocated ligature cutters to each area of
the ED. However, where they were stored was inconsistent. In resus they are stored in the control
drugs cupboard and in the top drawer of the resus trolley. In majors they were stored in a little box
with a key. In paediatrics they were stored in the bottom drawer of the resus trolley and in the drug
cupboard. The nurse in charge of each area knew where they were, but other staff were unsure.
The paediatric ED used a side room for supporting any patients with a mental health condition, but
also could utilise the room in the adult ED if necessary and if staff had completed the necessary
risk patient risk assessments. The trust had a dedicated risk assessment process for children who

may present with mental health needs, which gave staff clear guidance on how to manage the risk
of self-harm or harm to others.
We checked 20 items of electrical equipment and consumables within the department and found
that electrical equipment had been safety tested and serviced appropriately and consumables
were in date for use.
Staff had access to adequate supplies of available, accessible and suitable equipment, including
resuscitation equipment. There was a schedule for regular checks for equipment which had been
followed and recorded in all areas we inspected. Staff had used a highlighter pen to highlight dates
on equipment packaging to show clearly when consumables, for example catheters, or airway
equipment needed replacement.
All the department’s emergency resuscitation trolleys were tamperproof and records we reviewed
demonstrated that in January 2019, staff completed daily checks of emergency resuscitation
equipment.
The service had enough equipment specifically for accommodating bariatric (Clinically obese)
patients, including seating, trolleys, and wheelchairs however staff told us these had to be ordered
in.
Due to the separation of the adult and paediatric ED, there was clear audio and visual separation
between adults and children and appropriate seating and space for children and families to wait.
The trust had effective systems and processes in place for the segregation and management of
clinical and non-clinical waste. Staff had access to sharps bins throughout the department and we
found them to be labelled and dated in line with trust policy.
The cubicle curtains would collapse if pulled upon, to reduce the risk of ligature.
Assessing and responding to patient risk
Emergency Department Survey 2016
The trust scored worse than other trusts for two questions and about the same as other trusts for
the remaining three questions in the Emergency Department Survey relevant to safety.
Question Score RAG

Q5. Once you arrived at the hospital, how long did you wait
Worse than other
with the ambulance crew before your care was handed over 6.4
trusts
to the emergency department staff?
Q8. How long did you wait before you first spoke to a nurse Worse than other
5.2
or doctor? trusts
Q9. Sometimes, people will first talk to a nurse or doctor
About the same as
and be examined later. From the time you arrived, how long 6
other trusts
did you wait before being examined by a doctor or nurse?
Q33. In your opinion, how clean was the emergency About the same as
8.1
department? other trusts
Q34. While you were in the emergency department, did you About the same as
9.6
feel threatened by other patients or visitors? other trusts
(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)
Median time from arrival to initial assessment (emergency ambulance cases only)
It should be noted that the trust reported incomplete ED quality data to NHS Digital for the 12
months from January to December 2018. With the exception of November 2018, the trust
reported 15 or fewer total attendances to its emergency department for patients arriving by any
means for each of these months. In all cases this was contradicted by the trust’s submission to
ED situation reports, which showed thousands of attendances each month.
When only those attendances brought in by ambulance were analysed, the trust reported no data
for February and March 2018. Otherwise, with the exception of November 2018, the trust reported
fewer than six such attendances each month.
The trust’s median time from arrival to initial assessment for November 2018 was 13 minutes
compared to the England average of eight minutes.
(Source: NHS Digital - ED quality indicators)
Following the inspection, the trust provided the following data relating to the average time from
arrival to initial assessment for December 2018 to March 2019:
December January February March

A&E waiting times (minutes)
2018 2019 2019 2019
Arrival to triage 34 37 43 35
Please note that, due to possible differences in the methodology used, this data may not be
directly comparable to the analysis provided from NHS Digital.
Percentage of ambulance journeys with turnaround times over 30 minutes for this trust
From February to May 2018 there was a slight downward trend in the monthly percentage of
ambulance journeys with turnaround times over 30 minutes at Princess Alexandra Hospital from
77% in February 2018 to 69.3% in May 2018. There was then little change in the hospital’s
performance against this metric until January 2019, when performance deteriorated to 78.4%.
Ambulance: Number of journeys with turnaround times over 30 minutes - Princess

Alexandra Hospital

Ambulance: Percentage of journeys with turnaround times over 30 minutes - Princess
Alexandra Hospital
(Source: National Ambulance Information Group)
Number of black breaches for this trust
A ’black breach’ occurs when a patient waits over an hour from ambulance arrival at the
emergency department until they are handed over to the emergency department staff. From
December 2017 to December 2018 the trust reported 693 “black breaches”.
There was a dramatic improvement in May 2018, when the number of black breaches reported
by the trust reduced to 11 from 77 in April 2018. With the exception of July and November 2018,
this improvement was largely sustained over the subsequent seven months.
The trust reported that the factors influencing hand over delays were a combination of capacity
constraints within the organisation, including bed closures, secondary to infection prevention and
control (IPC) outbreaks or estates issues; nursing and medical staffing numbers across the
emergency departments and often within the wider hospital; demand exceeding supply; surges in
a local NHS Ambulance trust demand; and times when that trust had conveyed multiple patients
in one hour.

(Source: Routine Provider Information Request (RPIR) - Black Breaches tab)
Following our last inspection in December 2017, we told the provider that it must ensure patients
arriving by ambulance to the emergency department are appropriately assessed and triaged in a
timely manner in accordance with Royal College of Emergency Medicine (RCEM) guidelines.
During our recent inspection we found the trust had made improvements in the rapid assessment
and treatment of patients arriving by ambulance.
Clear streaming processes were in place for patients arriving on foot, by ambulance and air
ambulance and we reviewed the trust’s policy on deteriorating patients, which was in date and
reflected best practice guidance. This meant the trust had effective systems to identify patients
likely to be at risk of deterioration on arrival at the department.
The patient risk assessment documents identified the changing risks to patients, including
deteriorating health and wellbeing, medical emergencies or behaviour that challenges and staff
were able to seek support from a doctor who was assigned to the RAT area, usually between 9am
and 5pm. This was an improvement on our last inspection. The trust employed paramedics to
work in the RAT area. These members of staff worked alongside the RAT team to provide
oversight of patients waiting to be seen and could escalate any deteriorating patients to the
clinician in charge.
The trust used the national early warning score 2 system (NEWS2) for adult patients and the
paediatric early warning score (PEWS) for children. An early warning score is a guide used by
medical services to quickly determine the severity of illness of a patient. It is based on vital signs
such as respiratory rate, oxygen saturation, temperature, blood pressure, pulse and heart rate.
Staff completed NEWS and PEWS scores appropriately within the patient records we reviewed.
However, we did identify that staff did not always complete patient risk assessments fully, this was
a concern at our last inspection. The trust told us that their own records audit showed a 75%
compliance with completion of the documentation and they had an audit and staff education
process in place to specifically improve performance in this area. We did not find any incidents
related to patient harm because documentation was not completed.
The trust had introduced new patient risk assessment documentation, changed staff allocation and
improved the physical environment to provide timely triage and reduce the risk of overcrowding.
During our inspection we noted that most patients arriving by ambulance were triaged within 15
minutes meeting RCEM guidelines. This was an improvement since our last inspection. We did not
see any ambulances waiting significant periods to handover patients to trust staff.
Staff used the sepsis six bundle to assess patients arriving with possible sepsis or neutropenic
sepsis. Neutropenic sepsis is a life-threatening complication of anticancer treatment, the term is
used to describe a significant inflammatory response to a presumed bacterial infection in a person
with or without fever. Neutropenic patients carried a red card which gave them priority for
screening and treatment. Data supplied by the trust following inspection showed that between
September 2018 and February 2019 on average, 89% of patients received antibiotics within an
hour of arrival in the ED.
We tracked three patients with suspected sepsis and noted that staff completed the sepsis six
bundle correctly. The trust had installed a new blood screening machine in the adult emergency
department to reduce waiting times for screening and improved sepsis identification. If staff
identified a patient with possible sepsis, they bleeped the nurse in charge who would allocate an
additional nurse to support staff with that patient, complete the risk assessment and administer
antibiotics within an hour. Patient records we reviewed showed that patients received antibiotics
on time.
All areas where fully stocked with equipment, emergency trolleys and medicines to treat patients.
Patients who were critically ill or required resuscitation were brought directly into the resuscitation
area. This facility was appropriately equipped for the resuscitation of adults, and the paediatric ED
was appropriate for children and babies. If arriving by ambulance, ambulance staff telephoned
ahead, which enabled the department to prepare to receive the patients.
The trust had a process for screening patients for frailty which could trigger further multidisciplinary
team (MDT) assessments and referral to the frailty unit which could be accessed directly from the
adult emergency department.
The trusts hip fracture report from February 2019, shows that based on the National Hip Fracture
Database (NHFD) Best Practice Criteria, National Institute for Health and Care Excellence (NICE)
and NICE Clinical Guideline 124, NICE Quality Standard 16 and British Orthopaedic Association
and British Geriatric Society Blue Book patients should be transferred to an orthogeriatric unit
within 4 hours of admission to ED. Data showed that in October 2018, 72.7% of patents achieved
this standard. However, this figure declined to 42.1% in November 2018, 30.8% in December
2019, before increasing to 46.4% in January 2019. Data from February 2019 showed that only
12.5% of patients met this care standard.
Staff competed risk assessments for patients presenting with mental health conditions. The ED
had access to an adult psychiatric liaison service 24 hrs per day, seven days per week and was
based within the hospital. The psychiatric liaison team aimed to attend to patients referred to them
within an hour of referral, if the patient was intoxicated or unable to be assessed, the team
returned when it was suitable to do so. Paediatric ED staff had access to an external children and
adolescent mental health services (CAMHS) provided by a local mental health trust. Staff told us
that response to this service was variable due to capacity issues and sometimes patients had to
wait long periods to be seen. We asked the trust if they audited this process but however no data
was available following our inspection.
Information required to deliver care was available in a timely manner for example referring patients
for X rays, computerised tomography (CT) scans and blood results. Information required for
ongoing care was shared appropriately when patients moved between services
Data supplied by the trust following our inspection showed nursing staff achieved 100%
compliance with both adult and paediatric basic life support. Medical staff achieved 85.3%
compliance, which was lower than the 90% compliance target set by the trust.
Nurse staffing
The service did not have enough nursing staff with the right qualifications, skills, training
and experience to keep patient's safe from avoidable harm and to provide the right care
and treatment.
Planned vs actual

Princess Alexandra Hospital reported the following whole time equivalent (WTE) nursing staff
numbers in urgent and emergency care as of March and October 2018.
As of March 2018 As of October 2018

Reporting unit / team
Actual Planned Staffing Actual Planned Staffing
name
staff staff rate (%) staff staff rate (%)
ED staff 38.6 58.1 66.5% 41.9 73.7 56.9%
Emergency Nurse
Practitioner (ENP) 9.4 12.2 77% 7.7 12.2 63.2%
Service
Paediatric ED 11.4 13.6 83.8% 13.7 13.8 99.3%
Total 59.4 83.9 70.8% 63.4 99.8 63.5%
As of October 2018, the nursing staffing fill rate within urgent and emergency care at Princess
Alexandra Hospital was 63.5%. This was lower than the rate of 70.8% as of March 2018.
As of October 2018, the ED reporting unit, which accounted for the majority of qualified nursing
staff in urgent and emergency care at the hospital, had a very low fill rate of 56.9%.
(Source: Routine Provider Information Request (RPIR) – Total staffing tab)
The trust used a nationally recognised staffing tool to manage and plan staffing levels in line with
patient acuity. At the time of our inspection, the department was staffed according to the planned
rota. However, there were not always sufficient substantive qualified nurses and health care
assistants to staff all areas in the ED to trust’s specified level. The trust had a recruitment plan to
fill vacancies and used bank and agency staff to cover any shortfalls within the department.
The trust met the Royal College of Paediatrics and Child Health (RCPCH) standard of having two
registered children’s nurses on every shift.
Vacancy rates
From November 2017 to October 2018, Princess Alexandra Hospital reported a vacancy rate of
32.2% for qualified nursing staff in urgent and emergency care. This was approximately four
times higher than the trust target of 10%.
A breakdown of vacancy rates by ward and unit is below. There were very high vacancy rates
reported in some units. However, care should be taken when interpreting staffing rates due to
small numbers of staff in some teams.
Reporting unit / team name Annual vacancy rate

Emergency assessment unit 38.2%
ED staff 37.5%
ENP Service 26.3%
Paediatric ED 10.3%
(Source: Routine Provider Information Request (RPIR) – Vacancy tab)
Turnover rates

From November 2017 to October 2018, Princess Alexandra Hospital reported a turnover rate of
26.1% for nursing staff in urgent and emergency care. This was higher than the trust target of
10%.
A breakdown of turnover rates by reporting unit is shown below. There were very high turnover
rates reported in some units. However, care should be taken when interpreting staffing rates due
to small numbers of staff in some teams.
Reporting unit / team name Annual turnover rate

ED staff 28.8%
Paediatric ED 28.1%
ENP Service 11.3%
(Source: Routine Provider Information Request (RPIR) – Turnover tab)
Sickness rates
From November 2017 to October 2018, Princess Alexandra Hospital reported a sickness rate of
2.8% for nursing staff in urgent and emergency care. This was lower than the trust target of 3.5%.
A breakdown of sickness rates by reporting unit for each site is shown below.
Reporting unit / team name Annual sickness rate

ED staff 3.7%
ENP Service 1.2%
Paediatric ED 0.9%
(Source: Routine Provider Information Request (RPIR) – Sickness tab)
Bank and agency staff usage
It should be noted that the trust was unable to supply the total number of hours worked by all
permanent and temporary staff. Therefore, it was not possible to calculate the percentages of hours
worked by bank and agency staff and left unfilled.
The table below shows the numbers of nursing hours in urgent and emergency care at Princess
Alexandra Hospital from December 2017 to November 2018 that were covered by bank and
agency staff or left unfilled.
Over this time period 30,849.1 working hours were filled by bank staff and 22,212.7 were covered
by agency staff to cover sickness, absence or vacancy for qualified nurses. There were 23,516.2
hours that were unable to be filled by either bank or agency staff to cover sickness, absence or
vacancy for qualified nurses.
Over the same time period, 15,702.9 working hours were filled by bank staff and none were
covered by agency staff to cover sickness, absence or vacancy for non-qualified nurses. There
were 4,617.1 hours that were unable to be filled by either bank or agency staff to cover sickness,
absence or vacancy for non-qualified nurses.
Staff group December 2017 to November 2018

Not filled by bank
Bank usage Agency usage
or agency
Hours Hours Hours
Qualified 30,849.1 22,212.7 23,516.2
Non-Qualified 15,702.9 0 4,617.1
Total 46,552 22,212.7 28,133.3
(Source: Routine Provider Information Request (RPIR) - Nursing – Bank and Agency tab)
Medical staffing
The service had enough medical staff with the right qualifications, skills, training and
experience to keep patient's safe from avoidable harm and to provide the right care and
treatment.
Planned vs actual
Princess Alexandra Hospital reported the following WTE medical staff numbers in urgent and
emergency care as of March and October 2018.

Reporting unit / team
Actual Planned Staffing Actual Planned Staffing
name
ED medical staff 40.6 42.5 95.5% 46.1 44.5 103.6%
As of October 2018, the medical staffing fill rate within urgent and emergency care at Princess
Alexandra Hospital name was 103.6%. This was higher than the rate of 95.5% in March 2018
and indicated a slight over-establishment.
The trust was recruiting medical staff to ensure the department had established staff within the
medical team. The trust provided an ED consultant in the department from 8am to 12am seven-
days per week and ED consultant on-call from 12am to 8am which met the 16 hours consultant
cover per day recommended by the Royal College of Emergency Medicine (RCEM). Consultant
medical staff managed care throughout the department as needed and one consultant acted as
the emergency physician in charge of services.
Staff held ‘board rounds’ regularly throughout the day to discuss key issues in relation to patient’s
needs and safety as well as the flow through the department and bed state. Staff used this time
as an opportunity for more senior medical staff to encourage junior staff to discuss patient’s
needs, condition management, and the department situation.
The children’s emergency department saw approximately 25,000 patients a year that were less
than 17 years of age. The RCEM recommends that emergency departments seeing more than
16,000 children per year should have at least one paediatric emergency consultant. The trust
provided 24-hour paediatric consultant cover through an on-call rota.
Vacancy rates
4.2% for medical staff in urgent and emergency care. This was lower than the trust target of 8%.

A breakdown of vacancy rates by reporting unit is shown below. It should be noted that the trust’s
vacancies data includes two reporting units for medical staff in urgent and emergency care.
However, in the total staffing, turnover and sickness data, all medical staff in urgent and
emergency care are included in the “ED medical” reporting unit.
Reporting unit / team name Annual vacancy rate

ED medical staff 4.3%
Medical staffing – emergency assessment unit (EAU) 2.6%
Turnover rates
13.4% for medical staff in urgent and emergency care. This was higher than the trust target of
12%. All the staff were included under the ‘ED medical staff’ reporting unit.
The trust reported that their turnover data for medical staff did not include deanery trainee grades.
Sickness rates
1.9% for medical staff in urgent and emergency care. This was lower than the trust target of
3.5%. All the staff were included under the ‘ED medical staff’ reporting unit.
Bank and locum staff usage
permanent and temporary medical staff. Therefore, it was not possible to calculate the percentages
of hours worked by bank and locum medical staff and left unfilled.
The table below shows the numbers of medical hours in urgent and emergency care at Princess
Alexandra Hospital from December 2017 to November 2018 that were covered by medical bank
and locum staff or left unfilled.
Over this period 10,089.4 working hours were filled by bank staff and 5,983.3 were covered by
locum staff to cover sickness, absence or vacancy for medical staff.
The trust was unable to supply the numbers of medical staff hours that were unable to be filled by
either bank or locum staff over this period.
December 2017 to November 2018

Site name Bank usage Locum usage
Hours Hours
Princess Alexandra Hospital 10,089.4 5,983.3
(Source: Routine Provider Information Request (RPIR) – Medical Bank and Locum tab)
Staffing skill mix
As of November 2018, the proportion of consultant staff reported to be working in urgent and
emergency care at the trust was lower than the England average and the proportion of junior
(foundation year 1-2) staff was also lower than the England average.
Staffing skill mix for the 42 whole time equivalent staff working in urgent and emergency
care at The Princess Alexandra Hospital NHS Trust
This England
Trust average
Consultant 19% 30%
Middle career^ 21% 15%
Registrar group~ 46% 34%
Junior* 14% 21%
(Source: NHS Digital - Workforce Statistics - Medical (01/11/2018 - 30/11/2018)
Records
Staff did not always keep detailed records of patients care and treatment. However, records
were clear and easily available to all staff providing care.
The service used a blend of paper and electronic patient record systems and staff we spoke with
felt confident in using the systems. However, staff we spoke with agreed that with the number of
systems running side by side there was an opportunity for details to be missed.
The trust was aiming to reduce the number of paper-based records and increase the use of an
electronic system within the ED and was due to implement hand held electronic tablets for staff
use in April 2019.
From July 2018, each month the trust randomly selected 30 ED patient notes from the minors,
majors and resus areas of the ED. The audit referenced to eight of the Royal College of
Physicians (RCP) generic medical record keeping standards, including demography/sticker,
doctors name and grade, date, time management plan, legibility of writing and signature.
Data supplied by the trust following our inspection showed that in November 2018 13% of notes
were fully completed in line with RCP standards. In December 2018, 50% of notes were fully
completed. In January 2019, 83% of notes were fully completed and in February 2019, 57% of
notes were fully completed. To try and improve performance the trust had informed doctors and
about the standards required and carry out regular ED teaching sessions about documentation
standards, especially for new members of staff as well as conduct live audits.
We reviewed 35 sets of patient records, including seven in relation to children. All the records we
reviewed contained details of patients’ presenting conditions, medical history and current
medication. Risk assessments were not fully completed in 11 of the records we reviewed, this was
an issue at our last inspection.

Information required to deliver care was available in a timely manner for example when referring
patients for X rays and blood results. Information required for ongoing care was shared
appropriately when patients moved between services.
Paper based patient records were stored in key pad-controlled cabinets in between use by staff.
We noted throughout our inspection that staff ensured all paper-based patient records were stored
away and were diligent in ensuring cabinets were locked as appropriate.
Medicines
The service prescribed, administered, recorded and stored medicines well. Patients
received the right medication at the right dose at the right time.
Medicines were checked, managed, stored and disposed of safely. Controlled drugs (medicines
that require extra checks and special storage arrangements because of their potential for
misuse), were checked by two members of qualified staff twice a day in line with the trust’s
medicines policy and were stored correctly in a double locked cupboard.
Medicines used for emergencies were accessible, checked daily and stored in a tamper proof
way. Staff checked refrigeration temperatures in line with trust policy, and this was an
improvement from our last inspection. All medicines we randomly checked were within their
expiry dates. Oxygen cylinders were full and within their expiry date. Oral syringes were available
for the administration of oral liquid medicines
We reviewed 13 medication administration records and found that medicines were administered
in a timely manner. We noted throughout our inspection that staff administering medication
checked the patients name, date of birth and any allergies with the patient record to confirm the
right medicine was given to the right person at the right time.
There were trust protocols, for the administration and supply of certain medicines by nurses
under patient group directions (PGDs). PGDs are written instructions for the supply or
administration of medicines to groups of patients who may not be individually identified before
presentation for treatment. We reviewed the folder of PGDs, all were in date with authorisation
signatures in place. PGDs were used in the emergency department for analgesia (paracetamol,
ibuprofen etc), for adults only. The electronic prescribing and administration system restricted the
use to adults only but since there is a separate children’s ED open all the time there is no risk to
patients in this restriction. All PGDs were for the administration of one dose of analgesia, and
mostly used in the triage area of the department. S staff recorded the use of PGD’s on the
electronic prescribing medication administration (EPMA) record which was visible to prescribers
and so restricted the likelihood of duplication.
We reviewed four sets of monthly pharmacy audits in relation to the ED dating from December
2018 to March 2019. The pharmacy team highlighted any areas for concern to the ED staff team
and reviewed any actions at its next planned audit.
Incidents
The service reported safety incidents well, staff recognised incidents and reported them
appropriately.
Never Events
Never events are serious patient safety incidents that should not happen if healthcare providers
follow national guidance on how to prevent them. Each never event type has the potential to
cause serious patient harm or death but neither need have happened for an incident to be a
never event.

From February 2018 to January 2019, the trust reported no never events for urgent and
emergency care.
(Source: Strategic Executive Information System (STEIS))
Breakdown of serious incidents reported to STEIS
In accordance with the Serious Incident Framework 2015, the trust reported seven serious
incidents (SIs) in urgent and emergency care which met the reporting criteria set by NHS
England from February 2018 to January 2019.
The breakdown by incident type was as follows:
• Diagnostic incident including delay (including failure to act on test results): three serious
incidents (42.9%)
• Treatment delay: three serious incidents (42.9%)
• Blood product/ transfusion incident: one serious incident (14.3%)
Staff reported Incidents using a trust wide electronic system. All staff we spoke with understood
their responsibilities to raise concerns and to report safety incidents internally and externally.
Medical staff we spoke with told us they had received training and support on incident reporting
and using the trust electronic reporting system to report incidents.
Staff told us that they had the opportunity on the incident reporting system to request feedback at
the time of raising an incident.
We reviewed five incident reports and observed that these incidents were investigated by a
multidisciplinary team, a full root cause analysis had been undertaken and recommendations
identified. The ED clinical leads attended governance meetings and staff we spoke with told us
senior staff cascaded any learning from incidents back to the department. Staff told us that key
learning from incidents was communicated at team huddles, staff handovers, through the trusts
intranet, emails or face to face.
Duty of candour is a regulatory duty that relates to openness and transparency. It requires
providers of health and social care services to notify patients or other relevant people of certain
notifiable safety incidents and provide reasonable support to that person. The regulation requires
staff to be open, transparent, and candid with patients and relatives when things go wrong. Staff
we spoke with knew what duty of candour was and told us they would not hesitate in reporting
such incidents to a senior manager.
Mortality meetings happened monthly and were attended by multidisciplinary staff to ensure that
any learning was shared, and to improve practice. The trust had a mortality improvement board
with oversight of mortality across the trust. We reviewed three sets of mortality and morbidity
meeting records from September and November 2018 and January 2019. Meeting records
reflected learning from mortality and set actions with timescales for staff to make improvements
in the service.
Safety Thermometer
The service monitored performance and activity to understand risks and provide a clear
accurate picture of patient safety.
The Safety Thermometer is used to record the prevalence of patient harms and to provide
immediate information and analysis for frontline teams to monitor their performance in delivering
harm free care. Measurement at the frontline is intended to focus attention on patient harms and
their elimination.
Data collection takes place one day each month. A suggested date for data collection is given but
wards can change this. Data must be submitted within 10 days of the suggested data collection
date.
Data from the Patient Safety Thermometer showed that the trust reported one new pressure
ulcer, three falls with harm and two new urinary tract infections in patients with a catheter from
January 2018 to January 2019 within urgent and emergency care.
Prevalence rate (number of patients per 100 surveyed) of patient harms at The Princess
Alexandra Hospital NHS Trust
1
Total
pressure
ulcers
(1)
2
Total falls
(3)
3
Total CUTIs
(2)
1 Pressure ulcers levels 2, 3 and 4

2 Falls with harm levels 3 to 6
3 Urinary tract infections in patients with a catheter
(Source: NHS Digital - Safety Thermometer)
Is the service effective?

Evidence-based care and treatment
The service provided care and treatment that was planned and delivered in line with
current evidence-based guidance.
Emergency department (ED) staff could access local policies, guidelines and procedures on the
trust’s intranet. Guidance for staff was also placed next to work stations so staff could quickly find
them, for example standards around sepsis and resuscitation.

Policies and procures related to national and local guidance. For example, the deteriorating
patients’ policy related to the National Patient safety Agency (NPSA) 2007. Recognising and
Responding to Early Sign of Deterioration in Hospital Patients. The National Institute for Health
and Clinical Excellence (2012). NICE CG 50 Acutely Ill Patients in Hospital and Improving the
detection and response to patient deterioration (20011)
Care and treatment for example, mental health, pain, feverish children and head injury in adults
as was delivered in line with the National Institute of Health and Clinical Excellence (NICE) and
College of Emergency Medicine clinical standards (2014).
There were a range of clinical care pathways in use that aligned with national guidelines. We
reviewed three pathways: sepsis, asthma, and fractured neck of femur. These pathways were
multidisciplinary and up to date.
The department ensured care was provided in line with the ‘Clinical Standards for Emergency
Departments’ guidelines.
The ED used the “sepsis six-tool” interventions to treat patients and identify those at high risk.
The department monitored compliance which had improved since our last inspection in
December 2017. We reviewed the records of three patients who had presented as a risk for
sepsis and observed the sepsis bundle and treatment was given within the recommended
timeframe of an hour.
The physiotherapy and occupational therapy teams used equipment to enhance the delivery of
effective care and treatment and to support people’s independence. This included working with
the frailty team at the hospital and community-based therapy teams to source equipment, for
example walking frames to aid patient independence on discharge.
Staff followed NICE guidance CG138. This guidance relates to the patient experience in adult
NHS services and improving the experience of care for people using adult NHS services. Staff
handovers routinely referred to the psychological and emotional needs of patients, as well as
their relatives/carers. However, staff we spoke with during our inspection had varied levels of
understanding of the Mental Health Act 1983 (MHA) and MHA Code of Practice. Data supplied by
the trust following our inspection showed 64% of clinical staff had received training on the Mental
Health Act. The ED had a mental health champion who supported staff to provide additional
knowledge and understanding to improve patient outcomes.
Patients had access to information leaflets in relation to their condition and staff gave additional
advice to patients when they needed to seek further help and gave advice of what to do if their
condition deteriorated.
Older patients who were frail or vulnerable received a comprehensive assessment of their
physical, mental and social needs during initial assessment. Staff routinely referred patients who
were over 65 and frail directly to the frailty unit adjacent to the ED. Staff explained how this sped
up the assessment and referral process for frail patients as well as reducing their waiting time in
the ED.
Nutrition and hydration
Staff gave patients enough food and drink to meet their needs and improve their health.
In the CQC Emergency Department Survey, the trust scored 6.4 for the question “Were you able
to get suitable food or drinks when you were in the emergency department?” This was about the
same as other trusts.
Staff reviewed patient’s nutrition and hydration needs following the initial triage assessment. If it
was safe for patients to eat and drink, staff offered food and drink to meet their needs.
Since our last inspection, the trust had added a dedicated section within the patient care record,
asking staff if they had checked the patient’s nutrition and hydration during hourly comfort rounds.
This was an improvement from our last inspection. Staff also used a malnutrition universal
screening tool (MUST) as part of the patent risk assessment process.
We observed staff checking with patients and relatives if they needed food or drink. Patients we
spoke with told us they had been offered food and drink whilst in the department. One patient told
us they had breakfast and staff gave lots of options of what was available to eat and drink.
The trust also had vending machines for snacks and drinks in the reception areas and patients
and relatives could also access restaurants and food kiosks around the hospital site if they were
visiting for long periods.
We noted four occasions on the paediatric ED where staff had specifically asked children and
family members if they would like food and drinks whilst in the department, when it was clinically
safe to do so.
Pain relief
Staff assessed and monitored patients regularly to see if they were in pain.
In the CQC Emergency Department Survey, the trust scored 5 for the question “How many
minutes after you requested pain relief medication did it take before you got it?” This was about
the same as other trusts.
The trust scored 7.5 for the question “Do you think the hospital staff did everything they could to
help control your pain?” This was about the same as other trusts.
Staff monitored patients’ pain using pain assessment tools. They had a visual chart ranging from
zero to ten, zero being the least pain with a happy face and ten the worst the pain could be with a
very sad face. This was useful to use for children and patients with learning disabilities or for those
with impaired communication or cognitive impairment.
We noted throughout our inspection that staff routinely asked patients if they were in pain and
when they were, staff responded promptly.
Nurses could administer simple pain relief (analgesia) under a patient group direction (PGD) which
permits suitably trained staff to supply prescription-only medicines to groups of patients, without
individual prescriptions.
We observed a patient with an acute medical condition being supported by the staff team. The
doctor clearly explained the patient’s condition to them, and the patient said their pain was
increasing. The doctor immediately explained the best action would be to increase the level of
medication, review the level of pain again and then explained what action they would take if the
pain continued to increase.

Patient outcomes
RCEM Audit: Moderate and acute severe asthma 2016/17
In the 2016/17 Royal College of Emergency Medicine (RCEM) Moderate and acute severe
asthma audit, Princess Alexandra Hospital’s emergency department failed to meet any of the
national standards.
The department was in the lower UK quartile for one standard:
Standard 2a (fundamental): As per RCEM standards, vital signs should be measured and
recorded on arrival at the emergency department. This department: 12%; UK: 26%.
The department’s results for the remaining six standards were all within the middle 50% of
results.
(Source: Royal College of Emergency Medicine)
RCEM Audit: Consultant sign-off 2016/17
In the 2016/17 Consultant sign-off audit, Princess Alexandra Hospital’s emergency department
failed to meet any of the national standards.
The department’s results for all four standards were all within the middle 50% of results.
The trusts urgent care board (UCB) oversaw all improvement projects including those
associated with recommendations from national audit results. The UCB oversaw the introduction
of the rapid assessment and treatment (RAT) process, along with the completion of a workforce
review for the medical and nursing rosters. Changes have included improving the method of
identifying senior review. Working towards increasing the number of senior doctors on shift in
the department (including consultants) at any one time and provide senior medical presence at
the front door. The trust was also considering ways of identifying unscheduled returns and
ensure junior doctors are aware of these standards.
This RAT standard operating procedure was devised to describe the structured way patients
were received and assessed within the ED. The purpose of the SOP was to provide a
standardised procedure for the clinical assessment of patients using a nationally recognised
RAT model, including those patients who presented with sepsis, moderate and acute asthma.
The ED has adopted a senior decision maker led approach to promote patients being assessed
quickly and encourage staff to devise and implement a patient care plan at the earliest
opportunity.
In addition the trust has been working with national teams such as ECIST (Emergency Care
Intensive Support Team) to review the medical workforce in the ED.
RCEM Audit: Severe sepsis and septic shock 2016/17
In the 2016/17 Severe sepsis and septic shock audit, Princess Alexandra Hospital’s emergency
department failed to meet any of the national standards.
The department was in the lower UK quartile for three standards:
• Standard 1: Respiratory rate, oxygen saturations (SaO2), supplemental oxygen requirement,

temperature, blood pressure, heart rate, level of consciousness (AVPU or GCS) and capillary
blood glucose recorded on arrival. This department: 26.6%; UK: 69.1%.
• Standard 2: Review by a senior (ST4+ or equivalent) emergency department medic or

involvement of critical care medic (including the outreach team or equivalent) before leaving
the emergency department. This department: 48.4%; UK: 64.6%.
• Standard 5: Blood cultures obtained within one hour of arrival. This department: 17.5%; UK:
44.9%.
The department’s results for the remaining five standards were all within the middle 50% of
results.
The trust appointed an ED consultant as sepsis ED lead in summer 2018. The trust sepsis six
protocol is included at the beginning of the ED patient assessment booklet and a senior nurse
on duty in ED carried the sepsis bleep to promote early assessment and support for any patient
who may have sepsis.
Lactate measurement, oxygen prescription and administration are part of the sepsis six protocol.
The antibiotic policy for the trust informs staff on the best antibiotics to be used and was
available on the trusts intranet. The Trust sepsis protocol states that urine output must be
measured, and staff are trained to consider catheterisation if a patient cannot pass urine or
cannot recall when they have last past urine. The ED sepsis protocol triggers for all patients
with a national early warning score greater than three to have sepsis screening.
Sepsis leaflets are available in ED and throughout the organisation for patients and their
relatives.
The sepsis protocol defines the pathway for patients who have sepsis to improve outcomes for
patients.
The trust has provided a range of education and training events to raise awareness of sepsis
throughout the trust. This has included “tea trolley” training that visited all clinical areas with
sepsis training and stood regularly in the organisation for staff and patients. All clinical areas
had sepsis champions updated and supported by the trust’s sepsis lead and the critical care
outreach team.
Trauma Audit and Research Network (TARN)
The table below summarises Princess Alexandra Hospital’s performance in the 2016 Trauma
Audit and Research Network audit. The TARN audit captures any patient who is admitted to a
nonmedical ward or transferred out to another hospital (e.g. for specialist care) whose initial
complaint was trauma (including shootings, stabbings, falls, vehicle or sporting accidents, fires or
assaults).
Comparison
Metrics Hospital Meets national
to other
(Audit measures) performance standard?
trusts
Case Ascertainment
(Proportion of eligible cases reported to
TARN compared against Hospital
41.6-48.7% n/a 
Episode Statistics data)
Crude median time from arrival to CT
scan of the head for patients with
Takes longer
traumatic brain injury
(Prompt diagnosis of the severity of 62 minutes
than the
TARN 
traumatic brain injury from a CT scan is
aggregate
critical to allowing appropriate treatment
which minimises further brain injury.)
Crude proportion of eligible patients
receiving Tranexamic Acid within 3
hours of injury Lower than
(Prompt administration of tranexamic 66.7% the TARN n/a
acid has been shown to significantly aggregate
reduce the risk of death when given to
trauma patients who are bleeding)
Crude proportion of patients with
severe open lower limb fracture
receiving appropriately timed Higher than
surgery (Outcomes for this serious type 50% the TARN 
of injury are optimised when surgery is aggregate
carried out in a timely fashion by
appropriately trained specialists.)
Risk-adjusted in-hospital survival
rate following injury
(This metric uses case-mix adjustment
2.2 additional Similar to
to ensure that hospitals dealing with
survivors expected ✓
sicker patients are compared fairly
against those with a less complex case
mix.)
(Source: TARN)
Following the inspection, the trust provided updated audit data from the Trauma Unit Dashboard
for 2018/19 quarter 2 (July to September 2018). This showed the following:
Metrics Hospital National

Audit rating
(Audit measures) performance mean
Similar to
TU01 Quality of patient data submitted to TARN 96.4% 95.7%
expected
Much worse
TU02a All TARN eligible patients submitted 42.7% 76.7%
than expected
TU02b All TARN eligible patients submitted
Similar to
within 40 days of discharge or death (excluding 34.7% 36.5%
expected
coroner’s cases)
TU03 Proportion of patients meeting NICE head
Similar to
injury guidelines that receive CT scan within 60 66.7% 52.9%
expected
minutes of arrival at trauma unit
TU04 Trauma units administer Tranexamic Acid
within three hours of incident to patients that Much better
100.0% 70.0%
receive blood products within six hours of than expected
incident

TU05a Trauma units deliver consultant led
trauma teams within 30 minutes with Pre-Alert Similar to
60.0% 44.9%
and/or Trauma Team and injury severity score expected
(ISS) greater than 15 patients
TU05b Trauma units deliver consultant led
Better than
trauma teams within 30 minutes for patients with 43.8% 19.5%
expected
ISS greater than 15
TU06a Trauma units deliver grade specialty
registrar (STR) 3 or above led trauma teams on Similar to
50.0% 55.2%
arrival for Pre-Alert and/or Trauma Team expected
patients
TU06b Trauma units deliver grade STR 3 or Better than
32.3% 16.4%
above led trauma teams on arrival expected
TU07a Rapid access to specialist major trauma
Similar to
centre care - patients transferred to major 100.0% 69.4%
expected
trauma centre within 12 hours of referral request
TU07b Rapid access to specialist major trauma
Similar to
centre care - patients transferred to major 100.0% 84.3%
expected
trauma centre within two days of referral request
TU08 Proportion of patients with a Glasgow
Coma Scale (GCS) less than nine with definitive Worse than
0.0% 32.7%
airway management within 30 minutes of arrival expected
in emergency department
TU09 Proportion of directly admitted patients
Better than
receiving CT scan within 60 minutes of arrival at 37.0% 22.1%
expected
trauma unit
TU 10 Proportion of patients with an ISS of
Similar to
more than eight that have a rehabilitation 34.8% 35.1%
expected
prescription completed
Unplanned re-attendance rate within seven days
It should be noted that although the trust reported incomplete ED quality data in relation to
unplanned re-attendances to NHS Digital for the 12 months from January to December 2018 the
data was incomplete. This was due to an issue at NHS Digital and was out of the trust’s control.
With the exception of November 2018, the trust reported 15 or fewer attendances to its
emergency department for each of these months. In all cases this was contradicted by the trust’s
submission to ED situation reports, which showed thousands of attendances each month.
From January to October 2018 the trust reported no data for unplanned re-attendances to its ED
within seven days. In December 2018 there were fewer than six re-attendances within seven days,
and therefore the rate for this month was suppressed.
The trust’s unplanned reattendance rate within seven days for November 2018 was 8%
compared to the England average of 8.2% minutes.
Following the inspection, the trust provided updated data in relation to unplanned re-attendance
rates within seven days for December 2018 to March 2019:
Month Unplanned re-attendance rate within seven days

December 2018 7.0%

January 2019 7.6%
February 2019 7.0%
March 2019 6.9%
* Please note that March 2019 only includes data up to 26 March 2019.
Competent staff
The service made sure staff were competent for their roles.
Appraisal rates
From April to October 2018, 88.8% of staff within Princess Alexandra Hospital’s emergency
department received an appraisal compared to a trust target of 90%.
The breakdown by staff group is shown in the table below.
April to October 2018

Staff group Appraisals Eligible Completion Trust Met
required staff rate target (Yes / No)
Other qualified scientific, 2 2 100% 90% Yes
therapeutic & technical staff
Medical staff 17 17 100% 90% Yes
Qualified allied health 1 1 100% 90% Yes
professionals
Qualified nursing staff 46 50 92% 90% Yes
Support to doctors and 37 46 80.4% 90% No
nursing staff
Total 103 116 88.8% 90% No
The 90% completion target was met for both medical and qualified nursing staff. All medical staff
and 92% of qualified nursing staff had received an appraisal.
(Source: Routine Provider Information Request (RPIR) – Appraisal tab)
Patients had their needs assessed, preferences and choices met by staff with the right skills and
knowledge.
Staff learning needs were identified and agreed during appraisal, supervision or in sessions with
mentor. Staff we spoke with during our inspection were positive regarding their training needs and
how their mangers provided them ongoing support to achieve their competencies and training
needs. Staff saw appraisals as an opportunity to discuss ongoing development needs and any
issues staff had within their roles or generally work-related issues within the departments.
Staff told us that mangers encouraged and gave them opportunities to develop new skills. Doctors
we spoke with said that medical staff were extremely supportive and gave them opportunities to
challenge their competencies in live work activities to embed additional teaching they had
received.
The trust had qualified nurses specifically to support patients with learning disability and dementia.
Staff we spoke with throughout our inspection were clear on their roles in relation to supporting
patients who may need additional support.
Doctors we spoke with told us they had access to training appropriate to their roles and
responsibilities. The trust provided teaching days on a weekly basis and encouraged all doctors to
attend and update their competences and skills. Doctors told us they were given lots of
opportunities to practice competencies in live work situations and received feedback from their
supervisors on how they had performed and any areas where improvement was needed. The
doctors valued this live work opportunity, as they felt supported and able to develop their skills.
The trust provided additional evidence to show how it supported staff to complete core
competencies including understanding hand hygiene and use of protective clothing, nutrition,
pressure ulcer care, continence and bowel care and obtaining vital signs amongst other core
competencies.
Multidisciplinary working
Staff of different specialities worked together as a team to benefit patients.
Throughout our inspection we noted positive and mutually respectful multidisciplinary team (MDT)
working across the ED. The MDT staff developed their own patient documentation that worked
alongside ED records and gave additional advice to staff on care pathways and condition
management.
We spoke with occupational therapy and physiotherapy staff, who were very positive about their
relationships with the ED teams and were able to explain how they worked together to improve
patient outcomes and how they used links with community-based staff and resources to
coordinate patient care and where possible speed up safe patient discharge.
The ED had strong links and relationships with the psychiatric health liaison team, who provided
support to the adult ED. The teams had good working relationships and communicated together
regularly to plan patient care and treatment.
Seven-day services
Key services were available seven days a week to support patient care.
The adult ED, paediatric ED and the clinical decisions unit (CDU) were open 24 hours a day,
seven days a week. Patients arrived by ambulance, on foot or as a referral from their general
practitioner. The ED had 24-hour access to pathology, and diagnostic tests such as, blood tests, x-
rays, computed tomography (CT) scans and magnetic resonance imaging (MRI) scans.
The chaplaincy service was available 24 hours a day seven day a week.
Health Promotion
Staff were proactive in supporting patients to live healthier lives.
Staff understood the needs of patients with long term health conditions who may repeatedly attend
the ED and those who may have compromised immune systems.
The ED had an end of life care champion, to offer support and guidance to staff when dealing with
patients who may be at the end of their life. Staff understood the do not attempt cardiopulmonary
resuscitation (DNA CPR) process for patients who may have advanced decisions around their
care and treatment.
The multidisciplinary team (MDT) worked closely with patients to offer additional guidance on
condition management and worked with the community-based health care staff and general
practitioners to provide ongoing treatments and support.
Staff we spoke with were aware of national priorities to improve the population’s health, for
example, smoking cessation, obesity, drug and alcohol dependency, dementia and cancer.
Leaflets and guidance were displayed around the department for these conditions and staff
explained how they would refer patients for additional support if required.

Consent, Mental Capacity Act and Deprivation of Liberty safeguards
Staff obtained consent to care and treatment in line with legislation.
Mental Capacity Act and Deprivation of Liberty training completion
Training in Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) is covered
within the trust’s safeguarding adult level 2 training module. A specific course in MCA and DoLS
is available to staff that want to enhance their safeguarding skills but is not offered as part of the
trust’s standard training package.
A breakdown of compliance for safeguarding adults level 2 training as of October 2018 for
qualified nursing staff and medical staff in urgent and emergency care at Princess Alexandra
Hospital is shown below. The completion target for this module is 95%.
As of October 2018
Staff Completion Trust Met
Staff group trained Eligible staff rate target (Yes/No)
Qualified nursing staff 60 62 96.8% 95% Yes
Medical staff 23 39 59% 95% No
In urgent and emergency care the target was met for safeguarding adults level 2 training for
qualified nursing staff. However, the target was not met for medical staff.
Data supplied by the trust showed nursing staff had achieved 96.8% compliance with Mental
Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (2009) (DoLS) training.
Medical staff achieved 59% compliance, which was a small increase on the data supplied for
October 2018, but still below the 90% compliance target set by the trust. All staff we spoke with
understood their roles and responsibilities in relation to MCA and DoLS.
The trust had an up to date and version-controlled policy for MCA and DoLS and staff knew to
access this on the trust’s intranet.
Staff understood their roles and responsibilities under the Children’s Act (2004), however there
was varied understanding of staff in relation to the Mental Health Act (MHA) (1983).
We observed staff routinely asking patients for consent prior to care and treatment.
Staff we spoke with in the paediatric ED understood the importance of the law relating to Fraser
guidelines and Gillick competencies when caring for a patient under the age of 16. The Fraser
guidelines refer specifically to consent for sexual health services and are an additional guideline to
the Gillick competency framework that relates to consent for any healthcare intervention. There
were no examples to review during our inspection.
Is the service caring?

Compassionate care
Staff treated patients with compassion, dignity and respect during interactions.

Friends and Family test performance
The trust’s urgent and emergency care Friends and Family Test response rate was 20.9% from
January to December 2018.
The trust’s urgent and emergency care Friends and Family Test performance (% recommended)
was consistently better than the England average from January to December 2018.
The trust’s performance was consistently higher than 85%, and higher than 90% in all but two
months (January and May 2018). There was an overall improvement in the trust’s performance,
from 89.7% in January 2018 (compared to the England average of 86.4%) to 98.8% in December
2018 (compared to the England average of 86.5%).
ED Friends and Family Test performance - The Princess Alexandra Hospital NHS Trust
(Source: NHS England Friends and Family Test)
Updated analysis received on inspection for January and February 2019, showed that the trust’s
urgent and emergency care Friends and Family Test performance (% recommended) had
decreased from 98.8% in December 2018 to 90.9% and 90.2% in January and February 2019,
respectively.
In January 2019 the urgent and emergency care Friends and Family Test response rate was only
0.2%, based on 11 of the 4,640 eligible patients responding, while 15.8% of patients responded in
February 2019.
We observed examples of staff responding with kindness when patients needed help and
support, even during exceptionally busy periods. Staff offered reassurance to patients who were
in pain or frightened.
Reception staff were welcoming, kind and offered patients clear guidance on waiting times and
who would be assessing them.

All patients we spoke with told us staff were very helpful and caring and they were treated
respectfully.
We spoke with one patient who told us staff had been kind, and that no judgements had been
made on their condition, and this had reduced their anxiety during treatment.
Staff recognised patient’s individual needs and we noted on the paediatric emergency
department (ED) that children were treated with kindness and patience. We discreetly observed
calm, kind conversations between staff, children and their parents during assessments and
treatments.
Staff offered care that was kind and promoted dignity. Where patients were receiving care and
treatment in cubicles we observed staff closing curtains to protect people’s privacy and routinely
asking for consent prior to undertaking examinations or treatment.
Staff in the ED worked with patients who presented with behaviours that staff might find
challenging. We observed one patient who had been left to sleep due to alcohol intoxication, staff
carried out care rounds and took on board the patients request for privacy, whilst maintaining
oversight of their wellbeing.
Emotional support
Patients were given support to cope emotionally with their care, treatment or condition.
We routinely observed staff asking patients and their relatives if they needed any additional
support and where possible staff involved patients and their relatives in decisions about care and
treatment.
We spoke with four patients and relatives of patients who all told us staff had explained
treatments and care in a way that their child could understand.
Patients we spoke with told us staff kept them updated about their condition, treatment plans, and
prognosis.
Patients could access the hospitals chaplaincy team, who would visit patients and family to
provide religious or pastoral support at times of need, for example and unexpected death.
We observed a patient who became upset during their treatment, staff offered appropriate
support and time to explain what was happening and gave reassurance and kindness.
Understanding and involvement of patients and those close to them

Staff involved patients and those close to them in decisions about their care, treatment and
changes to the service.
The trust scored worse than other trusts for three of the 24 Emergency Department Survey
questions relevant to the caring domain and about the same as other trusts for the remaining 21
questions.
The trust’s performance for question 10, patients being told how long they would have to wait to
be examined, was particularly poor, scoring 2.7 out of 10.
Trust
Question 2016 RAG
2016
Q10. Were you told how long you would have to wait to be 2.7 Worse than

Trust
Question 2016 RAG
2016
examined? other trusts
Q12. Did you have enough time to discuss your health or medical About the same
8.2
problem with the doctor or nurse? as other trusts
Q13. While you were in the emergency department, did a doctor or
About the same
nurse explain your condition and treatment in a way you could 8
as other trusts
understand?
About the same
Q14. Did the doctors and nurses listen to what you had to say? 8.7
as other trusts
Q16. Did you have confidence and trust in the doctors and nurses About the same
8.3
examining and treating you? as other trusts
Q17. Did doctors or nurses talk to each other about you as if you About the same
9.1
weren't there? as other trusts
Q18. If your family or someone else close to you wanted to talk to a About the same
7.6
doctor, did they have enough opportunity to do so? as other trusts
Q19. While you were in the emergency department, how much About the same
8.4
information about your condition or treatment was given to you? as other trusts
Q21. If you needed attention, were you able to get a member of Worse than
7
medical or nursing staff to help you? other trusts
Q22. Sometimes in a hospital, a member of staff will say one thing
About the same
and another will say something quite different. Did this happen to 8.8
as other trusts
you in the emergency department?
Q23. Were you involved as much as you wanted to be in decisions About the same
7.8
about your care and treatment? as other trusts
Q44. Overall, did you feel you were treated with respect and dignity About the same
8.5
while you were in the emergency department? as other trusts
Q15. If you had any anxieties or fears about your condition or About the same
6.5
treatment, did a doctor or nurse discuss them with you? as other trusts
Q24. If you were feeling distressed while you were in the About the same
5.5
emergency department, did a member of staff help to reassure you? as other trusts
Q26. Did a member of staff explain why you needed these test(s) in About the same
8.1
a way you could understand? as other trusts
Q27. Before you left the emergency department, did you get the About the same
7.8
results of your tests? as other trusts
Q28. Did a member of staff explain the results of the tests in a way About the same
8.9
you could understand? as other trusts
Q38. Did a member of staff explain the purpose of the medications About the same
9.2
you were to take at home in a way you could understand? as other trusts
Q39. Did a member of staff tell you about medication side effects to About the same
4.8
watch out for? as other trusts
Q40. Did a member of staff tell you when you could resume your About the same
5.6
usual activities, such as when to go back to work or drive a car? as other trusts
Q41. Did hospital staff take your family or home situation into About the same
4.7
account when you were leaving the emergency department? as other trusts
Q42. Did a member of staff tell you about what danger signals
About the same
regarding your illness or treatment to watch for after you went 5.2
as other trusts
home?
Q43. Did hospital staff tell you who to contact if you were worried
About the same
about your condition or treatment after you left the emergency 6.5
as other trusts
department?
Worse than
Q45. Overall... (please circle a number) 7.4
other trusts
Throughout our inspection, we observed staff introducing themselves and their role to patients
they were caring for within the ED.
We heard staff explaining care and treatment plans in a way that people could understand and
engaging with family members.
Patients and their relatives told us staff listened to and involved them in their care and treatment.
Patients, carers and those close to them were encouraged to be active partners in their care.
Staff routinely explained their actions to patients and encouraged them to make decisions about
their care and treatment.
We observed several examples where patients and those close to them had been involved in their
care and treatment, for example we saw a patient who had a do not attempt cardiopulmonary
resuscitation (DNACPR) order in place. Staff involved in the patients care explained all their
actions and engaged with the patient and their family to discuss their care and treatment whilst
respecting their decisions.
We observe the care of a child in the paediatric ED, who had presented with a chesty cough and
feeling generally unwell. Staff explained fully what the procedure would be, distracted the child
whilst carrying out assessments and offered the opportunity for the parents to ask questions and
participate in the assessment process.
Is the service responsive?

Service delivery to meet the needs of local people
Services were tailored to meet individual needs and person-centred pathways involved
other providers.
Information about the needs of the local population was used to inform service planning and
delivery. The trust was involved with local commissioners and other health care providers
working together to provide urgent and emergency care to patients.
Since our last inspection the trust had increased the size and capacity within its emergency
department (ED) based on the needs of the local population. The clinical decisions unit and
paediatric emergency department were fully functional and the minor injuries and general
practitioner (GP) services had moved out of the adult ED, which lessened crowding and improved
space within the ED.
All ambulatory patients arrived at the front door of the ED and were triaged by a member of
streaming staff who ensured each patient was directed to the area of ED that best met their
needs. This ensured that patients moved to appropriate areas and were aware of where they
needed to go to be seen. The paediatric department had an ambulatory care area which had
increased staff ability to offer appointments and treatments to meet the needs of parents and
families.
The trust had several working groups and committees for example the learning disability steering
group and dementia steering group and patient panel to gain feedback on its service and make
reasonable adjustments to meet the needs of patients and their families.
The environment of the ED was suitable to meet the needs of patients with a physical and/or
learning disability. Staff we spoke with told us they would request the learning disability nurse or
dementia nurse to visit if they needed support with a patient.

Throughout the ED there was adequate seating available for patients and patients had access to
vending machines for food and drink.
Emergency department staff attended monthly meetings with the police, paramedics, fire brigade,
crisis team, dementia service, alcohol liaison nurses to discuss the needs of patients with mental
health needs and how to tailor services to demand.
Meeting people’s individual needs

The service demonstrated a pro-active approach to understand the needs of the different
patient groups to deliver care to meet those needs, which is accessible and promotes
equality.
Staff we spoke with told us that translators were offered to patients whose first language was not
English. The provider used a translation service for patients whose first language was not
English.
The trust referred patients with drug and alcohol dependencies to a service in the community.
Information about the community support service was available for patients.
There were processes in place to support patients with a learning disability. Staff told us they
could request the support of a learning disability nurse if required. Staff explained how they
reviewed the ‘This is me’ documentation (this provided professionals with information about the
person with a disability and/or health condition which caused communication difficulties). Staff
used an electronic flag system within the patient records to identify patients who may need
additional support.
Staff we spoke with were aware of how to support patients living with dementia. Staff knew where
the resources to support patients living with dementia were located. The adult ED had designated
private cubicles which used a blue forget-me-not sign to show they were designated for this
purpose. The living with dementia resources contained various aids designed to reduce anxiety
for a patient living with dementia and staff we spoke with knew how to use these when supporting
patients.
The trust provided relatives and friends of patients carrying out roles as carers with a carer card.
The carer card entitled relatives and carers for patients to flexible visiting hours to meet the
needs of the patient. Staff we spoke with throughout our inspection had a very open approach to
family and carers supporting patients in the department.
We spoke with the trusts dementia lead who had implemented a virtual dementia training
package. The training used sensory equipment to enable staff to experience some of the
challenges patients and families living with dementia may face, for example the impact on loss or
change of vision, touch and spatial awareness.
The psychiatric health liaison team provided support to ED. The teams had good working
relationships and communicated together regularly to plan patient care and treatment.
The paediatric ED had access to play specialists, located in the children and young people’s
department at the hospital. This enabled specialist staff to assist patients in the use of distraction
techniques and play.
Bariatric equipment used to support clinically obese patients could be requested by staff. We
noted that in the minors waiting area, a comfortable arm chair specifically for use by bariatric
patients was always available.

The ED offered a wide range of information booklets throughout all its departments, designed to
support patients to self-manage conditions and minor injuries, for example ankle injury, sprain
and strain. However, none of these were in other accessible formats, for example Braille or for
people who used English as a second language.
The adult ED had introduced a toilet and changing area specifically to meet the needs of people
with disabilities who may need additional support. This is part of a national initiative called
“Changing Places”. People with profound and multiple learning disabilities, as well people with
other physical disabilities such as spinal injuries, muscular dystrophy and multiple sclerosis often
need extra equipment and space to allow them to use the toilets safely and comfortably. These
needs are met by “Changing Places” toilets and the ED had developed one of its toilets
specifically for this purpose.
The trust scored about the same as other trusts for the three Emergency Department Survey
questions relevant to the responsive domain.
Question – Responsive Trust 2016 2016 RAG

Q7. Were you given enough privacy when discussing your About the same as
7.4
condition with the receptionist? other trusts
Q11. Overall, how long did your visit to the emergency About the same as
6.5
department last? other trusts
Q20. Were you given enough privacy when being About the same as
8.6
examined or treated? other trusts
Access and flow
People could not always access the service when they needed it.
Median time from arrival to treatment (all patients)
It should be noted that although the trust reported ED quality data to NHS Digital, for the 12
months from January to December 2018 the data was incomplete. This was due to an issue at
NHS Digital and was out of the trust’s control. With the exception of November 2018, the trust
reported 15 or fewer attendances to its emergency department for each of these months. In all
cases this was contradicted by the trust’s submission to ED situation reports, which showed
thousands of attendances each month.
The figures shown in the chart below should therefore be treated with caution as, with the
exception of November 2018, they are based on incomplete data and, therefore, a small sample of
the patients that attended ED. In January, February, June and July 2018 there were fewer than six
eligible patients for this indicator, and therefore the rates for these months were suppressed.
The Royal College of Emergency Medicine recommends that the time patients should wait from
time of arrival to receiving treatment should be no more than one hour. The trust met the
standard in three of the eight months where data were available from January to December 2018.
In December 2018 the median time to treatment was 48 minutes compared to the England
average of 60 minutes.
Median time from arrival to treatment from January 2018 to December 2018 at The
Princess Alexandra Hospital NHS Trust

Following our inspection, the trust provided some additional information on their A&E waiting
times for December 2018 to March 2019:

2018 2019 2019 2019
Arrival to triage 34 37 43 35
Triage to exam 94 106 118 118
Exam to referral to specialty 83 85 97 97
Referral to seen by specialty 82 84 85 85
Seen by specialty to decision to admit 97 105 109 109
Please note that, due to differences in the methodology used, this data may not be directly
comparable to the analysis provided from NHS Digital.
Percentage of patients admitted, transferred or discharged within four hours (all

emergency department types)
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 February 2018 to January 2019 the trust consistently failed to meet the standard and also
consistently performed worse than the England average.
From February to October 2018 there was a trend of improvement in the trust’s performance
against this metric. However, this was followed by a deterioration in performance, from 85% in
October 2018 (compared to the England average of 89%) to 68% in January 2019 (compared to
the England average of 84%).
Four hour target performance - The Princess Alexandra Hospital NHS Trust

(Source: NHS England - ED Waiting times)
Percentage of patients waiting more than four hours from the decision to admit until being
admitted
From February 2018 to January 2019 the trust’s monthly percentage of patients waiting more
than four hours from the decision to admit until being admitted was worse than the England
average in 10 out of 12 months.
From February to August 2018 there was a trend of improvement in the trust’s performance
against this metric. However, this was followed by a deterioration in performance, from 9.6% in
October 2018 (compared to the England average of 12.3%) to 39.1% in January 2019 (compared
to the England average of 20.1%).
Percentage of patients waiting more than four hours from the decision to admit until being
admitted - The Princess Alexandra Hospital NHS Trust
The table below shows the numbers of patients waiting more than four hours from the decision to
admit to being admitted by month:
Month Number of patients waiting more than four hours to admission

February 2018 898
March 2018 893
April 2018 687
May 2018 454
June 2018 318
July 2018 489
August 2018 184
September 2018 339
October 2018 241
November 2018 608
December 2018 552
January 2019 862
(Source: NHS England - ED Waiting times).
Following the inspection, the trust provided updated data in relation to the average waiting time
from decision to admit to departure from A&E for December 2018 to March 2019:

2018 2019 2019 2019
Decision to admit to departure 209 312 308 308
Please note that, due to possible differences in the methodology used, this data may not be
directly comparable to the analysis provided from NHS Digital.
Number of patients waiting more than 12 hours from the decision to admit until being
admitted
Over the 12 months from February 2018 to January 2019, 210 patients waited more than 12
hours from the decision to admit until being admitted. The highest numbers of patients waiting
over 12 hours were in March (88) and April 2018 (99).
Month Number of patients waiting more than 12 hours to admission

February 2018 14
March 2018 88
April 2018 99
May 2018 2
June 2018 0
July 2018 0
August 2018 0
September 2018 0
October 2018 0
November 2018 0
December 2018 6
January 2019 1
(Source: NHS England - ED Waiting times)
Percentage of patients that left the trust’s urgent and emergency care services before
being seen for treatment
It should be noted that although the trust reported ED quality data to NHS Digital, for the 12
months from January to December 2018 the data was incomplete. This was due to an issue at
NHS Digital and was out of the trust’s control. With the exception of November 2018, the trust
thousands of attendances each month. In addition, in January and December 2018 there were
fewer than six eligible patients for this indicator, and therefore the rates for these months were
suppressed.
From February to October 2018 the trust reported that no patients left its emergency department
without being seen. However, this data was based on only a small sample of the patients that
attended the trust’s ED.
In November 2018 the percentage of patients that left the trust’s urgent and emergency care
services before being seen for treatment was 5%, compared to the England average which was
1.9%.
Following the inspection, the trust provided updated data in relation to the percentages of
patients that left the trust’s urgent and emergency care services before being seen for treatment
for December 2018 to March 2019:
Month Percentage of patients left before treatment

December 2018 4.1%
January 2019 3.4%
February 2019 4.5%
March 2019 3.8%
* Please note that March 2019 only includes data up to 26 March 2019.

Median total time in ED per patient (all patients)
It should be noted that the trust reported incomplete ED quality data to NHS Digital for the 12
months from January to December 2018. With the exception of November 2018, the trust
thousands of attendances each month.
The figures shown in the chart below should therefore be treated with caution as, with the
exception of November 2018, they are based on incomplete data and, therefore, a small sample
of the patients that attended ED. In January, June and July 2018 there were fewer than six
eligible patients for this indicator, and therefore the rates for these months were suppressed.
From February 2018 to January 2019 the trust’s monthly median total time in ED for all patients
was higher than the England average for eight of the nine months for which data were available.
In December 2018 the trust’s monthly median total time in ED for all patients was 216 minutes
compared to the England average of 158 minutes.

Median total time in ED per patient - The Princess Alexandra Hospital NHS Trust
Following the inspection, the trust provided updated data in relation to the median total time in
A&E (in minutes) for December 2018 to March 2019:

2018 2019 2019 2019
Median total time in A&E per patient 195 200 217 188
Please note that, due to differences in the methodology used, this data may not be directly
comparable to the analysis provided from NHS Digital.
Throughout our inspection we observed that patients had access to timely initial assessment, test
results, diagnosis, and treatment. Changes in the rapid assessment and treatment (RAT) process
and the move of the minor injuries and general practitioner (GP) services had been influential in
supporting patient to receive a timely triage.
Patients with the most urgent needs had their care and treatment prioritised, and risk
assessments clearly identified those patients likely to deteriorate or in need of immediate urgent
care. The RAT area was over seen by a doctor between 9am and 5pm most days, and the trust
had employed additional paramedics within the RAT area to aid with the assessment and
improve the flow of patients entering the department by ambulance. We spoke with staff who told
us that in busy times if there was a delay in getting patients off the ambulance, medical staff
would assess the patient within the ambulance which ensured the sickest patients were
prioritised for treatment this also avoided delays in patients receiving a medical assessment.
Data supplied by the trust following inspection showed that between September 2018 and
February 2019 on average, 82% of patients were assessed within 15 minutes of arrival within the
ED.
The clinical decision unit (CDU) and ambulatory care unit within the paediatric emergency
department had increased the trust capacity and reduced crowding in the major and minor areas.
The paediatric ambulatory care unit enabled paediatric patients to return for follow on treatments
at agreed times, when staff were available to deal with any specific medical needs.

At the time of our inspection, the ED saw between 300 and 350 patients each day. However, the
department was not over crowded, staff were clear on their designated roles and responsibilities
and encouraged other specialities to review patients to assist flow across the hospital. Mangers
within the ED were clear that flow was a whole hospital issue and worked closely with colleagues
across the hospital to manage bed allocation and discharge patients safely.
We observed flow being monitored by ’Patient Trackers’, this was a new role since our last
inspection. The trackers worked across the ED to ensure clinically stable patients were referred
for a surgical or medical assessment as appropriate. We observed the trackers throughout our
inspection and found them liaising with other teams to ensure patients were being reviewed in a
timely manner and moved to the appropriate departments in the hospital. This role assisted with
the departmental flow and helped to further reduce breaches associated with the four-hour
standard.
Walk in patients arriving at the ED reception were initially streamed by streaming nurses, this
enabled staff to stream patients to the right department for the right treatment. The streamers
could direct patients to the GP services on site for minor treatment and assessment reducing
crowding in the ED. The minor’s area within the main adult ED had nine seats for patients who
were deemed fit to sit to be seen by staff, we noted throughout our inspection that walk-in
patients were often directed to this area to wait to be seen after their initial assessment.
Staff completed an initial risk assessment that identified any patients who may have mental
health needs. Staff could complete the assessment and then complete an additional mental
health triage form prior to referring the patients to the mental health teams. The records we
reviewed in relation to patients with mental health needs showed these patients were seen by the
mental health team within two and four hours of referral.
Learning from complaints and concerns
The service managed and responded to concerns and complaints.
Summary of complaints
From December 2017 to November 2018 the trust received 37 complaints about urgent and
emergency care at Princess Alexandra Hospital (15.7% of total complaints received by the
hospital).
The trust took an average of 57.4 days to investigate and close complaints. They noted that all
deadlines for completion were agreed with their individual complainants, however they worked
towards a target of 180 days.
A breakdown of complaints by department is shown below. The detail of the complaints relating
to general medicine, general surgery and ophthalmology indicate that the issues arose in ED.
Department Number of complaints Percentage of total

Emergency department 27 73%
General medicine 3 8.1%
Emergency ambulatory care & acute medicine 2 5.4%
Paediatrics ED 2 5.4%
General surgery 2 5.4%
Ophthalmology 1 2.7%
Total 37 100%

A breakdown of complaints by subject is shown in the table below:
Subject Number of complaints Percentage of total

Patient care 17 45.9%
Communications 8 21.6%
Admissions and discharges (excluding delayed
5 13.5%
discharge due to absence of a care package)
Privacy, dignity & well being 3 8.1%
Integrated care (including delayed discharge
1 2.7%
due to absence of a care package)
Access to treatment or drugs 1 2.7%
Waiting times 1 2.7%
Values & behaviours (staff) 1 2.7%
Total 37 100%
The trust had a complaints policy which ensured that systems and processes were in place to
enable patients and relatives to make a complaint. Information about how to complain was
available in the ED. Staff understood their responsibilities to support people to complain.
All staff we spoke with were aware of the complaints process and where to direct patients to if they
could not resolve the complaint within the department. Staff explained they would try and resolve
complaints locally if possible but understood the importance of escalating concerns when
necessary.
Staff received feedback from complaints in team huddles, supervision and through email if
appropriate. If learning was identified from any complaints this was shared amongst the staff team.
We noted that some complaints related to incidents that had occurred within the department were
still under investigation. The managers could identify which complaints were active and knew the
actions being taken by the trust.
Number of compliments made to the trust
From December 2017 to November 2018 there were 277 compliments about urgent and
emergency care at Princess Alexandra Hospital.
The trust noted that the most common theme resulting from 2,400 compliments received trust
wide in a year was care and caring (586 compliments), followed by being friendly (446
compliments), helpfulness (332 compliments), explanations (288 compliments) and being kind
(202 compliments).
(Source: Routine Provider Information Request (RPIR) – Compliments tab)
Is the service well-led?

Leadership
Managers at all levels in the service had the right skills and abilities to run a service
providing high-quality sustainable care.
The emergency department had an established leadership structure that included the emergency
department consultant, associate medical director, head of operations, interim service manager,
associate director of nursing, ED matron and the practice development nurse.

All staff we spoke with across the ED valued the management and leadership team, stating they
felt valued and part of a wider team.
Leaders within the emergency department understood and could tell us the challenges that the
department faced, including risks. All the leaders and mangers we spoke with were passionate
about delivering high quality care to patients, whilst supporting and leading operational staff to
achieve this.
The trust’s management structure and emergency department structure was clearly displayed in
prominent areas around the emergency department (ED). All staff we spoke with knew who the
local and senior leadership team were and how to access them.
The nurse and clinician in charge allocated staff to specific areas in the department at the
beginning of each shift. Senior nursing staff maintained regular oversight of demand in the
department throughout the shift to move staff to areas of high demand. The nurse in charge within
the majors area was clearly visible, wearing an arm band to signify their role within the
department. We routinely observed the nurse and clinician in charge giving clear direction and
motivating the staff team towards achieving positive outcomes for patients.
Vision and strategy
The service had a vision for what it wanted to achieve and workable plans to turn it into
action.
The trust had an overarching vision, “Achieving excellence, living our values” and to be an
excellent provider of integrated acute services. Five strategic goals underpinned the trust values
which were for staff to be respectful, caring, responsible and committed when carrying out their
role.
All staff we spoke with in the ED knew the trust values and we noted the trust’s values were clearly
displayed in prominent areas throughout the ED.
The staff induction handbook contained a local vision for the emergency department, which aimed
to create the best ED in the area and encouraged staff to always put the patient first. Staff we
spoke with within the adult ED knew this vision and were proud to work in the ED.
Culture
Managers across the service promoted a positive culture that supported and valued staff,
creating a sense of common purpose based on shared values.
Throughout our inspection we spoke with staff from all disciplines all of who were committed to
providing excellent care for patients and supporting each other.
Staff told us they felt very supported and valued in their roles, by staff of all grades and we noted
consistent mutually respectful interactions between staff. Staff described an open culture where
they felt able to raise concerns and suggestions to managers who staff described as
approachable, interested and willing to provide them with advice and support at any time.
Staff were very proud of the care they provided, and of the resources they had. The improvements
in the physical environment had created a strong sense of ownership within the team, who felt the
changes had lifted staff morale and created a pleasant working environment for patients and staff.
Staff described leaders as always prepared to go the extra mile, willing to be involved in day to
day work and not afraid to do any tasks however menial, in ensure patients and staff were
supported.
There was a high level of enthusiasm and motivation for working in the department. Staff knew
they had shortages in the work force, but they knew the recruitment plans were in place and were
confident that the management team listened to their concerns and supporting them to recruit new
staff.
Staff told us the matron and clinical lead were both highly respected and valued members of staff
and that they were welcome to ideas and suggestions to improve the department.

Governance
Governance arrangements are proactively reviewed and reflected best practice. A

systematic approach was implemented to work with other organisations to improve patient
experiences and outcomes.
The trust had an established governance system and all staff we spoke with knew how the various
quality and assurance groups fed into the governance structure.
The medical health care group (MHCG) met monthly to review details from the trust quality and
safety meetings which also occurred monthly. The urgent care board met weekly to discuss issues
that affected performance and patient care, and the senior clinicians met fortnightly for the same
purpose.
The urgent care operational team, ED team and ED patient safety and quality group met weekly,
and shared key information with the MHCG. Mortality and morbidity meetings occurred monthly
and minutes from these meetings along with any actions were scrutinised by the MHCG.
Meetings had an agreed clinical governance agenda and minute action log template for
department clinical governance meetings and agreed template reporting from these meetings to
divisions.
The trust had a mortality improvement board with oversight of mortality across the trust. We
reviewed three sets of mortality and morbidity meeting records from September and November
2018 and January 2019. Meeting records reflected learning from mortality and set actions with
timescales for staff to make improvements in the service.
The service had good systems to identify risks, plan to eliminate or reduce them, and cope
with both the expected and unexpected
The trust identified its risks by using a trust board assurance framework (BAF). The trust executive
directors reviewed the BAF risks allocated to them regularly, usually once a month while the trust
board received and reviewed the BAF bi-monthly.
Risks identified at health care group level (across wards and services), were escalated via health
care group (HCG) governance processes to the trusts associate medical director, associate
director of operations and the associate director of nursing through regular reviews at the health
care group governance meeting via the HCG risk register.
We reviewed the ED risk register and found this to be up to date, with named staff allotted to each
risk and clear timescales for improvement, as well as mitigation to manage any risk. Risks
included the amount of qualified nursing and medical staff in the ED, the timely completion of
discharge summaries, overcrowding, and patient safety during periods of high demand during the
offloading of ambulances.
Staff fed risks identified at committees or other groups to the relevant HCG or escalated risks to
the trust’s risk management group (RMG). We noted in meeting minutes from the RMG that the
RMG and performance review panels, patient quality and safety group and the quality and safety
committee challenged the health care and corporate groups on the identification and management
of risks. The RMG checked that all risks in the HCG register were updated on a regular basis and
met monthly to review and challenge risks. All HCG risks were reviewed by the group on a
rotational basis.

Staff within the ED completed training to deal with major incidents. Data provided by the trust
following our inspection showed 85% compliance with major incident training and exercises.
Topics covered in training included command and control, incident response and triage, chemical,
biological, radiological and nuclear (CBRN) response and table top exercises.
The service collected, analysed, managed and used information well to support all its
activities, using secure electronic systems with security safeguards.
The trust had arrangements to ensure the availability, integrity and confidentiality of identifiable
data, records and data management systems and these were in line with data security standards.
The trust had arrangements to ensure that the information used to monitor, manage and report on
quality and performance was accurate, valid, reliable, timely and relevant. Information was shared
via team meetings, on the internal trust dashboard, and at governance and mortality and morbidity
meetings. Senior staff we spoke with during our inspection understood key performance data and
how this was used to drive improvement. Staff within the department were aware of internal
performance standards and worked with other teams meet performance standards.
The trust had effective arrangements to ensure data and notifications were submitted to external
bodies, for example the CQC, and Clinical Commissioning Groups.
Staff used information technology systems effectively to monitor and improve the quality of care.
The ED had an abundance of computer work stations on wheels, which enabled staff to access
key patient information across the department. Staff ensured that monitor screens were locked
when not in use, and we noted staff usually used the screens facing away from patients, so no
information could be seen by the patient themselves.
The trust considered people’s views on quality, operations and finances. The trust held annual
general meetings throughout the year to encourage stakeholders and the public to feedback on its
service and performance.
The majors area contained an information screen with non-identifiable patient information which
enable staff to see what patients were arriving and their planned destination within the department.
This meant that staff had oversight of a patients position and destination within the department, so
they could allocate resources effectively.
Nurses and medical staff had access to information technology systems to track patients through
journey in the emergency department. All receptionists and clinical staff had access to this system.
The trust was due to implement staff hand held tablets during April 2019, to enable staff access to
patient information at the bed side. The trust used an electronic flagging system to identify patients
who were vulnerable or those who were living with complex needs, this enabled staff to quickly
identify patients who may need additional support.
Doctors working in ED were with local guidelines and had ready access to these on the trusts
intranet and in some cases, these were in folders near work stations, for example in the paediatric
emergency department high dependency bays. Staff knew when and how to access more senior
or specialist advice promptly. This was in line with Royal College of paediatrics and Child Health
Standards for Children and Young People in Emergency Care Settings 2012.
Staff we spoke with explained that they had limited access to records in relation to patients with
mental health needs, once they had been handed over to the mental health teams. Staff
understood the reason for this but felt this could be an issue if the patient was a frequent attender.
Staff had access to policies, procedures and clinical guidance through the trust’s intranet and staff
could access these in a timely manner. We observed staff supporting a patient in the resuscitation
area, who used the intranet whilst supporting a patient to find the latest guidance and ensure the
patient accessed up to date treatment.

Engagement
The service engaged well with patients, staff, the public and local organisations to plan and
manage appropriate services and collaborated with partner organisations effectively.
The department engaged with patients in a variety of ways and took people’s views and
experiences into account. Staff told us they were actively engaged with developments in the
department and that their views were reflected in the planning and delivery of services and in
shaping the culture.
A magazine for staff, patients and visitors was available within the waiting area. Staff displayed
departmental performance for public information, for example waiting times and staffing levels.
The trust’s public website provided a range of information for patients and visitors including
alternative support options including NHS 111, general practitioner (GP) services and pharmacy
services.
Staff described an improved culture of openness both locally and with the trust wide senior
management team. Staff described the weekly meeting with the chief executive, as a positive
opportunity to raise concerns and feedback information if they could attend.
The trust worked with young people in the community across a wide range of engagement and
direct work experience to strengthen their health awareness in support of keeping healthy. They
also work closely with local council and commissioning groups to support their community
activities.
The trust worked with a range of local primary schools and introduce children to the different types
of health services and the roles in each service. There were opportunities for the children to be
introduced to simple health awareness information such as the importance of hand washing, and
what to do in an emergency (resuscitation awareness).
The trust participated in a ‘Changing Lives project in Harlow’, working with young people to raise
awareness about personal health. Workshops on health education, physical and mental and
wellbeing are provided by the Trust as well as problem solving workshops.
At the trust’s annual celebration (Event in A Tent) the trust invited young people to participate in
learning about the different roles in the trust including an introduction to some of the activities
associated with each role including roles within the ED.
The trust visited local secondary schools and sixth form colleges to introduce young people to the
varied career opportunities in health and social care. The approach is very much aligned with
individual well-being; raising aspirations and widening participation particularly for young people
from a lower socio-economic background. Each academic year the trust hosts around 180 work
experience students who have expressed an interest in a career in healthcare.
Volunteers were recruited by the trust’s voluntary services manager from local schools and
colleges to support programmes such as dementia buddies, meal time buddies and also other
placements to raise the career aspirations of our local young people, including those with
additional needs who take part in the trusts ‘Supported Internship Programme’.
The service was committed to improving services by learning from when things went well
or wrong, promoting training, research and innovation.
Changes within the physical environment had significantly impacted on reducing crowding and
created safe areas for escalation and to manage access and flow.
The adult ED had a toilet and changing area specifically to meet the needs of people with
disabilities who may need additional support. This is part of a national initiative called ‘Changing
Places’. People with profound and multiple learning disabilities, as well people with other physical
disabilities such as spinal injuries, muscular dystrophy and multiple sclerosis often need extra
equipment and space to allow them to use the toilets safely and comfortably. These needs are met

by “Changing Places” toilets and the ED had developed one of its toilets specifically for this
purpose.
The trusts dementia lead implemented a virtual dementia training package, 97% of staff had
completed this training. The training used sensory equipment to enable staff to experience some
of the challenges patients and families living with dementia may face, for example the impact on
loss or change of vision, touch and spatial awareness.
The ED team worked with the trusts quality first team and the emergency care intensive support
team (ECIST) to improve performance against the four-hour access target, and to improve safety
and the overall patient experience. The improvements within the rapid assessment and treatment
process is an example of innovation due to this collaborative working.
The ED implemented a standard operating procedure (SOP) to support the structured way in
patients were received and assessed within the ED. The addition of a senior decision maker led
approach aimed for improve the way patients were assessed.
The ED introduced nasal high flow oxygen in the ED, a frailty pathway, abdominal pain pathway
and timely blood cultures for ED patients triggering the sepsis six bundle.

Medicine

The medical care service at Princess Alexandra Hospital provides care and treatment for
specialties including cardiology, dermatology, diabetes and endocrinology, gastroenterology,
geriatric medicine, neurology and respiratory medicine.
The hospital has 286 medical inpatient beds located across 14 wards and units:
Inpatient
Ward/unit Specialty or description
beds
Cardiac catheterisation lab – Provides inpatient cardiac interventions, not
N/A
inpatient requiring a cardiothoracic centre
Day case facility for all endoscopy procedures
Endoscopy N/A
(adult)
Fleming ward is a short stay ward which enables
staff to assess the condition of emergency
patients before deciding on the most appropriate
Fleming Ward care or treatment to be delivered. Following 26
assessment and investigations patients may be
discharged or admitted to an appropriate area for
further treatment.
Providing care for patients over the age of 75 who
require a comprehensive geriatric assessment or
Frailty assessment unit 4
will require short hospital admission up to 72
hours
A refurbished purpose-built ward for patients with
dementia, do not attempt cardio-pulmonary
Gibberd Ward resuscitation (DNACPR) decision and ceiling of 27
treatment in place. In addition, it will facilitate end
of life care.
Specialist fractured neck of femur ward
Harold Ward incorporating elderly medicine and early amputee 28
rehabilitation. Led by consultant ortho-geriatrician
Harvey Ward provides specialist
Harvey Ward gastroenterology, hepatobiliary oncology and 20
haematology care to patients
Providing care for patients over the age of 75 who
John Snow Ward require a comprehensive geriatric assessment or 22
short hospital admission up to 72 hours
Kingsmoor Ward Cardiology Inpatient Ward 20
Care of the elderly, accredited with the Royal
Lister Ward 28
College of Psychiatrists quality mark
Respiratory medicine. The 27 beds include a
Locke Ward three-bedded acute respiratory unit for higher 27
clinical acuity respiratory patients
Ray Ward A complex elderly care ward 28
Short stay ward. Medical patients flow from the
Fleming short stay ward and emergency
Saunders Ward 28
department to Saunders. Length of stay up to 72
hours
Winter Ward Adult endocrine and medical ward 28
(Source: Routine Provider Information Request (RPIR) - Sites tab
The trust had 26,660 medical admissions from November 2017 to October 2018. Emergency
admissions accounted for 15,901 (59.6%), 114 (0.4%) were elective, and the remaining 10,645
(39.9%) were day case.
Admissions for the top three medical specialties were:
• General medicine: 13,755

• Gastroenterology: 3,512
• Clinical haematology: 2,825
(Source: Hospital Episode Statistics) Is
During this inspection we inspected seven medical wards, Harvey, Saunders, Lister, Ray,
Gibberd, Fleming and Winter, as well as the chemotherapy day unit and endoscopy service. We
spoke with 47 members of staff including service leaders, nurses, doctors, allied health
professionals, pharmacists, healthcare assistants and clinical nurse specialists. We spoke with
six patients and three relatives. We observed care and looked at 23 sets of patient care records.
We also looked at 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.


Mandatory training
The service provided mandatory training in key skills to staff and were working towards all
staff completing it.
For nursing staff, the service was meeting their target with an overall rate of 90.3% as of October
2018 and seven out of the 13 mandatory training topics meeting the target. This was an
improvement on our previous inspection where we found that mandatory training rates for nursing
staff were 75% overall. However, we were concerned that immediate life support training rates
were still low. Only 46.3% of eligible nursing staff had completed this training. This posed a risk
that there may not always be a member of staff on duty that was available to deal with a patient
who experienced respiratory or cardiac arrest.
The service did not meet the 90% target in any module for medical staff as of October 2018. The
services overall mandatory training rate for medical staff was 68.79% which was an improvement
on the overall rate of 47% at our previous inspection.

Princess Alexandra Hospital medical department
nursing staff Princess Alexandra Hospital’s medical department is shown below:
As of October 2018
Infection prevention & control level 1 1 1 100% 90% Yes
Values & behaviours 216 220 98.2% 90% Yes
Equality, diversity and human rights 212 220 96.4% 90% Yes
Dementia awareness 212 220 96.4% 90% Yes
Learning disabilities awareness level 1 213 222 95.9% 90% Yes
Adults & paediatrics basic life support 134 160 83.8% 90% No
Introduction to information governance 179 220 81.4% 90% No
Immediate life support level 3 25 54 46.3% 90% No
In Princess Alexandra Hospital’s medical department the 90% target was met for seven of the
Following our inspection, the trust provided updated mandatory training data as of March 2019
for qualified nursing staff in medical care at Princess Alexandra Hospital:
As of March 2019
Health, safety and welfare 172 184 93.5% 90% Yes
Slips, trips and falls 57 61 93.4% 90% Yes
In Princess Alexandra Hospital’s medical care department, the 90% target was met for 11 of the
15 mandatory training modules for which qualified nursing staff were eligible. As in the earlier

time period, the immediate life support level 3 module had the lowest completion rates, however
completion had improved.
Princess Alexandra Hospital’s medical department is shown below:
As of October 2018
Manual handling level 1 9 12 75% 90% No
Dementia awareness 102 138 73.9% 90% No
In Princess Alexandra Hospital’s medical department, the 90% target was not met for any of the
13 mandatory training modules for which medical staff were eligible.
Following the inspection, the trust provided updated mandatory training data as of March 2019
for medical staff in medical care at Princess Alexandra Hospital:
As of March 2019
Health, safety and welfare 74 103 71.8% 90% No
Manual handling level 1 1 4 25.0% 90% No

In Princess Alexandra Hospital’s medical care department, the 90% target was not met for any
of the 14 mandatory training modules for which medical staff were eligible. None of the three
eligible staff had completed the infection prevention and control level 1 module compared to
66.7% previously.
We asked senior managers in the service what actions they were taking to improve the services’
mandatory training rates for medical staff. Actions included discussing compliance as part of
appraisals and a new measure of informing the medical staff that they would not be granted
additional study leave if their mandatory training was not up to date. Medical staff we spoke with
throughout our inspection told us the service was active in ensuring staff completed their training
by emailing and telephoning them when they had training due.
The service’s mandatory training was delivered as a combination of online learning and face to
face training.
We were concerned that only 31.3% of medical and nursing staff had received sepsis training.
Sepsis training did not form part of the trusts mandatory training; however, the trust’s outreach
team had been providing face to face sepsis training on the wards using ‘sepsis trolleys’ to
nursing staff and as part of teaching sessions for doctors throughout their grand rounds. 120
members of nursing and medical staff out of 383 had completed either face to face or e-learning
sepsis training. The e-learning training was optional, and staff received trolley training depending
on whether they were on shift the day that the trainers attended their ward.
All members of staff we spoke with were aware of the requirement to complete mandatory
training and managers had a good understanding of their individual team’s compliance levels.
Safeguarding
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 but the service
did not meet their targets for safeguarding training for medical staff.
Nursing staff within the service met the training targets for safeguarding in five out of the six
modules as of October 2018. However, medical staff did not meet the target for any of the six
safeguarding modules.
Princess Alexandra Hospital medical department
nursing staff Princess Alexandra Hospital’s medical department is shown below:
As of October 2018
Safeguarding adults level 1 1 1 100% 95% Yes

In Princess Alexandra Hospital’s medical department the trust’s training targets were met for five
of the six safeguarding training modules for which qualified nursing staff were eligible.
2019 for qualified nursing staff in Princess Alexandra Hospital’s medical care department:
As of March 2019
In Princess Alexandra Hospital’s medical care department, the 90% target was met for all six
safeguarding training modules for which qualified nursing staff were eligible. The completion
rate for the safeguarding children level 3 module had improved from 66.7% in the earlier time
period to 100% based on all nine staff members having completed the training.
staff Princess Alexandra Hospital’s medical department is shown below:
As of October 2018
Safeguarding children level 1 9 12 75% 95% No
In Princess Alexandra Hospital’s medical department, the trust’s training targets were not met
for any of the six safeguarding training modules for which medical staff were eligible.
2019 for medical staff in Princess Alexandra Hospital’s medical care department:

As of March 2919
In Princess Alexandra Hospital’s medical care department, the 90% target was not met for any
of the six safeguarding training modules for which medical staff were eligible. Neither of the two
eligible staff had completed the safeguarding adults and children level 1 modules which was
lower than the completion rates in the earlier time period.
Safeguarding training formed part of the trust’s mandatory training. The service was aware of the
poor training rates among medical staff and had used measures such as restricting additional
training access for staff if they haven’t completed their mandatory training.
Staff that we spoke with were aware of the different types of abuse, how to identify them and were
aware of how to escalate concerns. Staff could give examples of situations where they had raised
safeguarding concerns and reported them through the trust’s procedures. Staff told us they had
access to a page on the trust’s intranet that had information on safeguarding and the referral
process.
Staff used a paper-based referral system to record safeguarding concerns, completed an
electronic incident record and notified the local authority through an email referral system.
Safeguarding concerns were flagged on the trust’s electronic patient record system. All staff we
spoke with were clear on how to use the safeguarding referral system.
The service had a safeguarding team comprising of a named doctor and nurse for children and
adults safeguarding. All five of the trust’s named professionals for safeguarding had completed level
four training in safeguarding.
Staff we spoke with could explain to us their responsibilities in relation to female genital mutilation
(FGM), how to contact the safeguarding teams and make a safeguarding referral.
Senior members of nursing staff were aware of the Mental Health Act S5(4) nurse’s holding power
but informed us that training had not been provided by the trust and that they were not aware of any
examples of the power being used.
Patients who were receiving cancer treatment were given alert cards where required for
chemotherapy and spinal cord compression which meant these patients were immediately
identifiable to staff if attending the emergency department.

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.
Whilst the environment was found to be clean, we found strips for monitoring blood glucose
levels that had been used in blood glucose monitoring boxes on Fleming ward. The blood
glucose monitoring boxes were unclean on the inside and there was no process for them being
regularly cleaned on Saunders ward. This posed a risk that infection could be spread through the

use of the boxes on wards.
Three members of domestic staff we spoke with on Fleming ward told us that they did not always
have access to suitable equipment to clean the wards. Staff showed us that they had to tape a
cloth to a mop because the service did not provide them with the appropriate mop attachment.
On site waste management was designated appropriately with separate colour coded bins for
general, clinical and sharp waste.
I am clean stickers were used on equipment throughout the service and equipment that we
checked had been cleaned on the date of our inspection. This indicated that equipment was
being regularly cleaned.
Side rooms were available to isolate patients suspected or with confirmed infection. Specific care
arrangements were used for these patients, which enabled staff to take extra precautions and help
prevent the spread of infection. We were assured that patients with infections were nursed in side
rooms and appropriate signage was used to alert staff and visitors of action they needed to take.
Visitors were advised about hand cleansing and protective clothing.
Personal protective equipment (PPE) such as gloves and aprons were readily available on all
wards we visited, and we observed staff adhering to infection prevention and control standards
by wearing PPE when undertaking tasks such as providing personal care.
The service held quarterly infection prevention and control (IPC) committee meetings. Infection
Prevention and Control nurses, infection prevention and control information officers, patient panel
representatives, consultants in communicable disease control, and the director of nursing
attended these meetings. The meetings were used to discuss infection rates, concerns, audit
data and screening. The meetings identified actions arising from concerns and assigned action
owners with dates for completion.
Hand hygiene audits were undertaken throughout the service and audit results were displayed on
boards at the entrance of wards to provide information for patients, members of the public and
staff. For January and March 2019 all wards scored over 90%, in February 2019 both Winter
ward and Saunders ward scored 83%. Both wards had hand hygiene audit action plans in place
to improve compliance with actions including inhouse training on hand hygiene, discussion at
safety huddles and creating a challenge book to monitor and record practice.
Between March 2018 and March 2019, the service had no cases of MRSA Methicillin-resistant
Staphylococcus aureus (MRSA). MRSA is a type of bacteria that's resistant to several widely
used antibiotics. This means infections with MRSA can be harder to treat than other bacterial
infections. The service had nine cases of Clostridium difficile (C. difficile). C.difficile is a bacteria
that can infect the bowel and cause diarrhoea. The infection most commonly affects people who
have recently been treated with antibiotics. It can spread easily to others. The service had four
cases of methicillin-susceptible Staphylococcus aureus (MSSA). MSSA is also known as Staph
infections, which are caused by bacteria called staphylococcus. They most often affect the skin.
They can go away on their own, but sometimes they need to be treated with antibiotics.
The service had eight cases of Escherichia coli (E. coli), which is a type of bacteria common in
human and animal intestines, and forms part of the normal gut flora (the bacteria that exist in the
bowel). There are a number of different types of E. coli and while the majority are harmless some
can cause serious food poisoning and serious infection.
Domestic staff completed checklists of areas they had cleaned to evidence that different areas
throughout the service had been cleaned. These check sheets were collated by the domestic
team managers. We saw completed sheets for Fleming ward on our inspection.
The endoscopy service decontaminated reusable equipment in line with national guidance and
was following the guidance outlined in the management and decontamination of flexible
endoscopes HTM. We saw that cleaning schedules were complete for the different areas of the
endoscopy service.

The use of facilities in the service did not always keep people safe. We found
inappropriately stored glass waste, one piece of broken equipment in use and a hazardous
substance left in an unlocked dirty utility room.
We found that glass waste was not appropriately stored on Saunders and Fleming ward. On both
wards we found buckets in the dirty utility room that had glass medicine bottles, part of a used
intravenous giving set and other glass waste stored in them. The buckets were not sealable and
posed a risk to staff when emptying the contents. We raised the issue with senior trust staff on our
inspection but saw that the issue had not been resolved when we returned to the trust for an
unannounced inspection 12 days later. We saw that on Saunders ward that a bucket of glass
waste including medicines bottles were yet again stored in the dirty utility. We raised this again
with the trust who provided us with assurances that sealable glass waste buckets had been
ordered and would be circulated for glass waste in future.
Staff did not have knowledge on the correct process for condemned equipment. On Fleming ward
we found a pat slide that had splintered in four places meaning that it could pose a risk of harm to
a patient by cutting them when used. A pat slide is a full body sliding board that is designed to be
used when transferring a patient in a semi reclined or lying position.
When we questioned two different members of staff about the process for getting rid of faulty
equipment we were provided with differing answers. One member of staff told us that they would
put the broken item in a skip on the trust site and another member of staff told us that there was a
process were members of the estate team would come and collect faulty equipment. Staff we
spoke with were aware that the pat slide was broken and had ordered a new one but had not
taken any action to prevent staff from using it. This was despite the service having other pat slides
available on Fleming ward.
On Fleming ward the service did not consistently lock the door to the dirty utility room. We found
that chlorine tablets had been left out on the side in the dirty utility room when they should have
been locked in a cupboard in accordance with the Control of Substances Hazardous to Health
Regulations 2002 (COSHH). This posed a risk that unauthorised people could have access to a
hazardous substance.
Resuscitation equipment, including emergency medicines, was readily available on all wards we
visited. We reviewed four resuscitation trolleys and saw that all consumables and emergency
medicines were in date. The trolleys had a system in place to prevent the equipment and
medicines from being tampered with in line with the Resuscitation Council (UKs) guidance that all
resuscitation medicines must be stored in tamper-proof containers. The service audited their
resuscitation trolleys, we saw for the month of February 2019 the trust achieved 100%
compliance.
On site waste management was designated appropriately with separate colour coded bins for
general, clinical and sharp waste.
The flooring within the endoscopy unit was worn and the seal around the edges had broken in
places. This meant that cleaning the flooring would be more difficult and that the surfaces could
therefore may be a source of infection.
We reviewed the services maintenance and servicing equipment registers for the medical wards
and saw that all electrical and medical equipment had been serviced within relevant timescales.

We were not assured that risks to patients were always managed positively within the
service. Comprehensive risk assessments were not always completed. However, the
service had effective systems in place to manage deteriorating patients.
On Saunders, Fleming and Gibberd ward we saw poor documentation in relation to skin care
plans. We reviewed 15 sets of patient records on these wards, out of these, four patients’ records
had assessed a patient as being at risk of developing a pressure ulcer but there were no
subsequent skin care action plans in place.
One patient on Gibberd ward had a pressure ulcer dressing care plan which had instructions to be
updated weekly but had not been updated in over three weeks at the time of our inspection.
There was confusion among staff as to where pressure care should be documented. A patient on
Gibberd ward had a pressure ulcer care plan with instructions to change the dressing every three
days. The changing of the dressing was recorded in the medical notes and not into the designated
area in the care plan in the nursing notes. It was not clear from the medical notes when the
dressing had been changed as the medical notes had many entries and staff needed to turn back
multiple pages to find entries regarding the patient’s pressure care. We saw that there was an
instance where the dressing had not been changed for five days. Staff on Giberd, Fleming and
Saunders wards told us that they had concerns with documentation.
Falls assessments were not always completed in full or updated following a patient fall. Out of
seven sets of eligible patient records that we reviewed on Saunders and Fleming ward, four sets
had incomplete falls assessments. The section of the assessment that asks for a lying and then
standing blood pressure was repeatedly not completed for all four records. The assessment was
meant to be completed for all patients who were not bed bound.
We raised our concerns about the care plans for falls and skin care with registered nurses in the
service, three staff nurses told us they felt under pressure and did not have time to complete all
the assessments. One staff nurse told us that as a result of this pressure that nurses prioritised the
nutritional assessment and tissue viability assessment.
In other areas of the service we found positive work to prevent pressure ulcers and falls. On
Harvey ward staff told us they had implemented a skin champion for each shift to ensure that
patients tissue viability was prioritised. The service had developed ‘agents for nutrition and tissue
viability’ who had received additional training on tissue viability and nutrition to promote nutrition
and tissue viability care planning on the wards. Within the service there was a weekly panel where
new pressure ulcers were presented to determine whether they were avoidable and whether any
learning could be established. Following a patient fall on Lister ward the service had implemented
a toilet checklist to ensure the area was safe. The service had falls stickers that were placed in the
patient’s medical records to document the fall and actions taken to mitigate the risk of falling again.
The service had a falls coordinator responsible for educating staff on falls risks and who played a
role in the route cause analysis investigations to ensure learning from falls was shared.
The service had a deteriorating patient policy dates 12 November 2018. The policy detailed what
staff should do if a patient deteriorated. We saw evidence in the patient records that staff were
following the policy, for example, contacting the critical care outreach team in the event that a
patient significantly deteriorated.
Staff used national early warning scores (NEWS2) on the medical wards to continually monitor,
assess and identify any deteriorating patients. All records we reviewed showed that staff routinely
completed NEWS and alerted senior staff to any patient that may be deteriorating.
Nursing staff completed patient observations on hand held computer tablets. The tablets provided

the ward manager and matron with an overview of patients. In addition, if a patient was triggering
on their NEWS, this alerted the critical care outreach team (CCOT) who were able to take
appropriate action in accordance with the patient’s observations. The CCOT were available
onsite 24 hours a day, seven days a week. We saw evidence in two patients records that we
reviewed that patients were escalated appropriately to the CCOT.
The trust conducted Venous thromboembolism (VTE) assessments on admission. VTE is a

condition where a blood clot forms in a vein. This is most common in a leg vein, where it's known
as deep vein thrombosis (DVT). The assessments were completed on the services electronic
prescribing document and we saw evidence that they had been completed in the prescribing
records we reviewed.
All the wards we visited had a named sepsis champion. Sepsis champions are staff members that
undertake additional sepsis training and in turn provide sepsis training to other staff members in
their department or ward. We observed nursing staff using the sepsis six screening tool. A NEWS
score indicative of sepsis sent an automatic electronic alert to and prompted the nurse to seek
medical input for the patient concerned.
The service could access mental health liaison and psychiatric support 24 hours a day, seven
days a week through the local mental health trust’s crisis team. Staff we spoke with were aware of
the team and knew how to make urgent referrals to the team.
All the medical records we reviewed evidenced that the service was meeting the NHS services,
seven days a week priority clinical standard two in that all emergency admissions were seen by a
consultant within 14 hours of arrival at the hospital.
Nurse staffing
The service did not have enough staff with the right qualifications, skills, training and
experience to keep people safe from avoidable harm and to provide the right care and
treatment.
Nurse staffing remained a concern with significant vacancies and recruitment continued to be a
major risk on the trust risk register and the medicine healthcare group (MHCG) risk register.
However, there was a continuous recruitment programme for nursing staff and the trust was
looking at implementing nursing apprenticeships and was engaged with overseas recruitment.
Registered nurse staffing levels on Gibberd and Saunders were consistently below planned
levels. We requested the staffing numbers for Gibberd ward and Saunders ward for the three
months prior to our inspection. On Saunders there were 18 shifts where the ward was three
registered nurses below the template staffing of five and 101 shifts where the ward was two
below the template staffing of five registered nurses. On Gibberd ward there was 61 shifts were
the ward was two below the template staffing of four registered nurses. On Harvey and
Saunders ward during our inspection the service was two registered nurses below the planned
template of five
Staff on Saunders ward told us the ward was consistently below their template staffing and that
the impact of this was poor documentation for patients and that not all risk assessments were
completed for patients. Nursing staff told us that it had become normalised to work below their
template staffing and that this had impacted on staff morale. Staff told us they were frequently
moved to work on other wards to ensure safe levels of staffing on those wards and that this had
contributed to problems with staff retention.
The service used a nationally recognised ‘Safer Nursing Care Acuity Tool’ to plan staffing
requirements according to patient need. The trusts senior nurses held three meetings throughout
the day to address staff needs across the hospital and flexed staff between the wards where
necessary to ensure safe care.

To address the shortfall of nursing staff on wards at night, the trust block booked twenty agency
nurses per night and then distributed the agency nurses across the wards that were below
template to meet clinical acuity. We saw that this could be monitored using the services online
staffing tool. At our unannounced inspection, we saw that Gibberd ward was allocated two
agency nurses from the block booking to meet template staffing.
Nursing staff we spoke with told us they escalated any staffing concerns to the services matrons.
The service had a matron on duty who could be accessed through the trust’s switchboard 24
hours a day.
The service used band four nursing associate practitioners to increase the skill mix on wards, we
saw that Ray ward had one nursing associate practitioner.
On Fleming ward three nurses were being trained as advanced nurse practitioners which meant
they could clerk and examine patients to assist the medical workforce.
Planned and actual Nurse and healthcare assistant staff numbers were displayed on the wards
for patients and relatives to see.
Princess Alexandra Hospital reported the following WTE nursing staff numbers in medicine as of
March and October 2018.

Ward / team name Actual Planned Staffing Actual Planned Staffing
Cancer clinical nurse spec 17.2 15.3 112.6% 15.2 16.1 94.5%
Cardiac catheter lab 5.5 5.3 104.8% 5.5 7.1 78.4%
Cardiology specialist nurses 4.8 4.9 98.6% 5.8 4.9 119.1%
Diabetics 3.8 2 190% 3.7 4.2 88.9%
Endoscopy service 13.5 21.3 63.3% 14 21.3 65.5%
Fleming MAU 21.7 45.3 48% 26.1 43.2 60.4%
Gibberd Ward 4 20.9 19.2% 8.5 20.1 42.1%
Gastroenterology 2.8 4 70% 2.8 4 70%
Harold Ward 14.6 20.8 70.2% 10.6 20.8 51%
Harvey Ward 10.5 21 49.8% 11.9 20.2 58.9%
John Snow Ward 14 21 66.6% 13 20.2 64.5%
Kingsmoor cardiac care unit 19.2 23 83.5% 20.6 24.6 83.7%
Lister Ward 9.6 20.8 46.2% 12.6 20 63.2%
Locke Ward 14 22.2 62.9% 15.2 25.4 59.8%
Medical short stay unit
13.9 20.8 66.7% 11.9 25.3 47.2%
(Saunders)
Patient at home 14.6 19.3 75.4% 9 19.3 46.6%
Ray Ward 11.3 21 53.8% 15.9 21 75.9%
Respiratory 3.7 3.5 106.7% 3.4 3.5 97.5%
Winter Ward 13.5 21.1 63.7% 14.5 20.5 70.6%
Total 212.2 335.5 63.2% 220.2 343.5 64.1%
As of October 2018, the nursing staffing fill rate within medicine at Princess Alexandra Hospital
was 64.1%. This was about the same as the rate of 63.2% as of March 2018.
As of October 2018, cardiology specialist nurses were the only one of the 23 nursing teams
listed that were over established. However, care should be taken when interpreting staffing rates
due to small numbers of staff in some teams.

Vacancy rates
37.3% for nursing staff in medicine. This was higher than the trust target of 8%.
A breakdown of vacancy rates by ward and unit is below. There were very high vacancy rates
reported in some units and also three reporting units that were over-established. However, care
should be taken when interpreting staffing rates due to small numbers of staff in some teams.
Ward / team name Annual vacancy rate

Dietetics & nutrition 100%
Neurology 100%
Elderly medical staffing 100%
Gibberd Ward 73.6%
Lister Ward 50.3%
Fleming MAU 46.6%
Harvey Ward 45.1%
Locke Ward 42.6%
Saunders medical short stay ward 42%
John Snow Ward 39.6%
Winter Ward 37.1%
Ray Ward 36.9%
Harold Ward 36.2%
Patient at home 34.6%
Gastroenterology 31.7%
Endoscopy service 30.2%
Fleming Ward 29.6%
Kingsmoor cardiac care unit 16.8%
Cardiac catheter lab 14.2%
Cardiology specialist nurses 0.6%
Cancer clinical nurse spec -2.6%
Respiratory -4.8%
Diabetics -17.7%
Nurse vacancy rates were high across all medical wards we visited. Managers we spoke with on
the medical wards were aware of the individual wards vacancy rates.
Turnover rates
11.8% for nursing staff in medicine. This was lower than the trust target of 12%. This was an
improvement since our last inspection.
A breakdown of turnover rates by ward and unit is below. There were high turnover rates
Ward / team name Annual turnover rate
Endoscopy service 33%
Locke Ward 21.1%
Lister Ward 19.5%
Gibberd Ward 18.1%
Saunders medical short stay unit 15.3%
Harold Ward 14.8%
Fleming MAU 12.4%
Harvey Ward 8.6%
John Snow Ward 7.8%
Cancer clinical nurse spec 6.1%
Diabetics 0%
Cardiac catheter lab 0%
Ray Ward 0%
Respiratory 0%
Oncology 0%
Winter Ward 0%
Cardiology specialist nurses 0%
Sickness rates
3.6% for nursing staff in medicine. This was higher than the trust target of 3.5%.
A breakdown of sickness rates by ward for each site is below:
Ward / team name Annual sickness rate

Ray Ward 7.2%
Endoscopy service 5.6%
John Snow Ward 4.2%
Winter Ward 4%
Locke Ward 3.8%
Cancer clinical nurse spec 3.8%
Saunders medical short stay unit 3.8%
Gibberd Ward 3.7%
Harvey Ward 3.3%
Fleming MAU 3.3%
Respiratory 2.5%
Cardiac catheter lab 2.1%
Harold Ward 2%
Lister Ward 1.8%
Gastroenterology 1%
Diabetics 0.9%
Cardiology specialist nurses 0.4%

Oncology cancer 0%
It should be noted that the trust was unable to supply the total number of shifts worked by all
permanent and temporary staff. Therefore, it was not possible to calculate the percentages of shifts
The table below shows the numbers of nursing hours in medicine at Princess Alexandra Hospital
from December 2017 to November 2018 that were covered by bank and agency staff or left
unfilled.
Over this time period, 55,472.4 working hours were filled by bank staff and 64,971 were covered
by agency staff to cover sickness, absence or vacancy for qualified nurses. There were
112,686.9 hours that were unable to be filled by either bank or agency staff to cover sickness,
absence or vacancy for qualified nurses.
Over the same time period, 89,859.5 working hours were filled by bank staff and 31 were covered
by agency staff to cover sickness, absence or vacancy for non-qualified nurses. There were
55,720.3 hours that were unable to be filled by either bank or agency staff to cover sickness,

Not filled by bank
Staff group Bank usage Agency usage
or agency
Hours Hours Hours
Qualified staff 55,472.4 64,971 112,686.9
Non-qualified staff 89,859.5 31 55,720.3
All nursing staff 145,331.8 65,002 168,407.2
Medical staffing
Planned vs actual
Princess Alexandra Hospital reported the following WTE medical staff numbers in medicine as of

Cardiology 16.1 15.7 102.3% 16 15.8 101.4%
Cellular pathology 12.7 11.1 114% 14.5 13.1 110.3%
Dermatology 5 6.6 76% 6.2 6.8 92%
Diabetes 5.4 9.2 58.7% 6.1 10.1 60.3%
Elderly medical staffing 34.8 39.8 87.4% 27.8 39.8 69.8%
Fleming MAU 27.8 25 111.1% 23.9 28.4 84.2%
Haematology 8 7 114.3% 8 7 114.3%

Neurology 1.7 1.7 95.6% 2.8 2.5 113%
Oncology 7.6 6.3 119.5% 7.6 8.3 90.7%
Patient at home 1 3.8 26.5% 0 3.8 0%
Total 120 126.3 95% 112.9 135.5 83.3%
As of October 2018, the medical staffing fill rate within medicine at Princess Alexandra Hospital
was 83.3%. This was lower than the rate of 95% as of March 2018.
As of October 2018, four of the 10 medical staffing reporting units listed were over established.
However, care should be taken when interpreting staffing rates due to small numbers of staff in
some teams.
Vacancy rates
11.1% for medical staff in medicine. This was higher than the trust target of 8%.
A breakdown of vacancy rates by ward is below. A breakdown of vacancy rates by ward and unit
is below. There were very high vacancy rates reported in some units and also four reporting units
that were over-established. However, care should be taken when interpreting staffing rates due to

Diabetes 37.3%
Elderly medical staffing 22%
Dermatology 13.9%
Respiratory 5.9%
Neurology 3.6%
Rheumatology 1.9%
Fleming MAU 0.9%
Cardiology -1.4%
Oncology -1.9%
Cellular pathology -7.3%
Haematology -11.9%
Despite the number of medical staff in post being lower than the establishment, there was
evidence that medical staffing was providing safe patient care, for example each ward still had a
named consultant responsible on the ward and junior doctors we spoke with told us they had
sufficient access to senior medical staff. The trust used locum doctors to fill vacant shifts. The
wards we visited including Fleming and Saunders had recently increased the number of
consultants working and staff told us they felt the cover was adequate.
Turnover rates
14.5% for medical staff in medicine. This was higher than the trust target of 12%.
A breakdown of turnover rates by specialty and unit is below. There were high turnover rates

Elderly medical staffing 35.3%
Dermatology 16.9%
Fleming MAU 15.4%
Cardiology 12.5%
Respiratory 8.2%
Cellular pathology 4.4%
Patient at home 0%
Oncology cancer 0%
Diabetes 0%
Rheumatology 0%
Neurology 0%
Haematology 0%
The trust reported that their turnover data for medical staff did not include deanery trainee
grades.
Sickness rates
1.6% for medical staff in medicine. This was lower than the trust target of 3.5%.
A breakdown of sickness rates by ward for each site is below

Oncology 9.1%
Respiratory 3.9%
Cellular pathology 1.7%
Cardiology 1.2%
Haematology 1.2%
Diabetes 1%
Elderly medical staffing 0.7%
Fleming MAU 0.5%
Neurology 0.4%
Dermatology 0.2%
Rheumatology 0.1%
Patient at home 0%
of shifts worked by bank and locum medical staff and left unfilled.
The table below shows the numbers of medical hours in medicine at Princess Alexandra Hospital
from December 2017 to November 2018 that were covered by medical bank and locum staff or
left unfilled.
Over this period 30,438.5 working hours were filled by bank staff and 8,438 were covered by

Hours Hours
Princess Alexandra
30,438.5 8,438
Hospital
Staffing skill mix
In November 2018, the proportion of consultant staff reported to be working in medical care at the
trust was lower than the England average. The proportion of junior (foundation year 1-2) staff was
higher than the England average.
Staffing skill mix for the 113 whole time equivalent medical staff working in medicine at
The Princess Alexandra Hospital NHS Trust
This England
Trust average
Consultant 40% 44%
Junior* 26% 20%
^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty
~ Registrar Group = Specialist Registrar (StR) 1-6
* Junior = Foundation Year 1-2
(Source: NHS Digital - Workforce Statistics - Medical (01/11/2018 - 30/11/2018))
The service had consultant cover 24 hours a day, seven days a week. There were consultants on
site from 8am until 8pm on weekdays. Out of hours consultant cover was provided from 8pm until
8am the following morning. At weekends the service had two consultants on site from 8am until
8pm who undertook medical ward rounds and were contactable out of hours for support. Junior
doctors contacted consultants by mobile phone for advice and support when required at night.
The service performed daily consultant-led ward rounds at 8am. A medical handover took place
every morning, seven days a week, which included discussion of clinical incidents, significant
patients, scans, and investigations requiring urgent review. The handover meeting also included a
review of medical staffing gaps and agreed redistribution of doctors.

Records
Staff did not always keep clear records of patients’ care and treatment and records were
not always written and managed in a way that kept patients safe.
As part of this inspection, we reviewed 23 sets of medical and nursing care records and found
documentation concerns with 11 sets of records.
All records were paper based apart from physiological observation records, which staff recorded
on hand held electronic devices. Nursing records were kept by each patient’s bedside, whilst
medical records were stored at the nurse’s station. Nursing records contained patient
assessments and care plans including nutritional and skin care plans. Nursing records were
completed by registered nurses and health care assistants.
Of the records we reviewed we found conflicting information in one patient’s record about the
severity of their pressure ulcer on Gibberd ward and when the dressing had last been changed.
Another set of patient records on Penn ward for a medical outlier had no record of care in the
medical records over the weekend from 2am on 23 March 2019 until 25 March 2019. We raised
this with the ward’s matron who told us that nurse should write contemporaneous records of
patients care in the medical records twice daily and that they were disappointed that this hadn’t
been done. On Fleming ward, we saw that a patient had a fluid balance chart, but this was not
documented in frequently. We raised this with a member of staff who told us this was because a
doctor had asked for the fluid balance sheet to be stopped, however this was not documented in
either the nursing or medical records. The same patient also had a catheter that had not been
written onto the invasive bodyline map.
In three sets of nursing records we reviewed on Saunders ward we saw inconsistencies in the
instructions to how often a patient should be turned. The patient’s skin care plan indicated the
patient should be repositioned every two hours but in the record sheets it stated the patient should
be repositioned every four hours with no rationale for the change in any of the records.
In three sets of records we reviewed we saw that the patient demographic sheet had not been
filled out with the patient’s next of kin or allergy details.
Records did not always contain full details of patients’ mental health or learning disability needs. A
patient on Fleming ward had been assessed as not having capacity to make decisions due to
acute delirium but no best interest decision had been documented for this patient and in the
patient’s nursing record there was conflicting information stating they did have capacity. One
patient on Gibberd ward had a communication assessment completed which stated they had a
history of agitation, confusion and delirium, however there was no subsequent care plan on how to
manage this or information about the patient’s current mental health. A patient on Fleming ward
had learning difficulties but the services page for cognitive impairment information in the nursing
record had not been completed. We raised this with the nurse in charge who told us that this
would be updated to reflect the patients’ needs.
The service had plans in place to improve documentation including adding a discussion of
outstanding assessments to the daily safety huddle on wards and looking to alter the
documentation from A&E to the medical assessment unit (MAU) to reduce the repetition of
assessments when a patient will only be on the MAU for a few hours. However, at the time of our
inspection these actions had yet to be implemented and did not have a commencement date.
The service did not have systems in place to identify patients with pre-existing health conditions
such as learning difficulties, mental health conditions or dementia. Staff within the service told us
there was no flagging system for patient’s health conditions on the trust-wide electronic record and
staff would have to read the patient’s medical records to find this information. This posed a risk
that staff may not be able to identify a patient’s pre-existing condition quickly and respond
accordingly.
We requested the services documentation audit data. The service provided percentages that
wards had achieved in the documentation audit but did not provide any information on how the

documents were audited or what was done in the event of poor results. We saw that in January
2019 both Fleming and Ray ward scored 40% against a target of 100%.
Discharge summaries of patient’s medicines were sent to the patient’s GP using the services
electronic pharmacy system. Nursing staff completed a discharge checklist for patients which
included their medical condition, transport, medicines and access to property. Patients received a
copy of their discharge summary and district nurse letter where appropriate.
Medicines
The service prescribed, administered, recorded and stored medicines well. Patients
received the right medication at the right dose at the right time.
Medicines were checked, managed, stored and disposed of safely. Controlled drugs (medicines
that require extra checks and special storage arrangements because of their potential for
misuse), were checked by two members of qualified staff twice a day in line with the trust’s
medicines policy and were stored correctly in a double locked cupboard.
Medicines used for emergencies were accessible, checked daily and stored in a tamper proof
way.
We reviewed six medicines charts and found them to be correctly completed and up to date. For
example; any known allergies to medicines were recorded to prevent the potential of a medicine
being given in error and causing harm.
Antimicrobial prescribing had doses, indication and the duration for administration noted on the
electronic prescribing record which supported good antimicrobial stewardship.
Pharmacists were assigned to the medical wards who reviewed patient’s medicines, including
patients who had medication changes that needed to be prescribed urgently.
Pharmacists’ we spoke with told us the service held a monthly audit programme to oversee
controlled drugs, medicines reconciliation and take home medicines. We reviewed the services’
controlled drug audits and saw that they were completed by senior pharmacists and that learning
was shared for any concerns identified.
The service was trying to improve the time it took to prepare to take away (TTA) medicines to
improve discharge times for patients. This included ‘one stop dispensing’ which is a process where
medicines are dispensed in a way that a patient should not have to wait for a separate supply of
medicines to be dispensed on discharge.
Nursing staff went through each patient’s discharge summary and a medicines checklist with them
to ensure the patient understood their medicines and to avoid any potential errors.
Staff monitored the medication fridge temperatures daily and were aware of the processes for
escalating temperatures that were out of acceptable range. This was an improvement since our
last inspection.
Nurses told us if a patient was admitted who was dependent on alcohol or illegal drugs, they were
offered medicines to assist with their withdrawal and associated side effects and would be referred
to the trust’s alcohol liaison nurse.
All patients receiving chemotherapy had a completed consent form which was checked prior to the
administration of treatment. All chemotherapy prescriptions were checked by a trained cancer
pharmacist in line with national guidance. Cancer nurse specialists provided patients with
appropriate verbal and written information on their to take home medicines.
The cancer service had protocols in place to guide staff and minimise the risk of chemotherapy
being administered by the incorrect route.

Incidents
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.
Staff reported Incidents using a trust wide electronic reporting system. All staff we spoke with
understood their responsibilities to raise concerns and to report safety incidents internally and
externally.
Staff throughout the service could provide examples of learning shared from incidents. One
example included learning following a patient that had developed a pressure ulcer. In response
the manager of Ray ward had created a pressure ulcer stamp for the patient records which asked
the grade, incident report number, date identified and if the tissue viability team had been
contacted. The new stamp was due to be rolled out to the entire service following a successful
trial.
The trust held daily serious incident group meetings to review all incidents reported the previous
day to ensure that serious incidents were identified and investigated promptly. The service
leaders reviewed incidents at the Medical Health Group Board Meeting by reviewing and
discussing a monthly incident exception report.
Staff received feedback from incidents through emails and daily safety huddles and staff told us
they found this helpful for learning.
Staff within the endoscopy service were able to give examples of incidents that had occurred and
where learning had been shared. For example, there was an incident where a patient with a
learning disability had attended the endoscopy unit without the learning disability team being
informed. Following this incident, the service had put in controls to ensure that the learning
disability nurses were made aware of any patients with a learning disability attending endoscopy
in future, so they could assist and support the patient if required.
Duty of candour is a regulatory duty that relates to openness and transparency. It requires
providers of health and social care services to notify patients or other relevant people of certain
notifiable safety incidents and provide reasonable support to that person. The regulation requires
staff to be open, transparent, and candid with patients and relatives when things go wrong. Staff
we spoke with knew what duty of candour was and were aware of their responsibilities to inform
patients and their families of any incidents and to document this in the patient’s records. We saw
evidence in the patient records that the duty of candour had been exercised in the event of a fall
on Gibberd ward.
Never Events
never event.
From February 2018 to January 2019, the trust reported no never events for medicine.

Trust level
In accordance with the Serious Incident Framework 2015, the trust reported four serious
incidents (SIs) in medicine which met the reporting criteria set by NHS England from February
2018 to January 2019.
There was one SI each of the following incident types:

• Diagnostic incident including delay (including failure to act on test results)
• Pressure ulcer
• Slips/trips/falls
• Treatment delay
We requested the last three root cause analysis (RCA) investigations undertaken by the service.
All three of the RCA reports the trust sent us were for incidents that had occurred in 2017. Whilst
we found that these were appropriately investigated with contributing factors to the incident and
learning identified, we were concerned that the service did not send us more recent incidents.
The service held bi-monthly mortality and morbidity meetings which reviewed a sample of cases to
identify learning and when good practice had been adhered to.
Safety Thermometer
Staff collected safety information and shared it with staff, patients and visitors.
their elimination.
Data collection takes place one day each month – a suggested date for data collection is given
but wards can change this. Data must be submitted within 10 days of suggested data collection
date.
Data from the Patient Safety Thermometer showed that the trust reported 44 new pressure
ulcers, 23 falls with harm and 23 new urinary tract infections in patients with a catheter from
January 2018 to January 2019 for medical services.
Prevalence rate (number of patients per 100 surveyed) of patient harms at

1
Total
Pressure
ulcers
(44)

Total
Falls
(23)
3
Total
CUTIs
(23)

Each ward displayed harm free care statistics for the previous month at the entrance. This
ensured that patients, staff and visitors were kept informed about the ward performance.

The service provided care and treatment that was planned and delivered in line with
current evidence-based guidance.
Staff could access local policies, guidelines and procedures on the trust’s intranet. Guidance for
staff was also placed next to work stations so staff could quickly find them, for example standards
around sepsis and resuscitation.
National guidance implementation including guidance from the National Institute of Clinical
Excellence (NICE) was monitored as part of the service’s monthly performance review to the trust
board. The medicine service tracked outstanding guidance. As of January 2019, 18 pieces of
guidance were under review and three had not been assessed yet to see if the service was
compliant.
Where patients triggered a need to be screened for sepsis, staff had clear prompts and processes
to enable effective management. All staff we spoke with were aware of the process. The hospital
used a sepsis screening tool and an evidence-based sepsis care pathway modelled on the ‘sepsis
six’ which is a national screening tool for sepsis.
Staff assessed patients for their risk of venous thromboembolism (VTE), and where a risk was
identified, offered prophylaxis and specialist equipment in line with NICE guidance. The service
audited compliance with the VTE pathway monthly and reported the results in the Medicine
Healthcare Group Quality Improvement Dashboard Report. The Trust supplied us with their
dashboards for April and May 2018. We had requested the dashboard for the previous 12 months,
but this was not provided. The target was 98% and from April 2018 to May 2018 audit showed
compliance ranged between 97% and 98%.
The service followed NICE guidance for the assessment and treatment of cancer including
stratified pathways and providing appropriate information for those living with cancer.
The wards held daily consultant-led ward rounds. Once patients were transferred to a general
ward, they were reviewed during a consultant delivered ward round at least once every 24 hours,
seven days a week, unless it was deemed that this would not affect the patient’s care pathway.

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.
Patient’s nutrition and hydration needs were identified, monitored and met. Patient needs were
identified through nationally recognised nutritional assessments, which we saw completed in full
within the patient’s records we reviewed.
The service offered different menus for differing diets, including culturally appropriate menus and
menus for patients whose diet was restricted by a medical condition.
Patient’s had access to fluids, water jugs were placed in reach of patients and the service had
intravenous fluids for patients who required them.
The service had access to dietitians and speech and language therapists. Staff were aware of how
to refer to the services. Nurses and healthcare assistants helped patients who required additional
support with eating and drinking.
The service ensured that there was appropriate nutritional support for patients living with cancer
and the management of nausea through prescribing anti-sickness medicines and gaining input
from the specialist palliative care team where appropriate.
Pain relief
Staff assessed and monitored patients regularly to see if they were in pain. They supported
those unable to communicate using suitable assessment tools and gave additional pain
relief to ease pain.
Patients told us they were always asked about their pain during comfort rounds and we saw
evidence of this in the nursing records we reviewed. Patients told us their pain had been managed
well by the service and that staff had provided pain relief promptly when it was needed.
Staff were able to access the specialist pain team and they told us they responded quickly when an
assessment was required. The pain team consisted of two registered nurses supported part time by
a consultant anaesthetist and was available Monday to Friday 8am to 4pm.
Staff told us they could use specialist assessment tools for patients who could not verbalise, for
example the Abbey Pain Scale for people with dementia or communication difficulties. The Abbey
Pain Scale is an instrument designed to assist in the assessment of pain in patients who are unable
to clearly articulate their needs.
Patient outcomes
Staff did not always monitor the effectiveness of care and treatment. The service had a
limited local audit programme and did not provide us with action plans for national audits
when we requested them. As a result, we could not see evidence that staff used the
findings to improve outcomes for patients.
Relative risk of readmission
From September 2017 to August 2018, patients at Princess Alexandra Hospital had a higher than
expected risk of readmission for elective admissions when compared to the England average.
• Patients in medical oncology and clinical oncology had higher than expected risks of
readmission for elective admissions
• Patients in clinical haematology had a similar to expected risk of readmission for elective
admissions
Elective Admissions – Trust Level
Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive
finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top
three specialties for specific trust based on count of activity.
Patients at Princess Alexandra Hospital had a lower than expected risk of readmission for non-
elective admissions when compared to the England average.
• Patients in general medicine, respiratory medicine and geriatric medicine had lower than
expected risks of readmission for non-elective admissions
Non-Elective Admissions – Trust Level
three specialties for specific trust based on count of activity.
(Source: Hospital Episode Statistics - HES - Readmissions (01/09/2017 - 31/08/2018))
Lung Cancer Audit
The table below summarises the trust’s performance in the 2017 National Lung Cancer Audit.
Meets
Metrics Trust Comparison to
national
(Audit measures) performance other Trusts
standard?
Crude proportion of patients seen by a Does not meet
cancer nurse specialist 27.9% the audit 
(Access to a cancer nurse specialist is aspirational
associated with increased receipt of anti- standard
cancer treatment)
Case-mix adjusted one-year survival rate
(Adjusted scores take into account the Within expected No current
40.1%
differences in the case-mix of patients range standard
treated)
Case-mix adjusted percentage of
patients with Non Small Cell Lung
Cancer (NSCLC) receiving surgery
(Surgery remains the preferred treatment for 22.1%
Within expected
range ✓
early-stage lung cancer; adjusted scores
take into account the differences in the
case-mix of patients seen)
Case-mix adjusted percentage of fit
patients with advanced NSCLC receiving
systemic anti-cancer treatment
(For fitter patients with incurable NSCLC
anti-cancer treatment is known to extend life
90% Good practice ✓
expectancy and improve quality of life;
adjusted scores take into account the
differences in the case-mix of patients seen)
Case-mix adjusted percentage of
patients with Small Cell Lung Cancer
(SCLC) receiving chemotherapy
(SCLC tumours are sensitive to
chemotherapy which can improve survival
86.5% Good practice ✓
and quality of life; adjusted scores take into
account the differences in the case-mix of
patients seen)
(Source: National Lung Cancer Audit)
We asked the service to provide us with the action plan for the National Lung Cancer Audit
however, this was not provided. We were therefore not assured the trust was appropriate acting
to address areas of poor performance to improve.
National Audit of Inpatient Falls
The table below summarises Princess Alexandra Hospital’s performance in the 2017 National
Audit of Inpatient Falls. The audit reports on the extent to which key indicators were met and
grades performance as red (less than 50% of patients received the assessment/intervention),
amber (between 50% and 79% of patients received the assessment/intervention) and green
(more than 80% of patients received the assessment/intervention.
Meets national
Metrics Hospital standard?
Audit’s Rating
(Audit measures) performance (Delete tick or
cross)
Does the trust have a
multidisciplinary working group
for falls prevention where data on Yes n/a ✓
falls are discussed at most or all
the meetings?
Crude proportion of patients who
had a vision assessment (if
applicable) (Having a vision 48.3% Red 
assessment is indicative of good
practice in falls prevention)
Crude proportion of patients who
had a lying and standing blood
pressure assessment (if
applicable) 7.1% Red 
(Having a lying and standing blood
pressure assessment is indicative of
good practice in falls prevention)
Crude proportion of patients
assessed for the presence or
absence of delirium (if applicable)
(Having an assessment for delirium
0% Red 
is indicative of good practice in falls
prevention)
Crude proportion of patients with
a call bell in reach (if applicable)
(Having a call bell in reach is an 86.7% Green 
important environmental factor that
may impact on the risk of falls)
(Source: National Audit of Inpatient Falls)
In response the findings of this audit, the service had created an action plan to address the areas
where the service did not perform well. Actions included raising awareness among staff of
completing lying/standing blood pressures, trialling a new vision assessment tool, continence care
planning and assessing patients for the presence of delirium. However, actions were not assigned
to specific members of staff and the action plan was dated 2017/2018 yet a lot of the actions were
said to be still in progress. We were not assured that the action plan was being updated and
reviewed regularly.
The trust performed poorly in relation to the crude portion of patients who had a lying and standing
blood pressure assessment metric. We were concerned that on our inspection all patients that we
reviewed on Fleming, Saunders and Gibberd ward had not had a standing/lying BP taken despite
this being an area that the trust had highlighted that they needed to improve on.
Chronic Obstructive Pulmonary Disease Audit
The table below summarises Princess Alexandra Hospital’s performance in the 2018 Chronic
Obstructive Pulmonary Disease Audit.
Meets national
Audit’s Rating
cross)
Percentage of patients seen by a
member of the respiratory team
within 24hrs of admission? 98.1% Better ✓
(Specialist input improves processes
and outcomes for COPD patients)
Percentage of patients receiving
oxygen in which this was
prescribed to a stipulated target
oxygen saturation (SpO2) range
(of 88-92% or 94-98%)
(Inappropriate administration of
100% Better ✓
oxygen is associated with an
increased risk of respiratory acidosis,
the requirement for assisted
ventilation, and death)
Percentage of patients receiving
non invasive ventilation (NIV)
within the first 24 hours of arrival
who do so within 3 hours of arrival 0% Worse 
(NIV is an evidence-based
intervention that halves the mortality
if applied early in the admission)
Percentage of documented current
smokers prescribed smoking-
cessation pharmacotherapy
(Smoking cessation is one of the few
28.1% Better 
interventions that can alter the
trajectory of COPD)
Percentage of patients for whom a
British Thoracic Society, or
equivalent, discharge bundle was
completed for the admission 93.4% Better ✓
(Completion of a discharge bundle
improves readmission rates and
integration of care)
Percentage of patients with
spirometry confirming FEV1/FVC
ratio <0.7 recorded in case file
(A diagnosis of COPD cannot be
56.6% Better ✓
made without confirmatory spirometry
and the whole pathway is in doubt)
(Source: Chronic Obstructive Pulmonary Disease Audit)
We asked the service to provide us with their action plan for the Chronic Obstructive Pulmonary
Disease Audit however, this was not provided. We were therefore not assured the trust was
taking appropriate action to address areas of poor performance to improve.
National Audit of Dementia
Audit of Dementia.
Meets national
Audit’s Rating
cross)
Percentage of carers rating
overall care received by the
person cared for in hospital as
Excellent or Very Good (A key aim No current
76.9% Better
of the audit was to collect feedback standard
from carers to ask them to rate the
care that was received by the person
they care for while in hospital)
Percentage of staff responding
“always” or “most of the time” to
the question “Is your ward/
service able to respond to the
needs of people with dementia as
No current
they arise?” 58.1% Worse
standard
(This measure could reflect on staff
perception of adequate staffing
and/or training available to meet the
needs of people with dementia in
hospital)
Mental state assessment carried
out upon or during admission for
recent changes or fluctuation in
behaviour that may indicate the
presence of delirium No current
13.2% Worse
(Delirium is five times more likely to standard
affect people with dementia, who
should have an initial assessment for
any possible signs, followed by a full
clinical assessment if necessary)
Multi-disciplinary team
involvement in discussion of
discharge
(Timely coordination and adequate
No current
discharge planning is essential to 27% Worse
standard
limit potential delays in dementia
patients returning to their place of
residence and avoid prolonged
admission)
(Source: National Audit of Dementia)
We asked the service to provide us with their action plan for the national audit of dementia
however, this was not provided. We were therefore not assured the trust was appropriate taking
action to address areas of poor performance to improve.
The service participated in the Joint Advisory Group (JAG) on GI Endoscopy and held Level One
JAG accreditation.
The service had a limited local clinical audit programme and conducted audits into procedural
sedation, delirium, heart failure and anticoagulation referral. We viewed these audits and saw that
conclusions were drawn, and action plans created to address any concerns found. Action plans
had assigned actions to members of staff with designated completion dates. Following our
inspection, we requested the service’s local audit programme and action plans and only the above
four audits were sent. We were therefore not assured that medical staff were encouraged to
undertake local audit.
The cancer service had a clinical nurse specialist (CNS) assigned to clinical trials. The CNS
worked alongside a consultant to identify and support patients through treatment trials.
Sepsis outcomes were monitored at the services Patient Safety and quality meetings and were
featured as one of the services quality initiatives.
Competent staff
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.
Appraisal rates
From April to October 2018, 90.2% of staff within Princess Alexandra Hospital’s medical
department received an appraisal compared to a trust target of 90%. The service met its target
for five out of the eight staff groups.

Staff group Appraisals Eligible Completion Met
Trust target
required staff rate (Yes / No)
Support to scientific, 16 16 100% 90% Yes
Support to doctors and 223 238 93.7% 90% Yes
nursing staff
Qualified healthcare 23 25 92% 90% Yes
scientists
Qualified allied health 26 30 86.7% 90% No
professionals
Qualified nursing staff 147 170 86.5% 90% No
NHS infrastructure support 20 31 64.5% 90% No
Total 504 559 90.2% 90% Yes
The 90% completion target was met for medical staff. However, 86.5% of qualified nursing staff
had received an appraisal, which was below the 90% target.
The service’s ward clerks tracked the appraisal rate of ward staff using a Red-Amber-Green
(RAG) system to show when staff were up to date, were nearly due or were overdue for their
appraisal. The ward clerks used this system to ensure staff were booked in for their appraisal.
All staff we spoke with told us they found their appraisals meaningful and had been given the
opportunity to set goals and identified training needs within their appraisal discussions. Staff told
us the service encouraged them to learn and provided opportunities for them to develop. One
member of nursing staff we spoke with told us that the trust had supported and funded them
through two masters degrees. A healthcare assistant we spoke with told us that they had been
supported to take additional qualifications and had become the end of life care and dementia
champion for their ward.
Senior nurses in the service told us that they had regular one to one meetings with their
managers who offered them support and the opportunity to discuss their training needs.
The service had a practice development team of nurses to help induct new staff into their role
and mentor international recruits when they started at the trust.
The service’s dementia specialist team provided training on topics such as delirium for registered
nursing staff on the trust’s induction. Medical staff were provided with an hour-long session on
delirium as part of additional training available throughout the year. All staff within the service
participated in a ‘virtual dementia tour’. This was an in-house training session provided by the
trust that used videos to simulate how situations may appear to a patient living with dementia.
This helped staff to understand and empathise with patients who were living with dementia.
There were systems and processes in place to ensure newly appointed staff, bank and agency
staff completed local inductions. We spoke with agency nurses and health care assistants (HCAs)
who told us they received an induction to their specific ward. We saw evidence that local
inductions took place on each ward we inspected, and these were kept on each ward.
The service had a temporary staff checklist for agency staff to ensure that they were inducted to
the area and had assessed competencies. The service provided agency staff with access to the
IT systems for 48 hours at a time. This ensured that if a member of staff was booked for two days
in a row that they could access the system on both shifts.
Junior doctors had protected teaching time on Thursday afternoons and junior doctors we spoke
with told us they had positive experiences with their assigned educational supervisors. There was
a journal club held on Wednesday mornings which raised topics for discussion among medical
staff.
Cancer nurse specialists and doctors had access to advanced communication skills and in-house
breaking bad news training.
Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and
other healthcare professionals supported each other to provide good care.
Staff consistently told us there was good multidisciplinary team (MDT) working across the trust.
Nursing staff told us there was good communication between therapy teams, nurses and doctors
and that they regularly held effective MDT meetings to discuss patient care.
Pharmacists were assigned to wards and told us there was strong MDT working across the hospital.
Social workers were part of the service’s discharge teams and worked within the team to facilitate
complex discharges. All wards had established links with the dementia services and staff could
explain how they would access their services.
We observed board rounds on Ray ward and Harvey ward and saw that medical staff,
occupational therapists, physical therapists, social workers and nurses all attended and inputted
into patient’s treatment plans and discussions.
We observed physiotherapist and occupational therapists contributing to patients care on the
wards and within the medical records that we reviewed.
Relevant teams worked effectively together to discharge patients in a timely manner. The service’s
patient journey coordinators worked with doctors, nurses, social workers and pharmacists to try to
ensure patients were discharged at an appropriate time of day. Each ward monitored and reported
on discharges after 10pm as part of the ward exception reports which were reviewed by the
healthcare group board.
Seven-day services
Key services were available seven days a week to support timely patient care.
Staff could access a range of imaging services, including; X-ray, magnetic resonance imaging
(MRI) and computerised tomography (CT) scanners 24 hours a day, seven days a week,
facilitated by a team of radiographers. An outside provider interpreted results and fed back to staff
within indicated timeframes.
The endoscopy service was open seven days a week from 7:30am until 6:30pm.
The alcohol liaison nurse was available Monday to Friday. Between these times the service would
refer to the mental health team based in the hospital and managed by a separate provider.
Staff reported good access to therapies such as physiotherapy, occupational therapy and speech
and language therapy Monday to Friday, with reduced access at weekends for physiotherapy and
speech and language therapy.
Learning disability support nurses were available Monday to Friday. Outside of these hours, staff
flagged patients to the site team for the nurse specialist to pick up the following day.
The trust provided mental health nurse cover 24 hours a day, seven days a week for adults.
There was access to psychiatry through a doctor’s referral to a team that was based in a mental
health services centre that was based in the hospital and was managed by a separate provider.
Health Promotion
Staff gave patients practical support and advice to lead healthier lives.
Throughout the service leaflets were available on smoking cessation, healthy minds, staying safe
and active and support groups for people living with long term conditions.
The cancer service had access to referral services for smoking cessation, bowel awareness,
wellbeing walks and alcohol and nutrition advice. The cancer service supported the delivery of the
Macmillan recovery package of interventions, which looked at holistic input from services into a
patient’s treatment.

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.
within the trust’s safeguarding adults level 2 training module. A specific course in MCA and DoLS

qualified nursing staff and medical staff in medicine at Princess Alexandra Hospital is shown
below. The completion target for this module is 95%.
As of October 2018
Staff group Staff Eligible Completion Trust Met
Medical staff 80 128 62.5% 95% No
In medicine the 95% training target was met for safeguarding adults level 2 training for qualified
nursing staff. However, the target was not met for medical staff.
Following the inspection, the trust provided updated data for safeguarding adults level 2 training
as of March 2019 for qualified nursing staff and medical staff in Princess Alexandra Hospital’s
medical care department:
As of March 2019
In Princess Alexandra’s medical care department, the 90% target for safeguarding adults level 2
training was met by qualified nursing staff. Although the target was not met for medical staff, the
completion rate was higher than in the previous time period.
The trust had a consent policy, which was found to be in date, available electronically and was
in keeping with current guidance. Procedures around the Mental Capacity Act (2005) and the
Deprivation of Liberty Safeguards (DoLS) was included within the consent policy, which was in
keeping with best practice guidance. The DoLS aim is to ensure that people in care homes and
hospitals are looked after in a way that does not inappropriately restrict their freedom.
The mental capacity of patients formed part of discussions at MDT meetings and patients that
required a mental capacity assessment were reviewed.
Where a patient had been assessed as lacking mental capacity to make certain decisions, the
central safeguarding team were alerted to those patients where a mental capacity act decision
had been made so they could undertake an independent review and provide support and
guidance to staff. The safeguarding team prepared a quality assurance audit of the mental
capacity act decisions they had reviewed and found that not all MCA decisions in the trust had
been sent to them. They also found that the main area of missing data on forms was the best
interest decision form not being completed as it should be. From this audit they prepared
recommendations including creating a new email address to send MCA decisions, an update of
the MCA form and a new audit tool to be devised.
We reviewed four mental capacity assessments. Medical staff had completed them appropriately,
evidenced discussions with each patient’s family having signed and dated them. However, on
Fleming ward a patient had been assessed as not having capacity due to acute delirium but no
best interest decision was documented for this patient and in the patient’s nursing record there
was conflicting information as to whether they did have capacity. This could have caused
confusion for staff and possibly led to decisions being made without a patient’s consent when
they had capacity to consent.
Staff we spoke with had good knowledge of the Mental Capacity Act and DoLs procedures and could
give appropriate examples of where they would place a patient under a DoLs.
Compassionate care
Staff treated patients with compassion and kindness, respected their privacy and dignity,
and took account of their individual needs.
Staff took the time to interact with patients and their relatives in a respectful and considerate way.
We observed staff assisting patients with eating and supporting them in a kind, respectful manner,
allowing them to take their time to eat. We observed staff trying to ensure patients were happy
with the food choices and were comfortable in the position they were in whilst eating.
All six patients we spoke with told us they were happy with their care and that staff treated them
with kindness. One patient told us “the staff are absolutely charming, absolutely fantastic. They
smile, and you melt”.
We spoke with three patients’ relatives who told us they had visited the service before and felt the
level of care provided to patients had improved since previous years.
Nursing and medical staff preserved patient privacy and dignity by closing curtains before
undertaking care. They also asked for permission before entering patient rooms and curtained
bed spaces.
The Friends and Family Test response rate for medicine at Princess Alexandra Hospital was 38%
which was better than the England average of 24% from January to December 2018.
A breakdown of FFT performance by ward for medical wards at this hospital over the same
period is shown below.
The percentage of respondents that said they would recommend the ward to family or friends
was 86% or higher for all medical wards for these 12 months overall. However, caution is advised
in interpreting these results given the low response rates for some wards.
1. The total responses exclude all responses in months where there were less than five responses at a particular
ward (shown as gaps in the data above), as well as wards where there were less than 100 responses in total over
the 12 month period.
2. Sorted by total response.
3. The formatting above is conditional formatting which colours cells on a grading from highest to lowest, to aid in
seeing quickly where scores are high or low. Colours do not imply the passing or failing of any national standard.

Emotional support
Staff provided emotional support to patients, families and carers to minimise their distress.
They understood patients’ personal, cultural and religious needs.
Staff provided patients and their families with appropriate and timely support and provided
information to assist them to cope emotionally and socially.
There was a trust wide chaplaincy service who could also provide emotional support and we saw
this advertised using leaflets in different areas of the service.
Nursing managers on Lister ward supported and praised their staff through the ‘hug in a jug’. Staff
told us that this meant that a manager would give positive feedback to staff monthly and stored the
feedback slips in a book on the ward for all staff to look at.
The cancer service signposted patients to counselling with the Macmillan service. The cancer
nurse specialists supported patients with their emotional needs by providing psychological
support. The service had access to wellbeing sessions on makeup and massages through the
Macmillan service.

Staff supported and involved patients, families and carers to understand their condition
and make decisions about their care and treatment.
Staff routinely involved patients and their relatives in care planning and decision-making, for
example discharge planning. This was evidenced in patients’ nursing and medical care records.
We observed doctors and nurses involving patients in discussions during every interaction and
asking patients whether they had anything they would like to ask or whether they needed any
clarification.
All the patients and relatives we spoke with told us they had felt involved in their care planning and
decision-making.

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 worked with local and specialist clinical commissioning groups and other NHS trusts
to determine service provision and working in partnership with other NHS service providers to
achieve this.
Since our previous inspection, a softly furnished quiet room had been created on Saunders ward
to provide a quiet environment where staff could speak with relatives and patients in private. On
Harvey ward nursing staff told us that oncologists and cancer nurse specialists broke bad news to
patients as they had undergone advanced communication skills training.
The cancer service worked closely with their local sustainability and transformation partnership
and East of England Cancer Alliance to plan their services and give patients access to new cancer
trials and drug treatments.
The cancer service was working alongside Macmillan to improve the environment of the day
centre.
The cancer service had implemented the MacMillan recovery package for patients. The package
encompasses four main interventions: holistic needs assessment and care planning, treatment
summary, cancer care review and health and wellbeing events. The service had a manager in
charge of the package who told us that the package allowed patients to be in charge of their
treatment pathway and catered to patients’ individual needs.
The endoscopy service ensured they managed patients’ expectations by displaying a whiteboard
with the waiting time to go into endoscopy. On the day of our inspection the waiting time was 30
minutes.

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 trust’s learning disability team were visible throughout the service and consisted of one
specialist nurse and support workers. Staff within the service knew how to access the teams and
we saw evidence of their input into patient care in the patient’s medical records. Information was
available for staff and patients about the service.
The trust used ‘health passports’ to communicate the health and social care needs of people living
with a learning disability to doctors, nurses and other healthcare professionals. This passport gave
detailed information in relation to a patient’s preferences of care, family, and social circumstances.
We saw the passport in use for a patient on Harvey ward and it contained all the relevant
personal, social and medical information to assist staff with caring for the patient.
The service had put in place additional measures for relatives of patients with learning disabilities
including open visiting hours, free parking and offering meals so the patients could eat with their
relatives.
The service had a dementia specialist team comprising of nurses and support workers. Gibberd
ward was the service’s dementia friendly ward. The ward had an enclosed sensory garden that
had been landscaped from charitable funds. Throughout the trust there were 48 dementia
champions who had received training on caring for patients with dementia.
Ray ward had received the Royal College of Psychiatrists (RCPSYCH) Dementia Friendly Quality
Mark. We saw that throughout the service the toilets were identified by large pictures to make the
toilets more easily spotted by patients suffering with a cognitive impairment. Lister ward had also
been awarded the Quality Mark for Elderly Friendly Wards from RCPSYCH. The ward had a quiet
room that had pictures, radio and board games for patients to play with their relatives.
The trust used a ‘Forget Me Not’ symbol above the patient’s bed to identify patients with dementia
additional needs and used the ‘This Is Me’ tool to support those patients. However, on Gibberd
ward we reviewed nine patients’ ‘This Is Me’ booklets and saw that five of them were blank. We
were concerned that the ‘This is me’ document was not embedded practice.
There was an interpretation service available for patients and their families who did not speak
English as their first language. Staff knew how to access the translation service.
On Harvey ward staff had access to a communication folder with information for staff about
different ways patients may wish to communicate and visual guides to assist these patients with
communication.
The hospital chaplaincy service had chaplains of various denominations that could be contacted to
provide support for patients and families 24 hours a day, seven days a week.
Access and flow

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 monitored by the service. There were measures in place to improve flow
throughout the hospital.
Patients were usually admitted to the medical wards from the emergency department (ED), the
short stay medical ward (Saunders ward) or the Fleming Medical Assessment Unit (MAU).
Patients could also be admitted to the MAU through their GP. Patients were admitted to the MAU
to receive further assessments and to determine which speciality was most appropriate if the
patient was to be admitted to a ward.
Nursing staff told us that throughout winter the MAU had been operating with the assessment
areas as a bedded space in line with trust policy. Staff told us that it had been running as an
assessment unit once more for about ten days prior to our inspection.
The service had a number of initiatives in place to improve flow and discharges within the hospital.
Across the wards there were board rounds three times daily, these were attended by the
multidisciplinary team, including physiotherapists, nurses, discharge facilitators and doctors. At the
board round the team used the services ‘red to green’ initiative to speed up patient discharges and
ensure patients were discharged safely. The red to green system was a way of monitoring patients
who were waiting active treatments and further investigations such as scans. A patient was
marked red on the board if they were awaiting treatment or investigations and green if they were
ready to be discharged. The red marker prompted staff to chase up any investigations to improve
discharge planning.
The service had patient journey coordinators to assist staff with patient discharges. The
coordinators discussed discharge with patients when they were admitted to wards to ensure that a
focus was on discharge planning from the outset and patient’s expectations were managed. The
coordinators were involved with planning care and determining discharge pathways with the
doctors and nurses responsible for the patient’s treatment from an early stage with the aim of
reducing each patient’s length of stay. The coordinators tracked delayed transfer of care patients
on an electronic system daily to identify whether patient discharge plans had progressed or
needed to be escalated. The coordinators met weekly to discuss guidelines, learning and ways to
improve the discharge process.
The service had clinical site managers whose role was to ensure that patients pathways operated
smoothly in the hospital and to assist wards with patients that required escalating on the red to
green process. The clinical site managers would perform daily walk rounds on wards to speak with
staff to understand their concerns.
Patient flow and bed management meetings were held three times a day, to discuss capacity,
patient transfers, issues in the local health system and planned discharges for that day. This was
attended by the chief operating officer, the associate directors for nursing, bed managers and
representatives from the health care groups.
The service had medical outliers during our inspection on surgical wards. Medical outliers are
where patients receiving care on a different specialty ward. The service had arrangements in place
for medical staff to review medical outliers daily, we saw evidence of this in the two sets of outlier
patient records that we reviewed on Penn ward. Nurses on the receiving wards told us that the
medical team were very responsive when bleeped to see patients on the wards. The service had
an average of 20 outliers per day from January to December 2018.
The endoscopy service had a pathway in place to improve flow within the unit by using an
experienced band 6 nurse to triage patients on a lower risk pathway and referring them for
endoscopy. This meant patients could be fast-tracked through the service without having to see a
consultant.
Average length of stay
From October 2017 to September 2018 the average length of stay for medical elective patients at
Princess Alexandra Hospital was 5.8 days, which was similar to the England average of 5.9 days.
Average length of stay for elective specialties:

• Average length of stay for elective patients in gastroenterology was similar to the England
average.
• Average length of stay for elective patients in cardiology was twice the England average.
• Average length of stay for elective patients in general medicine was longer than the England
average.
Elective Average Length of Stay - Princess Alexandra Hospital
Note: Top three specialties for specific site based on count of activity.
From October 2017 to September 2018 the average length of stay for medical non-elective
patients was 6.5 days, which was similar to the England average of 6.3 days.
Average length of stay for non-elective specialties:
• Average length of stay for non-elective patients in general medicine was similar to the England
average.
• Average length of stay for non-elective patients in respiratory medicine was longer than the
England average.
• Average length of stay for non-elective patients in geriatric medicine was more than 50%
longer than the England average.
Non-Elective Average Length of Stay - Princess Alexandra Hospital
Individual wards were aware of their average length of stay and spoke about plans in place to
reduce the length. On Ray ward, nursing staff told us the length of stay had been reduced
following the introduction of board rounds and the red to green process.
Referral to treatment (percentage within 18 weeks) - admitted performance
It should be noted that the number of completed admitted referral to treatment pathways in
medical specialties reported by the trust for the period from January to December 2018 was very
small. Over the whole 12 months there were only 34 completed admitted pathways. Due to small
numbers, the graph below shows large fluctuations in trust performance.
There were no completed admitted pathways for medical specialties at the trust in September
2018, and fewer than six in December 2018. Therefore, no data was available for either month.
Over the whole 12 months period from January to December 2018, 26 of the 34 completed
admitted pathways (76.5%) were completed within 18 weeks of referral.
The chart below shows RTT performance at the trust compared to the England average.
However, these rates should be interpreted with care given the small numbers involved.
Referral to treatment (percentage within 18 weeks) – by specialty
Of the 34 completed admitted pathways in medicine reported by the trust from January to
December 2018, 13 (more than a third) were in one specialty: gastroenterology. All these
pathways were completed within 18 weeks of referral. This was better than the England average
of 93.3%. However, the trust figure should be treated with caution, as it is based on a small
number of completed pathways.
RTT performance at the trust has not been calculated for the other medical specialties as there
were fewer than six completed admitted pathways in each specialty.
Patient moving wards per admission
Please note that the trust was only able to provide data for the four-month period from September
to December 2018.
Over these four months, 99.4% of individuals on medical wards did not move wards during their
admission, and 0.6% moved once. There were no individuals that moved wards more than once
on medical wards over this period.
(Source: Routine Provider Information Request (RPIR) – Ward moves tab)
Patient moving wards at night
From December 2017 to November 2018, there were 2,411 patients moving wards at night within
medicine.
The highest numbers of ward moves at night were reported in May 2018 (239), April 2018 (237)
and October 2018 (229).
The highest numbers of ward moves at night were reported by Kingsmore Ward (462), Saunders
Ward (454) and Locke Ward (332).
(Source: Routine Provider Information Request (RPIR) – Moves at night tab)

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.
From December 2017 to November 2018 the trust received 73 complaints about medicine at
Princess Alexandra Hospital (31.1% of total complaints received by the hospital).
The trust took an average of 53.7 working days to investigate and close complaints. They noted
that all deadlines for completion were agreed with their individual complainants, however they
worked towards a target of 180 working days.
A breakdown of complaints by department is shown below:
Number of Percentage of
Department
complaints total
Complex care (care of the elderly) and fractured neck of femur 20 27.4%
Respiratory 10 13.7%
Cardiology 5 6.8%
Gastroenterology 2 2.7%
Cancer services and oncology 1 1.4%
Dermatology 1 1.4%
Diabetes 1 1.4%
Endoscopy, bronchoscopy, colonoscopy, endoscopic
retrograde cholangio-pancreatography (ERCP), gastroscopy, 1 1.4%
sigmoidoscopy
Total 73 100%
Type of complaint
complaints total
Admissions and discharges (excluding delayed discharge due 9 12.3%
to the absence of a care package)
Total 73 100%
Patients we spoke with were aware of how to complain and knew how they could complain if
necessary. Ward managers told us that they invited complainants to discuss the complaint in the
first instance, to identify and resolve issues in a timely manner. If this was unsuccessful in
resolution the complainant was directed to the trusts Patient advice and liaison service (PALS).
PALS is an independent service which offers confidential advice, support and information on
health-related matters. They provide a point of contact for patients, their families and their carers
or relatives.
Staff were aware of the trust’s complaints policy; this was in date, accessible to staff and in line
with best practice recommendations.
Learning from complaints was shared in the service’s feedback Friday newsletters. An example
of which was a complaint about communication from a ward to relatives when a patient had
deteriorated. The service had identified actions to learn from the complaint including reminding
staff of the importance of contacting patient’s relatives when a deterioration occurs and asking
relative on arrival if and how they would like to be contacted.
From December 2017 to November 2018 there were 317 compliments about medicine at
Princess Alexandra Hospital.
Of these compliments 314 concerned inpatient medical services, and three concerned cancer
services.
(202 compliments).

Leadership
We were not assured that managers at all levels in the service had the right skills and abilities
to run a service providing high-quality sustainable care.
The medicine healthcare group covered the emergency department as well as the medical care
services at the trust. The service was led by a triumvirate management system, with an associate
clinical director, associate director of nursing, and associate director of operations who worked
together to lead the health care group. Service matrons, clinical leads for each medical specialty
and service managers supported the triumvirate management team.
Wards and departments were led by band seven ward managers and were supported by band six
nurses. We were not assured that leaders had the right skills and abilities on some of the wards
we visited. We were concerned that some leaders demonstrated a lack of knowledge and
oversight on processes for condemned equipment and had not rectified issues that had previously
been identified by staff including hazardous chemicals being left in an unlocked room and the
inappropriate storage of glass waste. We raised this with the trust and support plans were put in
place.
The service had a number of different leadership management courses available to staff including
training on coaching conversations, route cause analysis, leadership core programme and talent
programmes. All leaders within the service we spoke with had undertaken leadership training.
Nursing staff consistently told us across the service that they felt supported by their immediate
managers. Staff told us that they felt they could go to their ward managers with any concerns and
that they would be escalated appropriately. Nursing staff told us that the matrons were visible
throughout the service. Nursing leaders we spoke with told us that they felt they were able to ask
for support from matrons and their peers.
Staff consistently told us that the executive team were visible within the service and could be seen
on the wards.
The trust had a whistleblowing policy and named freedom to speak up guardian. Freedom to
speak up guardians work alongside trust leadership teams to support staff to speak up, ensure a
culture of speaking up is instilled, and ensure processes are effective and improved. Staff knew
how to raise a whistleblowing concern and felt they would receive support from their freedom so
speak up guardian if required.
Vision and strategy

The trust had a vision for what it wanted to achieve however it did not yet have a strategy
that was regularly reviewed and updated.
The trust’s vision and values were clearly displayed in staff and public areas in the department.
The vision was to be an excellent provider of integrated acute care services. The values were
that staff were respectful, caring, responsible and committed when carrying out their role.
All the staff we spoke with knew the hospital wide values and told us they felt staff embodied them.
The service had created a ‘strategy on a page’ which aligned with the trust wide goals regarding
performance, people, patients, places and pounds. This ensured the vision and strategy was
accessible to all staff throughout the health care group.
The cancer service did not have a specific vision and strategy but was working alongside the local
sustainability and transformation partnership on creating one in line with the national cancer
agenda.
Culture
Most staff that we spoke with told us that they felt valued and respected in their role. However,
staff told us that staffing issues had an impact on morale and that working below planned staffing
numbers and getting pulled to other wards had created low morale.
Members of the senior leadership team were accessible and undertook ‘walkarounds’ and
supported staff. It was evident from the way in which they spoke about their staff that managers
were proud of their teams and their departments.
The service had a freedom to speak up guardian. Freedom to speak up guardians provide
independent support and advice to staff who want to raise concerns. Staff we spoke with were
aware that the service had one and told us that they could find the contact details on the intranet.
Governance
The service had structures, processes and systems of accountability in place to support
the delivery of the trust’s strategy. However, ward level governance structures were not
always effective or embedded.
The service had a clear governance structure within the medical health care group. Some
specialities in the service had recently introduced speciality patient safety and quality group
(PS&Q) meetings. The intention was that the speciality meetings fed into the established Medicine
Directorate Patient Safety and Quality group meetings, which in turn fed into the Medical Health
Care Group meetings. There was good oversight of the services risks, incidents and operational
concerns at the triumvirate level, however we found that governance processes and systems at
speciality and ward level were not always effective.
We reviewed the minutes for the speciality PS&Q meetings and found the new system was not yet
embedded across all wards and did not have set agendas. We reviewed the meeting minutes for
the gastroenterology PS&Q meetings and saw they were used to discuss mortality and morbidity
only and did not reflect the agendas of the wider service PS&Q meetings.
We reviewed the medicine directorate PS&Q group meeting minutes and action log and saw that
the meetings were poorly attended and not an embedded part of the services governance
structure. We saw there had been one medicine directorate speciality PS&Q meeting in the three
months prior to our inspection. We reviewed the meeting minutes for March 2019, the January
2019 meeting had been cancelled due to operational pressure.
The meeting had standing agenda items that included local risk registers, complaints, audits and
incidents. We saw in the January 2019 meeting minutes for the health care group board that
PS&Q meetings had not been taking place due to a lack of attendees and that staff had noted that
this was affecting the governance of the service.
The medical health care group (MHCG) board meeting met monthly. The group had standing
agenda items which included risk, quality (which included incidents, complaints and NICE
guidance), policies, workforce, performance reports from the individual specialities, governance
and finance. Each ward completed an exception report that fed information about risks, staffing,
complaints and incidents into the MHCG. We reviewed the meeting minutes which were reflective
of the concerns within the service and saw actions were assigned to members of staff with
completion dates. We felt assured that high level concerns were appropriately escalated through
the service’s systems and processes.
There were effective measures in place for ward-based risks to be escalated to the trust board.
Ward managers completed monthly exception reports, which included the ward-based risk
register. The risk profile for the wards were managed by the medical services leadership and
reported in to the trust board meetings. Exception reports also provided information on complaints,
compliments, appraisal rates, sickness rates and staff retention, discharges, mental capacity act
training and staffing levels,
The health care group had recently changed from monthly ward manager and matron meetings to
twice weekly huddles due to poor attendance. The new huddles were not minuted but had a
running action log and were attended by ward managers and matrons.

The service had effective systems for identifying risks, planning to eliminate or reduce
them at triumvirate level. However, there was not effective systems in place to identify and
manage local risks on some of the wards we inspected.
The service had individual risk registers for each ward which fed into the medicine healthcare
group risk register. Risks on the register reflected concerns that staff had raised such as the age
of the equipment in the endoscopy department, staffing concerns and falls risks to patients. The
risk registers detailed mitigating actions, with actions being assigned to appropriate staff members
with progress tracked. Risks were discussed at the services patient safety and quality group
meetings and health care group board meetings.
Ward managers and matrons were aware of their ward’s top risks and the risks they told us
reflected what was written on the registers. For example, Fleming ward’s risk register reflected that
pressure ulcers were a risk in this area alongside staffing and falls risks. Matrons told us they had
received training recently on the services risk register.
We were not assured that there was adequate oversight of risks on all the ward environments.
Nursing leaders within the service told us there was a system of audit in place to oversee the ward
environment, documentation and medicines. However, ward managers and matrons we spoke
with agreed that this system had failed to pick up some of the issues we identified during our
inspection including faulty equipment and inappropriate storage of glass and hazardous
chemicals. We raised this concern with a ward matron who informed us that they would ensure
they did daily ward walk rounds to ensure the environment was safe. However, at our
unannounced inspection, we found the same issue with glass storage on Saunders ward so were
not assured that our concerns within the environment had been addressed or that there was
adequate oversight from senior staff.
One matron we spoke with regarding hazardous substances not being locked away in line with
regulations, told us that this was a concern they had been made aware of before and had sent
emails to staff regarding it. Senior leaders were therefore aware of this issue but had not followed
this up to ensure appropriate action had been taken.
Each ward completed a monthly exception report which fed into the patient safety and quality
meetings. Each report looked at staffing levels, training, risks to be added to the risk register,
sickness rates, complaints and quality audit information. We saw in Fleming ward’s exception
report for March 2019 that planned staffing levels were only met for 15 out of 56 shifts, however
we saw no evidence that there was discussion at the services Medical Health Group Board Meeting
(MHCG) about wards consistently operating below the planned staffing level. Information
presented to the (MHCG) included vacancy rates and bank usage but did not include information
on how many shifts did not meet planned staffing levels and how the service was unable to fill
these shifts. We reviewed the minutes of the March 2019 MHCG board meeting and saw that fill
rates were not discussed. However, the service did have a recruitment plan in place to address
the vacancy which included international recruitment.
We were not assured the service was using patient outcome audit data to improve the quality of
services. The minutes of the medicine directorate patient safety and quality group minutes for
March 2019 demonstrated the service was aware that there was a lack of clinician engagement
with audits. The service had a limited number of local audits and we did not see within any meeting
minutes where the progress against action plans for national or local audits were discussed.
The trust had a major incident plan in place. This was regularly updated and available on the trust
intranet page. Action cards which were part of the plan, were available on each ward
The service collected, analysed, managed and used information well to support all its
activities, using secure electronic systems with security safeguards.
The service had clear and robust service performance measures which were regularly reported
and monitored on using the services quality dashboards. The dashboards were reported as part of
the medicine health care group board. these included financial and performance-based targets
including financial targets, discharges, ward transfers, length of stay and more holistic targets such
as complaints and compliments.
Staff received training on information governance as part of their mandatory training.

Information stored electronically was secure. Computer access was password protected and we
observed staff logging out of computer systems or hand-held devices they had completed tasks.
There were arrangements to submit relevant data to national audit programmes. The trust had
systems to ensure notifications of serious incidents causing harm to patients were reported in line
with national requirements.
There were effective arrangements to ensure the information used to monitor, manage and report
on quality and performance was accurate, valid, reliable, timely and relevant.
Staff had access to the trust’s intranet system which provided a range of internal and external
resource material to assist staff in their daily tasks. All referrals and diagnostic requests were
made electronically and staff within the department told us they had access to the information that
was needed for them to undertake their roles effectively, this included agency staff and staff
assisting from other wards and departments.
Engagement
Ward managers engaged with their staff using different methods including team meetings, ward
newsletters, away days and using closed social media groups. Ray ward held monthly staff
meetings that discussed complaints, compliments, findings from ward walkarounds and incidents.
The service presented patient stories to the trust board including a patient story in December 2018
about a patient living with cancer, who was concerned about finances. The story detailed how the
service had assisted the patient to ensure they were not financially vulnerable.
The service had a feedback Friday newsletter that was sent to staff weekly that had a message
from the CEO, patient compliments, incidents and complaint information. Staff were provided the
opportunity to give feedback and hear about updates within the service through the ward’s daily
safety huddles.
The trust held an awards evening annually, teams within the service had won awards in 2018
including the endoscopy service and cancer service.
The cancer service sought input from former oncology patients as part of their patient panel. The
cancer service conducted bi-annual patient experience surveys. Staff in the service could provide
examples of where the survey’s feedback had impacted services including increasing space in the
waiting area by removing cupboards.
The service held a Tuesday morning brief where the executive team gathered in the cafeteria to
brief staff on developments within the trust and provided staff with an opportunity to feedback
information to the executive team and trust colleagues.
and when they went wrong.
Staff of all levels told us they were encouraged to develop and if they identified courses that were
suitable, senior staff strived to arrange funding.
Staff told us that improvement of care was a core philosophy of the trust. The service employed an
improvement officer from another local trust who had been seconded to support staff to embed
safer ‘red to green’ principles. The role was to advise on best practice and provide one to one
discharge training with the aim of improving the services average length of stay. The improvement
officer reported directly into the chief executive officer.
We saw effective participation in and learning from internal reviews relating to mortality, the learning
was shared and used to make improvements within the service.
Surgery

Princess Alexandra Hospital has eight main operating theatres and four day surgery theatres.
The surgery core service at the hospital provides care and treatment for specialties including
breast surgery, general surgery, head & neck surgery, ophthalmology, trauma and orthopaedics,
urology and vascular surgery.
(Source: Acute Routine Provider Information Request (RPIR) – Context Acute tab)
The hospital has 74 surgical inpatient beds located across eight wards and units: Surgical
patients were also located on Jon Snow Ward (gynaecology) and Tye Green Ward which was
part of the medical directorate and cared for elderly patients, some of whom were admitted
following trauma such as falls with fractured hips that required surgical treatment.
Inpatient
Ward/unit Specialty or description
beds
Alexandra day unit Day surgical unit for planned care n/a
Bevan unit Oral surgery outpatients & day case procedure unit n/a
Henry Moore Ward Elective and planned orthopaedic ward 19
Netteswell same day Same day admissions for elective surgery and pre-
n/a
admissions unit assessment clinics
Penn Ward A mixed sex surgical ward 28
Post anaesthetic care Integrated with main operating theatres and provides
n/a
unit (PACU) immediate post-operative recovery
Charnley Ward
formerly Tye Green A mixed sex surgical ward 27
Ward
Jon Snow Ward Some general surgical patients were also
(gynaecology) and Tye accommodated on a non general surgical ward (the
Green ward (medical gynaecology ward) and specific trauma patients (hip
elderly care ward) fracture) on a medicine elderly care ward.
The trust planned to realign the surgical wards following the opening of a new purpose-built ward
in January 2019.
The trust had 17,758 surgical admissions from November 2017 to October 2018. Emergency
admissions accounted for 6,091 (34.3%), 9,704 (54.6%) were day case, and the remaining 1,963
(11.1%) were elective.
During this inspection we, we visited the wards, operating theatres, post anaesthetic care unit
(PACU) admission/pre-assessment unit, day stay unit and the Bevan unit. We spoke with 38
staff, including medical, nursing and administrative staff and seven patients and relatives. We
reviewed policies and information supplied by the trust and 14 patient records and 13 prescription
records.
The service was last in inspected in December 2017 where safe and responsive were rated as
requires improvement and effective, caring, responsive and well led were rated good with an
overall rating of requires improvement.


Mandatory training
The service provided mandatory training in key skills to staff and mostly made sure
everyone completed it.
nursing staff in Princess Alexandra Hospital’s surgery department is shown below:
As of October 2018
Immediate life support level 3 20 25 80% 90% No
In Princess Alexandra Hospital’s surgery department, the 90% target was met for seven of the
The trust provided a range of mandatory training as seen in the tables above, delivered both
face to face and by electronic learning. Nursing staff overall compliance was 92% which met the
trust target of 90% and was a considerable improvement since our last inspection. Some areas
such as immediate life support and adult and paediatric basic life support were slightly lower at
80% and 85%.
for qualified nursing staff in Princess Alexandra Hospital’s surgery department:
As of March 2019
Slips, trips and falls 20 20 100.0% 90% Yes
Introduction to information governance 144 147 98.0% 90% Yes
Adults & paediatrics basic life support 99 107 92.5% 90% Yes
In Princess Alexandra Hospital’s surgery department, the 90% target was met for 13 of the 14
mandatory training modules for which qualified nursing staff were eligible. As in the earlier time
period, the immediate life support level 3 module had the lowest completion rate, however the
completion rate had now increased.
The service had a system in place for alerting individuals when mandatory training was due and
staff and managers were able to check their own compliance and due dates on the electronic
system.
Staff told us they were given time to do their training, although at times it was difficult due to
workload. They could claim time owing back if they did this in their own time at home.
Nursing staff we spoke with were up to date with mandatory training and the ward managers
had good oversight of staff who still required training.
in Princess Alexandra Hospital’s surgery department is shown below:
As of October 2018
Blood training for non registered staff 0 1 0% 90% No
In Princess Alexandra Hospital’s surgery department, the 90% target was not met for any of the
12 mandatory training modules for which medical staff were eligible.
for medical staff in Princess Alexandra Hospital’s surgery department:
As of March 2019
Blood training for non registered staff 0 1 0.0% 90% No
NHS conflict resolution (England) 0 1 0.0% 90% No
Infection prevention and control level 2 0 1 0.0% 90% No
Moving and handling level 1 0 1 0.0% 90% No
In Princess Alexandra Hospital’s surgery department, the 90% target was not met for any of the
16 mandatory training modules for which medical staff were eligible. Apart from the four
modules for which only one member of staff was eligible, the completion rate for adults and
paediatrics basic life support was the lowest, at 53.9%, and there had been a deterioration
compared to the previous rate.
Data supplied by the trust following the inspection showed that medical staff training overall
compliance as of March 2019 was 73% which although still below the trust target was an
improvement since our last inspection.
The service reported that the next audit day had been converted to statutory mandatory training
for face to face, and electronic learning sessions. The audit days were usually scheduled one
afternoon per month for the department to review current audit activity. There was a trajectory for
all medical staff to have completed their mandatory training by July 2019.
Training compliance was monitored through the Surgery and Critical Care Health Group
(SCCHG) Quality Assurance Dashboard. The February 2019 dashboard reported that medical
staff training compliance remained an issue but that the directorate was addressing this with
bespoke training on the regular departmental audit days. The February dashboard training
compliance was reported as 86% overall for all directorate staff.
Safeguarding
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.
nursing staff in Princess Alexandra Hospital’s surgery department is shown below:
As of October 2018
In Princess Alexandra Hospital’s surgery department, the trust’s training targets were met for
three of the four safeguarding training modules for which qualified nursing staff were eligible.
Following our inspection, the trust provided updated safeguarding training data as of March
2019 for qualified nursing staff in Princess Alexandra Hospital’s surgery department:
As of March 2019
In Princess Alexandra Hospital’s surgery department, the 90% target was met for three of the
four safeguarding training modules for which qualified nursing staff were eligible. The
completion rate for the safeguarding children’s level 3 module was the lowest, at 82.3%, and
this was a decrease when compared to the previous time period.
Surgical nursing staff met the trust targets for safeguarding in three out of the four modules. The
safeguarding children level 3 training for theatre and post-operative care unit (PACU) staff had
been introduced since out last inspection with the only staff who had not completed it being very
new staff. This was an improvement since our last inspection.
staff in Princess Alexandra Hospital’s surgery department is shown below:
As of October 2018
Safeguarding adults level 2 75 134 56% 95% No
Prevent/health WRAP 50 125 40% 90% No
In Princess Alexandra Hospital’s surgery department, the trust’s training targets were not met for
any of the four safeguarding training modules for which medical staff were eligible.
2019 for medical staff in Princess Alexandra Hospital’s surgery department:
As of March 2019
In Princess Alexandra Hospital’s surgery department, the 90% target was met for one of the five
safeguarding training modules for which medical staff were eligible. However, the rates had
increased when compared to the previous time period.
There were arrangements to safeguard adults and children from abuse and neglect that reflected
relevant legislation and local requirements. The service had a safeguarding policy in place which
was within review date and accessible to staff electronically.
Staff we spoke with could explain what they would do if they had concerns around safeguarding
and they understood the correct process to follow. Staff understood their responsibilities, adhered
to safeguarding policies and procedures, and worked with other agencies when required.
The trust had a safeguarding lead who could support and advise staff on safeguarding issues.
Staff told us they knew how to contact them and had received advice and support when they had
concerns.
The service controlled infection risk well. Staff kept their uniforms, equipment and the
premises clean. They used control measures to prevent the spread of infection.
From April 2018 to March 2019 the service reported nine cases of hospital-acquired infections. Of
these; there were none from Methicillin-resistant Staphylococcus aureus (MRSA), a bacteria
resistant to the methicillin group of antibiotics. Three infections from Clostridium Difficile, (a
bacteria that can affect the bowel causing diarrhoea and spreads easily to others), four from
Escherichia Coli (a further bacteria found in the bowel), one from Methicillin-sensitive
Staphylococcus Aureus (MSSA) and one from Pseudomonas Aeruginosa. These all belong to a
group of infections described as "opportunistic" organisms, which can cause a serious infection
when peoples’ normal immune systems are weakened.
All patients booked in for planned/elective surgery in the pre-assessment clinic were screened for
MRSA at their clinic appointment. Staff checked and recorded results in the patients’ notes. If the
patient tested positive they were alerted and asked to attend their GP for treatment prior to their
admission. This was to prevent the risk of cross infection.
The hospital had a screening emergency and elective patient’s policy in place which was in date.
The policy explained the process for screening for patients and they had pathways in place for
both emergency and elective patients if the results came back as negative.
Henry Moore ward, was the designated orthopaedic joint replacement ward, and patients were
only admitted once they had been screened for MRSA.
Formal sepsis teaching was included on induction for medical and nursing staff to ensure they
were aware of the trust’s sepsis guidelines.
The wards and theatre environments we inspected were visibly clean. Although the theatre
environment was worn in places, there was an ongoing refurbishment plan in place which
included renewing the floor covering. All theatre equipment we inspected was suitable for use
without rips or tears which might have present an infection risk. This was an improvement since
out last inspection.
Hand cleansing gel was available outside the theatres, in the post anaesthetic care unit (PACU),
at the entrances to the wards and in every patient bay.
Daily cleaning checklists were available in the clinical areas and were up-to-date and signed by
the completing staff member.
The service audited the cleaning of surgical areas monthly. From January 2018 to December 2018
the scores ranged between 92.5% and 100% with an average of 96.9%. We noted that there were
11 omissions for the same period where areas did not submit audit data. This meant that we were
not be assured that all areas performed cleaning audits and submitted data. This was reported in
the monthly dashboard report.
Curtains around bed areas in the wards and day surgery units were mostly disposable or changed
regularly to reduce the risk of cross infection and were marked with the date when this had been
done. We found no curtains that were out of date for changing during our inspection and all were
visibly clean.
We observed dated “I am clean stickers” on equipment to show staff had cleaned items, and that
they were ready for use on the wards, theatres, PACU and in the Alexandra day surgery unit
(ADSU).
The service had designated infection prevention and control (IPC) ‘link nurses’ on each ward, in
theatres and recovery who were available as a point of contact for advice, guidance and training,
and resource folders in all of the surgical wards and departments for staff to refer to.
The service audited hand hygiene compliance monthly and from April 2018 to February 2019
compliance averaged between 94% and 100%. Henry Moore ward achieved the lowest
compliance score of 81% in July 2018.
During our inspection all staff demonstrated good hand hygiene practices. We observed staff were
bare below the elbows in line with trust policy. Clinical staff either washed their hands and/or used
antibacterial gel in line with IPC guidelines. Staff had access to hand washing sinks and anti-
bacterial hand gel was readily available by each bed space and throughout the clinical areas.
Staff cared for patients identified as having an infection in side rooms to protect patients from the
risks of cross-infection. We observed this on several wards. Instructions were displayed on the
closed doors to the rooms advising staff and visitors the precautions they needed to take when
they entered these rooms.
Nursing staff on the wards had access to and used personal protective equipment (PPE) such as
aprons and gloves. Theatre and PACU staff used white coats over their theatre scrubs when
leaving the department. This was in line with trust policy.
The nursing staff used an ‘invasive lines care bundle’ to help reduce infection risk for those
patients with peripheral intravenous therapy lines and catheters.
The service mostly had suitable premises and equipment and looked after them.
The design, maintenance and use of most facilities were adequate to meet the needs of patients
and the service. The main theatre suite was dated and displayed signs of wear and tear with the
doors to the theatre areas being marked and pitted in places and the floor areas being scuffed and
scratched in places. This was on the trust risk register and there was a refurbishment plan in
place.
The trust had reconfigured main surgical services since our last inspection to ensure all the main
surgical wards were on the same floor as the main operating theatres. This meant that there was
less movement for patients and staff between the wards and theatres.
Since our last inspection, the trust had introduced a new purpose built general surgical ward
(Charnley ward, previously based on Tye Green ward) which was spacious and airy. However, this
ward did not have a purpose built dirty linen storage area. The trust was looking at ways to
address this, but in the mean time staff were storing soiled linen in the dirty sluice room.
All surgical areas and wards had access to resuscitation equipment stored in and on trolleys in
accessible locations. The equipment within the trolleys had been standardised across the trust and
was in sealed plastic bags, which meant that it was clean and ready to use and staff were assured
that nothing had been removed. All trolleys were further sealed with a numbered tag. We
inspected the contents of six sealed resuscitation trolleys throughout the service and found all
items were within date and had been consistently checked in line with trust policy.
The difficult intubation trolleys in the theatres contained all the relevant items and checks were
consistently performed in line with trust policy on a daily basis.
Equipment and consumable items used in the theatre were stored in clean storage areas above
floor level and items such as the lead aprons used for protecting staff during x-rays were stored
appropriately. This was an improvement since our last inspection.
Reusable surgical instruments were cleaned and sterilised by the theatre sterile services unit. The
turnaround of equipment was efficient and there was an urgent service available should items be
needed quickly. Both clean and dirty items were segregated within theatres to ensure there was
no risk of cross contamination.
We checked 32 consumable items including dressings, syringes and intravenous infusion giving
sets across the surgical wards and areas and found all to be stored correctly and within their
expiry date.
Waste and clinical specimens were handled and disposed of in a way that kept people safe. We
observed staff using the correct system to handle, store and sort different types of waste and
these were labelled correctly in all areas we visited during our inspection. Staff managed clinical
waste in line with trust policy. Sharps were disposed of safely in correctly assembled and dated
sharps disposal boxes.
The medical engineering department was responsible for overseeing equipment servicing and
maintenance and kept an asset register with details of servicing dates.
We reviewed 19 pieces of electrical equipment across the wards and theatre areas. These
included hoists, blood pressure monitors and specialist theatre equipment. All items carried
portable electrical appliance testing (PAT) stickers to show the equipment had been tested for
electrical safety within the last 12 months.
Surgical and anaesthetic equipment was available and checked in line with professional guidance
such as the Association of Anaesthetists of Great Britain & Ireland (AAGBI) ‘pre-use check to
ensure the correct functioning of anaesthetic equipment’ prior to surgical procedures.
Each surgical ward entrance contained a board showing pertinent information about each ward
and the nursing staff on duty. This included information such as ward visiting times, ward pledge,
champions, safety dashboard information, performance data and compliments and complaints.
This was updated regularly (staffing daily) and provided patients and visitors with the most recent
information about the ward.
All areas used a colour coding procedure for cleaning mops and buckets which was clearly visible
to staff.
Fire extinguishers we checked were found to be in date throughout all areas we inspected.
Within the areas we inspected, chemicals were stored in line with national legislation and were
found to be in date. The trust was undertaking a review of safety management systems across the
trust regarding the Control of Substances Hazardous to Health (COSHH) regulations and had
identified some gaps in compliance. We saw processes in place to improve and action plans to
monitor going forward.
The admission team and the pre-assessment team shared a small area with clinical consulting
rooms and a patient waiting area with a reception on Netteswell unit. They also shared a utility
room that was used for the storage of both ‘clean items’ such as the medication cupboard and pre-
operation drinks and also for the testing of urine. Staff confirmed that they used different sides of
the room for each activity. During our inspection we raised concerns that it was inappropriate to
have clean and dirty utility in the same space due to IPC concerns. In addition, this had also been
highlighted by the trust’s IPC team. Following our inspection, the trust confirmed that it had made
arrangements to relocate these activities in separate rooms.

Staff mostly completed and updated risk assessments for each patient. They kept clear
records and asked for support when necessary.
Patients attended a pre-operative assessment clinic in the weeks prior to surgery where staff
assessed their general health and suitability for surgery. Any required Investigations such as
electrocardiograph (a test to assess heart activity) were performed at this time. We reviewed 12
sets of patient notes, which showed that the appropriate risks and concerns had been addressed.
Any patient identified as a potential anaesthetic risk or other concern was reviewed by an
anaesthetist.
Staff completed standard risk assessments on admission and used specific tools including, but not
limited to; pressure ulcer risk, moving and handling, bed rails risk, nutrition, falls, and dementia
screening. The 14 patient records we reviewed showed that risks were mostly updated as patient
conditions changed although there we identified some gaps in five sets of records.
Venous thromboembolism (VTE) assessments were undertaken for all surgical patients and
reviewed in the holding bay area of the operating theatres prior to surgery. Any patients who did
not have a completed VTE pathway were flagged to the medical staff for action. Staff we spoke
with were aware of the process and there was oversight both within the theatre department and
wards.
Staff used the World Health Organisation (WHO) “Surgical Safety Checklist and five steps to safer
surgery" prior to all surgical procedures. We observed this being undertaken prior to two surgical
procedures. There was good practice in conducting the checks both within the day unit theatre and
the main operating theatres. The theatre team completed comprehensive team briefs prior to
surgery and this was well documented. This meant that in the event of an untoward incident, the
details of the briefing could be used for reflection to establish what may have gone wrong and any
lessons that could be learned.
The service undertook electronic audits of the WHO “Surgical Safety Checklist and five steps to
safer surgery" and information supplied by the trust showed between 99% and 100% compliance
with the electronic audits from March 2018 to February 2019. During our last inspection in 2017
we raised a concern that there was no observational element to the checklist. Following our
previous inspection, the trust introduced an observational element to the audit looking at ‘sign in,
timeout, and sign out’ for an average of 50 random patients per month. From April 2018 to
February 2019 the average compliance observed was 89.7% with the lowest percentage 67.5% in
September 2018 and the highest percentage 98.6% in May 2018. Individuals not compliant with
sign out were reported to the appropriate team leaders for supervision and forward action and to
the clinical leads for the surgery clinical governance group. A summary of learning/action
plans/safety measures implemented following the audit results monthly report were shared with all
clinical leads and team leaders.
The surgical wards used the National Early Warning System 2 (NEWS2) to identify patients who
were at risk of deterioration and to aid the escalation of their care. The NEWS2 was recorded on
hand held electronic tablets and any NEWS2 score of five or above immediately flagged to the
critical care outreach team (CCOT). The tablet also directed the user to escalation actions in the
case of deteriorating patients. The six records we reviewed showed that staff consistently
completed NEWS2 and alerted senior staff and medical staff to deteriorating patients. At our
previous inspection in 2017 the PACU did not use the NEWS2 however following a serious
incident in 2018 this had been introduced.
Following our inspection, we requested NEWS2 monitoring audit data. The service reported that
they did not formally audit the completion of NEWS2 observations as these were undertaken on
the electronic system and all the requirements that made up a full set of NEWS2 observations
were mandatory within the system, for example; observations could not be submitted if they were
not complete. They did supply monitoring data for the months January to March 2019 which
showed seven metrics including, but not limited to; the number of observations recorded in a given
week, the percentage of observations overdue within the first 24 hours and the percentage of
observations with a score of more than five (indicating a possibly deteriorating patient) that were
overdue more than 30 minutes. We noted that the scores ranged from 29.1% to 39.4% for January
and February indicating that that this group of patients did not receive timely condition monitoring.
For the month of March 2019, the scores ranged from 41.5% at the beginning of the month to
15.8% at the end of the month again indicating that there were patients whose observation
monitoring was not recorded as per trust policy. We did not see any evidence that there was any
oversight of this or action plans to improve.
Staff followed a sepsis screening pathway based on the Sepsis Six protocol on the surgical wards
which gave staff clear direction on escalating patients where there was a suspected infection. The
Sepsis Six care bundle outlines six actions, to be undertaken within one hour, for early
management of sepsis. We saw four patient records where this was in use.
The trust performed monthly inpatient audits of sepsis diagnosis and treatment as part of a
Commissioning for Quality and Innovation (CQUIN). This is a system introduced in 2009 to make a
proportion of healthcare providers' income conditional on demonstrating improvements in quality
and innovation in specified areas of care. Data supplied following our inspection regarding sepsis
audits was not broken down by service and we were unable to comment on compliance.
Nursing staff confirmed that junior medical staff were responsive when called regarding concerns
about patients. This was an improvement since our inspection in 2017.
There were 15 medical staff and all the critical care outreach nurses (apart from one new staff
member) within the surgery healthcare group with current advanced life support training who were
available on a bleep rota system to support staff with patients who suddenly deteriorated. Staff did
not have any concerns this this was enough to meet the needs of the service.
Nurse staffing
The service did not consistently have enough staff with the right qualifications, skills,
training and experience to keep people safe from avoidable harm and to provide the right
care and treatment.
Planned vs actual
numbers in surgery as of March and October 2018.

Day stay unit 11.9 16 74.4% 12.7 17.3 73.8%
Henry Moore Ward 10.5 12.3 85.5% 10.7 14.8 72.3%
Penn Ward 17.1 22.1 77.3% 12.3 22.1 55.6%
Post anaesthetic care unit 12.3 16.2 75.9% 14.5 16.2 89.4%
Pre-op assessment nurse 6.9 7.9 87.3% 5.9 7.9 74.7%
Surgery management team 6 6 100% 6 7 85.7%
Surgical assessment unit - - n/a 5 6 82.9%
Theatres 41.8 46.9 89.1% 37.3 47.1 79.1%
Tye Green Ward non-
15 24.2 61.7% 12 24.2 49.5%
elective surgery
Total 121.5 151.6 80.1% 116.4 162.7 71.6%
As of October 2018, the nursing staffing fill rate within surgery at Princess Alexandra Hospital
was 71.6%. This was lower than the rate of 80.1% as of March 2018.
As of October 2018, none of the 10 nursing teams listed were over established.
Nurse staffing remained a concern with significant vacancies and recruitment reported as a major
risk on the trust and surgical risk registers. There was a continuous recruitment programme for
nursing staff with the trust looking at nursing apprenticeships and overseas recruitment.
The service used a nationally recognised ‘Safer Nursing Care Acuity Tool’ to plan staffing
requirements according to patient need. The senior nurses held three meetings throughout the day
to address staff needs across the surgical wards and flexed staff between the wards where
necessary to ensure safe care.
Staff we spoke with said that staffing had improved and although it remained their biggest concern
they could manage patient acuity with the addition of regular agency staff.
Staff in the PACU reported that although they still had concerns regarding staff levels when
patients were transferred back to them from the ADSU in the evening until discharge home, this
had reduced significantly since our last inspection. They had also recruited new staff since our last
inspection.
The surgical healthcare group reported nursing staff fill rates on the surgical wards in the
monthly Surgery and Critical Care Health Group (SCCHG) Quality Assurance Dashboard with a
target of at least 95% fill rate. Between December 2018 and February 2019, the average fill rate
was 81.3% on days and 97.6% at night.
Vacancy rates
21.3% for nursing staff in surgery. This was higher than the trust target of 8%.
A breakdown of vacancy rates by ward is below. There were very high vacancy rates reported in
some units. However, care should be taken when interpreting staffing rates due to small numbers
of staff in some teams.

Penn Ward 33.8%
Tye Green non elective surgery 30.7%
Day stay unit 27.9%
Henry Moore Ward 23.4%
Post anaesthetic care unit 16.8%
Theatres 14.9%
Pre-op assessment nurse 14.1%
Surgical assessment unit 11.9%
Orthopaedic surgical unit 11.4%
Surgery management team 5.5%
The wards reported nurse vacancies on the whiteboard at the entrance to each ward and which
staff were on duty. This ensured that both patients and visitors were informed of the current staff
available. For example; on Henry Moore Ward the vacancy rate was displayed at the time of the
inspection as 28.7% for registered nurse staff and 40% for healthcare assistants (HCAs). Charnley
Ward (previously Tye Green Ward) reported 50% registered nurse vacancies and 10% HCAs.
We reviewed ward staffing rotas and saw that actual nurse staffing levels did not always meet the
planned staffing levels but the service flexed to ensure that patient safety was at the forefront of
service delivery.
Turnover rates
18.4% for nursing staff in surgery. This was higher than the trust target of 12%.
A breakdown of turnover rates by ward is below. There were very high turnover rates reported in

Tye Green non-elective surgery 45.4%
Penn Ward 25.3%
Post anaesthetic care unit 18.8%
Theatres 15.1%
Pre-op assessment nurse 14.7%
Day stay unit 11.9%
Henry Moore Ward 0%
Surgical assessment unit 0%
Sickness rates
3.7% for nursing staff in surgery. This was slightly higher than the trust target of 3.5%.
A breakdown of sickness rates by ward for each site is below.

Day stay unit 6.2%
Theatres 4.8%
Henry Moore Ward 3.9%
Penn Ward 3.8%
Post anaesthetic care unit 2%
Pre-op assessment nurse 2%
Surgical assessment unit 2%
Tye Green non-elective surgery 1.7%
The table below shows the numbers of nursing hours in medicine at Princess Alexandra Hospital
from December 2017 to November 2018 that were covered by bank and agency staff or left
unfilled.
Over this time period 26,145.4 working hours were filled by bank staff and 17,123 were covered
by agency staff to cover sickness, absence or vacancy for qualified nurses. There were 36,081.2
hours that were unable to be filled by either bank or agency staff to cover sickness, absence or
vacancy for qualified nurses.
Over the same time period, 21,107.5 working hours were filled by bank staff and 28.5 were
covered by agency staff to cover sickness, absence or vacancy for non-qualified nurses. There
were 14,250 hours that were unable to be filled by either bank or agency staff to cover sickness,

Staff group
Bank usage Agency usage Not filled by bank or agency
Hours Hours Hours
Qualified 26,145.4 17,123 36,081.2
Non-qualified 21,107.5 28.5 14,250
Total 47,252.9 17,151.5 50,331.2
The trust had induction processes for bank and agency staff who had not previously worked in the
hospital or on the ward and induction records were kept on the wards with copies given to the
agency staff for competencies such as the trust’s intravenous drug administration for their own
records and to show other ward staff.
Staff commented that where possible they requested the same agency staff to ensure continuity of
care as on some night shifts there might be only one substantive ward nurse on duty and there
was a rapid response system to book twenty agency staff for overnight who were then distributed
to where they were needed.
Medical staffing
Planned vs actual
Princess Alexandra Hospital reported the following WTE medical staff numbers in surgery as of

Anaesthetics 54.4 52.6 103.3% 44.9 52.4 85.5%
ENT medical staff 7.4 10.4 71.1% 6.3 10.4 60.3%
General surgery medical
41 39.6 103.5% 42.6 37.6 113.3%
staff
Intra-op radiotherapy 0 0.1 0% 0 0.1 0%
Orthopaedic medical staff 34 36.7 92.6% 36 36.7 98.1%
Urology medical staffing 12.6 17.3 72.5% 9.9 17.3 57%
Total 149.3 156.7 95.2% 139.5 154.5 90.3%
As of October 2018, the medical staffing fill rate within surgery at Princess Alexandra Hospital
was 90.3%. This was lower than the rate of 95.2% as of March 2018.
As of October 2018, one of the six medical teams listed were over established. However, care
should be taken when interpreting staffing rates due to small numbers of staff in some teams.
Vacancy rates
8.4% for medical staff in surgery. This was lower than the trust target of 8%.
A breakdown of vacancy rates by ward is below. There were very high vacancy rates reported in
some units and one team that was over-established. However, care should be taken when
interpreting staffing rates due to small numbers of staff in some teams.
Intra-op radiotherapy 100%
ENT medical staff 32.4%
Urology medical staffing 31.9%
Orthopaedic medical staff 15.2%
Anaesthetics 3.5%
General surgery medical staff -8.3%
Turnover rates
11.8% for medical staff in surgery. This was slightly lower than the trust target of 12%.
A breakdown of turnover rates by ward is below. There were very high turnover rates reported in
Team name Annual vacancy rate

ENT medical staff 28%
Anaesthetics 19.7%
Orthopaedic medical staff 9.4%
General surgery medical staff 2.3%
Breast surgery 0%
grades.
Sickness rates
0.9% for medical staff in surgery. This was lower than the trust target of 3.5%.
A breakdown of sickness rates by ward for each site is below. There was a high sickness rate
reported for breast surgery. However, care should be taken when interpreting the staffing rate
due to small number of staff in the team.

Breast surgery 25.2%
General surgery medical staff 2.4%
ENT medical staff 0.7%
Urology medical staffing 0%
Orthopaedic medical staff 0%
Anaesthetics 0%
Oral surgery medical staff 0%

The table below shows the numbers of medical hours in surgery at Princess Alexandra Hospital
from December 2017 to November 2018 that were covered by medical bank and locum staff or
left unfilled.

Hours Hours
Princess Alexandra
17,690.8 21,695
Hospital
Staffing skill mix
As of November 2018, the proportion of consultant staff reported to be working in medical care at
the trust was lower than the England average. The proportion of junior (foundation year 1-2) staff
was slightly higher than the England average.
Staffing skill mix for the 155 whole time equivalent medical staff working in surgery at
This England
Trust average
Consultant 41% 49%
Registrar Group~ 29% 29%
Junior* 13% 11%
(Source: NHS Digital Workforce Statistics)
Medical staff were generally available to meet the needs of the service. Staff on the wards and
departments told us they could access medical staff when required and they attended the wards
frequently for wards rounds.
Junior medical staff of varied seniority told us they felt they were supported well by their senior
colleagues. Newly qualified foundation doctors told us they had received a good induction and
were supported by senior medical staff.
The General Medical Council (GMC) Training Survey 2018 showed a similar trust result to
national results and an improvement in junior staff workload from the previous two years.
The service acknowledged that urology and ear nose and throat (ENT) medical staffing was a
significant concern and the lack of urology consultants was highlighted as a contributing factor in
a urology serious incident.
Staff (both nursing and junior medical staff) reported inconsistencies with consultant medical staff
reviewing patients on wards rounds. We requested examples of consultant job plans to show how
often wards rounds should be undertaken but were supplied with anonymised consultant
calendars instead. These showed that out of 12 consultants the average number of ward rounds
was between two and three per week with one consultant scheduling daily ward rounds. National
guidance from the NHS Seven Day Services Clinical Standards (September 2017) suggests
there should be consultant-led board rounds on every acute inpatient ward every day, and every
patient should have a highly visible care plan that is updated daily at the board round. However,
there are considerations that may be used to exclude individual patients from requirement for
daily consultant review which meant that the service followed national guidance.
Records
Staff generally kept detailed records of patients’ care and treatment. Records were clear,
up-to-date and easily available to all staff providing care.
Patients care records were predominantly paper based for fluid and food balance charts, pressure
area charts, cannulation charts and stools charts either at the end of the patients’ bed or on the
wall outside single side rooms. Notes were multidisciplinary, so healthcare professionals involved
could see previous treatment and interventions delivered by other health care professionals. This
helped when patients were transferred between teams.
Some patient records were held electronically, for example; NEWS2 scores were recorded on
hand held electronic devices which required a user password to access. This ensured that patient
confidentiality was protected and that there was a system of tracking which care professional
performed the NEWS2 observation.
Medical records were securely stored in trolleys behind the nurse’s stations or in keycode locked
rooms on the surgical wards and the Alexandra Day Surgery Unit (ADSU). This meant that records
were only accessible by authorised personnel.
Pre-operative assessments were completed prior to attendance on the day of surgery and this
identified those patients with high surgery risks and ensured that the appropriate investigations
and plans were in place for the day of surgery.
Staff used a ‘patient passport’ document for patients with additional needs for example; patients
with a learning disability. The passport provided staff with important additional information about a
patient including any reasonable adjustments that were required to ensure care was tailored to
individual needs.
Staff confirmed they had good electronic access to diagnostic requests and test results for
informing treatment decisions.
The operating department used an electronic Operating Room Management Information System
(ORMIS) to record all surgical procedures which was only accessible with a specific user login.
The emergency admission notes we reviewed showed that patients were seen on the post take
ward round within 12 hours of admission which is in line with best practice.
During our inspection we looked at the standard of record keeping and how records were
managed and maintained.
We reviewed 14 patient records and 13 medication records and found that information was mostly
accurate, up to date and in line with best practice guidance. The majority were clear and legible
with the appropriate information recorded. Referrals were easily identifiable and there were clear
markers for patients on ‘do not attempt cardiopulmonary resuscitation’ (DNA CPR) orders,
deprivation of liberty safeguards (DoLS) and those with complex needs or dementia. Paper
records were mostly up to date, accurate and legible, although there were some omissions such
as one discharge form from the PACU having no patient identifiable data, others with medical staff
not including GMC number or grade and some assessments not updated.
Staff shared patient discharge information with patients’ GPs and provided a good level of detail.
We reviewed three discharge summaries and found they included appropriate information
although one discharge letter we saw on Charnley ward had been incorrectly completed by the
junior doctor. The nurse in charge contacted the doctor to review and amend the discharge
summary.
The service performed monthly records audits for the surgical wards, PACU, ADSU and theatres
measuring up to 14 compliance standards including but not limited to vital sign observations, pain,
infection control, essential documentation booklet completion, falls, and medicine management.
Data supplied by the trust showed that compliance varied between 50% and 100% with December
2018 to February 2019 showing improvements although there were 33 omissions of compliance
metrics out of a total 408 possible submissions.
Medicines
The service followed best practice when prescribing, giving, recording and storing
medicines. Patients received the right medication at the right dose at the right time.
Medicines were stored securely in locked cupboards in key code locked rooms accessible only by
staff.
Medication fridge temperatures were consistently checked and recorded daily with high and low
monitoring. When temperatures were outside of normal range staff escalated and took appropriate
action.
Two staff members checked the controlled drugs (CDs) against the ward/department CD register
daily at the beginning of day and night shifts. CDs are medicines which are regulated by legislation
(Misuse of Drugs Act 1971 and subsequent amendments). Records showed the appropriate
checks had been completed and signed with no gaps in the three wards reviewed and the PACU
in the three months preceding our inspection.
We reviewed a range of medicines and intravenous fluids on the wards and theatre areas and
found them to be within date. This was an improvement since our last inspection when we found
out of date intravenous fluids in storage cupboard.
Medicines and equipment for use in emergencies were readily accessible to staff and were
checked regularly. Staff returned unwanted medicines to the pharmacy department for disposal.
Staff had access to medicine supplies and advice throughout the day and out of hours.
We reviewed 13 medicine administration records (both paper and electronic) and found that
medications were given in a timely manner and the appropriate codes were used to indicate
omissions. Medicine administration records were completed in full and allergies were recorded.
Staff had access to current guidance and references relating to medicines such as British National
Formulary, local formulary and an intranet injectable medicines guide to administer medicines
safely.
Local microbiology protocols for the administration of antibiotics were available and staff had
access to a ‘PAH app’ on their mobile phones to access advice.
A member of the pharmacy team visited the surgical wards daily to carry out medicines
reconciliation for all patients within 24 hours of admission during weekdays, and within 72 hours
for weekend admissions. Medicines reconciliation is the process of ensuring that the list of
medicines a person is taking is correct.
Medicines prescribed for discharged patients to take home (known as TTAs) were reviewed by
clinical pharmacists and ordered from the pharmacy department. Staff commented that delays for
TTAs were not unusual, but that there were arrangements for ‘one stop dispensing’ which meant
that medicines could be dispensed on admission to include pre-prepared TTAs.
Nursing staff explained TTA medicines to patients on discharge to ensure that the patient
understood how and when to take their medicines and who to contact if they had any problems.
Incidents
The service did not always manage patient safety incidents in a timely way. Staff mostly
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
mostly apologised and gave patients honest information and suitable support.
From 01 March 2018 to 28 February 2019 the service reported 1705 incidents. Of these two were
reported as death, three as severe - permanent or long-term harm, 22 as moderate – short term
harm, 260 as minor - minimal harm/minor treatment and 756 as no harm. Review of the incidents
showed there were no specific themes.
Incidents were monitored in the monthly SCCHG Quality Assurance Dashboard as were any open
serious incident investigations.
Staff reported incidents on the trust wide electronic reporting system. All staff we spoke with
understood their responsibilities to raise concerns and report incidents.
Senior staff, who were band six and above and had completed root cause analysis (RCA) training,
investigated incidents and produced reports for shared learning.
Learning from incidents was apparent with staff having knowledge of recent incidents and learning
relating to them and staff confirmed that they received feedback regarding incidents reported
verbally, by e-mail and during team meetings. Learning from incidents was also displayed on the
staff noticeboards and reported in the monthly Matrons newsletter.
Staff that we spoke with understood their responsibilities in regard to duty of candour. From
November 2014, all NHS providers were required to comply with the Duty of Candour Regulation
20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The duty of
candour is a regulatory duty that relates to openness and transparency and requires providers of
health and social care services to notify patients (or other relevant persons) of ‘certain notifiable
safety incidents’ and provide reasonable support to that person.
Never Events
never event.
From February 2018 to January 2019, the trust reported no never events for surgery.
Trust level
In accordance with the Serious Incident Framework 2015, the trust reported three serious
incidents (SIs) in surgery which met the reporting criteria set by NHS England from February
2018 to January 2019. This was an improvement since the previous inspection when 11 SIs were
reported for a similar period.
There were two serious incidents relating to treatment delays, and one serious incident that was
categorised as abuse/alleged abuse of an adult patient by staff.
The service held monthly patient safety and quality meetings where SI cases were discussed as
part of sharing the learning. After every serious incident investigation, the service completed a
sharing the learning template detailing a summary of the incident, learning and actions in place.
This was shared by email to all staff within the service and discussed within ward safety huddles,
clinical operational meetings and senior nursing meetings.
We reviewed the root cause analysis (RCA) reports relating to three SIs and saw that they were
investigated appropriately, and actions and learning identified for sharing although we noted that
one RCA relating to a delay in removing/exchanging a urinary stent was not finally completed until
nine months following the incident. A contributing factor to the incident, the lack of a tracking
system/register for the insertion of urinary stents, was initially identified in June 2018 (prior to the
RCA being completed) and placed on the surgical healthcare group risk register. The service has
since developed a tracking system to identify patients who will require stent removal/exchange
and is in the process of tracing patients back to 2014 to identify any missed stent removals.
However, we were concerned that work did not commence on this until November 2018. This
meant there had been five months of missed opportunity to ensure that further stent
removals/exchanges were not delayed.
During our inspection a further SI was reported following concerns raised by the inspection team.
This related to the delayed exchange of a urinary stent which should have taken place in
November 2018. When the procedure was eventually performed in March 2019 there were
complications which meant there was a risk that further surgery may be required. We reviewed
the patient notes and saw that duty of candour had not taken place and was not applied until
raised by the inspection team. Although all of the staff we asked knew about their responsibilities
regarding duty of candour we were not assured that staff were always honest and open in a
timely manner when things went wrong.
All near miss, moderate, severe harm and death incidents were reviewed daily at the trust’s
oversight meeting with an executive lead present. This encompassed a harm review, recognition
of themes and management of the incident to enable urgent actions to be recommended. Due to
the SI identified during the inspection and the length of time it took to instigate a urinary stent
register following the previous similar incident, we were not assured that there was the necessary
level of urgency applied to the management and urgent actions to applied to ensure patient
safety.
Safety Thermometer
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.
their elimination.
Data collection takes place one day each month – a suggested date for data collection is given
but wards can change this. Data must be submitted within 10 days of suggested data collection
date.
Data from the Patient Safety Thermometer showed that the trust reported three new pressure
ulcers, four falls with harm and eight new urinary tract infections in patients with a catheter from
January 2018 to January 2019 for surgery.
Prevalence rate (number of patients per 100 surveyed) of pressure ulcers,

falls and catheter urinary tract infections at Princess Alexandra Hospital
NHS Trust
1
Total
Pressure
ulcers
(3)
2
Total
Falls
(4)
3
Total
CUTIs
(8)

Safety thermometer information was reported in the monthly SCCHG Quality Assurance
Dashboard with a target of at least 95% harm free care. For the period December 2018 to
February 2019 the service reported 97.8% compliance.
Each ward displayed harm free care statistics for the previous month at the entrance. This
ensured that patients, staff and visitors were kept informed about the ward performance.
The service provided care and treatment based on national guidance and evidence of its
effectiveness. Managers checked to make sure staff followed guidance.
Patient’s physical, mental health and social needs were assessed, and care, treatment and
support delivered in line with legislation, standards and evidence-based guidance. The service
used National Institute for Health and Care Excellence (NICE) guidelines and guidance from
authorities such as the Royal College of Surgeons to determine care and treatment.
Staff assessed patients for their risk of venous thromboembolism (VTE), and where a risk was
identified, offered prophylaxis and specialist equipment in line with NICE guidance. The service
audited compliance with the VTE pathway monthly and reported the results in the Surgery and
Critical Care Healthcare Group (SCCHG) Quality Assurance Dashboard report. The target was
98% and from March 2018 to February 2019 audit showed compliance generally ranged between
95% and 98% with one drop to 90% in January 2019.
Where patients triggered a need to be screened for sepsis, staff had clear prompts and processes
to enable effective management. All staff we spoke with were aware of the process. NICE
guidance/Quality Standard Assessments were monitored through the SCCHG. Monthly
compliance status reports were submitted to the trust Patient Safety and Quality Group, chaired by
the Chief Medical Officer, for review, assurance and any appropriate action/challenge.
Following our inspection, the trust supplied data for March 2018 to February 2019 which showed
two joint surgery infections, one superficial and one deep incisional infection. From January 2018
to December 2018 the service reported three out of 333 (0.9%) orthopaedic patients developed
surgical site infections following knee replacements procedures. No hip replacement patients (256)
developed infections.
Staff had access to policies, standard operating procedures and guidelines through the trust’s
intranet. These mostly reflected evidence-based care and treatment, which had been developed in
line with national guidance. These included the National Institute for Health and Care Excellence
(NICE) and Association for Perioperative Practice (AfPP). The trust had developed a number of
Standard Operating Procedures (SOPs) to guide staff for example; The transfer of patients
between the Post Anaesthetic Care Unit (PACU) and the Alexandra Day Surgery Unit (ADSU) and
the PACU discharge criteria. This was an improvement since our last inspection.
During our inspection, we noted not all policies were within their review date and the trust fasting
policy was out of review date in March 2014, although there was evidence of actions to review
within the Trust Policy Group (TPG) in 2017. Following our inspection senior staff reported that the
current policy, hydration card and patient information card had been reviewed against, recent
research and guidelines from other organisations and was in line with best practice. We were
informed that this information had been reinforced with all staff across the health care group and
that the refreshed policy would be ratified at the next TPG meeting in May 2019. However, a
member of substantive nursing staff on an elective surgery ward we spoke with was unaware of
any fasting policy which meant that we did not have assurance that all staff followed fasting
guidelines.
Staff used evidence-based care pathways for patients admitted for surgery. There were
designated integrated care pathways or enhanced recovery programmes, for example, for patients
undergoing total hip or knee replacements.
Staff in the pre-assessment clinic followed NICE guidelines. For example, the list of pre-operative
tests for elective surgery was in line with NICE NG45 Routine preoperative tests for elective
surgery.
National guidance was followed when checking the anaesthetic machines. Staff followed the
Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines. Copies of the
guidelines were attached to the machines so staff could make sure they were following these.
Sepsis screening and management was performed, in line with national guidance. Sepsis tools
were used to help identify and manage patients with sepsis.
Following our inspection, we requested data on National Safety Standards for Invasive Procedures
(NatSSIPs) and Local Safety Standards for Invasive Procedures (LocSSIPs) but the trust did not
supply any evidence of specific developments.
The anaesthetics service had Anaesthesia Clinical Services Accreditation (ACSA). The scheme is
a voluntary one for NHS and independent sector organisations that offers quality improvement
through peer review.

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.
Patient's nutrition and hydration needs (including those related to culture and religion) were
identified, monitored and met. The service provided access to dietary and nutritional specialists
where required for example where there were concerns about poor nutritional intake or bariatric
patients.
Staff assessed patients’ nutritional status using the nationally recognised Malnutrition Universal
Screening Tool (MUST). Any patient identified as malnourished or at risk of malnutrition was
referred to the dietetic service.
Patients were provided with information prior to admission which told them how long they were
required to fast for before surgery to avoid complications. On the Netteswell unit staff provided
patients with a ‘Hydration card’ which gave details of the time they could drink clear fluid to.
However, one patient out of the seven we spoke with had been ‘nil by mouth’ (NBM) or fasted
without food or drink for 17 hours prior to elective surgery. This was due to a breakdown in
communication when the operating theatre list was changed, and ward staff were unaware which
meant that the patient was denied fluids for much longer than recommended. This was escalated
to the trust who took action to address this communication gap with a change in the theatre list
documentation to show the NBM time.
Staff spoke of recently implemented intravenous therapy (IVT) practice for patients who were
fasting, but that it was not embedded or applied consistently. We requested evidence of IVT for
this group of patients, but it was not supplied. As a result, we were not assured that there was
robust guidance for staff.
Medical staff routinely prescribed ‘as required’ anti-nausea and vomiting medication for post-
operative patients to assist with side effects from surgery and nursing staff managed patients’
nausea following surgery.
Staff reviewed and monitored patient hydration. All patients we saw during our inspection had
access to water jugs. We saw fluid balance records where required were contained and completed
within patient notes.
We observed staff offering patients hot and cold drinks during our inspection. All patients we
spoke with who could eat and drink said they were offered a choice of food and refreshments.
During our inspection we observed that there was a varied choice of meals to choose from, on a
daily basis. Mealtimes were protected on all wards.
Patients we spoke with were satisfied with the quality and choice of the food that was provided
and snacks were available between meal times which was particularly important for patients
following surgery.
Pain relief
Staff assessed and monitored patients regularly to see if they were in pain. They supported
those unable to communicate using suitable assessment tools and gave additional pain relief to
ease pain.
Staff assessed and monitored patients pain regularly and supported those unable to communicate
using suitable assessment tools and gave additional pain relief to ease pain.
Staff discussed patients preferred post-operative pain relief at their pre-assessment appointment
and used pain scores to monitor pain symptoms at regular intervals following surgery. The surgical
wards and PACU regularly assessed pain as part of the ‘national early warning system’. The
measurement of pain levels was recorded electronically within the patients’ clinical observations.
The service had access to an acute pain management team whose remit was to review all post-
operative inpatients and see any patient with an acute pain referral made to the team including the
maintenance of patient-controlled analgesia (PCA) infusions. The pain team consisted of two
registered nurses supported part time by a consultant anaesthetist and was available Monday to
Friday 8am to 4pm. Outside these hours ward staff contacted the on-call anaesthetist. Staff told us
the team was responsive to the needs of the patient and carried out regular reviews.
We observed staff responding to patients in pain and saw that they responded quickly and
effectively managed patient pain.
Patients told us that staff gave them pain relief medication when required and reassessed their
pain regularly.
Patient outcomes
Managers monitored the effectiveness of care and treatment and used the findings to
improve them. They compared local results with those of other services to learn from them.
Relative risk of readmission
From September 2017 to August 2018, patients at Princess Alexandra Hospital had a similar to
expected risk of readmission for elective admissions when compared to the England average.
• General surgery patients at Princess Alexandra Hospital had a similar to expected risk of
readmission for elective admissions when compared to the England average.
• Urology patients at Princess Alexandra Hospital had a more than 20% higher than
expected risk of readmission for elective admissions when compared to the England
average.
• Trauma and orthopaedics patients at Princess Alexandra Hospital had a higher than
expected risk of readmission for elective admissions when compared to the England
average.
Elective Admissions - Princess Alexandra Hospital
three specialties for specific site based on count of activity
Patients at Princess Alexandra Hospital had a lower than expected risk of readmission for non-
elective admissions when compared to the England average.
• General surgery patients at Princess Alexandra Hospital had a lower than expected risk of
readmission for non-elective admissions when compared to the England average.
• Trauma and orthopaedics patients at Princess Alexandra Hospital had a more than 20%
higher than expected risk of readmission for non-elective admissions when compared to
the England average.
• Urology patients at Princess Alexandra Hospital had a similar to expected risk of
readmission for non-elective admissions when compared to the England average.
Non-Elective Admissions - Princess Alexandra Hospital
three specialties for specific site based on count of activity
National Hip Fracture Database
The table below summarises Princess Alexandra Hospital’s performance in the 2018 National Hip
Fracture Database. For five measures, the audit reports performance in quartiles. In this context,
‘similar’ means that the trust’s performance fell within the middle 50% of results nationally.
Meets national
Hospital Comparison to standard?
Metrics (Audit indicators)
performance other Trusts (delete cross or
tick)
Case ascertainment
(Proportion of eligible cases included in the 97.8% Similar 
audit)
Crude proportion of patients having
surgery on the day or day after
admission
(It is important to avoid any unnecessary
delays for people who are assessed as fit
71.1% Similar 
for surgery as delays in surgery are
associated with negative outcomes for
mortality and return to mobility)
Crude peri-operative medical
assessment rate
(NICE guidance specifically recommends
the involvement and assessment by a Care
92.8% Similar 
of the Elderly doctor around the time of the
operation to ensure the best outcome)
documented as not developing a
pressure ulcer
(Careful assessment, documentation and
preventative measures should be taken to
reduce the risk of hospital-acquired
98% Similar 
pressure damage (grade 2 or above) during
a patient’s admission); this measures an
organisation’s ability to report ‘documented
as no pressure ulcer’ for a patient
Crude overall hospital length of stay
(A longer overall length of stay may indicate
that patients are not discharged or
No current
transferred sufficiently quickly; a too short 19.2 days Similar
standard
length of stay may be indicative of a
premature discharge and a risk of
readmission)
Risk-adjusted 30-day mortality rate
(Adjusted scores take into account the Worse than No current
10.7%
differences in the case-mix of patients expected standard
treated)
(Source: National Hip Fracture Database)
The service provided evidence of eleven actions, five of which had been completed and the rest
due for completion in May and June 2019 to improve performance in the National Hip Fracture
Database. One of the actions was to review deaths and identify learning for this group of patients
and another was seen to be innovative - Putting together a training plan to train doctors, nurses,
physios and Allied Health Professionals (AHPs) to administer nerve blocks prior to theatre.
National Bowel Cancer Audit
The table below summarises the trust’s performance in the 2017 National Bowel Cancer Audit.
Trust Comparison to Meets

Metrics
performance other Trusts national
(Audit measures)
standard?
Case ascertainment
Good is over
(Proportion of eligible cases included in the 109.3% Good
80%
audit)
Risk-adjusted post-operative
length of stay >5 days after
Worse than national No current
major resection 83.3%
aggregate standard
(A prolonged length of stay can pose risks
to patients)
Risk-adjusted 90-day post-operative
mortality rate
(Proportion of patients who died within 90
Within expected No current
days of surgery; post-operative mortality for 7.6%
range standard
bowel cancer surgery varies according to
whether surgery occurs as an emergency
or as an elective procedure)
Risk-adjusted two-year post-operative
mortality rate
(Variation in two-year mortality may reflect, Within expected No current
11.5%
at least in part, differences in surgical care, range standard
patient characteristics and provision of
chemotherapy and radiotherapy)
Risk-adjusted 30-day unplanned
readmission rate
(A potential risk for early/inappropriate 5%
range standard
discharge is the need for unplanned
readmission)
Risk-adjusted 18-month temporary
stoma rate in rectal cancer patients
undergoing major resection
(After the diseased section of the
bowel/rectum has been removed, the Within expected No current
38.3%
bowel/rectum may be reconnected. In range standard
some cases it will not and a temporary
stoma would be created. For some
procedures this can be reversed at a later
date)
(Source: National Bowel Cancer Audit)
National Vascular Registry
The table below summarises the trust’s performance in the 2018 National Vascular Registry.
Please note that the trust did not submit data for the metrics relating to carotid endarterectomy,
as it performed fewer than five such procedures during the reporting period.
Metrics Trust Comparison to Meets national
(Audit measures) performance other Trusts standard?
Abdominal Aortic Aneurysm Surgery
(Surgical procedure performed on an enlarged major blood vessel in the abdomen)
Case ascertainment
(Proportion of eligible cases 103% Not applicable ✓
included in the audit)
Risk-adjusted post-operative in-
hospital mortality rate
Within the No current
(Proportion of patients who die in 5.1%
expected range standard
hospital after having had an
operation)
Carotid endarterectomy
(Surgical procedure performed to reduce the risk of stroke; by correcting a narrowing in the
main artery in the neck that supplies blood to the brain)
Case ascertainment
Fewer than five
(Proportion of eligible cases Not applicable n/a
procedures
included in the audit)
Crude median time from symptom
to surgery
Fewer than five
(Average amount of time patients Not applicable n/a
procedures
wait to have surgery after the onset
of their symptoms)
Risk adjusted 30 day mortality
and stroke rate
Fewer than five No current
(Proportion of patients who die or N/A
procedures standard
have a stroke within 30 days of their
operation)
(Source: National Vascular Registry)
National Oesophago-gastric Cancer Audit
(Audit of the overall quality of care provided for patients with cancer of the oesophagus [the food
pipe] and stomach)
The table below summarises the trust’s performance in the 2018 National Oesophago-gastric
Cancer Audit.

Trust-level metrics
(Measures of hospital performance in the treatment of oesophago-gastric (food pipe and
stomach) cancer)
Case ascertainment
(Proportion of eligible cases included >90% Better No current standard
in the audit)
Age and sex adjusted proportion
of patients diagnosed after an
emergency admission
(Being diagnosed with cancer in an
9% Better No current standard
emergency department is not a good
sign. It is used as a proxy for late
stage cancer and therefore poor
rates of survival. The audit
recommends that overall rates over
15% could warrant investigation)
Risk adjusted 90-day post-
operative mortality rate
Not eligible n/a No current standard
(Proportion of patients who die
within 90 days of their operation)
Cancer Alliance level metrics
(Measures of performance of the wider group of organisations involved in the delivery of care for
patients with oesophago-gastric (food pipe and stomach) cancer; can be a marker of the
effectiveness of care at network level; better co-operation between hospitals within a network
would be expected to produce better results. Contextual measure only.
treated with curative intent in the
Cancer Alliance
37.3% Similar No current standard
(Proportion of patients receiving
treatment intended to cure their
cancer)
(Source: National Oesophago-Gastric Cancer Audit)
National Emergency Laparotomy Audit
Emergency Laparotomy Audit. The audit reports on the extent to which key performance
measures were met and grades performance as red (less than 50% of patients achieving the
standard), amber (between 50% and 80% of patients achieving the standard) and green (more
than 80% of patients achieved the standard.
Meets national
Metrics Hospital Audit’s
standard? (Delete
(Audit measures) performance Rating
tick or cross)
Case ascertainment
(Proportion of eligible cases included in the 43% Red 
audit)
Crude proportion of cases with pre-
operative documentation of risk of death
(Proportion of patients having their risk of 63% Amber 
death assessed and recorded in their notes
before undergoing an operation)
Crude proportion of cases with access
to theatres within clinically appropriate
time frames 90% Green ✓
(Proportion of patients who were operated
on within recommended times)
Crude proportion of high-risk cases
(greater than or equal to 5% predicted
mortality) with consultant surgeon and
anaesthetist present in theatre
(Proportion of patients with a high risk of
88% Green ✓
death (5% or more) who have a Consultant
Surgeon and Anaesthetist present at the
time of their operation)
Crude proportion of highest-risk cases 81% Green ✓
(greater than 10% predicted mortality)
admitted to critical care post-operatively
(Proportion of patients with a high risk of
death (10% or more) who are admitted to a
Critical/Intensive Care ward after their
operation)
Risk-adjusted 30-day mortality rate
Within
(Proportion of patients who die within 30 No current
12.8% expected
days of admission, adjusted for the case- standard
range
mix of patients seen by the provider)
(Source: National Emergency Laparotomy Audit)
National Ophthalmology Database Audit
(Audit of patients undergoing cataract surgery)
The table below summarises the trust’s performance in the 2018 National Ophthalmology
Database Audit.

Trust-level metrics
(Measures of hospital performance in the treatment of cataracts
Case ascertainment
No current
(Proportion of eligible cases included 40.1% n/a*
standard
in the audit)
Risk-adjusted posterior capsule
rupture rate
(Posterior capsule rupture (PCR) is
the index of complication of cataract
surgery. PCR is the only potentially 0.9%
range standard
modifiable predictor of visual harm
from surgery and is widely accepted
by surgeons as a marker of surgical
skill.
Risk adjusted visual acuity loss
(The most important outcome Within expected No current
0.8%
following cataract surgery is the range standard
clarity of vision)
*National aggregate not available.
(Source: National Ophthalmology Database Audit)
National Joint Registry
(Audit of hip, knee, ankle, elbow and shoulder joint replacements)
Joint Registry.
Metrics Hospital Comparison to Meets national
(Audit measures) performance other hospitals standard?
Proportion of patients
consented to have personal
details included (hips, knees,
Trust-level
ankles and elbows)

(Patient details help ‘track and
trace’ prosthetics that are
86.6% Similar 
implanted. It is regarded as best
practice to gain consent from a
patient to facilitate entering their
patient details on to the register)
Risk-adjusted 5 year revision
ratio (for hips excluding
Hospital level: Hips
tumours and neck of femur Within expected

fracture)
10
range ✓
(Proportion of patients who need
their hip replacement ‘re-doing’)
operative mortality ratio (for
hips excluding tumours and Within expected
neck of femur fracture)
1.80
range 
Risk-adjusted 5 year revision
Hospital level: Knees
ratio (for knees excluding

tumours) Within expected
(Proportion of patients who need
0.71
range ✓
their knee replacement ‘re-
doing’)
operative mortality ratio (for
knees excluding tumours) 1.25
Within expected
range 
(Source: National Joint Registry)
National Prostate Cancer Audit
The table below summarises the trust’s performance in the 2017 National Prostate Cancer Audit.
Meets national
Metrics Hospital Comparison to
standard? (Delete
(Audit measures) performance other trusts
tick or cross)
Men with complete information to
determine disease status
(This is a classification that
describes how advanced the cancer
is and includes the size of the
94.8% n/a 
tumour, the involvement of lymph
nodes and whether the cancer has
spread to different part of the body)
Percentage of patients who had
No data No current
an emergency readmission within N/A
available standard
90 days of radical prostatectomy
(A radical prostatectomy involves the
surgical removal of the whole
prostate and the cancer cells within
it; emergency readmission may
reflect that patients experienced a
complication related to the surgery
after discharge from hospital)
Percentage of patients
experiencing a severe urinary
complication requiring
intervention following radical No data No current
N/A
prostatectomy available standard
(Complications following surgery
may reflect the quality of surgical
care)
Percentage of patients
experiencing a severe
gastrointestinal complication
requiring an intervention
No data No current
following external beam N/A
available standard
radiotherapy
(External beam radiotherapy uses
high-energy beams to destroy
cancer cells)
(Source: National Prostate Cancer Audit)
Patient Reported Outcome Measures
In the Patient Reported Outcomes Measures (PROMS) survey, patients are asked whether they
feel better or worse after receiving the following operations:
• Groin Hernias
• Varicose Veins
• Hip Replacements
• Knee replacements
Proportions of patients who reported an improvement after each procedure can be seen on the
right of the graph, whereas proportions of patients reporting that they feel worse can be viewed
on the left.
In 2016/17 the trust’s performance for patients reporting an improvement following surgery for
groin hernias was slightly worse than the England average according to the EQ VAS index.
However according to the EQ-5D index, the trust’s performance was better than the England
average.
The trust’s performance for patients reporting an improvement following hip replacement was
similar to the England average according to the EQ VAS and the Oxford Hip Score. However
according to the EQ-5D index, the trust’s performance was slightly worse than the England
average.
The trust’s performance for knee replacements was worse than the England average according
to the EQ VAS index and Oxford Knee Score. However according to the EQ-5D index, the trust’s
performance was slightly better than the England average.
The trust’s performance for varicose veins was similar to the England average according to the
Aberdeen Varicose Vein Questionnaire. However according to the EQ VAS index, the trust’s
performance was better than the England average. In contrast, the EQ-5D index showed a mixed
picture. The index showed a higher proportion of the trust’s patients reporting an improvement
following surgery compared to the England average, but also showed a higher proportion
reporting a worsening of their condition compared to the England average.
(Source: NHS Digital)
Competent staff
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
monitor the effectiveness of the service.
Appraisal rates
From April to October 2018, 85.9% of staff within surgery department at Princess Alexandra
Hospital received an appraisal compared to a trust target of 90%.
Appraisals Eligible Completion Trust Met

Staff group required staff rate target (Yes / No)
Support to scientific, therapeutic 2 2 100% 90% Yes
& technical staff
Support to doctors and nursing
96 113 85% 90% No
staff
Qualified nursing staff 85 105 81% 90% No
NHS infrastructure support 16 22 72.7% 90% No
Qualified allied health
1 2 50% 90% No
professionals
Total 286 333 85.9% 90% No
The 90% completion target was met for medical staff, all of whom had received an appraisal.
However, the target was not met for qualified nursing staff. Only 81% of qualified nursing staff
had received an appraisal.
Nursing staff and managerial staff told us they received regular supervision and appraisals and
that these were always worthwhile and of a good quality. Staff told us that senior members of
staff were always approachable for additional help if they needed it. Student nurses also told us
the support they received from mentors was positive.
Ward and theatre unit managers had systems in place to monitor when their staff were due an
appraisal.
Newly appointed staff across surgical services completed a trust induction and a six month
preceptorship programme. Competencies were assessed and signed off before staff were able to
work unsupervised.
Staff completed core skills training based on their role, with training incorporating online learning
and face to face sessions with clinical supervision and competency sign off for core skills, for
example healthcare assistants in the pre-assessment clinic had undertaken additional training
and competence assessment in skills, such as venepuncture (taking blood samples for testing)
and performing electrocardiograms (checking the heart’s rhythm and electrical activity). PACU
had a comprehensive competency assessment framework which required supervision, evaluation
and sign off by a senior clinician for skills such as assessing wound drainage and skills for
recovery emergencies. Following our last inspection, the PACU had developed a set of paediatric
competencies for staff to ensure they had the skills to care for children in the department as they
did not have a paediatric trained nurse. This was an improvement since our last inspection.
Practice education facilitators were available across the surgical service to ensure staff received
coaching and tuition relative to their role. Staff told us the education department sent regular
emails with details of available non-mandatory training courses and modules, they confirmed that
managers would release them if able to do so.
Staff were encouraged and given opportunities to develop, for example we spoke with a
physiotherapy practitioner who worked closely with the elderly care team on Tye Green ward and
had been supported to develop an acute fractured neck of femur pathway.
We spoke with three junior doctors, who told us they were up to date with their induction and
training. They felt they were well supported by their supervisor and there were good educational
opportunities available to them.
The General Medical Council (GMC) training results for 2018 showed that the general surgery
and orthopaedic surgery results were similar to and in some cases better than national results.
Every year the GMC surveys all doctors in training and trainers for their views
Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and
other healthcare professionals supported each other to provide good care.
The service demonstrated good working relationships with other staff and disciplines within the
hospital and trust. This included staff from medical and surgical specialities, theatres, recovery,
critical care, social services, occupational and physical therapy, and mental health.
Nursing staff told us they had good relationships with consultants and doctors of different
disciplines. We observed ward and theatre managers leading their departments, working closely
with the nursing staff, surgical and medical staff and senior management to facilitate patient care
and flow.
There were clear decisions about who was responsible for each patients’ care. Staff knew who the
consultant oversaw their patients care and treatment in each ward or department. Staff told us
surgical patients who were in other speciality beds (known as outliers) were regularly reviewed by
their consultant and medical staff and they could easily contact those surgical teams.
There was a good relationship between theatre, ADSU, PACU and ward staff. All staff we spoke
with told us that the different areas worked together as one team. Theatre staff communicated well
with staff on the rest of the unit and vice versa. Staff used the multidisciplinary care plan booklet
which ensured that all staff had access to the most up to date patient information used by other
members of the multidisciplinary team (MDT).
All relevant staff, including those working in different teams, were involved in assessing, planning
and delivering care and treatment. Staff worked across health and social care disciplines and with
other agencies, when required, to care for patients.
There were good links with specialist nurses, for example orthopaedic, stoma, breast care,
urology, palliative care, vascular, trauma and diabetes nurses the who visited the surgery wards
frequently. Medical and nursing staff described good support from the critical care outreach team,
who were very responsive and supported them to care for acutely unwell patients on the wards.
Wards held MDT board rounds, which formed part of the SAFER patient flow bundle (NHS
Improvement, 2017) and helped to identify and resolve any waits or delays in patients’ hospital
stay. SAFER is a practical tool to reduce delays for patients in adult inpatient wards and involves
five elements.
• Senior Review, all patients will have a senior review before midday.
• All patients will have an expected discharge date and clinical criteria for discharge.
• Flow of patients to start at the earliest opportunity from assessment units to inpatient wards.
• Early discharge, 33% of patients will be discharged from inpatient wards before midday.
• Review, a systematic MDT review of patients with extended lengths of stay.
The board rounds were attended by the nurse in charge on the ward, medical staff and allied
health care professionals. We observed a board round on one of the wards we inspected. A
member of the patient co-ordination team was involved in the board round. The role of the patient
co-ordination team was to support patients who had complex needs on discharge, who were
medically fit but required additional ongoing support and patients who were being transferred to
nursing or care homes. Their role also included contacting social care professionals to follow up
on funding or care packages/placements.
Seven-day services
Services were available to patients 24 hours a day, seven days a week.
The surgical healthcare group provided acute and emergency surgical services seven days a
week. Senior medical and anaesthetist cover was provided outside of normal working hours on a
rota basis. Junior and middle grade doctors provided out of hours medical care for patients on the
surgical wards during out of hours periods. There was also on-call cover provided by consultant
surgeons who could be contacted by telephone which was in line with national guidance.
There was a designated emergency surgical assessment unit on Melvin Ward available to assess
patients who presented with a surgical emergency. This was staffed between 8am and 10pm with
the last admission no later than 9pm. After this time patients attended the emergency department.
The service had an emergency theatre for urgent and emergency procedures, which was available
and staffed 24 hours a day, seven days a week.
The ADSU was operational from 7.45am till 10pm, Monday to Friday and Saturday until 8pm. The
ADSU had extended its operational hours since our last inspection which improved patient flow.
Previously a significant number of patients who were not ready for discharge transferred to the
PACU when the ADSU closed for the night at 8.30pm. Patients who were not ready to go home at
10pm were still returned to the PACU. Staff confirmed that patients transferring to the PACU from
the ADSU had reduced significantly during the previous year apart from a two-month period in
October and November 2018 when the trust reported higher than normal patient acuity and
insufficient staffing on the ADSU to operate the extended hours. This was an improvement since
our last inspection.
Specialist services such as dietitians, speech and language therapists, occupational therapists
and specialist nurses operated predominantly during core hours, however some surgical wards
had access to certain services at weekends for example; physiotherapy services to care for
patients assessed as a priority.
The trust pharmacy was available 9am to 5pm, Monday to Friday with extended hours until 7pm
for staff only, to support patient discharges. Weekends opening was 9am to 12pm on Saturday
and from 12pm to 2pm on Sunday. Outside of these hours there was an ‘on-call’ pharmacy
service.
Diagnostic screening tests, for example; blood tests and imaging such as x-ray and computerised
tomography (CT), 24 hours a day, 7 days a week.
Health Promotion
Staff supported patients to be in involved in monitoring of their health.
We observed staff at the pre-admission clinics providing healthy living advice and offering support
and referral to other professionals if they wanted to give up smoking. Health promotion was
encouraged and where appropriate patients were provided with information on smoking cessation,
healthy heart and diet at pre-assessment clinics and in the ADSU.
There were health promotion and education displays on the surgical wards for example, boards
which provided advice on smoking cessation, wound care and healthy heart lifestyles. Health
promotion leaflets were available on all surgical wards, including for example, advice on
preventing infections and the importance of exercise.
Staff told us that they routinely undertook health promotion discussions with patients as part of
their role and encouraged and supported patients to mobilise as soon as possible after surgery.
Staff understood how and when to assess whether a patient had the capacity to make
decisions about their care. They followed the trust policy and procedures when a patient
could not give consent but did not always consent patients for surgery in line with best
practice.
The trust had a consent policy, which was found to be in date, available electronically and was
in keeping with current guidance. Procedures around the Mental Capacity Act (2005) and the
Deprivation of Liberty Safeguards (DoLS) was included within the consent policy, which was in
keeping with best practice guidance. The DoLS aim is to ensure that people in care homes and
hospitals are looked after in a way that does not inappropriately restrict their freedom.
Staff we spoke with were able to describe the process of assessing patients’ mental capacity
and felt confident in doing so. There was access to a translation service for consent if required.
We observed staff asking for consent when performing examinations and personal care and
considering adjustments such as access to specialist support and environmental considerations
for patients with cognitive impairments such as dementia, or those living with a learning
disability.
Staff generally discussed planned surgical procedures during outpatient clinic consultations and
medical staff obtained informed consent however, staff on the Netteswell unit told us it was not
unusual for consent to be obtained on the day of the procedure. We observed medical staff
attending the unit to consent patients. This did not comply with national best practice. The Royal
College of Surgeons recommends ‘the patient has sufficient time and information to make an
informed decision’. Following our inspection, we requested audit data relating to consent
however, the trust reported that it had not undertaken any consent audit within the previous six
months. We were therefore not assured the trust followed its own consent policy, or best
practice guidance and had little oversight of consent practice in the surgery healthcare group.
Patients that we spoke with informed us they felt fully informed and were happy with the consent
process despite consenting on the day of procedure. Patients had information provided at their
assessment/consultation and had time to digest the information. Consent forms in patient notes
recorded information and risk including, but not limited to; explanation of the procedure,
complications, levels of discomfort, post-operative pain relief and discharge plan.
Staff followed best practice when making best interest decisions for patients who lacked
capacity to consent to treatment. Staff recognised when patients might lack capacity and held
meetings with the patient, family members, nursing staff and surgeon. The trust had separate
consent forms for patients who lacked capacity to make informed decisions at the point of care.
There was a section on the consent form where staff could document that an assessment of a
patient’s capacity had taken place. Staff described how they would support patients attending
the (ADSU) who did not have the capacity to make specific decisions. This included escalation
to medical staff and involvement of family members making ‘best interest’ decisions.
Staff understood their responsibilities in relation to ‘do not attempt active resuscitation’
(DNACPR) orders. We reviewed one form that had been completed in full and signed by the
consultant. The patient had been assessed as not having capacity to make this decision,
therefore, the form had been completed in their best interests with the agreement of their family
members.
We observed that ward and theatre handovers discussed patients awaiting capacity
assessments, vulnerable patients and those who were under a DOLS order. This meant that all
staff, regardless of grade were aware of patients within their respective areas who were
vulnerable.

Staff understood their roles and responsibilities under the Mental Health Act 1983 and the
Mental Capacity Act 2005. They knew how to support patients experiencing mental ill
health and those who lacked the capacity to make decisions about their care.
A breakdown of compliance for safeguarding adults level 2 training which included as of October
2018 for qualified nursing staff and medical staff in surgery at Princess Alexandra Hospital is
shown below. The completion target for this module is 95%.
As of October 2018
Eligible Completion Trust Met
Staff group Staff trained staff rate target (Yes/No)
Medical staff 75 134 56% 95% No
In surgery the 95% target was met for safeguarding adults level 2 training for qualified nursing
staff. However, the target was not met for medical staff.
as of March 2019 for qualified nursing staff and medical staff in Princess Alexandra Hospital’s
surgery department:
As of March 2019
In Princess Alexandra’s surgery department, the 90% target for safeguarding adults level 2
training was met by qualified nursing staff. Although the target was not met for medical staff, the
completion rate was higher than in the previous time period.
Compassionate care
Staff cared for patients with compassion. Feedback from patients confirmed that staff
treated them well and with kindness.
The Friends and Family Test response rate for surgery at Princess Alexandra Hospital was 28%
which was better than the England average of 27% from January to December 2018.
A breakdown of FFT performance by ward for surgical wards at this hospital over the same
period is shown below.
The percentage of respondents that said they would recommend the ward to family or friends
was 98% or higher for all surgical wards for these 12 months overall. However, caution is advised
in interpreting these results given the low response rate for each ward.
1. The total responses exclude all responses in months where there were less than five responses at a particular
ward (shown as gaps in the data above), as well as wards where there were less than 100 responses in total over
the 12 month period.
2. Sorted by total response.
3. The formatting above is conditional formatting which colours cells on a grading from highest to lowest, to aid in
seeing quickly where scores are high or low. Colours do not imply the passing or failing of any national standard.
During our inspection, we observed compassionate care and positive interactions in all areas we
inspected, including wards, operating theatres, the Alexandra Day Surgery Unit (ADSU) and post
anaesthetic care unit (PACU).
Patients and those close to them spoke highly of the care provided by staff and reported that staff
delivered care with compassion and kindness. One patient told us “nothing is too much trouble
for the nursing staff.” Another patient told us they were “happy with the care provided by happy
staff.” During our inspection we viewed a letter to the acute surgical unit based on Melvin ward
which was very complementary, documenting the kindness, support and understanding of
nursing, medical and radiology staff.
Staff took the time to interact with patients and those close to them in a respectful and
considerate way.
We observed patients being assisted with activities of daily living for example; personal hygiene,
going to the bathroom, and eating and drinking. All staff from the consultants to housekeepers
were kind and considerate with patients.
Staff protected patient’s dignity. During our inspection we observed that cubicle curtains were
drawn, and single side room doors were kept closed during patient consultations and care to
ensure privacy and dignity were maintained. Staff announced themselves prior to entering
curtained areas and knocked on closed side-room doors and clinic rooms. Staff made sure that
curtains were in place when male and female patients were cared for at the same time in the
PACU and ADSU recovery area and ensured that patients were covered during surgical
procedures to protect their dignity and privacy.
Staff were supportive of patients who felt anxious about surgery and did anything they could to
ensure that patients felt as comfortable as possible throughout their time on the unit. We
observed staff in the ADSU taking time to reassure a nervous patient prior to surgery and
ensuring that they were comfortable to proceed.
All staff introduced themselves to patients and communicated in a way that was appropriate, with
kindness and respect.
Staff provided calm reassurance, kindness and compassion in the PACU and ADSU to patients
who were distressed or disorientated, following their operations.
Emotional support
Staff provided emotional support to patients to minimise their distress.
Staff understood the impact that a patient’s care, treatment or condition may have on their
wellbeing and on those close to them, both emotionally and socially. Staff recognised a patient’s
condition could influence their wellbeing and were able to help support patients with this.
Patients had access to a trust wide chaplaincy service. This was advertised on notice boards
within the surgical wards and ADSU and there were faith champions available on the wards to
provide emotional support and spiritual care. Staff had access to guidance on arranging spiritual
support for relatives and patients irrespective of faith denomination.
On the Henry Moore ward, staff encouraged patients’ relatives to wait with them until it was time
for them to go to theatre for surgery and allowed brief visits on each patients’ return so that both
patient and relatives were able to emotionally support each other.
Clinical nurse specialists were available to provide additional support to patients in times of need.
A mental health liaison team were available to provide additional support for those with mental
health conditions and staff told us they responded in a timely manner, when requested.
Staff enabled patients to access additional services such as the patient advice and liaison service
(PALS), translators and sign language interpreters when they were required.
Staff recognised when people who used services needed additional support and enabled them to
access this.
We observed staff explaining the surgery process to patients to help reduce their anxiety. Patients
were given appropriate and timely support and information to cope emotionally with their care,
treatment and condition.

Staff involved patients and those close to them in decisions about their care and treatment.
Staff respected patient’s choices and delivered care with an individualised person-centred
approach. Patients’ care records were individualised and took into account the wishes and
preferences of each patient.
Staff understood the importance of involving family members and relatives in the care and
treatment of their loved one. Staff gave patients appropriate information regarding their care and
treatment.
We observed patients receiving an explanation of procedures, and staff checking understanding
and offering to repeat explanations. Patients were given time to ask questions and we also
observed family members being given explanations of what the operation would entail.
Patients and relatives, we spoke with told us they had received clear and comprehensive
information about the care and treatment they would receive, in a way they could understand.
Patients told us they felt fully informed about their care and described both medical and nursing
staff positively in respect of keeping them up to date with information and updates.

The service planned and provided services in a way that mostly met the needs of local
people.
Surgery services at the trust were established to meet the needs of local people, and also the
wider community. This included providing emergency and planned surgical services to patients.
The service worked with local and specialist clinical commissioning groups and the healthcare
community to determine service provision often working in partnership with other NHS service
providers to achieve this.
A range of elective surgical procedures were available, some of which were day case procedures
(meaning that patients could be discharged on the same day following the procedure). Patients
who were booked for planned surgery attended pre-assessment health checks prior to their
surgical procedure to assess their fitness for surgery and be screened for certain infections.
The acute surgical unit (ASU) based on Melvin ward was open seven days a week from 8am to
9pm and provided emergency and urgent access for patients with surgical concerns. Patients
were triaged within 15 minutes and seen by a doctor within one hour. The ward operated a ‘hot
clinic’ for a cohort of patients known to the service (for example; those with long term conditions
such as crohns disease or those receiving cancer treatment) who were able to self-refer rather
than attending the emergency department or their GP. Staff also provided facilities for ward
discharge referrals for follow-up treatment such as the administration of intravenous antibiotics.
The ASU service was newly opened on the last day of our last inspection in December 2017 and
since then has become well established. Patient numbers have increased from around 60 per
week in 2018 to averaging 145 patient attendances per week in 2019 and 153 the week prior to
the inspection.
The facilities and premises were appropriate for the services that were delivered. The service had
reconfigured wards so that the surgical wards were mostly on the same floor as the operating
theatres to improve patient flow and accessibility of staff.
Since our last inspection, the Alexandra day Surgery Unit had extended its operating times to six
days per week and up till 10pm at night to meet patient need. This was an improvement since our
last inspection.

The service took account of patients’ individual needs.
There were sufficient facilities within the surgical wards to allow access and use by patients who
had a physical disability including wide corridors and rails in accessible bathrooms. Staff had
access to appropriate equipment such as specialist commodes, hoists, beds or chairs to support
the moving and handling of patients who had a physical disability and patients who were bariatric
(patients with obesity).
The service provided interpretation and translation services for those whose first language was not
English or those who communicated through sign language. Interpreters and signers were
available to be booked in advance and could be with patients both pre-operatively and in recovery
areas, if required.
Clinical nurse specialists, such as stoma nurses, breast care, urology, palliative care, vascular,
trauma and diabetes nurses were available to provide additional support to patients in times of
need. Each ward, theatre and recovery area had a selection of dedicated ‘link champions’ for
mental health, dementia, learning disabilities, diabetes, and palliative care patients. These ‘link
champions’ provided additional help and support to patients, staff and relatives.
Meal times were protected on the surgical wards to ensure patients could eat their meals with
minimal interruption. The trust offered a range of food choices to meet cultural, religious
requirements or patients’ personal preference as far as possible. Patients we spoke with told us
the food was good and hot drinks were provided throughout the day to make sure patients were
kept hydrated.
There were processes to identify and inform relevant health care professional if patients were
living with dementia or a learning disability. Symbols were used on patient care records to identify
patients with specific needs, for example, mental health conditions, falls risks, infection control
risks, end of life care, and communication needs.
Patients living with dementia or a learning disability were supported for their admission to hospital.
Relatives and carers were accommodated on the wards and in the ADSU to support patients with
additional needs such as; dementia or learning disabilities. Staff told us arrangements could be
made for a patient with a learning disability to visit the hospital prior to their admission to see the
locations where they would be receiving their treatment and care. Where possible patients with
learning difficulties, dementia or complex health needs or co-morbidities, for example; diabetes,
were placed at the beginning of surgical lists to minimise any anxieties or disturbance for that
patient.
The wards displayed information on how to contact the mental health team and community teams
for patients with learning disabilities. Contact details and information was displayed for patients,
relatives and visitors who may be suffering from domestic abuse, detailing confidential advice
services that were available.
Although under the medicine healthcare group we visited Tye Green ward due to the pathway for
patients with a fractured neck of femur who were admitted there and were cared for post
operatively. Staff cared for a high number of surgical patients living with dementia on Tye Green
ward. We saw limited environmental changes or equipment to support this patient group, for
example; large blocks or colour- coded areas, or dementia friendly day rooms although the ward
had only recently been moved the ward space and staff acknowledged that there were plans for
renovation. The trust used a ‘Forget Me Not’ symbol above the patient’s bed to identify patients
with dementia additional needs and used the ‘This Is Me’ Tool to support those patients.
Three surgical wards were assessed for the Patient Led Assessments of the Care Environment
(PLACE) at the trust in 2018. One of the resulting scores assessed how friendly the environments
were for patients living with dementia. The trust scores were slightly worse at 76% than the
England average of 79%. The trust acknowledged that although some improvement had been
made on the 2017 score (72), it was challenged by the aged infrastructure of the hospital and was
continuing to work on improvements to the environment whilst taking forward plans for a new
hospital.
The ward staff we spoke with were aware of the ‘patient passport’ scheme. This is a personalised
document that has details about the person’s individual needs, likes and dislikes. This enabled
staff to minimise distress to vulnerable patients during possible stressful surgical admissions.
We observed that call bells were answered promptly on all surgical wards and patients told us
they did not usually have to wait for long if they requested assistance. This was an improvement
since our last inspection.
The service offered an enhanced recovery pathway for some surgical procedures led by a
specialist nurse with consultant anaesthetist and surgeon support. The enhanced pathway offered
personalised care and support and practical advice prior to, during admission, and after surgery
for patients undergoing, primarily gynaecology and bowel resection surgery with the aim of
reducing recovery periods.
There was a range of information leaflets and literature available for patients to read about a
variety of conditions and support services available. The leaflets were in English but could be
ordered in other languages or alternative formats if required.
The theatre staff had established a dementia friendly patient pathway to improve the patient
experience. This included a variety of innovations for example; forget me not patient slips for
collecting patients from admission, dementia friendly bays in the holding area of theatres and the
PACU, allowing relatives/carers to accompany patients as far as practicable to theatre, improved
numbers of dementia champions in the theatre environment (eight).
Access and flow

People could mostly access the service when they needed it. Waiting times from referral to
treatment and arrangements to admit, treat and discharge patients had not always been in
line with good practice but were improving.
Average length of stay
Princess Alexandra Hospital - elective patients
From October 2017 to September 2018, the average length of stay for patients having elective
surgery at Princess Alexandra Hospital was 3.6 days, which was similar to the England average of
3.9 days.
Average length of stay for elective specialties:
• Average lengths of stay for elective patients in trauma and orthopaedics, general surgery
and urology at Princess Alexandra Hospital were similar to the England averages.
Elective Average Length of Stay - Princess Alexandra Hospital
Princess Alexandra Hospital - non-elective patients
From October 2017 to September 2018, the average length of stay for patients having non-
elective surgery at Princess Alexandra Hospital was 4.2 days, which was similar to the England
average of 4.8 days.
• Average lengths of stay for non-elective patients in general surgery, trauma and
orthopaedics and urology at Princess Alexandra Hospital were similar to the England
averages.
Non-Elective Average Length of Stay - Princess Alexandra Hospital
Referral to treatment (percentage within 18 weeks) - admitted performance
From January 2018 to December 2018 the trust’s referral to treatment time (RTT) for admitted
pathways for surgery was consistently worse than the England average. There was a
deterioration from 56.4% in January 2018, to 37.9% in April 2018. However, this was followed by
an improvement to 64.1% in December 2018 (compared to the England average of 68.3%).
Referral to treatment (percentage within 18 weeks) – by specialty
One specialty was above the England average for RTT rates (percentage within 18 weeks) for
completed admitted pathways within surgery.
Specialty grouping Result England average

Ophthalmology 68.6% 66.2%
Five specialties were below the England average for RTT rates (percentage within 18 weeks) for
completed admitted pathways within surgery.
Specialty grouping Result England average

General surgery 62.8% 72.2%
Urology 57.7% 76.4%
Trauma & orthopaedics 50.2% 59.1%
Ear, nose and throat 48.7% 61.3%
Oral surgery 33.5% 57.5%
The service had an admitted RTT recovery plan and, although there is no national target for trusts
to achieve the 18 week admitted RTT performance, the surgery service had a trajectory to deliver
the 92% standard for RTT incomplete. As part of this, the service worked through the patients
who have been waiting longest on their pathways and this was monitored through the patient
access board on a weekly basis. The admitted performance was monitored, and data presented
as part of the surgery performance review meetings and we saw this in the Surgery and Critical
Care Health Group (SCCHG) Quality Assurance Dashboard.
As part of the strategy for the improvement of the admitted performance the service was
investigating the introduction of a 23-hour ward as part of the long-term planning for the surgery
healthcare group. A 23-hour ward is a surgical care unit which manages the patient's surgical
admission within a 23-hour period. Patients are admitted, prepared for their surgical intervention,
monitored and provided with the appropriate pain relief post-surgery. In the short term the surgery
healthcare group implemented a telephone reminder call for patients to remind them about their
date for planned surgery 10 days in advance; this had seen a positive impact on the did not attend
(DNA) rates for theatres and aimed to facilitate an improvement in theatres utilisation and the
admitted performance.
Cancelled operations
A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was
due to arrive, after they have arrived in hospital or on the day of their operation. If a patient has
not been treated within 28 days of a last-minute cancellation, then this is recorded as a breach of
the standard and the patient should be offered treatment at the time and hospital of their choice
With one exception, over the two-year period from quarter 4 of 2016/17 to quarter 3 of 2018/19,
the percentage of last-minute cancellations at the trust where the patient was not treated within
28 days was consistently lower (better) than the England average.
The only exception was the penultimate quarter, quarter 2 of 2018/19. In that quarter the trust
cancelled 45 operations and, of these, 11% of patients weren’t treated within 28 days.
In quarter 3 of 2018/19, there was an improvement in performance compared to the previous

quarter. In that quarter the trust cancelled 41 operations and, of these, 7% of patients weren’t
treated within 28 days.
Over the two years, the percentage of cancelled operations at the trust showed an upward
(deteriorating) trend in performance.
Percentage of patients whose operation was cancelled and were not treated within 28
days - Princess Alexandra Hospital NHS Trust
Over the same two-year period, the percentage of cancelled operations at the trust was better
than the England average in all but three quarters. There was an overall downward trend in the
percentage of cancellations over this period.
Cancelled operations as a percentage of elective admissions only includes short notice

cancellations.
Cancelled Operations as a percentage of elective admissions - Princess Alexandra Hospital

NHS Trust
During our inspection we noted that medical outlier patients were common on the surgical wards.
Due to the lack of beds in medical wards, many patients were placed in other departments' wards
(usually surgical wards). These patients were called ‘medical outliers’. Staff did confirm that there
was a medical outlier team who reviewed the medical patients as appropriate, and that they were
moved when beds became available on the medical wards.
Following our inspection, the trust supplied data that showed that from September 2018 to
February 2019, 1828 medical patients were placed on the surgical wards with Penn ward being
used the most (1300 patients). We spoke with staff on Penn ward who felt this group of patients
did have a negative impact on the ward with an example being given of a major surgery post-
operative patient being moved to accommodate the creation a ‘medical outlier’ bay. Senior staff
indicated that lack of space on surgical wards was one of the reasons for cancelling elective
patients.
Patient moving wards per admission
Please note that the trust was only able to provide data for the four-month period from September
to December 2018.
Over these four months, 99.3% of individuals on surgical wards did not move wards during their
admission, and 0.7% moved once. There were no individuals that moved wards more than once
on surgical wards over this period.
(Source: Routine Provider Information Request (RPIR) – Ward moves tab)
Patient moving wards at night
From December 2017 to November 2018, there were 658 patients moving wards at night within
surgery.
The highest numbers of ward moves at night were reported in January 2018 (89), April 2018 (74)
and February 2018 (71).
Ward moves at night data was reported for three surgical wards: Penn Ward (326), Tye Green
Ward (291) and Henry Moore Ward (41).
(Source: Routine Provider Information Request (RPIR) – Moves at night tab)
From March 2018 to February 2019 the PACU cared for 283 patients overnight. The main reason
for this was due to a lack of capacity on the high dependency or intensive therapy unit.
At our last inspection we were concerned by the number of patients who were transferred between
the ADSU and the PACU following surgery, especially due to the location of the ADSU as this
involved an outside trip. Staff told us this had improved significantly with between one and seven
patients per month transferred between the two units apart from the months of October and
November 2108 when there were 12 and 10 patients transferred. The trust reported this was due
to a higher number of patients converting to overnight stays from day case procedures due to
clinical acuity during those months. In addition, the trust was unable to operate the usual extended
ADSU opening hours due to staffing shortages which resulted in patients continuing their recovery
in the PACU.
The service had processes for effective patient flow within the surgical wards. A multidisciplinary
team attended twice daily ‘board rounds’ where the team used the ‘red to green’ initiative to
ensure patient discharges were managed in a timely and safe way. The ‘red to green’ system is a
method of monitoring patients awaiting active treatments and further investigations. Patients were
marked red on the board if they were awaiting treatment or investigations prompting staff to chase
investigations and results and green if they were likely to be ready for discharge.
The service treated concerns and complaints seriously, investigated them and learned
lessons from the results, and shared these with all staff.
From December 2017 to November 2018 the trust received 52 complaints about surgery at
Princess Alexandra Hospital (22.1% of total complaints received by the hospital).
Department Number of Percentage of

complaints total
Orthopaedics 17 32.7%
Urology 11 21.2%
Vascular surgery 3 5.8%
Oral surgery 1 1.9%
Surgical Directorate - staff related/miscellaneous 1 1.9%
Total 52 100%
Subject Number of Percentage of

complaints total
Appointments 6 11.5%
Admissions and discharges (excluding delayed
3 5.8%
discharge due to the absence of a care package)
Prescribing 1 1.9%
Total 52 100%
The service took complaints and concerns seriously, investigated them and learned lessons from
the results and shared these with staff at monthly team meetings. Staff were aware of the trusts
complaints policy; this was in date, accessible to staff and in line with best practice
recommendations.
Patients and their relatives/carers had access to information on how to make a complaint or raise
a concern. We observed information leaflets in departments and on the wards informing patients
and their relatives/carers on how to do this.
Patients we spoke with were aware of how to complain and knew how they could complain if
necessary. Ward and theatre unit managers told us that they invited complainants to discuss the
complaint in the first instance, to identify and resolve issues in a timely manner. If this was
unsuccessful in resolution the complainant was directed to the trusts Patient advice and liaison
service (PALS). PALS is an independent service which offers confidential advice, support and
information on health-related matters. They provide a point of contact for patients, their families
and their carers or relatives.
Staff learnt lessons and made changes as a result of complaints from patients and relatives.
Different staff members were able to provide examples of where the service had learnt lessons
from complaints and as a result changes had been made to the unit.
We reviewed three complaints and saw that; they were investigated in a timely manner,
responses provided, learning shared with the team and action plans developed to improve the
service. For example; a standard operation procedure (SOP) was in the process of being
developed detailing the process for managing patients with mental health concerns who required
elective surgery and an after-care leaflet was being developed for patients following oral surgery.
Complaints and compliments were included in the monthly Surgery and Critical Care Health
Group (SCCHG) Quality Assurance Dashboard. We saw that there was oversight both of the
number of complaints and the current status of each complaint.
From December 2017 to November 2018 there were 1,115 compliments about surgery at
Princess Alexandra Hospital.
Of these the vast majority (1,113 compliments) concerned inpatients services, whilst two
concerned theatres.
(202 compliments).

Leadership
Managers at all levels in the service had the right skills and abilities to run a service
providing high-quality sustainable care.
Leaders understood the challenges to quality and sustainability and could identify the actions
needed to address them. A senior management team oversaw the surgery healthcare group. This
included the Alexander Day Surgery Unit (ADSU) and the pre-assessment and admission units on
Netteswell ward. It did not include Tye Green ward where elderly trauma patients were admitted
as this was part of the medical healthcare group. The triumvirate supported matrons to deliver the
objectives and work of the surgery service.
There were visibly clear and strong leadership roles across the surgical healthcare group. This
was an improvement since our last inspection. The leads were supported by teams of directorate
and operational managers, matrons, ward and theatre managers.
Managers from across the surgery healthcare group were enthusiastic, skilled and knowledgeable
leaders; capable of meeting the demands of leading the servicWard and theatre managers and
matrons were well known to and respected by their staff. Staff told us that leaders were
approachable and supportive. Staff, in most cases, were able to tell us who the senior
management team were and could describe instances when they had visited wards/departments.
Staff told us, and we saw during our inspection, that matrons and the surgery director of nursing
were visible on the wards. Matrons attended trust wide bed occupancy and staff briefings three
times daily to discuss nurse staffing to ensure safe numbers of staff for the acuity of patients.
Medical and nursing staff understood management reporting structures and told us they were well
supported by their managers.
Vision and strategy

The service had a vision for what it wanted to achieve and workable plans to turn it into
action developed with involvement from staff, patients, and key groups representing the
local community.
The service aligned with the trust vision for what it wanted to achieve but had not yet developed its
strategy and plans to turn it into action.
The trust had a clear vision and set of values, which were based on the local Princess Alexandra
Hospital five P framework of:
• Our Patients
• Our People
• Our Performance
• Our Places and
• Our Pounds
Staff were aware of the values and told us it was about patient-centred care. We saw posters on
the surgical wards and areas with the five Ps and all staff we spoke with knew of the five Ps
framework.
The senior management team told us they were still developing their strategy, which will include all
surgical specialities. This was a similar position to our inspection in December 2017, however
there was a plan to launch the vision and strategy in April 2019.
Culture
Prior to our inspection, during focus groups, staff from the wards told us that morale was low and
attributed this to a lack of staff. However, during our inspection the culture within the operating
theatres and wards was positive and staff we spoke with were happy and told us they felt
supported. This was an improvement since our last inspection. Staff were actively engaged and
keen to tell and show us what they had been doing to improve services since our last inspection
for example;
Members of the senior leadership team were visible and did ‘walkarounds’ and supported staff. It
was evident from the way in which they spoke about their staff that managers were proud of their
teams and their departments. Staff told us that their opinions, views and ideas were listened to
and had seen positive changes made.
Most staff we spoke with told us there was a culture of openness and honesty. Staff told us they
liked working at the hospital and felt they had good teams of colleagues who were supported by
their line managers. We spoke with agency and bank nurses, who told us they were made to feel
welcome by staff and were included as part of the team when on longer contracts. However due to
the urology incident reported during inspection where duty of candour was not applied until raised
by the inspection team we were not assured that this was embedded with all staff.
Staff we spoke with reported good team working and a huge sense of pride in serving the local
community. Many of the staff and several managers had worked within the trust for many years
and demonstrated strong commitment to the hospital.
Junior doctors told us they felt welcomed into the organisation and had had a good introduction
and induction. There was also good support from their senior colleagues.
Staff told us they were aware of who their Freedom to Speak up Guardians
(FSUG) were and how to contact them if they felt they could not speak with their line managers.
Freedom to Speak up Guardians were employees who worked alongside the trust leadership
teams to support employees to raise concerns if required. They worked to ensure all staff were
actively encouraged and enabled to speak up safely and without the fear of retribution.
The operating theatres and post anaesthetic care unit (PACU) also had a nurse advocate (one of
seven in the trust) which was a slightly different role to the SUG. The workplace advocacy role
provided an opportunity for staff to discuss anything work related on their mind and the advocate
had received a form of counselling training to address any issues raised.
Governance
The service used a systematic approach to improve the quality of its services and
safeguard high standards of care by creating an environment in which excellence in clinical
care would flourish.
Governance structures, processes and systems of accountability were clearly set out within the
surgical healthcare group.
Both staff and managers were clear on their roles and responsibilities and were able to tell us how
information was fed up and down into the operational team.
There was evidence of good clinical governance procedures and quality measurement processes
in place. Risks were identified and escalated through a series of committees and working groups.
Staff told us they received regular communication from their managers and attended regular team
meetings to discuss current issues and priorities.
Clinical governance meetings were held monthly, which included the triumvirate leadership team
and matrons from within the healthcare group. A variety of topics were included as standard
agenda items where they were monitored and discussed including, but not limited to; incidents, the
risk register, complaints, patient falls and general concerns. This was also a forum to raise any
ongoing or new issues from ward level; as well as having information cascaded down from the
senior management level and above. Areas for concern were highlighted and appropriate
mechanisms were available to escalate through the healthcare group monthly quality assurance
meeting and then on to the monthly quality governance committee meeting (with board
representation). In this way information was passed up and down within the operational hospital
team. We reviewed minutes of meetings provided by the trust following our inspection which
showed that the process worked well and was fully embedded.
The service used the Get It Right First Time (GIRFT) process to monitor actions to improve the
service. We saw the GIRFT action plan which contained 70 separate areas for improvement
identified with red, amber, green ratings for progress against target date.
Systematic audits were undertaken and used to improve the service. Quality audits were compiled
on the wards, such as hand hygiene, and infection prevention and control. The results of each
wards monthly audit were fed into the service quality assurance dashboard.

The service had systems for identifying risks, planning to eliminate or reduce them, and
coping with both the expected and unexpected but there was inconsistent monitoring and
actions to resolve risks
The service had a risk register with four urology risks rated at 20 (25 was highest level) and 12
risks rated at level 15. Staffing was the most predominant theme with six of the risks related to
lack of staff or staff retention in both medical and nursing staff. Other risks involved information
technology (IT) systems, estates and facilities concerns, medical gas training compliance and
finance. The risk register showed that each risk had been reviewed and rated, and actions were
implemented to reduce the impact of the risk. The surgery healthcare group risk register was red,
amber, green rated according to the level of risk. The ward and department managers generally
had good oversight of what was on their risk register but it was not clear if this was shared with
junior staff.
The service monthly quality assurance dashboard report contained the top risks for the healthcare
group. The senior management team were aware of the procedure to escalate any of their risks to
the trust risk register so the trust board were aware of these and the mitigating actions they had
put in place.
The service held monthly risk committee meetings and the surgery healthcare group split the risk
register by ward/service. Access was made available to matrons, ward managers, service leads
and senior staff to allow individuals to add or edit their own risks and enable better oversight of
risk.
There was a systematic programme of clinical and internal audit to monitor quality, operational and
financial processes, and systems to identify where action should be taken. These were reported
on the quality assurance dashboard and fed into the
Senior management were able to articulate the top risks to the surgical healthcare group and we
saw evidence that these were recorded within the service electronic risk register detailing; the
owner of each individual risk, what actions were required to reduce the risk and timeframes in
which to complete this in. This meant that there was good oversight of risks and pertinent issues
affecting the service and that information was captured. However, the risk register also contained
a concern that had the potential to impact significantly on patient care. Following a serious incident
in May 2018, which was related to the late removal of a ureteric stent, the trust identified one of
the causes of the incident being the lack of a ureteric stent register in June 2018. Despite the
seriousness of the incident, the service did not commence any work on this until November 2018,
five months later. Following this a further patient also developed complications possibly related to
the late exchange of a ureteric stent (also the second time this patient had a late stent exchange).
Had the service put measures in place earlier to track patients with ureteric stent insertions, the
second patient may not have developed subsequent complications. We were not assured that the
service and escalated appropriately
The service had effective systems for monitoring and managing performance. The surgical
services used a comprehensive quality assurance dashboard report to monitor performance
information such as waiting time to referral, theatre utilisation, length of stay (LOS) and
unexpected returns to theatre. The dashboard allowed the service managers to compare
performance over time and against targets and seek ways in which to improve.
Each surgical speciality held regular mortality and morbidity meetings to share outcomes of
mortality reviews. We reviewed a selection of mortality and morbidity meeting records from
November 2018 to January 2019. The meeting records identified learning and actions to share
across the service.
The service mostly collected, analysed, managed and used information well to support all
its activities, using secure electronic systems with security safeguards.
There was an understanding of performance, which integrated patients’ views with other
information on quality, safety and operational performance. The monthly quality assurance report
for surgery included feedback from patients in the form of complaints and compliments These
were discussed at the meetings.
Staff received training on information governance as part of their mandatory training.
Information was shared effectively with staff. There were handovers and huddles throughout the
day on the wards and theatre department had introduced twice daily huddles since our last
inspection in December 2107 where they discussed any operational issues.
Information stored electronically was secure. Computer access was password protected and we
observed staff logging out of computer systems or hand-held devices they had completed tasks.
There were arrangements to submit relevant data to national audit programmes. The trust had
systems to ensure notifications of serious incidents causing harm to patients were reported in line
with national requirements.
There were effective arrangements to ensure the information used to monitor, manage and report
on quality and performance was accurate, valid, reliable, timely and relevant.
Staff had access to a trust intranet system which provided a range of internal and external
resource material to assist staff in their daily tasks. All referrals and diagnostic requests were
made electronically and staff within the department told us that they had access to the information
that was needed for them to undertake their roles effectively, this included agency staff and staff
assisting from other departments.
Engagement
The service engaged well with staff, the public, patients and local organisations to plan and
manage services.
Senior management had regular engagement walk arounds and drop in sessions were staff could
speak with them about anything they wished to.
The trust, ward and department managers engaged with their staff using different methods
including team meetings, ward newsletters, away days and using closed social media groups. The
theatre user group which was in its infancy at our last inspection was well embedded and provided
a platform for communication across the different theatre users.
The service gathered patients’ views and experiences and acted to shape and improve the
services and culture. We saw notice boards on the wards and day unit where patients feedback
was recorded and the outcome from actions taken by the staff to address their feedback.
There were orthopaedic and ophthalmic patient panels recently formed to look at patient
experience.
During our inspection we saw evidence of posters promoting staff well-being events such as
mindfulness and yoga sessions, as well as staff information for counselling services.
The surgical healthcare group held their own annual awards ceremony to celebrate individual
achievements. Nominees were presented with certificates in front of colleagues and staff who had
received awards said they felt very proud.

and when they went wrong, promoting training, research and innovation.
Staff of all levels told us they were encouraged to develop and if they identified courses that were
suitable, senior staff strived to arrange funding.
Leaders and staff strove for continuous learning, improvement and innovation. Following our last
inspection, the surgery healthcare group made some changes to improve patient experience. For
example; they developed standard operating procedures to improve discharge from the post
anaesthetic care unit PACU), staggered admissions times in the surgical admissions unit so
patients did not have to wait for long periods prior to having surgery and centred the surgical
wards on the same floor as the main operating theatres to improve patient flow.
The operating theatres had a wall of fame in the staff area, which was used to celebrate a variety
of theatre staff achievements. The theatre staff had submitted numerous posters to the NHS
Academy of Fabulous Stuff which is a web based social movement for sharing health & social care
ideas, services and solutions that work. The trust won the 2018 FabChange70 Organisation which
was awarded to the organisation whose energy, leadership and vision had empowered staff to put
their ideas into action and had embedded Quality Improvement (QI) as ‘the norm’ throughout their
organisation. The winning poster was from the operating theatres demonstrating an improved
dementia patient centred pathway to improve outcomes, care and experience. The runner up
poster was from the PACU for their work on developing standard operating procedures for
discharge.
Maternity

The family and women’s healthcare group provide both routine and emergency obstetric care. The
trust has a consultant led high risk labour ward with nine delivery rooms. There are two maternity
theatres, as well as a three-bedded recovery room. The antenatal ward includes a 16-bedded
ward with one bereavement suite. The postnatal ward has 22 beds.
There is a co-located birthing unit for low risk women to access midwifery led care. The birthing
unit has three delivery rooms, all with the provision for water births. There are also 12 postnatal
beds on the birthing unit. Infant feeding specialists and a maternity helpline are both located on
the birthing unit.
There is a maternal and fetal assessment unit which is open from 8am to 8pm seven days a week.
The trust has 65 maternity beds at the Princess Alexandra site. These beds are located within
four wards and units:
• Birthing Unit (midwife led birthing unit for low risk women): 12 beds
• Chamberlen Ward (antenatal ward): 16 beds and a bereavement suite.
• Labour ward (consultant led obstetric unit): 12 beds
• Samson Ward (Postnatal ward): 22 beds
From October 2017 to September 2018 there were 3,791 deliveries at the trust.
A comparison of the number of deliveries at the trust to the national totals for all acute trusts in
England during this period is shown below.
Number of babies delivered at The Princess Alexandra Hospital NHS Trust – comparison
with other trusts in England
(Source: Hospital Episodes Statistics)
A profile of all deliveries and gestation periods from July 2017 to June 2018 can be seen in the
tables below. The trust had a similar profile of deliveries when compared to the England
averages.
Profile of all deliveries (July 2017 to June 2018)
The Princess Alexandra Hospital NHS Trust England

Deliveries (n) Deliveries (%) Deliveries (%)
Single or multiple births
Single 3,384 98.5% 98.6%
Multiple 51 1.5% 1.4%
Mother’s age
Under 20 66 1.9% 3%
20-34 2,546 74.1% 74.8%
35-39 673 19.6% 18.2%
40+ 150 4.4% 4%
Total number of deliveries
Total 3,435 592,252
Notes: A single birth includes any delivery where there is no indication of a multiple birth.
This table does not include deliveries where delivery method is 'other' or 'unrecorded'.
Gestation periods (July 2017 to June 2018)

Gestation period
Under 24 weeks 0 0% 0.1%
Pre term 24-36 weeks 191 5.7% 7.8%
Term 37-42 weeks 3,179 94.3% 91.9%
Post term >42 weeks 0 0% 0.2%
Total number of deliveries with a valid gestation period recorded
Total 3,370 491,919
Notes: This table does not include deliveries where delivery method is 'other' or 'unrecorded'.
Gestation periods were unrecorded for 1.9% of deliveries at this trust compared to 16.9%
nationally.
(Source: Hospital Episodes Statistics (HES) – Provided by CQC Outliers team)
The number of deliveries at the trust by quarter for the last two years (October 2016 to
September 2018) can be seen in the graph below.
The number of deliveries at the trust followed a similar trend over the last two years, with the
numbers peaking in quarter two. In the most recent quarter (quarter two of 2018/19), there were
1,019 deliveries at the trust.
Number of deliveries at The Princess Alexandra Hospital NHS Trust by quarter
(Source: Hospital Episode Statistics - HES Deliveries (October 2016 - September 2018))
Our inspection was announced due to the number of core services we were inspecting. Before our
inspection, we reviewed performance information from, and about, the trust.
We previously inspected maternity services jointly with gynaecology services, therefore we are
unable to compare our new ratings directly with the previous ratings.
During this inspection, we visited the maternity wards, the midwifery lead birthing unit (MLBU), the
maternity outpatient department and maternity theatres. We spoke with six women and their
relatives and 42 members of staff including medical, midwifery and nursing staff, healthcare
assistants and domestic staff. We observed care and looked at 19 sets of medical records. We
also looked at a wide range of documents including policies, standard operating procedures,
meeting minutes, action plans, risk assessments and audit results.


Mandatory training
The service provided mandatory training in key skills to all staff, however not everyone
completed it.
Mandatory training completion rates were not consistent across maternity wards and staffing
groups. We found staff compliance was higher than the trust’s mandatory training completion
target on Chamberlen ward, Samson ward and the delivery ward. Midwifery staff had mostly
completed the trust’s mandatory training programme, but the medical staffing group had poor
compliance with mandatory training completion.
The trust set a target of 90% for the completion of mandatory training.
nursing and midwifery staff in the maternity department at Princess Alexandra Hospital is shown
below:
As of October 2018
Conflict resolution 150 153 98% 90% Yes
In Princess Alexandra Hospital’s maternity department, the 90% target was met for five of the 11
mandatory training modules for which qualified nursing and midwifery staff were eligible.
for qualified nursing staff in Princess Alexandra Hospital’s maternity department:
Training module name As of March 2019

Staff Eligible Completion Trust Met
Slips, trips and falls 12 14 85.7% 90% No
In Princess Alexandra Hospital’s maternity department, the 90% target was met for seven of the
13 mandatory training modules for which qualified nursing staff were eligible. As in the earlier
time period, the infection prevention and control level 2 and adults and paediatric basic life
support modules had the lowest completion rates. The completion rates for these modules were
similar to those in the earlier time period.
Please note that the trust reported that their medical staff work across maternity and gynaecology
services. As a result, they were unable to split staff into the individual core services.
in maternity and gynaecology at Princess Alexandra Hospital is shown below:
As of October 2018
Manual handling level 1 1 1 100% 90% Yes
Equality, diversity and human rights 18 24 75% 90% No
Across Princess Alexandra Hospital’s maternity and gynaecology departments, the 90% target
was met for two of the 13 mandatory training modules for which medical staff were eligible.
for medical staff in maternity and gynaecology at Princess Alexandra Hospital:
As of March 2019
Manual handling level 1 1 1 100.0% 90% Yes
In Princess Alexandra Hospital’s maternity and gynaecology department, the 90% target was
met for one of the 14 mandatory training modules for which medical staff were eligible. As in the
earlier time period, the adults and paediatric basic life support modules had one of the lowest
completion rates. The completion rate for this module was slightly lower than in the earlier time
period.
Staff we spoke with, told us that they found completing mandatory training more difficult by single
module rather than completing a whole day of training. Staff spoke about training that was held
off site for an hour at a time which was difficult for staff that commuted a long distance to work.
Staff received training in CTG monitoring. Data provided by the trust showed that 85% of
midwifery staff and 87.5% of doctors had completed this training.
Safeguarding
Staff understood how to protect women and babies 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 maternity service had processes in place to easily flag or identify existing safeguarding
concerns for women. Women identified as having previous or existing safeguarding or mental
health concerns were flagged on the trust’s electronic recording system. Staff could check a
national safeguarding system if a woman presented that was not booked at the trust for delivery.
Staff we spoke with confirmed the processes in place to access safeguarding information for the
women they cared for.
Information shared by the trust prior to our inspection demonstrated poor compliance with
safeguarding training completion across all staff group within maternity services. However, all
staff we spoke with told us that they had completed safeguarding training for children and adults.
The trust set a target of 95% for the completion of safeguarding training modules, apart from
prevent health WRAP training, where the target was 90%.
nursing and midwifery staff in the maternity department at Princess Alexandra Hospital is shown
below:
As of October 2018
In Princess Alexandra Hospital’s maternity department, the trust’s training targets were not met
for the three safeguarding training modules for which qualified nursing and midwifery staff were
eligible.
2019 for qualified nursing staff in Princess Alexandra Hospital’s maternity department:
As of March 2019
In Princess Alexandra Hospital’s maternity department, the 90% target was not met for any of
the three safeguarding training modules for which qualified nursing staff were eligible. The
completion rates for two of the individual modules were higher to those in the previous time
period while the rate for safeguarding adults level 2 module was the same.
staff in maternity and gynaecology at Princess Alexandra Hospital is shown below:
As of October 2018
Across Princess Alexandra Hospital’s maternity and gynaecology departments, the trust’s
training targets were not met for the three safeguarding training modules for which medical staff
were eligible.
2019 for medical staff in maternity and gynaecology at Princess Alexandra Hospital:
As of October 2018
In Princess Alexandra Hospital’s maternity and gynaecology department, the 90% target was
not met for any of the three safeguarding training modules for which medical staff were eligible.
However, with the exception of the safeguarding adults level 2 module, the rates had decreased
when compared to the previous time period.
The trust had a variety of policies in place to safeguard women and babies from abuse. Staff had
access to policies in electronic format though the trust’s intranet. We reviewed policies such as
safeguarding children, safeguarding adults, domestic violence and abuse and child abduction. All
these policies were within their review date and reflected relevant legislation, national guidance
and best practice.
Maternity services had one named midwife for safeguarding and an additional temporary post to
support the named safeguarding midwife. This post was expected to be made permanent. The
trust also had three specialist safeguarding midwives within the community service. Two of the
community midwives took the lead for vulnerable women in Harlow and managed identified risk
such as mental health, teenage pregnancy and drug abuse. The other midwife led in other
community areas.
The named safeguarding midwife received one to one clinical supervision every three months.
However, community midwifes did not have access to one to one safeguarding supervision. The
community safeguarding midwives did have access to group session every three months.
Staff escalated safeguarding concerns electronically which provided an alert to the local authority
and the trust’s safeguarding team. The safeguarding team liaised with local GPs and health
visiting teams to share information related to safeguarding concerns.
Staff we spoke with, understood their responsibilities in relation to raising any safeguarding
concerns. They gave examples of the types of concerns they would escalate an example they
gave was female genital mutilation (FGM). Staff also told us they would explore situations where
women seemed nervous in the presence of a spouse or partner to ensure they were not subject to
domestic abuse.
The trust had a child abduction policy in place. The policy was within the review date and made
reference to relevant national guidance and legislation. The maternity ward and the midwife led
birthing unit were secure with restricted access to visitors.
Midwives could refer women for mental health assessments during their pregnancy. These
assessments were provided by another healthcare provider but could be accessed in Harlow or
another local town. Women had access to a six-bedded mother and baby unit if staff had concerns
about their mental health following delivery. This unit was situated in a local town close to Harlow.
Maternity services provided care to 14 young women aged 17 years and under from October 2017
to September 2018. When a young person presented to the maternity service, they were referred
to a specialist midwife who ensured a full safeguarding review was undertaken. The young person
would be referred to the relevant departments. An information sharing form was completed, sent
to the safeguarding team and stored electronically for maternity staff to review.
Maternity clinics displayed information about domestic abuse. We saw information displayed in
areas where women waited for their appointment and a helpline number for women to call if they
were subject to domestic abuse.
The service mostly controlled infection risk well. Staff kept themselves, equipment and the
premises clean. They mostly used control measures to prevent the spread of infection.
The trust had a ‘standard infection prevention and control precautions policy’ for staff to follow.
The policy was within the review date with version control and made reference to national
guidance and legislation. Staff accessed this policy electronically through the trust’s intranet.
Most of the areas we visited including theatres were visibly clean, tidy and uncluttered. Personal
protective equipment (PPE), including gloves and aprons were available in all clinical areas and
wards we visited. However, some cupboards and storage areas in the clinical areas of the
postnatal ward were dusty. We escalated our concerns to the senior midwife on the ward who
arranged for these areas to be cleaned.
The curtains in ward bays were disposable to reduce the spread of healthcare associated
infections. We reviewed the curtains in one ward bay and three delivery rooms and found these
were within their expiry date.
Hand sanitising units were available at the entrance to all clinical areas for staff and visitors to use,
with further dispensers throughout the wards or clinical areas. Hand washing facilities were
available in each ward bay or single room for staff and visitors to wash their hands.
Staff did not always have access to a dirty utility in the antenatal clinics. We observed staff
completing urine testing in rooms where no handwashing facilities were available. This meant that
staff were not able to effectively follow infection prevention and control guidance.
There were systems in place for staff to maintain their cleanliness and prevent the spread of
infection. Staff wore uniforms with short sleeves adhering to the trust’s infection prevention and
control policy and bare below the elbows guidance. We observed staff washing their hands before
and after contact with women and babies. Staff also cleaned their hands when they moved
through clinical areas for example from one ward to another.
The service monitored staff hand hygiene practices monthly. Audit data provided by trust showed
that Chamberlen ward, the antenatal clinic and maternity and fetal assessment unit (MFAU)
achieved 100% consistently from March 2018 to December 2018. The labour ward, Samson ward
and the midwifery led birthing unit (MLBU) scored between 96% and 100% for the same time
period.
Personal protective equipment (PPE) was readily available we observed that staff used PPE such
as gloves and aprons appropriately.
Clinical areas had not met the 97% target for the ward audits consistently from January 2018 to
November 2018. We reviewed the audits undertaken for Chamberlen ward in January 2019 and
the March 2019 audit for Samson ward. The wards met the trust’s target for environment and
infection prevention and control elements of these audits.
Appropriate precautions were in place including the use of PPE, where it had been identified women
might present a risk of spreading infections to others. During this inspection, we observed a woman
who was being cared for in isolation. There was a sign on the door to indicate infection prevention
and control precautions were in place and the door was closed. Processes were in place to ensure
the room was deep cleaned before another woman was admitted to it.
Maternity services monitored women and babies for infections such as streptococcus group B and
provided appropriate treatment and observation. Streptococcus group B is normally harmless, and
most people won't realise they have it, however the infection can make babies very ill. Women
and their babies were observed for five days following delivery in the event this infection was
identified.
Maternity services had no cases of Methicillin-Resistant Staphylococcus aureus (MRSA) or
Clostridium Difficile (C-diff) reported from April 2018 to March 2019. MRSA is a bacteria resistant
to the methicillin group of antibiotics and C-diff is bacteria that can infect the bowel causing
diarrhoea, the infection most commonly affects people who have recently been treated with
antibiotics and it can spread easily to others.
In maternity theatres, staff scrubbed for surgical procedures and wore full sterile PPE. Staff who
were directly involved in surgical procedures wore a surgical mask. Maternity services had 15
readmissions to hospital, four of which were due to surgical site infections following caesarean
sections from September 2018 to March 2019.
Equipment cleaning was inconstant within maternity services. Most of the equipment we observed
had dated green “I am clean” stickers attached. We checked 39 items of reusable equipment used
for care and treatment of these we found that five items of equipment were not clean. We saw
blood spots and dirt on two items of equipment used in maternity theatres. We raised our concerns
to a shift leader, who took action to ensure the pieces of equipment were cleaned straight away.
Staff in antenatal clinics decontaminated ultrasound probes appropriately between scanning
appointments.

The service mostly had suitable premises and equipment and looked after them.
The maternity service had an antenatal ward, delivery ward and a postnatal ward located off one
corridor. The corridor had secure access with an intercom entry system and closed-circuit
cameras for staff to identify visitors at the point of entry. Two maternity theatres were located
within the delivery ward with a level two neonatal intensive care unit (NICU) located close by. Staff
from the NICU told us they could attend maternity theatres within two minutes to facilitate a
neonatal emergency and transfer.
The midwife led birthing unit (MLBU) was in close proximity to the other maternity wards, with a
separate entrance which was outside the main hospital building. The MLBU had a corridor linked
to the main hospital, however staff restricted internal access to the MLBU from the main hospital
building and only used this access in the event of an emergency transfer.
Maternity services completed daily equipment checks for resuscitation trolleys and other safety
equipment such as but not limited to the fluid warmer in the labour ward. We reviewed records
across all clinical areas and saw that these checks had been fully completed.
The maternity theatres had been refurbished, with a second theatre commissioned prior to our
inspection. This reduced the need for women to be transferred to the main theatre suite for
elective caesarean sections.
Maternity theatres had surgical equipment packs for the procedures they performed. Equipment
packs were sterile and stored appropriately. We checked a selection of these packs and found
these were within their expiry date.
Staff managed single use sterile equipment well. We checked 23 items of single use equipment
and additional equipment within resuscitation trolleys and found each item was within its expiry
date.
The trust told us prior to the inspection they had an equipment management team who co-
ordinated equipment safety testing and servicing. Each item of equipment had an asset label for
staff to ensure that equipment was up-to-date with safety testing and servicing. The maternity
service had the equipment recommended to monitor the health of women and babies in line with
the Safer Childbirth initiative. We reviewed 39 items of equipment used across maternity services
including but not limited to intravenous fluid pumps, fetal heart monitors and anaesthetic
machines. We found that 15 items of equipment were not up-to-date with electrical safety testing.
We raised this issue with the midwife co-ordinator on shift who took immediate action.
Birthing pools were available on the labour ward and the MLBU. The pools had a cleaning
schedule in place. We reviewed the records for the birthing pool on the MLBU and found that
scheduled cleaning had been missed twice from February to March 2019.
Staff did not always store chemicals securely. We found chemicals such as ethyl chloride stored in
three of the labour rooms which were not in secure storage cupboards. Ethyl chloride is for topical
application to control pain associated with injections. We raised our concerns with senior staff,
who took immediate action to remove the chemical from the rooms. We also found the storage of
chemicals such as bleach cleaning solutions in an unsecured dirty utility on Samson ward. This
meant these chemicals could be accessed by people, such as members of the public who were
not authorised to access them.
Maternity wards had processes in place to manage waste effectively. Clinical waste was
appropriately segregated from domestic waste and discarded sharp objects such as syringe
needles were discarded in sharps bins. However, staff did not always label sharps bins with the
date of assembling and clinical location. This meant that the trust was unable to trace the source
location of these sharps bins in the event of an issue.
Community midwifes had sealed delivery packs in their vehicles and a spare pack was kept in a
secured cupboard within community bases. Once the packs had been used, midwifes returned the
packs in a box to the hospital in exchange for a new box with a delivery pack.
Community midwifery staff had systems and process in place to safely dispose of placentas
following home deliveries. Staff sealed placentas in specialised self-sealing buckets for
transportation with the equipment packs. The bucket went for safe incineration unless women had
complications, where placentas required laboratory analysis.

Staff did not always complete and update risk assessments for each patient. They did not
always keep clear records and complete mandatory training necessary to manage risks to
patients.
The trust had an external review following an increase in intrauterine deaths and postnatal baby
deaths. The review identified key themes related to fetal heart rate monitoring, carbon monoxide
monitoring of women during pregnancy and fetal growth charts. The trust had an action plan in
place following the recommendations made following the review.
Maternity services had a telephone line for women to call for advice in the event of concerns or to
alert the service of a women in labour. We observed a member of staff providing advice to a
woman during a telephone call regarding reduced fetal movements. The advice provided did not
reflect national guidance and best practice. We found the guideline for the management of
reduced fetal movements was issued two weeks prior to our inspection. We were concerned that
this guideline was not fully embedded in clinical practice.
Staff did not classify all cardiotocograph traces (CTGs) used to monitor heart rates of babies
before birth when the monitoring was discontinued, staff documented this in women’s records this
was not in line with national guidance. We reviewed eight CTG traces and of these only one had
been classified and documented on the trace by a member of staff. None of the CTG traces were
dated and timed at the beginning and the end of the monitoring phase. This was not in line with
NICE guidance for Intrapartum care quality standard 105, quality statement 3. Interpretation of
CTGs forms part of the clinical decision-making process for the safety of mothers and babies
during labour. We reviewed the fetal monitoring and fetal blood sampling policy which was outside
of the review date of February 2018. One of the matrons we spoke with told us the policy was
under review and the service was changing the way staff classified CTG traces. Staff were
receiving training in the International Federation of Gynaecology and Obstetrics (FIGO)
classification tool; however, this was not supported within the out of date policy accessed by staff.
Staff compliance with adult and child basic life support was below the trust target of 90%.
Midwifery and nursing staff compliance with this training was 77% and medical staff was 66%.
This meant we were not assured that all staff had received training in accordance with the
recommendations set out by the resuscitation council to provide safe care. One of the band seven
midwifes we spoke with told us that all band seven midwives had completed neonatal life support
training and the service was trying to increase the number of midwives with this training.
Maternity services used early warning scores to monitor women and babies for deterioration. The
trust used the national modified obstetric early warning score (MOEWS) for adult patients and
newborn early warning score (NEWS) for babies following delivery. We found variable completion
of early warning scores. We reviewed 12 sets of records and of these we found only three had
been completed fully with the score calculated appropriately.
Medical staff we spoke with told us that consultants attended difficult deliveries to support junior
staff. When called they arrived promptly.
Senior midwives and consultants did not always participate in skills simulation training. The
practice development midwife held weekly interactive training simulations for staff. Staff worked
through simulations with discussions and debriefing following the simulation. Staff we spoke with
told us these sessions were valuable as they covered complex situations not encountered
routinely by staff. Data provided by the trust for midwifery staff showed that 100% of band five,
96% of band six and 85% of band seven staff had completed this training since April 2018.
However only 67% of band eight midwives had participated in this training. We saw that 90% of
junior doctors had completed this training. However, only 54% of consultants had attended this
training.
The hospital had a category two high dependency neonatal unit and had arrangements in place to
transfer babies to another local NHS hospital, in the event that a baby required level 3 high
dependency neonatal care. The trust had arrangements in place to safely transfer babies to a level
three high dependency unit. The trust used the acute neonatal transfer service (ANTS) to support
acutely unwell babies during their transfer to a level three high dependency unit.
Staff undertook risk assessments during pregnancy booking appointment at approximately 10
weeks. These risk assessments included mental health and safeguarding screening. We reviewed
19 pregnancy records and found 17 records contained appropriately completed risk assessments
and the other two were partially completed.
The MLBU had arrangements to transfer women and babies in the event of an emergency or a
deterioration detected during labour. The MLBU was located on the hospital site with access from
the unit to the maternity wards. Staff in the MLBU contacted the senior midwife or pulled the
emergency bell for assistance.
A second on-call midwife was scheduled on all shifts to assist with home births who could collect
additional equipment if required. In the event of a deterioration of health during a home birth,
community midwives called for emergency assistance from the local NHS ambulance service for
an emergency transfer to hospital.
Maternity theatres completed the World Health Organisation (WHO) five steps to safer surgery for
all surgical procedures. We observed staff complete the five stages of the checklist appropriately
in theatre. Maternity services had scored 100% consistently in the monthly WHO five steps to
surgical safety audit from April 2018 to February 2019.
Maternity services had developed Local Safety Standards for Invasive Procedures (LocSSIPs)
following the introduction of National Safety Standards for Invasive Procedures (NatSSIPs). The
LocSSIPs and NatSSIPs were in place to prevent surgical never events. The trust had a local
initiative in place call pause for gauze to ensure all gauze swabs were accounted for before a
surgical wound was closed. We observed this practice in theatres.
Maternity services had a triage helpline, which was answered by midwives on the labour ward.
Staff completed forms which detailed a woman’s name and the nature of the concern which could
range from bleeding, reduced fetal movements or labour. Staff directed women to different areas
of the service for appropriate care.
The service had processes in place to manage occasions where women went into labour whilst
visiting the local area. Staff contacted the booking hospital, completed safeguarding checks
through the national database and completed local documentation including risk assessments.
The maternity service had a process in place to ensure staff completed venous thrombo-embolus
(VTE) risk assessment. Midwives could not administer medicines through the electronic system
unless the VTE risk assess was complete and up-to-date. We observed women who had
caesarean sections had VTE prophylaxis prescribed. Staff used pneumatic compression systems
in theatre to prevent a VTE forming.
The anaesthetist was always present on the delivery ward as maternity theatres were located in
the clinical area. The anaesthetist liaised with critical care to facilitate a transfer if a women’s
condition deteriorated whilst on the maternity wards.
Maternity services had developed a red hat initiative for high risk babies that may require intensive
neonatal support. Staff placed a red hat on the baby following delivery if there were concerns
about their clinical observations following the birth. The use of this system meant midwives
monitored babies with red hats closely on the postnatal ward and babies stayed with their
mothers. This initiative had reduced the number of unplanned admissions to the neonatal intensive
care unit.
Maternity services completed 76% of booking appointments with risk assessments such as blood
tests and carbon monoxide testing between eight and 10 weeks gestation. Following risk
assessments women were streamed either to midwife led care or transferred to consultant led
care. One of the community midwives we spoke with told us that they had access to a consultant
for additional support where there were changes to pregnancy associated risks.
Community midwifes, and hospital teams could refer women with mental health concerns to the
local mental health team. The local mental health trust had a mother and baby unit to treat
conditions such as postnatal psychosis.
Midwifery and nurse staffing

The service mostly had enough midwifery staff with the right qualifications, skills, training
and experience to keep people safe from avoidable harm and to provide the right care and
treatment.
The maternity service used a nationally recognised tool to plan midwifery staffing for each clinical
area. The tool was used to calculate the individual ratio of clinical midwives to births for maternity
services. Maternity services did not meet the regional target for their midwife to birth ratio. The
midwife to birth ratio was one whole time equivalent (WTE) midwife to 30 births consistently every
month from April 2018 to March 2019. However, the regional target was one WTE midwife to 28
births.
The trust had commissioned an external team to conduct a staffing review, midwifery staffing data
was collected staff in December 2018 and January 2019. However, the senior leadership team for
maternity services had not received the information related to the staffing review at the time of our
inspection.
Staff held multidisciplinary team (MDT) safety huddles attended by midwives, doctors, theatre staff
and anaesthetists to review and discuss women on the labour ward. We attended the labour ward
on a Thursday morning to observe the safety huddle and staff told us that the safety huddle did not
take place on Thursdays due to doctor training or at weekends. We raised concerns with the trust,
that the safety huddle did not take place every day. During our unannounced inspection maternity
services had implemented a daily MDT safety huddle and recorded when these did not take place
and the reason.
The trust board minutes for January 2019 showed that the shift fill rate for registered midwives on
the labour ward was 81.9% in December 2018. The records also showed that the shift fill rates for
maternity care assistants was lower than 82% for all maternity wards and units. The trust reported
they mitigated low staffing levels by moving staff to the areas with the highest acuity. Each ward
and clinic area we visited displayed the number and skill mix of staff on duty for the day.
We conducted an unannounced inspection on 9 April 2019 and found that maternity ward staff
was lower than planned. Due to the low staffing level the MLBU unit had mitigated staffing level
risks by closing overnight.
Planned vs actual
Princess Alexandra Hospital reported the following whole time equivalent (WTE) qualified
nursing and midwifery staff numbers for the maternity core service as of March and October
2018:

Ante-natal clinic 4.9 4.2 116% 4.9 4.2 116%
Birthing unit 3.6 7.8 46.4% 2.6 7.8 33.7%
Chamberlen Ward 8.1 9.2 87.6% 7.7 9.2 83.2%
Community specialist
1.9 1 186.7% 1.9 1 186.7%
midwives
Harlow team (community
8.8 9.8 90.1% 8.6 9.8 88%
midwives)
Harlow teenage
pregnancy team 1 1 100% 1 1 100%
(community midwives)
Labour ward 11 16.7 66.3% 16.4 16.7 98.7%
Maternity nurses 4.4 6 73.1% 2.8 6 46.4%
Midwives (Princess
83.4 38.8 214.8% 78.6 38.8 202.5%
Alexandra Hospital)
Samson Ward 7.9 9.7 82.1% 7.4 9.7 76.3%
Village team (community
3.6 21.7 16.4% 2.8 21.7 12.7%
midwives)
Total 138.6 125.9 110.1% 134.7 125.9 107%
As of October 2018, the qualified nursing and midwifery staffing fill rate within maternity at
Princess Alexandra Hospital was 107%, indicating the service was over-established. This was
similar to the fill rate as of March 2018 of 110.1%. This reflected the development of unfunded
specialist posts in year in line with national best practice and service developments
In October 2018, three of the 11 qualified nursing and midwifery teams listed were over
established. However, care should be taken when interpreting staffing rates due to small
numbers of staff in some teams.
Vacancy rates
-3.3% for qualified nursing and midwifery staff in maternity, indicating the service was slightly
over-established. This was lower than the trust target of 8%.
A breakdown of vacancy rates by ward is below. Seven teams had rates above the 8% target
while three teams were over-established. However, care should be taken when interpreting
staffing rates due to small numbers of staff in some teams.

Village team (community midwives) 83.7%
Birthing unit 58.9%
Maternity nurses 42.4%
Labour ward 31.3%
Samson Ward 21.3%
Chamberlen Ward 17%
Harlow team (community midwives) 11.1%
Harlow teenage pregnancy team (community midwives) 3.3%
Ante-natal clinic -16%
Community specialist midwives -83.3%
Midwives (Princess Alexandra Hospital) -112.6%
The senior leadership team for maternity services told us they were awaiting the external staffing
review data to identify the number of staff required to safely staff the maternity service. They felt
that staffing requirements would vary slightly following the review. One of the clinic managers we
spoke with told us that antenatal clinics had a shortage of one whole time equivalent registered
midwife and one maternity health care assistant. The clinic manager told us they had escalated
the staff shortage to the department matron.
Turnover rates
12.2% for qualified nursing and midwifery staff in maternity. This was slightly higher than the
trust target of 12%.
A breakdown of turnover rates by ward is below. Four teams had annual turnover rates above
the 12% target.

Birthing unit 33.7%
Chamberlen Ward 18.6%
Midwives (Princess Alexandra Hospital) 12.9%
Samson Ward 10.3%
Ante-natal clinic 0%
Community specialist midwives 0%
Harlow teenage pregnancy team (community midwives) 0%
Labour ward 0%
Sickness rates
5.2% for qualified nursing and midwifery staff in maternity. This was higher than the trust target of
3.5%.
A breakdown of sickness rates by ward for each site is below. Eight teams had annual sickness
rates above the 3.5% target.

Birthing unit 25.9%
Samson Ward 11.2%
Chamberlen Ward 7.3%
Labour ward 4.8%
Midwives (Princess Alexandra Hospital) 4.1%
Ante-natal clinic 3.9%
Harlow teenage pregnancy team (community midwives) 0.2%
Community specialist midwife 0.1%
Reports submitted to the trust board in January 2019, stated that sickness and maternity leave
within the maternity service was improving. The trust reported that matrons and human resources
had undertaken formal meetings with staff regarding sickness absences. The senior leadership
team for maternity services told us that staff with persistent sickness absence was addressed by
line managers through the trust’s formal process.
The table below shows the numbers of nursing and midwifery hours in maternity at Princess
Alexandra Hospital from December 2017 to November 2018 that were covered by bank and
agency qualified nursing and midwifery staff or left unfilled.
Over this time, 12,425.1 working hours were filled by bank staff and 112 were covered by agency
staff to cover sickness, absence or vacancy for qualified nursing and midwifery staff. There
were 3,456.4 hours that were unable to be filled by either bank or agency staff to cover sickness,
absence or vacancy for qualified nursing and midwifery staff.
Over the same time, 4,978.1 working hours were filled by bank staff and no hours were covered
by agency staff to cover sickness, absence or vacancy for non-qualified nursing and midwifery
staff. There were 3,105.2 hours that were unable to be filled by either bank or agency staff to
cover sickness, absence or vacancy for non-qualified nursing and midwifery staff.
Staff group December 2017 to November 2018
Not filled by bank or
Bank usage Agency usage
agency
Hours Hours Hours
Qualified staff 12,425.1 112 3,456.4
Non-qualified staff 4,978.1 0 3,105.2
All nursing and midwifery staff 17,403.2 112 6,561.6
Medical staffing
The service had enough medical staff with the right qualifications, skills, training and
experience to keep people safe from avoidable harm and to provide the right care and
treatment.
Consultant staffing was in line with safer childbirth recommendation for consultant working hours
and the number of deliveries. Consultants were on the hospital site between the hours on 8am
and 8:30pm Monday to Friday with a consultant on call outside these hours. At weekends a
consultant was available on site for five hours each day and on-call off site for the rest of the time.
One of the consultants we spoke with told us that consultants had one on-call shift every 11 days.
The rota was adjusted to ensure weekday and weekend on-call shift did not fall together to prevent
fatigue.
A middle grade doctor and a junior grade doctor always covered the night shift to ensure the
labour ward had access to a doctor. Middle grade and junior doctors always had access to support
from a consultant either on an on-call basis or on site.
Planned vs actual
Princess Alexandra Hospital reported the following whole time equivalent (WTE) medical staff
numbers for maternity and gynaecology as of March and October 2018. All the staff were within
the trust’s women’s health team.

Women’s health 26.9 29.6 90.7% 23.1 29.6 78.1%
As of October 2018, the medical staffing fill rate within women’s health at Princess Alexandra
Hospital was 78.1%, with a deficit of 6.5 WTE staff. This was a decrease from the fill rate as of
March 2018 of 90.7%.
Vacancy rates
13.8% for medical staff in maternity and gynaecology. This was higher than the trust target of
8%. All the staff were within the trust’s women’s health team.
Turnover rates
12%. However, it should be noted that this related to only four members of staffing leaving the
team. All the staff were within the trust’s women’s health team.
The trust reported that their turnover data for medical staff did not include deanery trainee grades.
Sickness rates
3.5%. All the staff were within the trust’s women’s health team.
The table below shows the numbers of medical hours in maternity and gynaecology at Princess
Alexandra Hospital from December 2017 to November 2018 that were covered by medical bank
and locum staff or left unfilled.

Hours Hours
Princess Alexandra Hospital 2,500.5 3,456
We spoke with one locum consultant during our inspection and they told they had been
supported well by other consultants. They had worked for the trust as a registrar they knew the
hospital and the systems at the start of the locum post. Junior doctors we spoke with told us that
senior staff including consultants were supportive and they were not expected to work over their
scheduled hours.
Staffing skill mix
In November 2018, the proportion of consultant staff reported to be working in the trust’s
maternity and gynaecology services was slightly lower than the England average and the
proportion of junior (foundation year 1-2) staff was lower than the England average.
Staffing skill mix for the 26.7 whole time equivalent staff working in maternity at The
Princess Alexandra Hospital NHS Trust.
This England
Trust average
Consultant 38% 41%
Junior* 0% 6%
Doctors in training were expected to submit exception reports electronically if they worked beyond
their contracted hours, missed breaks, had insufficient support or were unable to attend
educational opportunities. The annual report on safe working hours for doctors and dentists in
training presented to the trust board in January showed that exception reports were not submitted
on 17 occasions for obstetrics and gynaecology from October 2017 to September 2018.
Records
Staff did not always keep detailed records of woman’s care and treatment. Records did not
always contain information such as completed fetal growth charts and records were not
always signed and dated by a responsible clinician.
Staff did not always complete woman’s records in line with trust policy and national guidance. We
found CTG traces were not signed and dated at the beginning and at the end of the of the
monitoring phase. The CTGs were not classified on the trace although this was evident in the
written record. This could cause issues if more than one CTG trace had been conducted without
dates and time to provide an accurate audit trail.
Staff did not always complete early warning scores appropriately. We found variable completion of
early warning scores for women and their babies. we reviewed 12 records and of these we found
only three had been completed fully with the score calculated appropriately both for mothers and
babies. We escalated our concerns with senior staff about the completion of the early warning
scores.
We reviewed 19 sets of hand-held records and none had a named midwife or consultant identified,
only 11 records were signed and dated correctly. Fetal growth charts and carbon monoxide levels
were not always recorded at every contact which formed part of the trust action plan following their
thematic review of serious incidents.
An external review following an increase in intrauterine and postnatal baby deaths found that staff
had not routinely documented measured fetal growth during routine antenatal appointments which
may have detected decreased fetal growth. Staff we spoke with told us that community midwifery
service had experienced issues obtaining growth charts to plot fundal height. We reviewed 19
hand held maternity records and of these 15 did not have completed growth charts. We were
concerned that the learning following serious incidents had not been embedded. Senior staff we
spoke with told us that fetal growth charts were not part of women’s handheld maternity records
and required an additional paper insert which often got separated from the main booklet. We
escalated our concerns about the use of growth chart with the trust. A new booklet with fetal
growth charts included was being printed at the time of our inspection.
Maternity services used a combination of electronic and paper based handheld records. Women
kept paper based handheld records which did not contain all information about the pregnancy. An
example of this was carbon monoxide readings as some staff completed these readings
electronically. This meant that information from two records sources were required to effectively
care for and treat women. We requested the medical record audit results following our inspection
and these were not supplied. Therefore, we were not assured that maternity records provided all
information to staff in a timely way.
Staff completed entries in a handheld red book following the birth of a baby which contained
information about baby such as birth weight, head circumference and baby length. The red book is
a record of baby and child development held by parents which midwifery staff, GPs and health
visitors recorded relevant information at each appointment. We saw staff completing this
information in the labour ward before hand over to the postnatal ward.
Staff completed a discharged letter for all women discharged from the maternity service. These
letters were sent electronically to the named GP of women which detailed the care they received
during their admission. Staff completed an electronic assessment following the birth of a baby
which generated an NHS number for the baby with the baby name assigned at the registration of
the birth. This meant that babies could access care from the mother’s GP prior to the registration
of the birth.
Medicines
The service did not always follow best practice when prescribing, giving, recording and
storing medicines. Medicines were not always stored securely on the labour ward.
Staff stored medicines such as intravenous fluids and lignocaine in labour rooms in unlocked
cupboards. We observed three labour rooms on the labour ward and found unsecured medicines
in each of the rooms. This meant that these medicines could have been accessed by unauthorised
people. We raise our concerns with a senior member of staff who informed us that this practice
was custom and practice and responded immediately and removed the items from all or the labour
rooms.
Maternity theatres had a fluid warmer in the main corridor of the labour ward. Staff had left a
sticker with the access code for the lock on the top surface of the fluid warmer. This meant that
members of the public could access the intravenous fluid inside. We raised our concerns with staff
and this sticker with the access code was removed.
Controlled drugs (CDs) are prescription medicines controlled under the Misuse of Drugs legislation
such as morphine. Maternity services stored CDs in line with legislation within a wall mounted
metal cupboard. Our check of five CDs found the CD stock matched the reconciliation records. We
reviewed reconciliation records within maternity theatres and Samson ward and found that CD
medicine reconciliation had taken place daily and the stock matched the records. Reconciliation
records showed that two members of staff had signed out CDs.
Medicines were stored within clean secure storage areas. We reviewed 39 medicines and found
these to be within their expiry dates and stored in line with manufacturers recommendations.
Maternity staff completed fridge temperature checks daily. We reviewed fridge temperature
records in all clinical areas we visited, and these demonstrated that checks had taken place.
Staff used paper based and electronic prescribing records. Chamberlen and Samson wards used
electronic prescription records, whilst the labour ward and MLBU used paper-based records. We
reviewed three electronic medicine prescribing and administration records which showed staff had
completed information such as allergies and sensitivities appropriately and medicines had been
administered as they had been prescribed. We reviewed five paper-based prescription records of
these records we found that three records were completed fully with the necessary patient
information such as weight, name and date of birth. Staff had not recorded the woman’s weight in
two of the records which was required to accurately prescribe VTE prophylaxis.
Community midwives made arrangements with the women’s GP to prescribe medicines required
for a home birth to be available in the home prior to their due date. Women collected these
medicines from a local pharmacy. Additional medicines where stored in secured fridge within
midwifery bases in the event further medicines were required. Community midwives carried
Entonox (gas and air) used for pain relief and returned the cylinders to the hospital after a home
birth in exchange for full cylinders. A second on-call midwife could collect additional medicines or
medical gases from the base if they were required.
Incidents
The service had processes in place to manage women and baby safety incidents. Staff
recognised incidents and reported them appropriately. Managers mostly investigated
incidents and share lessons learned with the whole team and the wider service. Managers
mostly identified when things went wrong, to ensure staff apologised and gave women
honest information and suitable support.
The trust had an incident management policy and procedure and staff could access this through
the trust’s intranet.
Staff we spoke with, knew how to report incidents and near miss events and were able to give
examples of the types of incidents they would report. Incidents were reported through the trust’s
electronic reporting system. Staff had the opportunity to request feedback on the incident reporting
system at the time of raising an incident.
At the time of our inspection, the trust had identified a backlog of incidents that remained open
trust wide on the trust’s electronic reporting system. This had been reported at the March 2019
patient safety and quality committee. Of these incidents, 389 belonged to maternity, 297 of these
incidents were being reviewed and 92 incidents were awaiting a review. This meant that during the
delay of incidents being fully reviewed, there may have been incidents that required immediate
actions to mitigate them happening again.
Maternity services had a team of midwives that reviewed women and baby safety and quality
incidents. The team observed all reported incidents from Monday to Friday. They allocated no
harm and low harm incidents to a manager to be reviewed. Incidents assessed as moderate harm
or above triggered the duty of candour process and a medical debrief such as post-partum
haemorrhage and unexpected admissions to the neonatal unit. A lead investigator completed a
root cause analysis for these incidents which was reviewed by the triumvirate and the central
safety and quality committee for sign off. All managers involved with incident investigations had
received training in the completion of root cause analysis investigations.
Staff we spoke with understood their responsibilities in relation to the duty of candour. Senior staff
we spoke with explained that they provided support for women during the duty of candour process,
an example of this was consultants completing duty of candour following a post-partum
haemorrhage. Duty of candour is a regulatory duty that relates to openness and transparency and
requires providers of health and social care services to notify women (or other relevant persons) of
certain ‘notifiable safety incidents’ and provide reasonable support to that person.
Leaning from incidents was shared within the Monday message bulletin emailed to all staff
employed by the family and women’s service including community midwives. Learning from
incidents was also shared within safety huddles and team meetings.
Never events
never event.
From February 2018 to January 2019, Princess Alexandra Hospital reported no never events for
maternity.
The trust had a process to review incidents that were deemed to meet the serious incident
threshold. Incidents that were considered as a serious incident were discussed and reviewed by
the multidisciplinary team and taken to the oversight and serious incident group meeting for
agreement. This meeting was chaired by the director of nursing and midwifery or the chief
medical officer. The oversight and serious incident group met daily Monday to Friday.
In accordance with the Serious Incident Framework 2015, Princess Alexandra Hospital
reported eight serious incidents (SIs) in maternity which met the reporting criteria set by NHS
England from February 2018 to January 2019.
A breakdown of the incident types reported is in the table below:
Incident type Number of incidents Percentage of total

Maternity/obstetric incident: mother and baby
4 50%
(this includes foetus, neonate and infant)
Maternity/obstetric incident: baby only (this
3 37.5%
includes foetus, neonate and infant)
Maternity/obstetric incident: mother only 1 12.5%
Total 8 100%
The trust’s safety committee had escalated concerns about the increased numbers of stillbirths
and perinatal deaths to the trust board in February 2019. We reviewed the trust board minutes
which demonstrated the safety committee had requested an external review of these incidents for
transparency and learning. In order to be open and ensure transparency and learning the senior
maternity team requested an external review be conducted of the notes following an increase in
deaths reported in August 2018. In December 2018 the senior maternity team, in conjunction with
the chief medical officer and director of nursing, requested a review of the previous 13 months and
approached NHSI for the external review. The trust had responded positively to the
recommendations of the external review. Staff we spoke with told us about learning from previous
serious incidents and told us about the ‘fresh ears’ initiative when using a sonic aid, to listen to the
fetal heart, a second midwife listens to the fetal heart during labour to ensure the correct
assessment has been made.
In 2018, the trust noted a slight increase in the number of babies who had died and undertook an
in-depth review and look at the individual details. This review was completed by NHS
Improvement and maternity experts from other hospital trusts. We reviewed three serious incident
reports for serious incidents where the trust identified learning and action plans were in place. The
serious incidents had been reviewed by a multidisciplinary team with a full root cause analysis,
learning identified and action plans. An external thematic review of eight serious incidents
identified additional learning and we saw that the trust had an action plan in place to address the
actions required to prevent similar incidents. The action plan included 14 action points, nine of
these were changes to process such as the implementation fetal growth charts, new paper records
were being printed at the time of the inspection to include fetal growth charts. We saw three action
points for staff education such as a revised guideline for reduced fetal movements. The trust had
completed this action in March 2019. The other two action points related to medical staffing which
included staffing of the second maternity theatre 24 hours a day seven day a week. The trust was
in the process of developing a business case for this.
The service held monthly morbidity and mortality meetings to discuss complex cases. We
reviewed the meeting minutes for meetings held in December 2018, January and March 2019. The
minutes demonstrated that staff had presented cases for discussion and learning. We saw a
register of attendance was noted but not included in the minutes which meant we could not identify
the grade and designation of the staff in attendance, to see if all staff type and grades attended
these meetings. The trust provided data for peri-natal deaths to MBRRACE.
Safety thermometer
The service used safety monitoring results. Staff collected safety information but did not
shared it women and visitors.
Samson ward (postnatal) collected safety thermometer information every month, however this
information was not displayed on the ward for women and visitors. One of the midwifery matrons
we spoke with told us that the information collected for the maternity safety thermometer was
complex and more difficult to display in a meaningful way. The ward was in the process of
exploring ways to display the safety thermometer information in way women and visitors could
easily understand.
Managers shared safety thermometer information with staff electronically and formed part of the
Monday message circulated to all staff.

The service did not always provide care and treatment based on national guidance and
evidence of its effectiveness. Managers did not always check to make sure staff followed
guidance.
Maternity care was not always delivered in line with evidenced based practice and national
guidance. We found the service did not follow National Institute for Health and Care Excellence
(NICE) guidance for the prevention of surgical site infections in relation to infection prevention
practices in theatres. Staff did not always provide the information and classify CTG monitoring
readings recommended in accordance with NICE intrapartum care guidance.
Staff did not always complete fetal growth charts at every appointment in line with NHS England
saving babies lives care bundle. Maternity services used population based fetal growth charts
rather than the customised growth charts advised by national guidance. We spoke with the clinical
lead for maternity who told us that, the trust’s obstetric consultants had made a conscious decision
not to use the customised growth charts as there was limited evidence to support their use instead
of population based growth charts.
The trust had processes in place to provide advice and assessments for women experiencing
reduced fetal movements. The guideline had been updated following a review of the cluster of
serious incidents in 2018. We reviewed the guideline which included national best practice
guidance, however, we were not assured that this had been reviewed in a timely manner, as staff
told us that this had been launched two weeks before our inspection. Although we overheard
advice given by a member of staff to a woman on the telephone which was not best practice, the
woman was transferred to have a full assessment. We escalated our concerns to the senior
leadership team who assured us that they would ensure that all staff were aware of the guidance
and correct advice to give to women.
The trust had a variety of policy and guideline documents that staff could access through the
trust’s intranet. We reviewed policies and guidelines such as but not limited to, ‘management of
weight loss in the new born guideline’, ‘trust uniform and dress policy’ and ‘deteriorating patient
policy’. Most guidance and policy documents were within their review date and referenced relevant
legislation, national guidance and best practice. However, we found the fetal monitoring and fetal
blood sampling guideline review date was February 2018.
Staff monitored women with mental health concerns appropriately and had a team of specialist
safeguarding midwives that led on the care of women with mental health concerns following
screening at the booking appointment.
Maternity services completed a monthly audit programme to monitor staff compliance with trust
policies. Clinical areas completed audits such as hand hygiene, equipment checking and record
keeping. We saw most of this audit information displayed on a board visible to staff, women and
the public.
The trust provided data for national audits such as MBRRACE, National Maternity and Perinatal
Audit Programme and Standardised Caesarean section rates and modes of delivery to monitor the
outcomes of women and babies. This provided the trust with information in order to compare their
performance against other similar NHS trusts.
Maternity services had a performance dashboard to monitor their progress with local audits and
key performance indicators set out by the trust’s commissioners. The service measured their
performance against national and regional targets. We saw the 100% of women had one to one
care from midwives during labour from April 2018 to February 2019.

Staff gave women enough food and drink to meet their needs and improve their health. The
service made adjustments for women’s religious, cultural and other preferences.
Maternity wards provided three meals a day for women with a range of menu choices. The trust
catered for women’s individual needs such as food sensitivities or allergies alongside cultural and
religious beliefs.
Women awaiting caesarean section deliveries were fasted pre-operatively in line with national
guidance and had access to sips of water to moisten their mouth. We saw an anaesthetist provide
sips of water to a woman in theatre once a spinal anaesthetic was effective, which provided
comfort to the woman from a dry mouth.
Staff could refer women to dieticians and the diabetes specialists to provide additional support with
dietary needs if required.
Women had access to water at their bedside except if they were awaiting surgery. Staff ensured
women remained hydrated while awaiting surgery with the use of intravenous fluids. Staff provided
regular hot drinks for women.
Women we spoke with told us that food was generally of a good standard and met their needs.
However, one woman we spoke with told us she felt hungry because she had not eaten a meal
except toast since a caesarean section birth the day before as she missed the evening meal.
Maternity services had milk kitchens on the Samson Ward and the midwife led birthing unit
(MLBU) for the storage of expressed breast milk and formula milk. The kitchens had unlocked
fridges with labelled breast milk which meant that it could be tampered with.
Staff ensured women had the information to make an informed choice on infant feeding. Women
we spoke with told us that staff had provided support with breast feeding and had not felt
pressurised. We observed poster with information about breast feeding and how women could
access additional support with breast feeding. Maternity services had UNICEF baby friendly
accreditation since 2013. The UNICEF baby friendly standards enable staff to support families with
feeding and to help parents build a close and loving relationship with their baby.
Pain relief
Staff assessed and monitored women regularly to see if they were in pain. They supported
those unable to communicate using suitable assessment tools and gave additional pain
relief to ease pain.
Women had access to a variety of pain relief during their labour such as pain-relieving opioid
injections, Entonox (gas and air) and if requested an epidural. Staff discussed appropriate pain
relief dependent on the stage of labour. The delivery ward and MLBU had facilities for water births
which can reduce the need for additional pain relief.
The labour ward had access to an anaesthetist 24 hours a day, seven day a week to provide pain
relief such as an epidural. The service did not audit the time from a request for an epidural to
women receiving one.
We reviewed 12 sets of women’s records of women following labour of these, 10 records
evidenced regular pain monitoring and the provision of adequate pain relief. Midwives could
administer pain relief via a patient group directive (PGD) to ensure women received timely pain
relief. A PGD allows some registered health professionals to supply and/or administer specified
medicines to a pre-defined group of patients, without them having to see a prescriber (such as a
doctor or nurse prescriber).
The pain assessment tool used a number scale of one to ten for pain assessment. The pain
assessment did not include a visual pain assessment for women with communication difficulties.
Patient outcomes
Managers monitored the effectiveness of care and treatment and used the findings to
improve them. They compared local results with those of other services to learn from them.
The maternity service had key performance indicators for antenatal screening, the lower threshold
was 95% with the aim to achieve 99% screening of all eligible women. The service met all
screening at the lower threshold and achieved the 99% target for antenatal screening from April to
December 2018.
The trust performed well against the England average for the readmission of women within 30
days of discharge. The readmission rate for maternity services was 1.8% compared with the
England average of 2.1%. The trust met the regional target of 1.9% readmission rate which formed
part of the service key performance indicators.
The trust had an action log to improve the continuity of care in midwifery services and the better
births 2016 guidance. We reviewed the action log which showed actions had been completed and
the trust had an action plan in place with six out of twelve actions incomplete. At the regional
continuity of care task and finish group held in September 2018, the action log noted that the trust
had not made sufficient progress with continuity of care for women. Community midwives we
spoke with told us that they were mostly meeting the continuity of care initiative as they worked
within small teams and women saw the same two midwives during their pregnancy.
We requested the trust’s maternal and neonatal health safety collaborative action plan, which was
not supplied. We reviewed progress reports for maternity services which reported a modest
improvement against the actions in place for February and March 2019, but we were unable to
ascertain the trusts progress with the whole action plan.
National Neonatal Audit Programme
Neonatal Audit Programme against measures related to maternity care.

Are all mothers who deliver
babies from 24 to 34 weeks
gestation inclusive given any
dose of antenatal steroids? Within expected
(Antenatal steroids reliably reduce
87.5%
range ✓
the chance of babies developing
respiratory distress syndrome and
other complications of prematurity)
Are mothers who deliver babies
below 30 weeks gestation given
magnesium sulphate in the 24
hours prior to delivery?
No current
(Administering intravenous 60.4% Similar
standard
magnesium to women who are at
risk of delivering a preterm baby
reduces the chance that the baby
will later develop cerebral palsy)
(Source: National Neonatal Audit Programme)
The trust met the national standard for mothers given a dose of antenatal steroids when babies
were delivered from 24 to 34 weeks. The trust had a similar rate of mothers given magnesium
sulphate in the 24 hours prior to delivery below 30 weeks gestation to other trusts.
National Maternity and Perinatal Audit Programme
Maternity and Perinatal Audit Programme against measures related to maternity care. The trust
only submitted data for two metrics.

Trust-level case ascertainment
(Proportion of eligible cases included in the 87.6% n/a 
audit)
Antenatal measures (before birth, during or relating to pregnancy)
Case-mix adjusted proportion of small-
for-gestational-age babies (birthweight
below 10th centile) who are not delivered
No data No current
before their due date n/a
available standard
(Babies who are small for their age at birth
are at increased risk of problems before,
during and after birth)
Intra-partum measures (during labour and birth)
Case-mix adjusted proportion of elective
deliveries (caesarean or induction)
No data No current
between 37 and 39 weeks with no n/a
available standard
documented clinical indication for early
delivery
(For babies with a planned (or elective) birth,
being born before 39 weeks is associated
with an increased risk of breathing problems.
This can lead to admission to the neonatal
unit. There is also an association with long
term health and behaviour problems)
Case-mix adjusted overall caesarean
section rate for single, term babies
(The overall caesarean section rate is No data No current
n/a
adjusted to take into account differences available standard
which may be related to the profile of women
delivering at the hospital)
Case-mix adjusted proportion of single,
term infants with a 5-minute Apgar score
of less than 7
(The Apgar score is used to summarise the
condition of a newborn baby; it is not always No data No current
n/a
a direct consequence of care given to the available standard
mother during pregnancy and birth, however
a 5 minute Apgar score of less than 7 has
been associated with an increased risk of
problems for the baby)
Case-mix adjusted proportion of vaginal
births with a 3rd or 4th degree perineal tear
(Third or fourth degree tears are a major
No data No current
complication of vaginal birth. Only tears that n/a
available standard
are recognised are counted therefore a low
rate may represent under-recognition as well
as possible good practice)
Case-mix adjusted proportion of women
with severe post partum haemorrhage of
greater than or equal to 1500 ml
(Haemorrhage after birth is a major source of
No data No current
ill health after childbirth. Blood loss may be n/a
available standard
estimated by visual recognition or by
weighing lost blood. High rates may be due
to more accurate estimation and low rates
due to under recognition)
Post-partum measures (following birth)
Proportion of live born babies who
received breast milk for the first feed and
at discharge from the maternity unit Middle 50% of No current
74.6%
(Breastfeeding is associated with significant units standard
benefits for mothers and babies. Higher
values represent better performance)
(Source: National Maternity and Perinatal Audit Programme)
The trust did not meet the target for eligible case reviews and only submitted data for breast
feeding. The trust was in the middle 50% of maternity units for the measure of the proportion of
babies receiving breast milk as their first feed.
Standardised Caesarean section rates and modes of delivery
From July 2017 to June 2018, the trust’s elective, emergency and total caesarean section rates
were as expected when compared to England.
Standardised caesarean section rate (July 2017 to June 2018)
England The Princess Alexandra Hospital NHS Trust

Type of
caesarean Caesarean Caesareans Caesarean Standardised National
rate (n) rate Ratio comparison
Elective Similar to
12.6% 444 12.9% 100.1 (z=0)
caesareans expected
Emergency (z=- Similar to
16.2% 536 15.6% 96
caesareans 0.3) expected
Total (z=- Similar to
28.7% 980 28.5% 97.8
caesareans 0.3) expected
Notes: Standardisation is carried out to adjust for the age profile of women delivering at the trust and
for the proportion of privately funded deliveries.
Delivery methods are derived from the primary procedure code within a delivery episode.
This table includes all deliveries, including where the delivery method is 'other' or 'unrecorded'.
In relation to other modes of delivery, from July 2017 to June 2018, the table below shows the
proportions of deliveries recorded by method in comparison to the England average. The
proportions at the trust were similar to the England averages.
Proportions of deliveries by recorded delivery method (July 2017 to June 2018)

The Princess Alexandra England
Hospital NHS Trust
Delivery method
Total caesarean sections1 980 28.5% 28.7%

Instrumental deliveries2 341 9.9% 12.3%
Non-interventional deliveries3 2,114 61.5% 59%
100%
Total deliveries 3,435 100%
(n=592,252)
Notes: This table does not include deliveries where delivery method is 'other' or 'unrecorded'.
1Includes elective and emergency caesareans
2Includes forceps and ventouse (vacuum) deliveries
3Includes breech and vaginal (non-assisted) deliveries
(Source: Hospital Episodes Statistics (HES))
Maternity active outlier alerts
As of February 2018, the trust had no active maternity outliers.
(Source: Hospital Evidence Statistics (HES))
MBRRACE-UK Perinatal Mortality Surveillance Report
The table below summarises The Princess Alexandra Hospital NHS Trust’s performance in the
2018 MBRRACE-UK Perinatal Mortality Surveillance Report for births in 2016.
Comparison to
other trusts
Metrics Trust Meets national
with similar
(Audit measures) performance standard?
service
provision
Stabilised and risk-adjusted
perinatal mortality rate
(The death of a baby in the time
Up to 10%
period before, during or shortly after
lower than the
birth is a devastating outcome for No current
4.67 average for the
families. There is evidence that the standard
comparator
UK’s death rate varies across
group
regions, even after taking into
account differences in poverty,
ethnicity and the age of the mother.)
(Source: MBRRACE-UK)
The trust performed below similar trusts for the stabilised risk adjusted perinatal mortality rate. The
service had eight intrapartum and neonatal deaths that had been identified through a retrospective
review completed by the hospital extending back over 13 months. The trust initiated an external
thematic review of these deaths and had an action plan in place.
In 2018, the trust noted a slight increase in the number of babies who had died and undertook an
in-depth review and look at the individual details. This review was completed by NHS
Improvement and maternity experts from other hospital trusts.
The service had made improvements to the number of women who had booked blood test
screening between eight and 10 weeks gestation. The antenatal co-ordinator told us that audits
had shown the screening rates had improved from 28% to 79%. The maternity dashboard showed
that over 81% of women had a booking appointment by 12 weeks and six days gestation.
Competent staff
The service mostly made sure staff were competent for their roles. Managers appraised
staff’s work performance to provide support and monitor the effectiveness of the service.
Staff mostly had the skills and competencies required for their role.
The service did not have robust processes in place to ensure staff had completed competencies to
recover women following surgery or caesarean sections in maternity theatres. We observed a staff
member caring for women in the maternity recovery area that had not completed their recovery
competencies. We spoke with one of the coordinators on the labour ward who told us they
assumed that registered nurses employed on the unit had these competencies and did not know if
there was an assurance process to check if staff were competent to work in the recovery role. This
meant we were not assured that all staff were competent to carry out their roles.
We requested information about the number of staff with theatre scrub and recovery competencies
and how the service ensured staff members with these competencies were available for each shift.
The trust told us, senior midwives (labour ward coordinators, and senior band 6 midwives), were
trained and assessed as competent in both scrub and recovery roles. Six WTE maternity nurses
were also recruited to work in these roles which facilitated a minimum of one member of staff on
each shift who is competent in scrub and recovery. All labour ward coordinators were competent in
in scrub and recovery to mitigate risks such as sickness absence or a vacancy.
The trust had a corporate induction in place and local inductions for individual clinical services.
Newly recruited staff we spoke with told us that the induction process was good, and the team was
supportive.
Maternity services provided development opportunities for staff. The trust had four registered
nurses on a midwifery training programme provided in conjunction with a local university. The
service also provided professional development for registered midwives where staff could access
postgraduate courses through local universities.
Hospital midwifery staff rotated within the hospital maternity wards and the MLBU to maintain
competencies. However, staff we spoke with told us that community midwives did not routinely
rotate within the hospital.
Appraisal rates
services. As a result, they were unable to split medical staff into the individual core services.
From April to October 2018, 78.2% of staff within maternity (and gynaecology) at Princess
Alexandra Hospital received an appraisal, compared to a trust target of 90%.

Staff group
Appraisals Eligible Completion Trust Met
required staff rate target (Yes / No)
Support to doctors and 36 53 67.9% 90% No
nursing staff
Total 161 206 78.2% 90% No
All of the medical staff working across both maternity and gynaecology had received an
appraisal. However, the appraisal completion rate for qualified nursing and midwifery staff was
79.9%, which was below the 90% target.
On inspection, we found that the appraisal completion rate for midwifery and nursing staff had
improved since October 2018. The appraisal completion rate on Samson was 95% and 96% on
the labour ward. Staff we spoke with told us they had completed the appraisal process within the
last 12 months and had clear goals and objectives in place.
Staff of different kinds worked together as a team to benefit women and babies. Doctors,
midwives and other healthcare professionals supported each other to provide co-ordinated
care.
Doctors, midwives, nurses and support staff worked well together to provide care to women and
their babies. Ward handovers we observed between staff and teams were appropriate and
relevant information was shared to provide a safe transfer of care to staff on the next shift.
Maternity wards did not have access to a dedicated maternity physiotherapist, staff could refer to
the physiotherapy department if required.
The service had processes in place to share information with GPs and health visitors. GPs
received discharge summaries for women and babies, which detailed the care and treatment
provided by the hospital. Health visitors received a handover of a woman and baby’s care once
the midwifery services completed discharge arrangements.
Midwifery services had systems and process in place to share safeguarding concerns with other
service provider. Staff maintained links with local safeguarding services and shared information
about any safeguarding concerns across local services including the local authority.
Doctors, midwives and theatre staff worked well together and were respectful of each role staff
had within theatres to provide co-ordinated care to women and their partners.
Seven-day services
Maternity services were available to women 24 hours a day, seven days a week.
Maternity services provided care on the maternity wards, MLBU and in the community 24 hours a
day, seven day a week. The labour ward always had access to a consultant anaesthetist to ensure
that women had access to timely pain relief and emergency surgery if required. Consultants
always worked to an on-call rota to ensure junior medical staff had access to consultant support
either in person or via the telephone.
The pharmacy was open Monday to Friday 9.am to 5pm with extended hours until 7pm to support
women’s discharges. At weekends the pharmacy was open from 9am to midday on Saturday and
from midday to 2pm on Sunday. Outside of these times the trust had an on-call pharmacy service
Staff could request screening tests such as blood screening and diagnostic imaging such as x-ray
and computerised tomography (CT), 24 hours a day, 7 days a week.
Health promotion
Staff gave patients practical support and advice to lead healthier lives.
An external review following an increase of intrauterine and postnatal baby deaths found that the
staff missed opportunities to refer women for smoking cessation. In some cases, women with a
social history of smoking were not identified during their first appointment.
The trust had increased capacity for ultrasound screen of women at 32 weeks and 36 weeks to
ensure women had additional screening if they were a smoker at the time of conception. This was
in line with saving babies lives guidance 2016.
The service provided mothers with information about vaccination programmes offered to them to
help prevent illnesses such as whooping cough and flu in young babies prior to their own
vaccination programme. Staff involved with antenatal care offered vaccinations to pregnant
women for example, flu and whooping cough in line with national guidance. We saw information
about these vaccinations was available to women in the antenatal clinics.
We saw poster displays providing information about safe sleeping for babies in Samson ward, the
postnatal ward where mothers and their babies were cared for.
All mothers received a discharge booklet that gave information about leaving hospital. However,
we reviewed the booklet and found this did not include information about how to provide feedback,
raise concerns or make a complaint.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards
Staff understood how and when to assess whether a woman had the capacity to make
decisions about their care. They followed the trust policy and procedures when a woman
could not give consent.
Staff understood their responsibilities in gaining consent to provide care and treatment especially
for invasive procedures. We reviewed five consent forms which staff had completed correctly and
gained women’s written consent for invasive procedures.
Staff prepared women well to make informed decisions about their care. Staff explained care in a
way that women understood, to provide consent to care and treatment. We observed staff taking
time to explain care and treatment and the complications of these treatments.
Staff had access to specialist nurses and safeguarding midwives to support women living with
learning disabilities. They supported women to make decisions about their care and assisted them
in the consent process.
Staff did not always complete Mental Capacity Act training which formed part of the trust’s
mandatory training programme.
qualified nursing and midwifery staff in maternity and medical staff working across maternity and
gynaecology at Princess Alexandra Hospital is shown below. The completion target for this
module is 95%.
As of October 2018
Qualified nursing and midwifery staff 137 153 89.5% 95% No
The 95% training target for the safeguarding adults level 2 training was not met by either qualified
nursing and midwifery staff in maternity or by medical staff working across maternity and
gynaecology.
as of March 2019 for qualified nursing and midwifery staff in maternity and medical staff working
across maternity and gynaecology in Princess Alexandra Hospital’s maternity department:
As of October 2018
Qualified nursing and midwifery staff 137 153 89.5% 90% No
In Princess Alexandra’s maternity department, the 90% target for safeguarding adults level 2
training was not met by qualified nursing staff, although the completion rate was only just under
the target, at 89.5%. The target was not met for medical staff in maternity and gynaecology,
however the completion rate was slightly higher than in the previous time period.
Compassionate care
Staff cared for women with compassion. Feedback from women confirmed that staff treated
them well and with kindness.
Women we spoke with about antenatal care told us they felt safe and happy with their care. They
felt they had always been treated with kindness and compassion.
Most of the women we spoke with told us they had experienced kind and compassionate care
from staff. One woman and her relative told us the “midwives were amazing” and that they felt
supported throughout labour. Another woman told us that “staff were kind and considerate”.
One woman we spoke with told us overall the care she had received was good. Although she had
not been prepared her baby might need an admission to the neonatal intensive care unit (NICU)
after her emergency caesarean section. Following the birth, the woman had not seen her baby for
12 hours after giving birth as the baby was transferred NICU. Although the women needed to
recover from the birth, staff had not kept her up to date with her baby’s progress, or provided a
picture, or recording of baby for her to see.
Staff mostly ensured that they maintained the dignity of women during personal care and
examinations. We observed that staff closed doors of private rooms and curtains within bed bays
for the duration of personal care. However, in the MLBU, intimate examinations were performed
behind curtains in a six-bedded bay rather than in a private birthing room.
Women’s feedback we reviewed was consistently positive. We saw thank you cards displayed in
ward areas, thanking staff for their care and kindness. An example of comments we reviewed
were “you made what was one of the scariest times of my life, feel controlled, safe and supported”.
“Thank you for the amazing care you gave me”.
Maternity services participated in the NHS friends and family test. The trust performed better than
the England average for antenatal, labour and postnatal care. However, the trust did not always
submit friends and family test data every month. We spoke with one of the matrons regarding the
gaps in friends and family test collection, they reported that they were due to a vacant post. The
information had not always been collected and analysed, however this was now part of the
matron’s role to ensure completion of the safety thermometer and friends and family data.
From January to December 2018, the trust’s maternity Friends and Family Test (antenatal)
performance (% recommended) was generally similar to the England average. In the most recent
available month of data (December 2018), the rate at the trust was 100%, which was greater than
the England average of 95%.
The trust did not submit data in June or September 2018 and this is the reason for the drops in
the graph.
Friends and family test performance (antenatal), The Princess Alexandra Hospital NHS
Trust
From January to December 2018, the trust’s maternity Friends and Family Test (birth)
performance (% recommended) was similar to the England average. In the most recent month
(December 2018), the rate at the trust was 100%, which was greater than the England average of
97%.
Friends and family test performance (birth), The Princess Alexandra Hospital NHS Trust
From January to December 2018, the trust’s maternity Friends and Family Test (postnatal ward)
performance (% recommended) was consistently better than the England average. In December
2018, the rate at the trust was 100%, which was greater than the England average of 95%.
Friends and family test performance (postnatal ward), The Princess Alexandra Hospital
NHS Trust
From January to December 2018, the trust’s maternity Friends and Family Test (postnatal
community) performance (% recommended) was similar to the England average. In the most
recent month (December 2018), the rate at the trust was 100%, which was greater than the
England average of 98%.
Friends and family test performance (postnatal community), The Princess Alexandra
Hospital NHS Trust
CQC Survey of women’s experiences of maternity services 2018
The trust performed worse than other trusts for one question and about the same as other trusts
for the remaining 18 questions in the CQC maternity survey 2018.
The trust performed worse than other trusts for the following question:
• If you raised a concern during labour and birth, did you feel that it was taken seriously?
Area Question Score RAG

At the very start of your labour, did you feel that you were given
About the
appropriate advice and support when you contacted a midwife or 8.3
same
the hospital?
During your labour, were you able to move around and choose the About the
8
Labour position that made you most comfortable? same
and birth Did you have skin to skin contact (baby naked, directly on your About the
9.5
chest or tummy) with your baby shortly after the birth? same
If your partner or someone else close to you was involved in your
About the
care during labour and birth, were they able to be involved as 9.8
same
much as they wanted?
Did the staff treating and examining you introduce themselves? About the
9.1
same
Were you and/or your partner or a companion left alone by About the
7.1
midwives or doctors at a time when it worried you? same
If you raised a concern during labour and birth, did you feel that it
7 Worse
was taken seriously?
Staff If attention was needed during labour and birth, did a staff member About the
8.7
during help you within a reasonable amount of time same
labour Thinking about your care during labour and birth, were you spoken About the
9.3
and birth to in a way you could understand? same
Thinking about your care during labour and birth, were you About the
8.2
involved enough in decisions about your care? same
Thinking about your care during labour and birth, were you treated About the
8.8
with respect and dignity? same
Did you have confidence and trust in the staff caring for you during About the
8.8
your labour and birth? same
Looking back, do you feel that the length of your stay in hospital About the
6.8
after the birth was appropriate? same
Looking back, was there a delay in being discharged from About the
5.2
hospital? same
Thinking about response time, if attention was needed after the
About the
birth, did a member of staff help within a reasonable amount of 7.9
same
time?
Care in
Thinking about the care you received in hospital after the birth of
hospital About the
your baby, were you given the information or explanations you 7.9
after the same
needed?
birth
Thinking about the care you received in hospital after the birth of About the
8.4
your baby, were you treated with kindness and understanding? same
Thinking about your stay in hospital, was your partner who was
About the
involved in your care able to stay with you as much as you 7.8
same
wanted?
Thinking about your stay in hospital, how clean was the hospital About the
8.4
room or ward you were in? same
(Source: CQC Survey of Women’s Experiences of Maternity Services 2018)
Emotional support
Staff provided emotional support to women to minimise their distress.
Staff demonstrated a family centred approach to supporting women, their partners and their
babies. Fathers could stay with women 24 hours a day to provide emotional support to their
partners. Two fathers we spoke with, told us they felt included in the care and were encouraged to
support their partners in hospital to bond with their babies.
Staff had access to a range of specialist services to provide emotional support to young women
such as the teenage pregnancy midwife and the mental health liaison service. The mental health
liaison service provided support to women with new and pre-existing mental health conditions.
A bereavement midwife was available to support women and their families in the event of a
pregnancy loss. The bereavement midwife had introduced a counselling service for bereaved
mothers following fundraising within maternity services.
The trust had a chaplaincy team that worked across the hospital to support all patients and carers
spiritual needs. Women did not have to have a religion to access support from the team.
Understanding and involvement of women and those close to them

Staff involved women and those close to them in decisions about their care and treatment.
Staff involved women and their partners in planning their care. We spoke with women and their
partners and they told us staff had included them in discussions about their care and treatment.
We observed staff providing information to women in a way they understood to make decisions
about their care.
Two women we spoke with in antenatal clinics had named midwives. Both mothers could name
their midwives and knew who to contact if they had any concerns.
The trust had completed the CQC Survey of women’s experiences of maternity services (2018)
about how they involved and listened to women. This showed:
• Staff involved women and those close to them in decisions about their care and treatment.
• New mothers using the service felt they were treated with respect and dignity, listened to
and given the help they needed.
• The trust scored about the same as other trusts in England for all but one of the measures.
However, the trust performed worse than other trusts in England for staff listening and taking
women’s concerns seriously during delivery.

The trust mostly planned and provided services in a way that met the needs of local people.
The environment did not always meet the needs of women. The layout of maternity wards did not
always meet the privacy and dignity needs of women in labour. Women had to move through the
antenatal ward to access the labour ward and women transferred from the midwife led birthing unit
(MLBU) were transferred through the postnatal ward in the event of complications. However, these
issues were constraints of the aged hospital building which the trust had little control to change.
The trust had car parking near the maternity wards and the MLBU for service users. There were
local bus services and taxi services to the hospital.
Partners could stay 24 hours a day with women while they were in hospital. Women had access to
amenity rooms with ensuite facilities subject to a small charge if they wanted more privacy.
Community midwives worked in locality teams to provide continuity of care to women. Community
midwifery teams had access to three safeguarding midwives within the community, in the event
that women required additional support with mental health conditions, drug abuse or there were
existing child protection concerns.
Midwives provided a handover for women on transitioning from the antenatal ward to the labour
ward and from the labour ward to the postnatal ward. Community midwives provided a handover
of care both written and verbally to the health visiting team once all postnatal checks were
complete.
Women accessed maternity services through their GP practice and could choose a consultant led
birth, a midwifery led birth or a home birth following a risk assessment to determine the safety and
suitability for each option.
Safeguarding midwives worked within hospital and community teams and provided additional
support to women with identified mental health needs, women living with learning disabilities and
identified safeguarding concerns such as drug addiction. An exclamation mark flagged these
women on the electronic records system.
There was a large Polish population in the local area. The trust was in close proximity to an
international airport which meant women of all nationalities may be transferred to the trust for
maternity care. The trust had access to translation services to ensure staff had effective
communication with women whose first language was not English.

The service took account of women’s individual needs.
Staff could access translation service for women or their partners that did not speak English or
women with hearing impairments who required a sign language interpreter.
The trust had a 51-point action plan for compliance with accessible information standards and had
completed 41 actions. The trust aimed to complete the remaining 10 actions by July 2019. The
actions related to data sharing and additional resources such as, development of easy read
Information, changes to the electronic records system and reasonable adjustments across all
protected characteristics through internal information campaigns on digital screens.
Maternity services had a room in the maternity outpatient department that women experiencing a
pregnancy loss could wait to see staff. Women were not put in a situation where they were
expected to mix with pregnant women when they were experiencing a potential pregnancy loss.
The service had the “star room” which looked like a normal bed room on the antenatal ward for
women who were experiencing a late pregnancy loss and they could give birth in this room rather
than on the labour ward. This room provided privacy and a quiet environment for women and their
partners away from women who had babies with them.
The postnatal ward (Samson) had five private amenity rooms, which women could access at an
additional charge subject to availability. These rooms provided additional privacy to women and
their partners. However, these rooms were also used to care for women who presented a risk of
spreading infections to others.
Maternity services offered women birth reflections following the birth of their baby with dedicated
midwives. This service offered women answers to questions they had about their birth and staff
discussed any concerns they had about future births.
Staff provided women with additional written information about conditions and investigations they
would be offered during their pregnancy such as scans and vaccinations.
Access and flow

People could access the service when they needed it. Waiting times from referral to treatment
and arrangements to admit, treat and discharge women were in line with good practice.
Women accessed maternity services through their GP surgery and completed a booking
appointment within the first 12 weeks of pregnancy. Maternity services cared for women with a
pregnancy loss from 16 weeks of pregnancy. Early pregnancy losses were managed by
gynaecology services in the early pregnancy assessment unit (EPAU).
Staff completed risk assessments during the pregnancy booking appointment and streamed
women depending on their pregnancy risk factors for consultant led care or midwifery led care.
These decisions were made between midwifery staff and women following a discussion about
their risks.
Community midwives managed the care for women booked for midwifery led care and booked
appointments for dating and growth scans in advance. Women under consultant led care
received shared care between community midwives and the hospital outpatient services. With
appointments booked in advance for consultations. Community midwives followed up women
who did not attend an appointment either by telephone or at their next booked appointment.
The service had processes in place to ensure women with an urgent mental health condition
were seen in a timely way. The service could refer women to local mental health services located
within the trust in the event of any concerns.
Women with increased risk factors such as smoking at the time of conception and gestational
diabetes were seen within the antenatal clinics and had additional diagnostic tests and growth
scans. Maternity services had employed additional sonographers due to the introduction of
additional scan at 32 weeks, for women who smoked at conception to meet the demand.
Maternity services completed a triage process either by telephone or in person when women had
concerns or were in labour, this provided the shift coordinator with information to allocate
resources to the demands of the service. This meant that women were streamed to prevent them
from giving birth in hospital outside of the labour ward or the midwifery led birthing unit.
Bed occupancy within maternity services was generally lower than the England average and the
trust managed the flow of women through the service well. During busy periods staff completed
risk assessments to move postnatal women and babies to the MLBU to increase capacity with
postnatal beds.
Women who missed antenatal appointments were followed up at home by the community
midwifery team.
Bed Occupancy
From July 2017 to December 2018 the bed occupancy levels for the trust’s maternity service
were generally lower than the England average.
In quarter 3 of 2018/19 (October to December 2018), the trust had an occupancy rate of 54.2%
compared to the England average of 58.2%.
The chart below shows the occupancy levels compared to the England average over the period.

The service treated concerns and complaints seriously, investigated them and learned
lessons from the results, and shared these with all staff.
Maternity service did not actively provide mothers or their visitors with complaints information. We
did not see posters displayed with complaints information or leaflets available.
Mothers we spoke with did not know the complaints process or how to raise concerns about their
care and treatment. There was not written information about how to make a complaint in any of the
wards or clinics we visited.
Senior staff acknowledged and investigated complaints about the service in line with trust policy.
Once the investigation was complete a response was provided with information the trust had
taken.
The divisional patient safety and quality committee discussed complaints during monthly meetings.
We reviewed the meeting minutes from January to March 2019, which provided limited information
about the types of complaints the service had received and the actions for learning. However, the
minutes documented the main theme of complaints was due to communication.
Staff we spoke with told us they received information about complaints at the start of the shifts in
the safety huddles, Monday message or in team meetings.
From December 2017 to November 2018 the trust received 21 complaints about maternity at
Princess Alexandra Hospital (8.9% of total complaints received by the hospital). All of the
complaints had the department specified as obstetrics/maternity.
The subjects of the complaints are shown in the table below:
Type of complaint
complaints total
Integrated care (including delayed discharge due to
1 4.8%
absence of care package)
Total 21 100%
From December 2017 to November 2018 there were 94 compliments about maternity at Princess
Alexandra Hospital.
(202 compliments).

Leadership
Managers in the service were slow to implement changes required to reduce risks and
increase the safety of the service provision.
Maternity services were manged by the family and women’s healthcare group. The healthcare
group was overseen by an associate medical director, a director of operations and an associate
director of nursing, who all reported directly to the executive team. Within the healthcare group,
the maternity service was led by a head of midwifery, clinical lead, lead obstetrician and matron.
The trust had processes in place for the head of midwifery to escalate any concerns to the trust
board. The chair of the trust’s health and safety committee had board oversight of maternity
services. The head of midwifery reported that they felt supported by the trust’s executive
management team.
The senior team maternity had made marginal improvements with the maternity and neonatal
health safety collaborative action plan, we were not assured that the actions were being
implemented in a timely manner. During our inspection we saw that senior leaders had not always
identified issues such as compliance with CTG monitoring, poor record keeping and poor
compliance with carbon monoxide monitoring, despite completing regular audits.
The maternity service had a dash board in place to monitor performance against key targets.
These targets included the nation targets in actions towards the saving babies’ lives. There was no
evidence within the dashboard or service meeting minutes that the trust compared their
performance to similar trusts.
The service leadership team was supported by midwifery matrons who had oversight of outpatient
services, inpatients services and community services. The midwifery matron we spoke with
understood their responsibility and felt able to raise concerns with the leadership team.
The ward managers, clinic managers and community co-ordinators reported to the midwifery
managers. We spoke with managers of all clinical areas including community co-ordinators who
felt supported by the matrons and the felt able to escalate concerns to the matrons of the head of
midwifery.
The senior leadership team and the matrons met monthly to discuss quality and safety agenda
items. These meetings had a fixed agenda to ensure all areas of service oversight were included.
Staff spoke positively about their managers and described feeling valued in their role. Ward and
departmental leads told us they felt supported by the senior leadership team. The senior
leadership team were accessible and approachable.
Staff had access to leadership skills and development opportunities, including a leadership
development programme. The service also had skills simulation sessions that covered labour
presentations that staff may be faced with. These sessions were developed to include all members
of the multidisciplinary team. Staff we spoke with told us they enjoyed taking part in these
sessions.
Vision and strategy

The trust had a vision for what it wanted to achieve and workable plans to turn it into action
developed with involvement from staff, women, and key groups representing the local
community.
The trust had an overarching vision, “Achieving excellence, living our values” and to be an
excellent provider of integrated acute services. Five strategic goals based on the five P’s (patients,
people, performance, places, pounds) was underpinned the trust values which were for staff to be
respectful, caring, responsible and committed when carrying out their role. The maternity service
followed the trust’s five strategic goals with meeting minutes covering these goals.
All staff we spoke to, knew the trust values and we saw the trust’s values were clearly displayed in
prominent areas throughout corridors and ward areas.
The maternity service worked with other partner NHS organisations within the local maternity
services network. This meant the service worked to align services to meet the needs of the local
maternity services network with action plans in place to meet national strategic priorities such as
the better births initiative and saving babies lives. The service had not developed firm working
processes within the sustainability and transformation partnership due to the geographical
distance between the trusts.
Community midwives worked within the local maternity services network and had links with other
midwifery services within the locality affiliated with other NHS trusts. They also had strong links
with mental health services such as the local mother and baby unit.
Culture
Managers across the trust promoted a positive culture that supported and valued staff,
Staff reported an open and honest culture, senior midwives and medical staff were actively
involved in the daily management and support of their service. Staff felt able to raise a concern
with their manager, and we observed leaders had an open-door policy.
Staff morale was high and staff reported they felt valued and well supported in their role. Staff we
spoke to told us that there were opportunities for further learning and development. We saw that
four nurses were in the process of completing a midwifery conversion course in conjunction with a
local university.
The trust had appointed a ‘freedom to speak up guardian’. Guardians promoted an open culture,
allowing staff to speak up about concerns easily. Staff we spoke with knew how to escalate their
concerns and knew they could seek support from the freedom to speak up guardian.
The trust had staff recognition awards for positive contributions to the service. Staff were
recognised for their contribution through the ‘employee of the month’ and ‘superstar of the month’
scheme. The service also acted when staff did not meet the expected level of performance
including the absence review process.
The trust had communication networks to ensure all staff had regular update about incident
learning and performance. The Monday message was sent electronically to all staff within the
maternity service including community staff. Community midwives we spoke with felt included in
service updates.
Community midwives had lone worker devices and processes in place to ensure staff remained
safe in the community setting.
Governance
The service did not have robust systems in place to improve safety and quality of care,
despite monitoring the quality and standards of its services and care.
Maternity services had a clear governance structure in place. The family and women service held
monthly board meetings. The divisional patient safety and quality committee compiled reports to
provide oversight to the trust board. We reviewed the board meeting minutes from November 2018
to January 2019 and found these were aligned to the trust’s five strategic goals. We saw agenda
items such as of safety incidents and complaints.
The patient safety and quality committee met monthly to discuss agenda items such as serious
incidents, incident reporting and complaints. We reviewed the meeting minutes from January 2019
to March 2019 and found these noted the areas of discussion but provided little detail about what
was discussed and the outcome. An example of this was the guideline and policy reviews, the
number of guideline reviews required were noted but not named. The action plans attached were
not completed for January 2019 and March 2019 to ascertain which policies and guidelines
required reviews and who was responsible for these actions.
The service had an action plan in place to meet the requirements of the saving babies lives care
bundle. The recommendations following the external review completed in January 2019 into
perinatal deaths identified areas for improvement associated with the care bundle for example the
use of fetal growth charts and policy review for the managing reduced fetal movements. Both
actions were in process at the time of our inspection.
Each clinical area had a pink folder with key information for staff and updates regarding incident
learning, policy updates and complaints. Community co-ordinators we spoke with told us that staff
were expected to review the folder on a monthly basis and to sign they had reviewed the updates.
Community midwifery co-ordinators attended regular meetings to review performance and quality
within the community service for oversight and shared this within their individual team meetings.

The trust did not have effective systems for identifying risks, planning to eliminate or
reduce them, and coping with both the expected and unexpected.
Maternity services did not have robust systems and processes in place to effectively identify risks.
We found unidentified risks, these included changes to cardiotocograph (CTG) classification tool
used where staff were not supported by up to date guidance documents. Following eight baby
deaths where CTG and fetal monitoring practices were identified as a theme. Prescription only
medicines were left unsecured in delivery rooms and the access code to the fluid warmer was
visible in a public access area. This posed a risk of medicines tampering or their misuse. The
service kept electronic records and women had hand held records, we found that staff did not
always document information in both records such as carbon monoxide readings in paper records.
This meant that women presenting at other services, staff would not have full access to important
information. Cleaning fluids containing bleach were not stored securely in open sluice rooms which
meant that the service was not compliant with the control of substances hazardous to health risk
assessments.
We requested risk register for each clinical area or ward, to ascertain if there were risk entries for
the additional risks we found, however these were not supplied.
The head of midwifery told us the concerns within the service were staffing, this was due to seven
members of staff on long term sickness leave and five members of staff on maternity leave. The
service was waiting for the results of the external staffing review undertaken in December 2018
and January 2019 to see if additional posts were required. Another concern for the service was the
increased number of serious incidents in the 12 months prior to the inspection. Although the
service had commissioned an external review and was working to complete the action plan. The
service reported progress on the action plan to the quality and safety committee for trust board
oversight.
Family and women’s services had a risk register in place, however we found that there were risks
dating back to 2013 which had no mitigating actions in place. The service had raised a risk around
information governance staff training in 2013 which had no mitigating actions in place and no
provisional completion date. There were 77 risk entries and only one risk entry had actions
completed in the evidence column. None of the risks had a provisional completion date. We also
found risks where actions were complete, and the risk should have been closed but remained
open. An example of this was the lack of a second maternity theatre, we found the second
maternity theatre was functional and had been in use for over a month at the time of the
inspection. We were not assured that maternity services managed risk effectively.
The service had systems and process in place to close the midwifery led birthing unit (MLBU) to
ensure the labour ward was staffed safely. We observed this process during an unannounced
inspection where the MLBU was closed to ensure there safe staffing levels on the labour ward due
to the higher risk associated with women under consultant led care.
The trust had appointed maternity safety champions in line with national guidance, the director of
nursing and a non-executive director were the maternity safety champions. The head of midwifery
did not attend trust board meetings. The head of midwifery reported to the director of nursing, with
regular one to one meeting scheduled. Risk, quality and performance issues were escalated to the
board via the quality and safety committee.
The trust collected, analysed, managed and used information to support all its activities,
using secure electronic systems with security safeguards.
Maternity services collected data about women’s outcomes for the purposes of performance
monitoring. Due to the lack of team meetings and detail in board and department meeting minutes
we were not assured that audit data was used to improve performance effectively and drive
change.
Staff used electronic medical records and paper based handheld records. Staff required
information from both record types to effectively care for women and their babies as not all
information about care was recorded in both records.
Staff including community midwives had access to password protected electronic records
including guidance and policy documents. Electronic records required an additional security
password to prevent unauthorised access to confidential information.
Engagement
The trust engaged well with women, staff, the public and local organisations to plan and
Maternity services had a variety of methods to communicate with staff. Staff received email
communications, the Monday message newsletter and face to face team meetings to share
information. Clinical areas had a pink folder which contained updates about risks, changes to
policy and guidance documents and incident learning.
The service engaged with service users through group feedback sessions and surveys which took
the form of the friends and family test, maternity safety thermometer and the picker survey.
Maternity service engaged well with other health care providers such as GPs and health visitors.
The trust had established communication pathways with local authority safeguarding boards for
both vulnerable adults and children.
The trust worked with other local trusts across the local maternity services network, but we saw
limited evidence of sustainability and transformation partnership working.
The service engaged with women through the maternity voices events and followed up feedback
provided by women in the maternity survey, to improve the experience of women.

The trust was committed to improving services by learning from when things went well and
when they went wrong, promoting training, research and innovation.
Maternity services had developed the fresh ears initiative for a second midwife to listen to fetal
heart rates during labour when using a sonic aid for intermittent monitoring. This was developed
following an external thematic review following eight serious incidents within the service.
The service had private rooms in the outpatient area and on the antenatal ward for women
experiencing pregnancy loss to use. This allowed women a private quiet space away from
pregnant women at a distressing time.
Maternity services had developed a red hat initiative for high risk babies that may require intensive
neonatal support. The red hats were knitted by volunteers and donated to the department to
identify at risk neonates. The use of this system meant midwives monitored babies with red hats
closely on the postnatal ward and babies stayed with their mothers. This initiative had reduced the
number of unplanned admissions to the neonatal intensive care unit.
Services for children and young people
The Princess Alexandra Hospital NHS Trust provides services for children and young people to a
local population, predominantly from West Essex and Hertfordshire. Children and young people
(CYP) services include an inpatient children’s ward, a neonatal unit, an ambulatory unit, a day
surgery service, and a children’s outpatient department. A neonatal community team provided
care to infants in homes across West Essex. A paediatric diabetes team ran outpatient clinics,
supporting children and young people with diabetes management and transition.
CYP services are mainly provided from Princess Alexandra Hospital, with some paediatric
outpatient clinics provided at St Margaret’s Hospital and Herts and Essex Hospital.
From November 2017 to October 2018, the trust had 3,107 children and young people spells
(inpatient stays). Emergency spells accounted for 75.6% (2,349 spells), 19% (590 spells) were
day case spells, and the remaining 5.4% (168 spells) were elective.
During this inspection, we visited the inpatient children’s ward (Dolphin Ward), the paediatric
ambulatory unit (PAU), the Neonatal Intensive Care Unit (NICU), the children’s outpatient
department and the Alexandra Day Surgery Unit. We spoke with two patients, six relatives and 26
members of staff including medical and nursing staff, healthcare assistants, therapy and domestic
staff. We observed care and looked at six sets of medical records. We also looked at 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.


Mandatory training
Staff received mandatory training in safety systems, processes and practices but not all
medical staff completed it. Staff told us that high levels of clinical demand meant that staff
could not always be spared to attend training.
Staff completed a number of mandatory training modules, as part of their induction, and were
required to update them in-line with the training policy. Mandatory training included fire safety,
information governance and infection prevention. Staff also received annual training on sepsis
management. Training was delivered through a combination of online assessment and practical
training days.
Nursing staff were required to complete paediatric immediate life support (PILS) on an annual
basis. The PILS training included learning about sepsis and the National Paediatric Early Warning
Score (PEWS) to assess patient deterioration.
Managers and a practice development nurse monitored training through a monthly report and
would notify staff when their training was due for renewal. The service also used a traffic light
system to highlight when mandatory training was approaching renewal. Staff were positive about
the training they received and were supported to attend additional training, if relevant to their role.
The trust set a target of 90% for the completion of mandatory training.
nursing staff in services for children and young people at Princess Alexandra Hospital is shown
below:
As of October 2018
Values & behaviours 67 67 100% 90% Yes
Equality, diversity and human rights 65 67 97% 90% Yes
Fire - general awareness 63 67 94% 90% Yes
Paediatric immediate life support 25 27 92.6% 90% Yes
Introduction to information governance 61 67 91% 90% Yes
In Princess Alexandra Hospital’s services for children and young people, the 90% target was
met for 10 of the 12 mandatory training modules for which qualified nursing staff were eligible.
for qualified nursing staff in services for children and young people at Princess Alexandra
Hospital:
As of March 2019
Paediatric immediate life support 27 30 90.0% 90% Yes
met for 10 of the 13 mandatory training modules for which qualified nursing staff were eligible.
As in the earlier time period, the adults and paediatrics basic life support module had the lowest
completion rates, however completion had improved.
in services for children and young people at Princess Alexandra Hospital is shown below:
As of October 2018
Values & behaviours 21 28 75% 90% No
Infection prevention & control level 1 7 10 70% 90% No
Conflict resolution 14 28 50% 90% No
In Princess Alexandra Hospital’s services for children and young people, the 90% target was not
met for any of the 12 mandatory training modules for which medical staff were eligible.
for medical staff in services for children and young people at Princess Alexandra Hospital:
As of March 2019
met for any of the 13 mandatory training modules for which medical staff were eligible. As in the
earlier time period, dementia awareness and learning disabilities awareness level 1 had the
lowest completion rates, however completion had improved slightly.
Although below trust targets, medical staff training compliance had significantly improved since
our last inspection. To improve mandatory training compliance, the service was running
additional training sessions at weekends. Service leads told us they were on track to achieve
mandatory training trust targets by July 2019.
Safeguarding
The service had effective processes in place to keep people safe and protected from abuse.
However, not all staff had received safeguarding training in line with national guidance.
Safeguarding training was part of the mandatory training programme and included information on
female genital mutilation and child sexual exploitation (CSE). Mandatory training also included
prevent training, a government-led training programme designed to identify and prevent the threat
of terrorism.
The trust set a target of 95% for completion of safeguarding training, with the exception of
PREVENT training where the target was 90%.
nursing staff in services for children and young people at Princess Alexandra Hospital is shown
below:
As of October 2018
In Princess Alexandra Hospital’s services for children and young people, the trust’s training
targets was met for two of the four safeguarding training modules for which qualified nursing
staff were eligible.
2019 for qualified nursing staff in services for children and young people at Princess Alexandra
Hospital:
As of March 2019
met for three of the four safeguarding training modules for which qualified nursing staff were
eligible. With the exception of the safeguarding adults level 2 module, the completion rates for
the individual modules improved when compared to those in the previous time period.
staff in services for children and young people at Princess Alexandra Hospital is shown below:
As of October 2018
Prevent/health WRAP 14 28 50% 90% No
In Princess Alexandra Hospital’s services for children and young people, the trust’s training
targets were not met for any of the three safeguarding training modules for which medical staff
were eligible.
2019 for medical staff in services for children and young people at Princess Alexandra Hospital:
As of March 2019
met for any of the three safeguarding training modules for which medical staff were eligible.
While the completion rates for prevent/health WRAP and safeguarding adults level 2 improved
when compared to the earlier time period, the rate for safeguarding children level 3 decreased.
Safeguarding training rates for medical staff did not meet trust targets or national guidance. The
intercollegiate document ‘Safeguarding children – roles and competencies for healthcare staff’
2014 published by the Royal College of Paediatrics and Child Health (RCPCH), provides
guidance on the level of safeguarding training required for different staff groups. The document
states that all clinical staff working with children and young people should be trained in
safeguarding children level 3. The service recognised safeguarding training levels as a risk and
safeguarding training was on the service’s risk register. The safeguarding team was mitigating
the risk by facilitating additional training sessions each week.
The trust provided bespoke safeguarding training to staff working in the day surgery theatres. All
day surgery staff were required to complete training in safeguarding children level 3 once every
three years. Training compliance met trust targets and as of February 2019, compliance was
95%. There were plans to make safeguarding training a yearly requirement, ensuring staff were
always up to date with the latest safeguarding policies and procedures.
The trust’s safeguarding team included a named doctor, named nurse and named midwife for
safeguarding adults and children. The team supported all staff with safeguarding concerns and
referrals. They logged all safeguarding activity onto a safeguarding dashboard, presented at the
trust’s monthly safeguarding steering group. The team also held an annual safeguarding
conference. This year, the conference was attended by 80 members of staff and focussed on
fabricated illness.
The safeguarding team worked in partnership with other agencies to safeguard children. For
example, the team attended a regional named safeguarding professionals meeting to discuss,
manage and learn from safeguarding cases across West Essex.
Staff knew what the term safeguarding meant and how to recognise signs of abuse. They could
explain the reporting process and knew how to seek support if needed. Staff knew how to contact
the trust’s safeguarding leads and gave examples of when the trust’s safeguarding team had
supported them.
An emotional wellbeing and mental health service (EWMHS), provided by a local NHS mental
health trust, assessed all children expressing suicidal ideation or self-harm. If a child or young
person was assessed to be at risk of suicide or self-harm, enhanced observations would be
initiated until the patient could be transferred to a more appropriate mental health setting.
Staff demonstrated a good awareness of child sexual exploitation (CSE). They could identify
possible CSE offences using a CSE risk assessment tool. The trust had also identified 12 CSE
champions, who had received additional training and could help staff detect and prevent the
maltreatment of children.
Effective safeguarding supervision and peer review reduces risks to children and young people,
while identifying their needs. The trust provided regular safeguarding supervision for nurses and
safeguarding peer review for doctors. Five paediatric nurses had been trained in supervision to
support their colleagues.
We saw safeguarding information displayed in paediatric areas, offering advice and guidance to
staff and patients on how to recognise and report abuse. Staff knew how to access safeguarding
policies and procedures on the trust intranet. The trust had an up to date abduction policy,
ensuring staff knew their roles and responsibilities in the event of an abduction.
The trust had introduced an electronic flagging system, used to identify children at risk or on a
child protection plan. The system provided nursing staff with access to the child’s social care team
details. It also automatically notified the social care team when a child attends a health care
setting.
When a safeguarding concern for a child or young person was identified by staff, a copy of the
health record was stamped for the attention of the safeguarding team. The safeguarding team
collected safeguarding records daily and scrutinised the records to ensure appropriate action had
been taken.
Staff followed a standard operating procedure (SOP) when admitting a young person to an adult
ward. The safeguarding team were notified about any 16 or 17-year-old admitted onto an adult
ward. The team would complete a risk assessment for all young people aged 16 and 17 and try to
ensure they were placed in a side room on the adult ward. Staff on Dolphin Ward, including play
specialists and a teaching assistant, were also available for advice and support. Any patients with
a mental health concern were referred to the emotional well-being and mental health service.
A safeguarding referral is a request made to the local authority or police to intervene, support or
protect a child or vulnerable adult from abuse. From November 2017 to October 2018, there were
432 child safeguarding referrals made by staff within the children and young people’s service.

Staff followed best practice in relation to infection prevention and control.
All locations we visited were visibly clean and tidy. Signed cleaning schedules were in place, and
both nursing and housekeeping staff cleaned the departments daily. Staff cleaned toys with a
disinfectant wipe daily and completed a weekly deep clean of all toys. Cleaning audits were
completed monthly and results were displayed at the entrance to each department.
Staff labelled equipment with ‘I am clean’ stickers to indicate that equipment was ready for use.
Personal protective equipment (PPE), such as gloves and aprons, was accessible for staff in all
clinical areas to ensure their safety and reduce the risk of cross-infection, when providing care. We
saw staff using PPE appropriately.
Staff used effective hand hygiene techniques and their arms were ‘bare below the elbow’ when
providing care. Hand sanitiser points were widely available to encourage good hand hygiene
practice and we saw staff washing their hands before, and after, contact with patients. This was
in line with National Institute for Health and Care Excellence (NICE) Quality Standard 61, which
states that staff should decontaminate their hands immediately before and after every episode of
direct contact care.
Each department completed monthly hand hygiene audits to monitor staff compliance and identify
areas that require improvement. Hand hygiene audits from October 2018 to March 2019 showed
that hand hygiene practice was good, with scores ranging from 97.8% to 100% compliant.
Staff took steps to prevent the transmission of infections, including isolating patients when
infection was suspected. On Dolphin Ward, patients were excluded from routine Methicillin-
resistant Staphylococcus aureus (MRSA) screening unless categorised as high risk, in line with
the trust’s MRSA policy. All children transferred from another hospital were screened for
carbapenemase-producing Enterobacteriaceae (CPE), a bacteria resistant to antibiotics. On the
Neonatal Intensive Care Unit, all babies were screened for infection, in line with standards set by
the British Association of Perinatal Medicine (BAPM).
CQC Children and Young People’s Survey 2016
In the CQC Children and Young People’s Survey 2016, the trust scored 8.4 out of ten for the
question ‘How clean do you think the hospital room or ward was that your child was in?’ This
score was about the same as other trusts.
(Source: CQC Children and Young People’s Survey 2016, RCPCH)

The service had suitable premises and systems were in place to ensure equipment was
maintained.
Throughout our inspection, we found that all paediatric areas were secure, with doors opened by a
swipe-card system and CCTV in operation. Ward areas and corridors were spacious, free from
obstruction and decorated for children. Fire exits were clear and fire extinguishers were available,
if required.
Dolphin Ward was a 16-bedded surgical and medical ward (made up of nine beds and seven
cubicles), for children up to the age of 16. The ward had two en suite rooms, allocated for
oncology patients and a designated close observation cubicle, used for children who required
higher levels of care. The ward also had a four-bedded ambulatory care bay, used for day surgery
patients.
The ward had a garden play area, a teenage ‘getaway shed’, and a sensory room, designed to
engage children with limited communication skills.
Most children receiving day surgery were nursed in a dedicated paediatric area on the Alexandra
Day Surgery Unit. However, if capacity was stretched, children could be nursed on Dolphin Ward.
The Alexandra Day Surgery Unit had a dedicated recovery area for children only, in-line with
guidelines from the Royal College of Anaesthetists.
The Neonatal Intensive Care Unit (NICU) was classified as a Level 2 unit, consisting of two
intensive care cots, four high-dependency cots and 10 special care cots. Care was provided for
both term and preterm babies. The unit had two parent rooms with en-suite facilities, allocated to
parents with the sickest babies or for mothers stabilising breastfeeding.
The children’s outpatient department was situated next to the hospital’s main outpatient
department. The department consisted of a small waiting area and three examination rooms. Staff
reported that when busy, the waiting area could become cramped, potentially having a negative
effect on the patient experience. Service leads were aware of these staff concerns and had placed
the waiting area on the service’s risk register.
Since our last inspection, the service had introduced a paediatric ambulatory unit (PAU), to
support flow and reduce Dolphin Ward admissions. The PAU was situated next to the children’s
emergency department. The unit had seven flexible spaces, used for children requiring periods of
observation following a review by the emergency department or for children receiving clinical
reviews, intravenous antibiotics or day case investigation.
Staff told us they had enough equipment to deliver safe care. Dolphin Ward, the children’s
outpatient department and the PAU all had a resuscitation trolley for staff to use in the event of a
cardiac arrest. Staff used tamper evident tags to alert staff if the resuscitation equipment had been
used. Staff checked resuscitation equipment against an equipment checklist to ensure essential
equipment was available and in working order. The top of each trolley was checked daily and the
rest of the trolley was checked weekly or after each use. In each area, we found checks had been
completed for the previous three months (January to March 2019).
The NICU had a neonatal intubation trolley and access to an adult resuscitation trolley. Again, we
found staff had completed daily and weekly checks (January to March 2019), ensuring all
equipment was available and ready to use in an emergency.
The service conducted a monthly resuscitation audit, to ensure staff were checking resuscitation
equipment in-line with trust policy. All areas had achieved 100% in the latest resuscitation audit
(February 2019).
There was a rolling testing programme for all medical devices, overseen by the trust’s equipment
maintenance team. We checked 14 pieces of medical equipment, including defibrillators and
suction machines. We found all pieces of equipment had been safety tested and were within the
stated date for review. We also checked the expiry dates of consumable equipment, including
needles and syringes. We found all items had expiry dates clearly marked on them and were
within date.
Staff correctly disposed domestic and clinical waste. We saw appropriate facilities for the disposal
of clinical waste and sharps (such as needles) in clinical areas. Sharps were safely disposed in a
clearly marked and secure container. Staff used different coloured bins to clearly identify
categories of waste, in line with current waste management legislation.
Health risks to children and young people were assessed, monitored and managed
appropriately.
All patients requiring surgery received a paediatric pre-operative assessment, completed by staff
on the Alexandra Day Surgery Unit. Patients had their general health and suitability for surgery
assessed and any required investigations would be performed.
Staff completed risk assessments for patients admitted onto a ward. We reviewed six patient
records and found that assessments were completed appropriately and updated, as required.
Staff took action to reduce any identified risk to patients. For example, for patients at risk of
infection, staff nursed the patient in a separate cubicle, reducing the risk of an infection spreading
to other patients on the ward. On the postnatal ward all infants were risk assessed for
hypoglycaemia (abnormally low level of blood sugar). Any infant identified as ‘at-risk’ would be
given a red hat, providing a visual aid for staff to easily identify infants that required enhanced
observations.
Staff on Dolphin Ward, the PAU and the children’s outpatient department used a national
Paediatric Early Warning Score (PEWS) to assess patient deterioration. The PEWS is a tool, used
by staff, to quickly determine the degree of patient illness, based upon key vital signs and patient
observation. The PEWS was completed on an electronic, handheld device and a high scoring
PEWS immediately flagged for escalation. We observed staff completing the PEWS appropriately
on the handheld device.
Staff on the NICU had been trained to use the Neonatal Alert, Trigger and Track tool (NATT), a
modified version of the PEWS, developed by the East of England Neonatal Operational Delivery
Network. The tool was designed to identify premature and new-born infants at risk of clinical
deterioration. At the time of our inspection, the tool was going through trust ratification and had not
yet been fully implemented. In the interim, and to ensure staff had oversight of patients at risk of
deterioration, the NICU was relying on notes and observations to detect deterioration.
Observations were hourly for high dependency neonates, and every two to three hours for special
care babies.
Staff followed a separate sepsis policy for neonates and for children up to the age of 16. Staff
followed the adult’s sepsis policy for young people aged 16 and 17. The neonatal policy was
based on NICE guidance and guided staff to treat infants for sepsis based on risk factors rather
than patient symptoms. In paediatrics, staff used an enhanced triage tool, that had been validated
in the Wessex region. The tool aims to empower staff with sepsis concerns to commence
treatment, following the Sepsis Six pathways. Sepsis Six is the name given to a set of clinical
tasks, to be carried out within one hour of the suspected deterioration.
All paediatric nurses were required to complete a competency in obtaining vital signs in a child,
which included PEWS scoring and escalation. Staff we spoke with had a good understanding of
the signs and symptoms of sepsis and knew how to respond if they identified concerns.
In the event of a neonate or child deteriorating, escalation charts were on display, with details of
who staff should contact. Any child requiring urgent critical care would be transferred by the local
intensive care transport team CATS (children’s acute transport service). The CATS team had
recently ran a training day for staff on Dolphin Ward. The NICU cared for both term and preterm
infants. Infants born under 27 weeks gestation or under 800g were resuscitated and stabilised,
prior to their transfer to a regional neonatal intensive care service by the acute neonatal transfer
service (ANTS).
The service did not comply with standards set out by the Royal College of Nursing which states
that at least one nurse per shift, in each clinical area, should be trained in advanced paediatric life
support (APLS) or European paediatric advanced life support (EPALS). At the time of our
inspection, three nurses had received training on EPALS. However, there was an EPALS trained
doctor on every shift. In addition, all nursing staff completed training in either paediatric immediate
life support or new-born life support yearly. The ward manager told us there were plans to train all
the nurses on Dolphin Ward in EPALS, once staff in the children’s emergency department had
received their training. The service was also looking to enrol staff on a paediatric acute illness
management course in May 2019.
Staff had access to mental health liaison and support 24 hours a day, seven days a week, for risks
associated with a patient’s mental health.
Dolphin Ward had a designated close observation cubicle, used for children who required higher
levels of care (high dependency). A high dependency unit (HDU) facilitator supported the ward
with the care of children in the close observation cubicle. The facilitator assessed all children
requiring higher levels of care and developed specialised care plans. They also ran high
dependency study days, participated in the regional high dependency unit network and liaised with
tertiary hospitals.
In the CQC Children and Young People’s Survey 2016 the trust scored 7.2 out of ten for the
question ‘Were the different members of staff caring for and treating your child aware of their
medical history?’ This was about the same as other trusts.
Nurse staffing
Although turnover rates were high, ward staffing levels and skill mix were planned and
reviewed so that patient needs were met.
The trust undertook a six-monthly staffing review to monitor staffing levels for patient safety, using
a nationally recognised safer staffing tool. The tool assessed patient acuity and dependency to
ensure nursing establishments reflected patient needs.
Staffing was also reviewed three times a day at the trust-wide bed meetings. The meetings
identified wards and departments that had significant absences or required additional support. On
a shift by shift basis, matrons adjusted staffing levels based on patient acuity. From what we
observed during the inspection, staffing levels met the needs of patients and the demands of the
service. Staffing levels were displayed on in all the areas we visited.
Services for children and young people were required to meet national staffing guidelines, set out
by the Royal College of Nursing and the British Association of Perinatal Medicine. The current
establishment on Dolphin Ward was compliant with most national guidelines. The service had at
least 10 whole time equivalent paediatric nurses and, on every shift, there was a minimum of two
registered children’s nurses working in inpatient and day case areas. On the Neonatal Intensive
Care Unit (NICU), nursing rotas complied with the British Association of Perinatal Medicine
staffing guidelines, ensuring all babies receiving intensive and high dependency care were
looked after by a nurse Qualified in Specialty.
At the time of our inspection, the agreed template for staffing on Dolphin Ward was five nurses
and two healthcare support workers on a day shift, and four nurses and two healthcare support
workers on a night shift. The agreed template for staffing on the NICU was five nurses and one
healthcare support worker on every shift. The trust was not always able to deliver the agreed
establishment, but felt staff were supported by supernumerary staff and had access to a senior
nurse, if needed. The service had recently introduced a senior nurse on-call system, ensuring staff
felt supported on every shift.
Planned vs actual staffing
The table below shows the service’s actual versus planned nursing staffing levels in October
2018.
As of October 2018
Ward / team name
Actual staff Planned staff Staffing rate (%)
Community neonatal team 2.3 1.9 121.1%
Dolphin Ward 24.7 24.7 100.2%
Neonatal Intensive Care Unit 25.5 28.6 89.2%
Paediatric ambulatory unit 1 6.3 16%
Paediatric diabetes 2.5 2.5 100.1%
Paediatric outpatient department 2.2 0.9 255.8%
Four of the six teams listed were over established. However, care should be taken when
interpreting staffing rates due to small numbers of staff in some teams.
By March 2019, the paediatric ambulatory unit had expanded their team. The team included a
band 7 nurse, band 6 nurse, band 5 nurse and four healthcare support workers.
Vacancy rates
11.1% for nursing staff in services for children and young people. This was higher than the trust
target of 8%.
As of March 2019, Dolphin Ward had two band 6 vacancies and five band 5 vacancies, the
Neonatal Intensive Care Unit had 4.6 band 6 vacancies and 4.7 healthcare support worker
vacancies, and the PAU had one band 6 vacancy and one band 5 vacancy. There were currently
no vacancies in the children’s outpatient department.
Service leads identified staffing as one of their biggest concerns and were actively looking at
ways to recruit and retain staff, while mitigating risk. For example, the service supported staff to
undertake additional training and had introduced a deputy manager role to support staff on
Dolphin Ward. The trust also had an oversees recruitment programme and had built good
working links with the local university to help recruit to nursing posts.
Turnover rates
From November 2017 to October 2018, the trust reported a high turnover rate of 17.8% for
nursing staff in services for children and young people. The Neonatal Intensive Care Unit had a
turnover rate of 29.2% and Dolphin Ward had a turnover rate of 16.1%, against a trust target of
12%.
Sickness rates
From November 2017 to October 2018, the trust reported a sickness rate of 3.4% for nursing
staff in services for children and young people. This was slightly lower than the trust target of
3.5%.
A breakdown of sickness rates by ward/team is below. One team had annual sickness rates
above the 3.5% target.

Neonatal unit 5%
Paediatric ambulatory unit 3%
Dolphin Ward 2.9%
Paediatric outpatients 2.7%
Community neonatal team 0.8%
Safeguarding team 0%
Paediatric diabetes 0%
The table below shows the number of nursing hours covered by bank and agency staff, or left
unfilled, within CYP services.
From December 2017 to November 2018, 3,565,2 nursing hours were unable to be filled by
either bank or agency staff to cover sickness, absence or vacancy. Over the same time period,
343.5 hours for healthcare support workers were unable to be filled by bank staff.

Staff group Bank usage Agency usage Not filled by bank or agency
Hours Hours Hours
Qualified staff 11,260.5 6,773.5 3,565.2
Healthcare support workers 2,421.6 0 343.5
All agency and bank staff had full access to the trust’s systems, ensuring they were effective
members of the team. All agency staff completed an orientation checklist before working on a
ward or in theatres. The service tried to use the same agency staff to promote continuity of care
for patients. The Neonatal Intensive Care Unit did not use agency staff to cover nursing shifts and
relied solely on bank staff.
Medical staffing
Medical staffing adequately met the needs of patients.
Paediatric medical staff worked on a rota, which provided medical cover to the ward, PAU and
Neonatal Intensive Care Unit 24 hours a day, seven days per week. Staff reported sufficient
medical cover throughout the areas we inspected. In the event of gaps in the rota, the service
used locum doctors. Many of these locum doctors were regularly used and considered part of the
team.
The service had a ‘consultant of the week’ on-call to respond to any concerns over patient risk or
deterioration. All children admitted to a paediatric department with an acute medical problem were
seen by a consultant paediatrician within 14 hours of admission. Specialist paediatricians working
at local tertiary centres provided immediate telephone advice.
Planned vs actual
The table below shows the service’s actual versus planned medical staffing levels in October
2018. The paediatric medical staffing fill rate was 81.1%, with a deficit of 7.2 WTE staff.
As of October 2018
Ward / team name Actual Planned Staffing
staff staff rate (%)
Child health 30.7 37.9 81.1%
Vacancy rates
From November 2017 to October 2018, the trust reported a vacancy rate of 11.8% for paediatric
medical staff. This was higher than the trust target of 8%.

Service leads identified medical staffing as a risk on their risk register and had put controls in
place to mitigate the risk. For example, on the Neonatal Intensive Care Unit, two neonatal nurse
practitioners were supporting the medical rota. Paediatric consultants completed locum shifts to
ensure outpatient clinics continued to run during staff shortages.
Turnover rates
From November 2017 to October 2018, the trust reported a turnover rate of 9.3% for paediatric
medical staff. This was lower than the trust target of 12%, and represented three members of
medical staff leaving the team.
Sickness rates
From November 2017 to October 2018, the trust reported a sickness rate of 1.2% for paediatric
medical staff. Again, this was lower than the trust target of 3.5%.
The table below shows the number of medical hours covered by bank and locum staff, or left
unfilled, within CYP services. From December 2017 to November 2018, 4,888.7 working hours
were filled by bank staff and 3,266.5 were covered by locum staff to cover sickness, absence or
vacancy. The trust was unable to provide the number of hours that had remained unfilled by either
bank or locum medical staff.
Hours Hours
Princess Alexandra Hospital 4,888.7 3,266.5
Staffing skill mix

The chart below shows the staffing skill mix for the 35 WTE medical staff working in children’s
services. As of November 2018, the proportion of consultant staff reported to be working at the
trust was lower than the England average and the proportion of junior (foundation year 1-2) staff
was higher than the England average.
Staffing skill mix for the 35 whole time equivalent staff working in services for children
and young people at The Princess Alexandra Hospital NHS Trust
This England
Trust average
Consultant 35% 42%
Registrar Group~ 57% 45%
Junior* 9% 6%
^ Middle Career = At least 3 years at SHO or a higher grade within their chosen speciality
Records
Patient records were accurate, stored securely, and provided detailed accounts of care and
treatment.
At our last inspection, we found that records were variable in their completion. During this
inspection, we found the quality of patient records had improved. The service had introduced an
orange sheet to document any discussion between staff and parents. A new paediatric care plan
booklet had also been introduced to reduce duplication, while still ensuring staff documented all
relevant information.
The service used paper records, stored securely in lockable trolleys. As part of our inspection, we
reviewed the records of six patients. All were clear, concise and accurate, focusing on the needs
of the child. Within the records, we saw evidence of good communication and multidisciplinary
team (MDT) working. Risk assessments had been completed which highlighted potential risks to
patient safety. On the Neonatal Intensive Care Unit, we saw staff had completed documentation
on the first hour of care. The first hour in a baby’s life can have a significant lifelong impact on
health and attachment, and so it is important that it is documented consistently.
In addition to paper records, staff used an electronic, handheld device to record a patient’s
clinical observations. The device alerted users if the recorded vital signs were outside acceptable
limits. The service completed regular audits to monitor patient record completion and identify
areas that required improvement. For example, following a documentation audit, staff were
reminded to always record the date when changing a patient’s optiflow tubing (a device which
provides nasal high flow therapy).
Staff used an electronic flagging system to record any special needs on a patient record
database, including pre-existing conditions. The flagging system was also used by staff to identify
children at risk or on a child protection plan.
A Personal Child Health Record, also known as a 'red book', is a national standard health and
development record, given to parents to record their child's health, growth and development. The
service encouraged parents to bring their red book to all hospital appointments, ensuring
information needed for their child’s ongoing care was shared appropriately. Discharge summaries
were sent to the patient’s GP to ensure continuity of care within the community.
Medicines
Staff followed best practice when prescribing, giving, recording and storing medicines.
The trust’s clinical pharmacy service was available Monday to Friday, 9am to 7pm, Saturdays 9am
to 3pm and Sundays 12pm to 2pm. Outside of these hours, staff could contact an on-call
pharmacist.
The service was provided by pharmacists, pharmacy technicians and pharmacy assistants.
Pharmacists were responsible for pharmaceutical review of patient care and clinical validation of
prescriptions. Pharmacy technicians supported pharmacists with medicine reconciliation at ward
level and checked validated and dispensed prescriptions. Pharmacy assistants undertook ward
stock top-up duties and dispensed prescriptions.
Medicines were prescribed by medical staff. Dolphin Ward and the Neonatal Intensive Care Unit
had a designated pharmacist, available Monday to Friday. The designated pharmacist was
currently completing a non-medical prescribing course to support the prescription process.
Since our last inspection, the trust had introduced electronic prescribing. Since the introduction of
electronic prescribing, service leads described a reduction in medication errors. We checked a
sample of electronic medicine administration records and found that they were all completed
appropriately, with allergies and weights clearly documented. Two trained nurses checked all
medicines prior to, and during, administration, as per trust policy.
Medicines were stored securely. In each area we visited, staff stored all medicines in a locked
cupboard or fridge, in a secure clinical room.
Some prescription medicines are controlled under the Misuse of Drugs legislation (and
subsequent amendments). These medicines are called controlled drugs (CDs). CDs were locked
securely and stored separately from other medicines. The master keys were locked in a digital
coded safe. Oxygen cylinders were also stored securely.
Staff checked and recorded medication fridge and room temperatures daily to ensure medicines
were stored at the correct temperature. In each area, we saw daily checks had been completed for
the last three months (January to March 2019). We saw evidence that when an irregular
temperature was recorded, staff took appropriate action to escalate this to the pharmacy and
estates team.
Our checks of medicines and CDs showed that all were within their expiry date. Green stickers
were placed on medicines which were coming up to their expiry date to reduce waste and ensure
they were used first. A stock check of CDs was carried out by two nurses, twice a day and staff
were required to sign the CD register once this had been completed. We reviewed the CD
register on Dolphin Ward and the Neonatal Intensive Care Unit and found both were completed
appropriately from January to March 2019.
Arrangements were in place to ensure that medicine incidents were reported, recorded and
investigated. All medication errors were discussed monthly at the patient safety and quality
meeting. Medication errors were also included as part of the monthly newsletter sent to all staff in
the family and women’s healthcare group.
In the CQC Children and Young People’s Survey 2016, the trust scored 9.9 out of 10 for the
question ‘Were you given enough information about how your child should use the medicine(s)?’
This score was better than other trusts.
Incidents
Systems to report, record and investigate incidents were robust.
Incidents were reported using the trust’s electronic reporting system. Staff we spoke with knew
how to report incidents and could give examples of the recent incidents they had reported. For
example, staff described how they had logged an incident on the system following a missed
outpatient appointment.
Never events
Never events are a type of serious incident that is wholly preventable, where guidance or safety
recommendations that provide strong systemic protective barriers are available at a national level
and should have been implemented by all healthcare providers. From February 2018 to January
2019, there were no reported never events within this service.
Breakdown of serious incidents reported to the strategic executive information system

(STEIS)
Serious incidents are adverse events, where the consequences are so significant or the potential
for learning is so great, that a heightened level of response is justified. From February 2018 to
January 2019, staff reported no serious incidents in services for children and young people which
met the reporting criteria set by NHS England.
Staff told us they received feedback from their manager when they had been directly involved in
an incident. Staff also received information about incidents by email, at safety huddles and
through a ‘sharing the learning’ document, shared with all staff. Ward managers had printed the
most recent learning document and displayed it in staff rooms for staff to read.
Staff gave examples of local changes in practice following an incident. For example, following an
incident, staff on the Neonatal Intensive Care Unit and maternity unit were receiving simulation
training to develop their skills in resuscitation.
Mortality and morbidity meetings took place monthly and learning from complex cases was
shared with staff. We reviewed the minutes of the mortality and morbidity meetings from
December 2018 to April 2019. The minutes included appropriate discussion of mortality and
morbidity cases, with actions from discussion documented. The service also ran ad-hoc post-
natal mortality meetings. These post-natal mortality meetings were mandated by the perinatal
mortality review tool (integrated within MBRRACE-UK). These meetings also had a fixed quorum
as indicated by the terms or reference.
Safety thermometer
The service used monitoring results well to improve safety.
Services for children and young people monitored safety performance in various ways including
the NHS safety thermometer. The safety thermometer is a monthly snapshot audit, used to record
the prevalence of patient harm and to provide immediate information and analysis for frontline
teams to monitor their performance in delivering harm free care. The types of harm the trust
monitored included falls, catheter urinary tract infections (UTI) and pressure ulcers.
From January 2018 to January 2019, services for children and young people reported no new
pressure ulcers, falls with harm or UTIs in patients with a catheter

Staff delivered care and treatment in line with evidence-based practice.
Staff had access to policies and guidance through the trust’s intranet and in paper format. Policies
were version controlled, ratified and included clear dates for review. For example, we reviewed the
trust’s consent to examination or treatment policy, and found it was ratified, in date for review and
referenced various national guidance such as guidelines from the Department of Health and the
General Medical Council.
The patient, safety and quality matron was responsible for managing and updating policies and
procedures following changes to national guidance. Service leads were alerted to any new policy
changes and would disseminate changes to their team.
National clinical audits benchmark the quality of the trust’s services and highlight best and
substandard practice to drive continuous improvement. The service participated in national audits
including the National Paediatric Diabetes Audit and the National Neonatal Audit Programme
(NNAP). We saw evidence that the trust used audit findings to improve the quality of care. For
example, in response to audit results from the NNAP, the service had developed an action plan to
improve administration of antenatal steroids and magnesium sulphate to meet national standards.
The service had a comprehensive local audit schedule to monitor performance. We saw that key
findings from local audits were documented, with actions for improvement. For example, an audit
assessing the use of antibiotics for early onset neonatal infection, identified that the service was
not issuing antibiotics within the recommended timeframe. Following the audit, an action plan had
been developed to address the delay, with input from the midwifery staff.
The Neonatal Intensive Care Unit (NICU) was working towards Bliss Baby Charter accreditation,
designed to standardise high quality family-centred care. The charter enables neonatal units to
audit their practice against seven core principles such as how a unit supports a baby’s social,
developmental and emotional needs.
In collaboration with the maternity unit, the NICU had achieved Unicef baby friendly accreditation
Level 3. This accreditation assesses whether staff support parents to have a close and loving
relationship with their baby. To achieve accreditation, the provider is required to demonstrate they
have met a set of evidence-based standards.
The NICU was part of the East of England’s Neonatal Operational Delivery Network (ODN),
bringing together 17 units to provide coordinated patient pathways and access to specialist
resources and expertise.
Staff understood the importance of nutrition and hydration for effective care and
treatment.
Staff recognised the importance of good nutrition, hydration, and protected meal times as an
essential part of patient care. Staff encouraged parents to support their child with eating and
drinking, where appropriate.
Staff on the Neonatal Intensive Care Unit and Dolphin Ward provided age-appropriate nutrition.
Children and young people had access to a dietitian to support their nutritional and hydration
needs. Catering staff were able to accommodate special dietary needs, including food allergies
and needs relating to religion and culture. Food allergies were clearly documented in patient
records.
Staff assessed nutritional risk using a Screening Tool for the Assessment of Malnutrition in
Paediatrics (STAMP). The tool is a validated nutrition screening assessment, for use in
hospitalised children aged 2 to 16 years. Staff told us that any patients found to be at risk of
malnutrition would have a specialised care plan in place and would be referred to a dietitian for
review.
Staff described how they followed good practice guidelines in relation to paediatric preoperative
fasting, endorsed by the Association of Anaesthetists of Great Britain and Ireland. Preoperative
fasting is intended to prevent pulmonary aspiration (inhaling food into the lungs) under general
anaesthesia.
The service promoted and supported breastfeeding. Breastfeeding mothers had access to fluids
and a fridge to store breastmilk. In the National Neonatal Audit Programme 2018, 62.5% of babies
born under 33 weeks were receiving their mother’s milk, either exclusively or as part of their feed,
at the time of discharge. The service was performing slightly better than the national average
(60.5%).
Pain relief
Staff assessed and managed patient pain well.
Staff used age-appropriate pain assessment tools to assess and record patient pain. For younger
children, the service used either the visual analogue scale for pain or the faces pain scale. For
infants and for patients unable to communicate their pain, staff used the Face, Legs, Activity, Cry,
Consolability scale (FLACC).
The trust had a specialist pain team, available Monday to Friday, 8am to 4pm, who could provide
advice and support for patients and staff. The play team could help distract children when they
experienced pain or when they were receiving pain relief.
Parents told us their child’s pain was well managed and that nursing staff administered pain relief
in a timely manner. Staff on the Alexandra Day Surgery Unit had introduced a pain relief protocol
for patients who had had a tonsillectomy (tonsil removal). Parents were instructed to give their
child regular analgesia for two weeks following their surgery. Since the protocol had been
introduced, the unit had seen a reduced number of telephone calls from parents reporting that
their child was in pain.
Patient outcomes
Information about the outcomes of patient care and treatment was routinely collected and
monitored.
The service regularly reviewed the effectiveness of care and treatment through local and national
audits. Paediatric departments displayed quality performance data, allowing patients, visitors and
staff to view their performance monthly. In all paediatric areas we saw information about
workforce, safety performance and patient feedback.
Local audit programmes were used to measure outcomes for patients and drive improvements to
the service. For example, in August 2018, the manager of the NICU conducted a documentation
audit to ensure care records were written and managed safely. Following the audit, an action plan
had been developed to address key concerns.
The service participated in national audit programmes to measure and promote improved patient
outcomes. The service was performing in line with expected outcomes for most of the national
audits in which it participated.
Paediatric diabetes audit
The table below summarises the trust’s performance in the 2016/17 National Paediatric Diabetes
Audit.

Completion rate for key health
checks for patients aged 12+
(There are seven key care processes Better than No current
78%
recommended by NICE for patients expected standard
with Type 1 diabetes that should be
performed at least annually)
Case-mix adjusted mean HbA1c
(HbA1c levels are an indicator of how
well an individual’s blood glucose Within expected No current
66.3
levels are controlled. This measure is range standard
provided for benchmarking against
other providers during an audit year)
Median HbA1c
(This measure is provided to give an
indicator of how performance has Clinically
No current
changed between the previous and 61.3 significant
standard
latest audit reports. A change of 1 improvement
mmol/mol is deemed to be clinically
significant)
(Source: National Paediatric Diabetes Audit)
National Neonatal Audit Programme
The table below summarises the trust’s performance in the 2018 National Neonatal Audit
Programme (NNAP).

Do all babies <32 weeks gestation
have a temperature taken within an
hour of admission that is 36.5ºc-
37.5ºc? (Low body temperature on
admission is associated with increased
64.8%
Similar to other
hospitals 
complications, such as hypoglycaemia,
jaundice and respiratory distress, and
death in pre-term infants)
Is there a documented consultation
Better than other
with parents by a senior member of 98.2%
hospitals 
the neonatal team within 24 hours of
admission?
(Timely consultation with
parents/carers is crucial to allaying fear
and anxiety and improves the
parent/carer experience)
Do all babies < 1501g or a
gestational age of < 32 weeks at
birth receive appropriate screening
for retinopathy of prematurity (ROP) 95.6%
Similar to other
hospitals 
(ROP is a preventable cause of
blindness in pre-term infants provided it
is detected and treated in a timely way)
Do all babies with a gestation at
birth <30 weeks receive a
documented follow-up at two years
gestationally corrected age? Similar to other
(It is important that the development of
52.7%
hospitals 
pre-term babies is monitored by a
paediatrician or neonatologist after
discharge from the neonatal unit)
(Source: National Neonatal Audit Programme)
Since the NNAP audit, areas for improvement had been identified and an action plan was created
to address poor performing metrics.
The service was participating in the Epilepsy 12 audit, commissioned by the Royal College of
Paediatrics and Child Health. The audit identified the need for an epilepsy nurse specialist, who
could support the service and improve patient outcomes. Since the audit, the service had recruited
an epilepsy nurse specialist. Their first task was to develop clear transitional arrangements for
children with epilepsy.
One way to assess the effectiveness of care and treatment is to review readmission rates. To
protect patient confidentiality, only cases where six or more readmissions were recorded by the
trust have been included in the data below.
Emergency readmission rates within two days of discharge
From June 2017 to May 2018, 20 children aged between one and 17 years old were re-admitted
to the hospital within 48 hours of discharge, following an emergency admission. The service was
therefore performing slightly better than the England average (2.8%), with a low readmission rate
of 1.5%.
Emergency readmissions within two days of discharge following emergency admission

among the 1-17 age group, by treatment specialty (June 2017 to May 2018)
Specialty
Readmission rate Discharges (n) Readmissions (n) Readmission rate
Paediatrics 1.5% 1,340 20 2.8%
Rate of multiple emergency admissions within 12 months among children and young
people for asthma, epilepsy and diabetes
From July 2017 to June 2018, the trust had no admissions for patients under one year old with
asthma or diabetes. There were fewer than six patients admitted with epilepsy in this age group
and therefore the analysis has been suppressed in the table below.
The trust’s multiple readmission rate for patients aged one to 17 years old with a long-term
condition of asthma was higher than the England average while the rate for epilepsy was slightly
lower. The trust had fewer than six patients with multiple admissions for diabetes, for patients
aged one to 17 years old, and therefore the analysis has been suppressed in the table below.
Rate of multiple (two or more) emergency admissions within 12 months among children
and young people for asthma, epilepsy and diabetes (for children aged under 1 year and
1 to 17 years) (July 2017 to June 2018)

Long term
condition Multiple At least one Two or more Multiple
admission rate admission (n) admissions (n) admission rate
Asthma
Under 1 - - - 8.5%
1 to 17 20.6% 68 14 16.1%
Diabetes
Under 1 - - - 11.1%
1 to 17 * 22 * 12.9%
Epilepsy
Under 1 * * * 33.6%
1 to 17 24% 25 6 27.5%
Notes: To protect patient confidentiality, figures between 1 and 5 and their associated proportions
have been suppressed and replaced with “*” (an asterisk). Where it was possible to identify
numbers from the total due to a single suppressed number in a row or column, an additional
number (generally the next smallest) has also been suppressed.
Staff described how they regularly developed and reviewed patient pathways to deliver the best
patient outcomes. For example, on the Alexandra Day Surgery Unit, there were plans to
streamline the pathway for children with obstructive sleep apnoea (a sleep disorder in which
breathing repeatedly stops and starts).
Congenital cytomegalovirus (cCMV) infection is a leading cause of childhood hearing loss. The
service was conducting targeted cCMV testing in infants who failed their new-born hearing test,
with the aim of detecting and treating cCMV, potentially preventing permanent hearing loss.
The NICU was participating in the Avoiding Term Admissions Into Neonatal Units (ATAIN)
programme, designed to reduce the harm caused by avoidable admission to a neonatal unit for
infants at term (gestational age ≥ 37 weeks). The programme focussed on four key clinical areas:
respiratory conditions; hypoglycaemia (abnormally low level of blood sugar); jaundice; and
asphyxia (condition arising when the body is deprived of oxygen). Staff reported positive outcomes
since the implementation of ATAIN, including a reduction in the number of infants with
hypoglycaemia.
Competent staff
Staff had the appropriate skills, knowledge and experience to deliver effective care and
treatment.
All new staff were required to attend a corporate induction and complete a local induction
programme. There were also competency assessments for new nursing and healthcare staff.
Competencies included medicines management and patient observations. All competencies
required sign off by a senior staff member.
The service had a new 12-month preceptorship programme for newly qualified nurses. The
programme ran in collaboration with six local trusts and provided 12 days of specialist training and
ongoing support to newly qualified nurses. For example, a local NHS acute trust that specialised in
plastic and burns ran a training day on wound and burn care. Two local hospices also supported
the programme and provided end of life care training. All staff who completed the programme
attended a graduation ceremony and received a pin badge. A practice development nurse
supported staff throughout the 12 months and was working with a local university to gain
accreditation for the programme. Service leads told us the programme had received positive
feedback and had played an important role in the recruitment and retention of staff.
The trust had suitable arrangements for staff supervision and appraisal. Staff identified their
learning needs and development opportunities through their yearly appraisal.
Appraisal rates
From April to October 2018, 85.1% of paediatric staff received an appraisal, compared to a trust
target of 90%.

received staff rate target (Yes/no)
Qualified allied health professionals 1 1 100% 90% Yes
Support to doctors and nursing staff 24 31 77.4% 90% No
Total 80 94 85.1% 90% No
Nursing staff told us they had been supported with their revalidation through clinical supervision.
Revalidation is the process where nurses renew their registration with the Nursing and Midwifery
Council.
The trust provided staff with training to deliver effective care, support and treatment. Dolphin
Ward ran three annual team days where staff were encouraged to suggest training topics.
Theatres ran a monthly audit session where staff received equipment demonstrations and face-
to-face mandatory training.
Additional training opportunities were communicated at team meetings and on staff notice
boards. All staff we spoke with told us that they were supported to pursue additional training
opportunities, relevant to their role. For example, specialist nurses ran in-house study days in
topics such as oncology and trauma. The high dependency unit (HDU) facilitator organised a
HDU course which focussed on key competencies such as optiflow (a device which provides
nasal high flow therapy) and continuous positive airway pressure (CPAP), a treatment involving a
machine that uses mild air pressure to keep breathing airways open.
All nurses working on the Neonatal Intensive Care Unit (NICU) had completed the Bliss family
and infant neurodevelopmental education (FINE) course. The course was designed to improve
staff knowledge and skills in delivering developmental care to babies and their families,
ultimately improving long-term outcomes.
Staff were trained and maintained competencies in life support. All nursing staff completed
training in either paediatric immediate life support or new-born life support yearly.
Qualified in Speciality (QiS) is an accredited post-registration qualification in specialised
neonatal care. Although not all staff on the NICU had completed the QiS course, the unit
complied with the British Association of Perinatal Medicine staffing guidelines, ensuring all
neonates receiving intensive and high dependency care were looked after by a nurse QiS.
Healthcare assistants could participate in the care certificate programme. The programme aimed
to prepare health and social care support workers with the knowledge and skills to provide safe
and compassionate care.
The local mental health trust provided staff with training on supporting children and young people
with their emotional wellbeing and mental health needs.
Although access to allied health professionals was limited, there was effective
multidisciplinary working across the service.
The service held multidisciplinary team (MDT) meetings to discuss, in detail, the needs of patients.
All members of the MDT were involved with assessing, planning and implementing patient care.
Multidisciplinary teams included paediatricians, nurses and therapy staff. Staff made referrals to
the wider MDT, such as the tissue viability nurse, if required.
The service held quarterly MDT meetings to discuss the needs of patients who had complex
conditions. In these circumstances, each patient had a complex needs care plan which would be
updated after each MDT meeting. The service also held monthly MDT meetings to discuss
children who were approaching the end of their life. Staff from the local hospice service attended
these MDT meetings to ensure a coordinated approach from hospital to home.
There were good working relationships between medical and nursing staff. We observed the daily
doctors’ handover on Dolphin Ward, which was attended by nine staff members including the
consultant of the week, the paediatric matron, ward manager, safeguarding named nurse and
nurse in charge. Each patient was discussed in detail, as were any safeguarding concerns,
expected admissions and discharges.
Staff also held daily ward rounds and safety huddles to discuss and plan patient care. Following
feedback from parents, the Neonatal Intensive Care Unit (NICU) had started to encourage parents
to join the discussion about their child on the ward round. This ensured parents were routinely
involved in decisions about their child’s care and treatment.
Staff had daily input from a pharmacist assigned to Dolphin Ward and the NICU. Physiotherapists
supported children on Dolphin Ward and the Alexandra Day Surgery Unit to restore movement
and function after surgery. Staff also had access to a dietitian who supported children with
diabetes and those with complex nutritional needs.
However, input from other allied health professionals was limited, particularly on the NICU.
Speech and language therapy on the NICU was only available once a week. There was no
physiotherapist assigned to the unit. As physiotherapists can assess and support babies with
respiratory, neurological and musculoskeletal disorders, the absence of a physiotherapist can
have a negative impact on the health and wellbeing of babies. Staff told us that although there was
no inpatient physiotherapy, a physiotherapy service was available once babies were discharged
into the community. At the time of our inspection, the head of children’s nursing was liaising with
the trust’s physiotherapy lead to establish physiotherapy cover for the NICU.
The paediatric service had a play team, available five days a week. The team was hoping to
recruit additional staff, in order to provide a seven-day service. Any department within the hospital
that cared for children and young people could access the qualified play specialists.
The service worked in collaboration with adult services to deliver the ‘ready, steady, go’
programme, supporting young people with their move to adult services. The adult learning
disabilities team were notified of any young people in the transition phase and created relevant
care plans to meet their needs.
The service had strong working links with external services and agencies. For example, staff on
Dolphin Ward told us that they worked closely with health visitors employed by a local community
provider. All patients under six years of age had a link health visitor, promoting a healthy lifestyle
following discharge. All school-aged children were assigned a link school nurse to ensure their
education continued while in hospital. The community nurses were also an integral part of the
team and worked closely with staff on Dolphin Ward to ensure care outside the hospital setting
was effective. Community nurses attended the morning handovers on Dolphin Ward and the
paediatric matron met with the community provider monthly.
The service had recently employed a physician associate to Dolphin Ward, supporting doctors in
the diagnosis and management of patients. Physician associates are medically trained, generalist
healthcare professionals, who work alongside doctors and provide medical care as part of the
multidisciplinary team.
The service worked in collaboration with staff from a local mental health trust to support children
and young people with mental health needs. Staff could refer children and young people requiring
mental health treatment to the local emotional wellbeing and mental health service (EWMHS). The
trust was looking to recruit a psychologist to meet the growing demand for mental health support.
In the CQC Children and Young People’s Survey 2016, the trust scored 8.2 out of ten for the
question ‘Did the members of staff caring for your child work well together?’ This score was about
the same as other trusts.
Seven-day services
Staff were working towards a seven-day service.
Seven-day services were provided on Dolphin Ward and the Neonatal Intensive Care Unit.
Children and young people had seven-day access to diagnostic services such as x-ray and CT
(computerised tomography) scanning.
The children’s outpatient department operated Monday to Friday, 9am to 5pm. The service
occasionally ran Saturday clinics to manage any backlog. The paediatric ambulatory unit operated
Monday to Friday, 7.30am to 8pm. The team held a staffing meeting each Monday to determine
whether the unit could also be safely staffed at the weekend. Service leads were looking to recruit
additional staff to increase the opening hours during the week.
Paediatric consultants were available on-site between 9am and 10pm, Monday to Friday. Out of
hours, there was a paediatric consultant on-call rota, in line with Royal College of Paediatrics and
Child Health guidelines. Pharmacy services were open Monday to Friday, 9am to 7pm, Saturdays
9am to 3pm and Sundays 12pm to 2pm. An on-call pharmacist was available out of hours. The
play team was available Monday to Friday but was working to provide this service seven days a
week.
Health promotion
The service supported people to live healthier lives.
The trust had a no smoking policy and only permitted smoking outside of the hospital grounds.
Staff advised new parents to keep their home smoke free, to reduce the risk of cot death and
prevent respiratory conditions. Dolphin Ward had recently put up posters detailing the health risks
of e-cigarettes.
Staff in the pre-assessment clinic gave patients and parents information on how to prepare for
surgery and how to improve their recovery after surgery. This included information on early
mobilisation with a physiotherapist and information on post-operative pain relief.
All paediatric care plan booklets contained information on how to minimise infection during a
hospital admission. Information included procedures around isolation and hand hygiene. We also
saw posters informing parents and visitors about how to correctly wash their hands, to reduce the
risk of spreading infection.

Consent to care and treatment was sought in line with legislation and guidance.
The term Gillick competence is used to describe when a child can consent to his or her own
medical treatment. Staff were aware of Gillick competence and applied this proportionately when
obtaining consent from young people. Staff encouraged young people to involve their families in
decisions about consent.
Staff followed an up-to-date mental capacity policy, which outlined how staff should formally obtain
and record a patient’s consent to care and treatment. The Mental Capacity Act (2005) is designed
to protect patients who may lack capacity, to make certain decisions about their care and
treatment. Information about the Mental Capacity Act (2005) and associated Deprivation of Liberty
Safeguards (DoLS) was covered as part of the trust’s safeguarding adults level 2 training module.
is available to staff that want to enhance their safeguarding skills, but is not offered as part of the
as of March 2019 for qualified nursing staff and medical staff in services for children and young
people at Princess Alexandra Hospital:
As of March 2019
In services for children and young people at Princess Alexandra Hospital, the 90% target for
safeguarding adults level 2 training was met by qualified nursing staff. Although the target was
not met for medical staff, the completion rate was slightly higher than in the previous time period.
At our last inspection, consent was not consistently documented in patient records and the service
was not conducting consent audits to identify where support was needed. During this inspection,
we found consent documentation had improved. Staff on the Neonatal Intensive Care Unit
documented consent using a daily summary sheet. Dolphin Ward had introduced a daily ward
round proforma, allowing staff to obtain consent, from either the patient or parent, for all
procedures that day. The service had also started to complete consent audits to monitor
compliance and identify any areas for improvement. The latest consent audit (February 2019)
showed staff on Dolphin Ward were 100% compliant with all aspect of consent documentation.
CQC Children and Young People’s Survey 2016 Data
The trust performed about the same as other trusts for four of the five questions relating to
effectiveness in the CQC Children and Young People’s Survey 2016. No score was provided for
the remaining question.
CQC Children’s Survey questions, effective domain, The Princess Alexandra Hospital NHS
Trust
Age Trust Comparison to

Question
group score other trusts
Did you feel that staff looking after your child
0-15 About the same
knew how to care for their individual or special 8.4
adults as other trusts
needs?
Did staff play with your child at all while they 0-7 About the same
6.4
were in hospital? adults as other trusts
Did different staff give you conflicting 0-7 About the same
7.8
information? adults as other trusts
During any operations or procedures, did staff
0-15 About the same
play with your child or do anything to distract 7.4
them?
Did hospital staff play with you or do any 8-11 No
No Score
activities with you while you were in hospital? children Score
0-7 adults = asked of parents and carers of children up to seven years of age
0-15 adults = asked of parents and carers of children up to 15 years of age
8-11 children = asked of children aged from eight to 11 years of age
Compassionate care
Staff provided compassionate care, treating patients with dignity and respect.
Staff protected the privacy and dignity of children and young people. Staff used coded symbols to
restrict the amount of patient information on display, and we saw staff drawing curtains around bed
spaces when treating patients or having sensitive conversations. Staff knocked and sought
permission before entering patient side rooms. The Neonatal Intensive Care Unit (NICU) had
curtains and a breastfeeding room, to ensure privacy was maintained for mothers when
breastfeeding.
We observed all staff to be courteous, professional and kind when interacting with patients and
those close to them. We observed staff greet patients appropriately for their age, and introduce
themselves by name. Parents told us that staff were attentive to their child and we observed that
call bells were answered in a timely manner.
Staff responded in a compassionate way to children who were frightened, confused or phobic
about aspects of care and treatment. Staff on Dolphin Ward worked with local nurseries to try and
educate young children about what happens in a hospital to reduce their fears.
Patient and parent feedback was positive. The parents we spoke with told us that staff were caring
and supportive. Dolphin Ward and the NICU displayed patient thank you cards and messages.
Comments from the cards showed that parents felt staff had treated their child with compassion.
The play team went above and beyond what was expected of them. For example, the team hired
laughter specialists to entertain and perform on Dolphin Ward and regularly invited special guests
to surprise the children, including famous football players. The team also decorated patient rooms
with their favourite cartoon characters, prior to their admission.
Children and young people were encouraged to provide feedback on the service using the monkey
feedback survey. The survey allowed children to draw a picture of their visit and state what was
good and bad about the service. Staff reported that most of the feedback was positive. Any
negative feedback was discussed at team meetings and acted upon, if appropriate.
Staff followed an up-to-date chaperone policy, protecting children and young people during
intimate personal care.
The results of the CQC national children’s survey 2016 are displayed in the table below. The
results show that the trust performed similar to other trusts for all 10 questions relating to
compassionate care.

Question
Did new members of staff treating your child 0-7 About the same
8.6
introduce themselves? adults as other trusts
Did you have confidence and trust in the 0-15 About the same
8.6
members of staff treating your child? adults as other trusts
Were members of staff available when your 0-15 About the same
7.3
child needed attention? adults as other trusts
Do you feel that the people looking after 0-7 About the same
8.7
your child were friendly? adults as other trusts
Do you feel that your child was well looked 0-7 About the same
8.6
after by the hospital staff? adults as other trusts
Do you feel that you (the parent/carer) were 0-15 About the same
7.6
well looked after by hospital staff? adults as other trusts
Was it quiet enough for you to sleep when 8-15 About the same
4.8
needed in the hospital? children as other trusts
If you had any worries, did a member of staff 8-15 About the same
8.4
talk with you about them? children as other trusts
Do you feel that the people looking after you 8-15 About the same
9.3
were friendly? children as other trusts
Overall, how well do you think you were 8-15 About the same
8.6
looked after in hospital? children as other trusts
Emotional support
Staff provided exceptional emotional support to patients to minimise their distress.
Staff understood the importance of providing emotional support for children and those close to
them. We observed staff providing assurance to anxious patients and parents. For example, staff
on Dolphin Ward provided assurance to a parent while their child was being prepared for an x-ray.
Staff on the Alexandra Day Surgery Unit prepared children for surgery using an interactive, virtual
reality app to help reduce their anxieties. The app allowed children to virtually ‘visit’ surgical areas
and meet animated hospital staff who explained what would happen during their procedure.
Children and young people received their own pair of virtual reality goggles to take home and were
encouraged to personalise their goggles with stickers. Children and young people could also visit
the hospital before their admission to familiarise themselves with staff and ask questions.
On the Alexandra Day Surgery Unit, parents could accompany their child to the anaesthetic room
and stay with their child until they were anaesthetised. Parents were also encouraged to be
present in the recovery room for when their child woke up. This ensured parents were able to
provide continuous emotional support and reassurance throughout the child’s surgery. The trust’s
play team supported children to prepare for treatment and surgery. Play specialists used
distraction therapy, such as games and puzzles, to help children cope with painful or difficult
procedures.
The service participated in the innovative Harvey’s gang initiative, enabling children with complex
needs and long-term conditions to become trainee biomedical scientists for the day. The children
received a tailored tour of the trust’s haematology laboratories with their families, where they could
ask questions and gain a better understanding of what happened to their blood samples. The
service reported the initiative had received consistent positive feedback from both the participating
families and the staff in the laboratory.
The trust employed specialist nurses to provide practical and emotional support for children and
young people with specific conditions, such as diabetes. Two oncology nurse specialists provided
a weekday on-call service, allowing parents to contact the service if they had concerns regarding
their child’s health.
Staff had access to a mental health liaison team who could support the mental health needs of
children and young people. Staff told us that the team responded in a timely manner when
requested.
The service supported children approaching the end of life. Staff made community support
referrals and created memory boxes for parents of children receiving end of life care on the ward.
Staff understood and respected the spiritual and religious needs of patients. The trust’s spiritual
care department offered emotional support to all faiths and was available 24 hours a day, seven
days a week. Parents on the Neonatal Intensive Care Unit (NICU) could access support from
Petals, a baby-loss counselling charity. The charity provided emotional and psychological support
for bereaved parents. The trust’s bereavement midwife had raised funds to build a counselling
room for bereaved parents and carers.
Staff on the NICU encouraged parents to provide Kangaroo care, a type of care commonly used
for premature babies. This involves skin-to-skin contact between parent and infant, promoting
emotional attachment and bonding. Kangaroo care can also increase rates of breastfeeding and
reduce the risk of hospital acquired infection.
results show that the trust performed similar to other trusts for all five questions relating to
emotional support.
Question
Was your child given enough privacy when 0-7 About the same
9.1
receiving care and treatment? adults as other trusts
If your child felt pain while they were at the
0-15 About the same
hospital, do you think staff did everything they 8.4
could to help them?
Were you treated with dignity and respect by 0-7 About the same
9.1
the people looking after your child? adults as other trusts
Were you given enough privacy when you 8-15 About the same
9
were receiving care and treatment? children as other trusts
If you felt pain while you were at the hospital,
8-15 About the same
do you think staff did everything they could to 9.1
children as other trusts
help you?

Staff communicated with patients about their care and treatment in a way they could
understand.
At our last inspection, parents told us they were not always kept informed about their child’s care
and treatment. During this inspection, parents and carers felt they were well informed and had the
opportunity to ask questions during ward rounds. The service had introduced new patient
documentation, including a staff and parent communication document, to improve communication
with parents.
Staff communicated with children and young people about their care and treatment in a way they
could understand. Staff provided patients and parents with relevant information, both verbal and
written, so they could make informed decisions about their care and treatment. For younger
patients, staff provided a picture book which showed the various stages of having surgery or a
magnetic resonance imaging (MRI) scan. Staff ensured patients and families were able to find
further information and support, including community and advocacy services.
Children and young people, and their parents were both treated as important partners in the
delivery of care. Dolphin Ward and the NICU offered unrestricted access for parents and staff
encouraged parents to stay with their child overnight. The NICU had two parent bedrooms,
prioritised for those parents with the sickest babies or for mothers stabilising breastfeeding.
Dolphin Ward had a bell which children could ring to celebrate the end of their chemotherapy
treatment. The ward also participated in the beads of courage programme. The programme
presents children with a bead following every stage of cancer treatment. The beads join together
to form a physical representation of the child’s recovery, keeping a record of every hospital trip
and treatment on their journey.
results show that the trust performed better than other trusts for one question and similar to other
trusts for 17 questions, relating to the understanding and involvement of patients and those close
to them. No scores were provided for three questions.
Question
Did members of staff treating your child give
0-15 About the same
you information about their care and treatment 8.9
in a way that you could understand?
Did members of staff treating your child
0-7 About the same
communicate with them in a way that your child 7.4
could understand?
Did a member of staff agree a plan for your 0-15 About the same
9
child’s care with you? adults as other trusts
Did staff involve you in decisions about your 0-15 About the same
8.1
child’s care and treatment? adults as other trusts
Were you given enough information to be
0-15 About the same
involved in decisions about your child's care 8.3
and treatment?
Did hospital staff keep you informed about
0-15 About the same
what was happening whilst your child was in 7.9
hospital?
Were you able to ask staff any questions you 0-15 About the same
8.7
had about your child’s care? adults as other trusts
Before your child had any operations or
0-15 About the same
procedures did a member of staff explain to 9.3
you what would be done?
Before the operations or procedures, did a
0-15 About the same
member of staff answer your questions in a 9.5
way you could understand?
Afterwards, did staff explain to you how the 0-15 About the same
8.4
operations or procedures had gone? adults as other trusts
When you left hospital, did you know what was 0-15 About the same
7.8
going to happen next with your child's care? adults as other trusts
Do you feel that the people looking after your 0-7 About the same
8.2
child listened to you? adults as other trusts
Did hospital staff talk with you about how they 8-15 About the same
8.7
were going to care for you? children as other trusts
When the hospital staff spoke with you, did you 8-15 About the same
8.7
understand what they said? children as other trusts
8-15 About the same
Did you feel able to ask staff questions? 9.7
8-15 About the same
Did the hospital staff answer your questions? 9.2
Were you involved in decisions about your care 8-15 About the same
6.4
and treatment? children as other trusts
When you left hospital, did you know what was 8-15 Better than
8.8
going to happen next with your care? children other trusts
12-15 children = asked of children aged from 12 to 15 years of age

The trust planned and delivered services to meet the needs and demands of local people.
The service had established effective relationships with a wide range of organisations including
local commissioners, GPs, schools, mental health services, hospices and charities, to address the
needs of local people and improve patient access to services. Staff on Dolphin Ward worked
collaboratively with staff from the local mental health NHS trust, to help support children with
mental health conditions.
To help improve patient access, staff ran community satellite clinics in several accessible locations
across Essex. Community clinics included a fortnightly diabetes clinic and a monthly transition
clinic. Staff had used patient satisfaction surveys to adjust the times of the clinics and meet patient
demand.
The service had recently started a paediatric insulin pump clinic, to help improve diabetes control.
When used appropriately, insulin pumps can reduce hypoglycaemia (low blood sugar) and
hyperglycaemia (abnormally high blood sugar levels).
Local children with sleep apnoea (a sleep disorder in which breathing repeatedly stops and starts)
had to travel to an acute NHS hospital in London for a review. The trust’s ears, nose and throat
(ENT) consultants were hoping to provide a more local review service for sleep apnoea and at the
time of our inspection, the service was awaiting the necessary monitoring equipment.
Where possible, the service involved children, young people and their families in the design and
running of the service. For example, the service regularly invited parents and children to attend
staff training sessions to provide insight on the patient’s experience. The ward manager on
Dolphin Ward had also contacted a local school to help design a new food menu.
The facilities and premises were appropriate for the services being delivered. Dolphin Ward had
separate bays for younger and older children and had an assortment of toys and games for all
ages. The ward also had a sensory room for children with limited communication skills and a
teenage ‘getaway shed’ for adolescents. The NICU had a private room for mothers who wished to
express breast milk.
Open visiting was available to parents on the NICU and Dolphin Ward. The service supported
parents by reducing hospital parking charges and providing sleeping facilities.
The service supported children to continue their education whilst in hospital. Dolphin Ward had a
teaching assistant based on the ward Monday to Friday, providing learning and educational
activities to children of all ages.
Dolphin Ward admitted children up to the age of 16. For young people aged 16 and 17, staff
followed a standard operating procedure (SOP) to ensure the patient was nursed in the most
appropriate environment. This environment was often on an adult ward, unless the young person
was on a planned transition pathway or had a learning disability. The safeguarding team were
notified about any 16 or 17-year-old admitted onto an adult ward. The team would complete a risk
assessment for all young people aged 16 and 17 and try to ensure that they were placed in a side
room on the adult ward. From October 2017 to September 2018, 98 young people had been
nursed on an adult medical ward.
Areas that saw children and young people, but were predominantly adult based, varied, with some
departments being more child-friendly than others. The adult areas with the highest proportion of
paediatric attendances were in outpatients (13.4%) and the emergency department (26.8%). The
hospital had a dedicated paediatric emergency department and paediatric outpatient department
for patients aged 15 and under.
All paediatric outpatient appointments, with the exception of four clinics, were held in the paediatric
outpatient department. Paediatric clinics were run by paediatricians and staffed by nurses trained
in paediatric immediate life support. The four exception clinics ran dedicated paediatric lists.
results show that the trust performed worse than other trusts for one question and similar to other
trusts for the remaining 14 questions relating to responsiveness. No score was provided for two
questions.

Question
For most of their stay in hospital what type of 0-15 About the same
9.9
ward did your child stay on? adults as other trusts
Did the ward where your child stayed have
0-15 About the same
appropriate equipment or adaptations for your 8.3
child's physical or medical needs?
Did you have access to hot drinks facilities in 0-15 About the same
8.5
the hospital? adults as other trusts
Were you able to prepare food in the hospital 0-15 About the same
4
if you wanted to? adults as other trusts
How would you rate the facilities for parents or 0-15 About the same
6.5
carers staying overnight? adults as other trusts
Were there enough things for your child to do 0-7 About the same
7.5
in the hospital? adults as other trusts
0-7 About the same
Did your child like the hospital food provided? 4.5
Did a staff member give you advice about 0-15 About the same
8
caring for your child after you went home? adults as other trusts
Did a member of staff tell you who to talk to if
0-7 About the same
you were worried about your child when you 7.5
got home?
Were you given any written information (such
0-15 Worse than other
as leaflets) about your child’s condition or 6.2
adults trusts
treatment to take home with you?
Were there enough things for you to do in the 8-15 About the same
5.4
hospital? children as other trusts
Did a member of staff tell you who to talk to if
8-15 About the same
you were worried about anything when you 7.1
got home?
Did a member of staff give you advice on how 8-15 About the same
8.6
to look after yourself after you went home? children as other trusts
Did the hospital give you a choice of 0-7 About the same
3.4
admission dates? adults as other trusts
Did the hospital change your child’s admission 0-7 About the same
9.1
date at all? adults as other trusts
12-15 children = asked of children aged from 12 to 15 years of age
Staff planned and delivered services to meet individual needs.
Pre-admission screening was used to plan services to meet individual needs. Nursing staff also
assessed patients on admission, ensuring any additional needs were identified following an acute
unplanned admission. Staff recorded specific dietary needs at the patient’s pre-operative
assessment or on admission. Menu options were available for patients who required special diets,
for religious or cultural reasons.
Staff used a flagging system to record any special needs on an electronic patient record database.
This ensured specialist teams were notified of an admission. For example, every child with a
learning disability or autism would be flagged on the electronic database. A daily list of flagged
children was sent to the learning disability team. The team would then be aware of each patient’s
admission and would create specific care plan to meet the patient’s needs.
Paediatric departments had elected ‘champions’ who received additional training in their chosen
speciality and attended working groups and conferences. Champions provided their colleagues
with training, advice and support on various topics such as domestic violence and suicide.
In addition to champions, the trust had clinical leads to identify and meet the individual needs of
patients. An allergy nurse specialist provided staff with support and training, to help meet the
needs of patients with complex allergies. A diabetes team was available to support children with
diabetes and the paediatric consultant lead for diabetes provided an out-of-hours advisory service,
in collaboration with consultants from other local NHS trusts. Dolphin Ward had two oncology
nurse specialists who ran oncology study days and provided a weekday on-call service for patients
and parents.
Staff had access to interpreting services for patients who did not speak English. Staff used the
language line provided by the trust or could arrange a face-to-face interpreter, if required.
Staff made adjustments to accommodate patients with additional needs. For children and young
people with a learning disability, the service used a variety of communication aids to support them,
including easy read books and sensory toys. On the Alexandra Day Surgery Unit, children could
be admitted onto the unit early morning, allowing time to settle and relax before surgery. All
departments could contact the play team to help distract children when they were being treated.
There was specialist equipment available for children with individual needs, such as bariatric
equipment (equipment for overweight children and young people) and mobility aids. All paediatric
areas were accessible for people using a wheelchair.
An emotional wellbeing and mental health service (EWMHS) for children and young people was
provided by a local NHS mental health trust. The service was nurse-led and available 24 hours a
day, seven days a week. The team assessed all children presenting with an acute mental health
need, expressing suicidal ideation or self-harm. Staff working in the emergency department, or on
Dolphin Ward, could access the crisis team through a single point of access number. Staff
reported that the EWMHS team were responsive and also offered specialist services for young
people with a learning disability.
At our last inspection, the service did not have a dedicated transition team or clear transition
pathway. During this inspection, we found transition arrangements had improved but there was still
more work to be done. Since our last inspection, a transition policy had been developed, outlining
key roles and responsibilities. The service had also implemented the ‘ready, steady, go’
programme, which helped young people gain the confidence and skills to move to adult services.
The programme was developed in line with the National Institute for Health and Care Excellence
(NICE) guideline NG43 ‘transition from children’s to adults’ services for young people using health
or social care services.’ The adult learning disabilities team were notified of any young people in
the transition phase and created relevant care plans to meet their needs.
The service had also recently recruited an epilepsy nurse specialist. As part of their role, they were
working to develop clear transitional arrangements for children with epilepsy. The trust’s allergy
nurse specialist was also looking to develop a pathway for children with complex allergies.
Transition arrangements for children with diabetes and rheumatological conditions were well
established. In September 2019, the service was going to participate in a NHSI project to improve
transition services nationally.
Access and flow

Children and young people could access the service in a timely way.
The service had clear operational guidelines for admitting patients. The Neonatal Intensive Care
Unit (NICU) was Level 2 and provided special, high dependency and intensive care. Infants born
under 27 weeks gestation or under 800g were resuscitated and stabilised, prior to their transfer to
a regional neonatal intensive care service. Children and young people up to the age of 15 were
admitted onto Dolphin Ward. Young people aged 16 and 17 were usually admitted onto adult
wards, unless on a planned transition pathway or had a learning disability.
The paediatric ambulatory unit saw children and young people following a referral from the
emergency department or a self-referral. The unit assessed, investigated, observed and treated
children and young people, with the aim of reducing unnecessary inpatient admissions on Dolphin
Ward.
Discharge planning began on admission and discharge delays were rare. The service ran daily
ward rounds, where staff discussed the bed plan for the day, patients ready for discharge and any
issues that could present a challenge for timely discharge. From May 2018 to April 2019, the NICU
reported no babies delayed at discharge. Within the same time period, Dolphin Ward reported five
children delayed at discharge.
Staff aimed to complete and send all discharge summaries to GPs within 72 hours of discharge.
The service recognised that this was not consistently happening, particularly within the paediatric
emergency department, and were looking at ways to improve discharge summary completion.
Service leads were hoping that the recently appointed physician associate would support staff to
send discharge summaries within 72 hours.
The service actively monitored patient waiting times to ensure services in high demand were
managed appropriately to prevent patient delays. The NHS Constitution sets out that patients
should wait no longer than 18 weeks from GP referral to treatment (RTT). Trusts are required to
submit data to NHS England outlining how long patients are waiting for non-urgent treatment.
From May 2018 to April 2019, 88.4% of children and young people were treated within 18 weeks
of referral.
Staff working in the children’s outpatient department monitored waiting times. Staff kept patients
and parents updated when delays occurred and updated a whiteboard in the waiting room.
The children’s outpatient department also monitored DNA rates (rate at which patients did not
attend their appointment) on an internal database. From May 2018 to April 2019, the service
reported 1026 DNAs. The DNA database was sent to the safeguarding team monthly. Patients
who ‘did not attend’ appointments were flagged and re-contacted to schedule another
appointment.

There were clear processes for staff to manage complaints and concerns.
Staff followed an up-to-date complaints and concerns policy, which provided guidance on how to
manage complaints efficiently. Staff logged all complaints and concerns onto the electronic
incident recording system. The patient, safety and quality lead triaged the complaint and appointed
an appropriate investigation coordinator.
From December 2017 to November 2018, services for children and young people received eight
complaints (equivalent to 3.4% of all complaints received by the hospital). The trust took an
average of 46.6 working days to investigate and close complaints. All deadlines for completion
were agreed with their individual complainants, however the trust worked towards a target of 180
working days.
Department Number of complaints

Paediatrics 6
Urology 1
Neonatal intensive care unit 1
Total 8
A breakdown of complaints by subject is shown below:
Number of
Type of complaint
complaints
Patient care 3
Integrated care (including delayed discharge due to
1
absence of a care package)
Privacy, dignity & well being 1
Communications 1
Admin/policies/procedures (including patient record) 1
Prescribing 1
Total 8
There were procedures for sharing and learning from complaints across the service. Complaints
were discussed both locally at team meetings and at a senior level at the healthcare group
governance meeting. Trends were identified, and learning shared by email.
The service used complaints to change practice and improve care. For example, following a
complaint around privacy, the Neonatal Intensive Care Unit had replaced screens with curtains to
ensure privacy was maintained for mothers when breastfeeding.
Complainants were contacted within seven days to agree the level of investigation required. All
complainants were offered a face-to-face meeting to enable effective learning from the complaint.
Interpreters could be used to assist with bringing a quick resolution to a complaint.
Complaints leaflets and posters, describing the trust’s complaints procedure, were available in all
paediatric areas. Parents told us they felt confident to raise a concern if necessary.
From December 2017 to November 2018, there were 213 compliments about services for
children and young people. Of these compliments, 207 were in relation to inpatient children’s
services, and six related to outpatient services.

Leadership
Service leaders had the capacity and capability to deliver high-quality, sustainable care.
Services for children and young people were manged by the family and women’s healthcare
group. The healthcare group was overseen by an associate medical director, a director of
operations and an associate director of nursing, who all reported directly to the executive team.
Within the healthcare group, paediatrics was led by a head of nursing, clinical lead and matron.
The wards and departments were managed by visible, experienced and enthusiastic leaders. They
had good oversight of the activity, performance, staffing and safety of their service, and strove to
continuously improve it. For example, on Dolphin Ward, staff had created new care plan booklets.
The booklets had been developed to remind staff to consistently obtain and document patient
consent.
Staff spoke positively about the managers and described feeling valued in their role. Ward and
department leads felt supported by the senior leadership team. The senior leadership team were
accessible and approachable. They understood the challenges to quality and sustainability, and
could identify the various actions needed to address them. Paediatric day surgery was also
managed within the family and women’s healthcare group, providing a consistent approach to
children’s services across specialities.
Staff had access to leadership skills and development opportunities, including a leadership
development program. Staff described how the trust promoted development by funding university
courses.
Vision and strategy

There was currently no formal strategy specifically for the service. Service leads had a plan
to develop a strategy with involvement from staff, patients, and key groups representing
the local community.
Each healthcare group had developed a strategic plan, based on the five P’s (patients, people,
performance, places, pounds). The 5 P plan included objectives for the children and young
people’s service. Objectives included retain staff and improve mandatory training compliance.
At the time of our inspection, the children’s service did not have a clear strategy in place.
However, service leads were able to provide evidence of preliminary strategy discussions and an
outlined plan. The service was aiming to have drafted their strategy by August 2019, following
engagement with staff and patients. Service leads described how the strategy would align with
local plans in the wider health and social care economy, including the plan to build a new hospital.
Services for children and young people, under the family and women’s healthcare group, were
represented in the trust wide quality strategy 2016 to 2021.
Although there was no formal strategy for the service, service leads were clear on the vision of the
service and their role within it. They were also clear on how the service aligned with the wider trust
strategy. For example, the service had plans to increase activity in the paediatric ambulatory unit
by developing hot clinics and outpatient pathways. This, in turn, will work to reduce pressures on
Dolphin Ward and the children’s outpatient department.
The trust had worked with staff and patients to agree four organisational values; respectful, caring,
responsible, and committed. We saw the values displayed in trust buildings and staff offices. Staff
knew what the values were and understood their role in achieving them.
Culture
Leaders across the trust promoted a positive culture that supported and valued staff,
Staff reported an open and honest culture, centred on the needs and experience of children and
young people. Senior nursing and medical staff were actively involved in the daily management
and support of their service. Staff felt able to raise concerns with their manager, and we observed
leaders had an open-door policy. The trust had appointed a ‘freedom to speak up guardian’.
Guardians promoted an open culture, allowing staff to speak up about concerns easily.
The duty of candour is a regulatory duty that relates to openness and transparency and requires
providers of health and social care services to notify patients (or other relevant persons) of certain
‘notifiable safety incidents’ and provide reasonable support to that person. Information about the
duty of candour was included in the trust’s corporate induction programme. The trust also had a
duty of candour policy which covered the requirements of the regulation. Staff we spoke with were
aware of the principles of duty of candour and could give examples of when it should be triggered.
Despite vacancies, staff morale was high. Staff felt valued and well supported in their role. Staff
told us that there were opportunities for further learning and development. Several members of
staff described how they had developed and progressed within the organisation. Staff told us that
they were encouraged to go on courses that enabled them to develop personally and
professionally. For example, having an expressed an interest in child mental health, two nurses
were currently enrolled on a suicide awareness course.
There were positive working relationships and cohesive team work across the service. There was
a clear culture of multidisciplinary learning to improve patient care. For example, the service
worked in collaboration with staff from the local hospice to ensure a coordinated approach for
children approaching the end of their life.
The trust ran staff recognition awards for positive contributions to the service. Several staff had
been recognised for their contribution through the ‘employee of the month’ and ‘superstar of the
month’ scheme.
Governance
There were clear responsibilities, roles and systems of accountability to support good
governance and management.
Staff were clear about their roles and understood what they were accountable for. Staff
demonstrated a good awareness of governance arrangements and knew how to escalate their
concerns.
There were regular team meetings throughout the service. The minutes for team meetings were
circulated to staff by email. These meetings fed into management meetings which, in turn, fed into
the Family and Women’s service board meeting. The minutes of these operational meetings
showed that incidents, staffing and risks were routinely reviewed by staff at all levels.
The patient, safety and quality matron produced a monthly quality and safety report, reviewed at
directorate and at trust-wide level. The report contained detailed information on key areas of
quality and safety.
There were clear lines of accountability for safeguarding children. The safeguarding team
produced a safeguarding dashboard, presented at the trust’s monthly safeguarding steering group.
The team also presented an annual safeguarding report to the board.
There were clear processes for managing risks, issues and performance.
Services for children and young people had an electronic risk register, maintained by the service
leads. Each risk was given a rating, based on the potential consequence of the risk and the
likelihood that the risk would happen. Risks were also given a review date, responsible individual
and action plan. Risks included transition pathways and high vacancy rates.
Progress was regularly recorded on the risk register, demonstrating active management of risks.
Staff, including service leads, were aware of the risks in their service area, such as the discharge
summary delays, and knew what mitigations were in place to reduce the risk. Risks on the register
were discussed and reviewed monthly at the patient safety and quality meetings.
The service collected performance data through quality and safety reports, which provided the
board with an overview of how the service was comparing to key quality indicators. There was also
a programme of clinical audit across the service, which meant senior staff could monitor
compliance with safety standards. Where audits had been carried out, there was evidence that
service leads had used the results to implement improvements and changes to the service.
Information management systems and processes were effective.
Staff collected, analysed and managed information using secure electronic systems, with security
safeguards. The trust had arrangements to ensure the availability, integrity and confidentiality of
data was in-line with data security standards. For example, an operational data quality group met
fortnightly to support monitoring and resolution of data quality issues.
Service leads monitored quality and risk information through a number of systems, such as
governance meetings, local audits, dashboards and quality reports. A trust-wide quality dashboard
was produced on a weekly basis, containing information on quality and safety indicators.
Staff told us they were able to access the information they needed to ensure they provided safe
and effective care.
With parental consent, all infants admitted onto the Neonatal Intensive Care Unit had their data
collected and stored securely on an electronic database. The database was used in all neonatal
units across the East of England and was collected to support the ongoing development of
neonatal care.
Engagement
Staff, patients and relatives were engaged and involved in the service, improving the care
and treatment delivered.
Children and young people could provide feedback on the service using the monkey feedback
survey or by contacting the trust’s patient advice and liaison service. The service also encouraged
children, young people and their parents to present at staff study days, providing insight into the
patient experience.
Staff engaged and involved patients and parents in the design and running of the service. For
example, the ward manager on Dolphin Ward had contacted a local school to help design the new
food menu for children.
Staff told us about actions that had been taken following patient and parent feedback. For
example, parents on the Neonatal Intensive Care Unit could provide feedback in the monthly
parent survey. Themes from the survey were identified and discussed in safety huddles. The unit
manager would then create an action plan to address any parental concerns. As a result of the
parent survey, the unit had refurbished their parent rooms and created additional competencies to
support kangaroo care.
Staff were engaged in the planning and delivery of the service. Staff attended regular team
meetings to share ideas, opinions and feedback their concerns. They were encouraged to suggest
and help implement developments. For example, a practice development nurse had improved the
preceptorship programme for newly qualified nurses. A weekly staff brief, held in the hospital’s
restaurant, provided staff with an opportunity to engage with the senior leadership team.

There were systems in place to improve services by learning, continuous improvement and
innovation.
Staff embraced new technology to improve the patient experience. For example, staff on the
Alexandra Day Surgery Unit were using innovative technology to prepare children for surgery and
reduce their anxieties. Prior to their admission, patients were given the opportunity to explore the
hospital’s unit and theatres using an interactive, virtual reality app. The app allowed children to
virtually ‘visit’ surgical areas and meet animated hospital staff who explain what will happen during
their procedure. Patients received their own pair of virtual reality goggle to take home and were
encouraged to personalise their goggles with stickers.
Service leads strove for continuous improvement, including participation in national programmes
and research projects. For example, the Neonatal Intensive Care Unit (NICU) was participating in
the Avoiding Term Admissions Into Neonatal Units (ATAIN) programme, designed to reduce the
harm caused by avoidable admission to a neonatal unit for infants at term (gestational age ≥ 37
weeks). The programme focussed on four key clinical areas: respiratory conditions;
hypoglycaemia (abnormally low level of blood sugar); jaundice; and asphyxia (condition arising
when the body is deprived of oxygen). Staff reported positive outcomes since the implementation
of ATAIN, including a reduction in the number of infants with hypoglycaemia.
The service was also participating in the innovative Harvey’s gang initiative, allowing children with
complex needs and long-term conditions to become trainee biomedical scientists for the day. The
children received a tailored tour of the trust’s haematology laboratories with their families, where
they could ask questions and gain a better understanding of what happens to their blood samples.
The service reported that the initiative has received positive feedback from both the participating
families and the staff in the laboratory.
Service leads encouraged staff to work on improvement projects. For example, the service had a
new 12-month preceptorship programme for newly qualified nurses. The programme ran in
collaboration with six local trusts and provided 12 days of specialist training and ongoing support
to newly qualified nurses. For example, a local NHS acute trust that specialised in plastic and
burns ran a training day on wound and burn care. Two local hospices also supported the
programme and provided end of life care training. All staff who completed the programme
attended a graduation ceremony and received a pin badge. A practice development nurse
supported staff throughout the 12 months and was looking to get the programme accredited by the
local university. Service leads described how the programme had received positive feedback and
had played an important role in the recruitment and retention of staff.
All nurses working on the NICU had completed the Bliss family and infant neurodevelopmental
education (FINE) course. The course was designed to improve staff knowledge and skills in
delivering developmental care to babies and their families, ultimately improving long-term
outcomes.
End of life care
The trust provides end of life care at its Princess Alexandra Hospital site. End of life care
encompasses all care given to patients who are approaching the end of their life and following
death. It may be given on any ward or within any service in a trust. It includes aspects of
essential nursing care, specialist palliative care, and bereavement support and mortuary
services. The trust had a dedicated dementia and end of life ward that was opened in
September 2017. Gibberd Ward is a 27 bedded ward and patient admitted to this ward must
have documented agreed ceilings of treatment, a Treatment Escalation Plan, (TEP) and they
must have an indefinite do not attempt cardiopulmonary resuscitation (DNACPR) order in
place.
The trust had 1,241 deaths from November 2017 to October 2018.
The Specialist Palliative Care Team (SPCT) consists of specialist palliative care nurses and
1.4 whole time equivalent (WTE) consultants.
The team supports the delivery of the specialist palliative care and end of life care strategy
alongside the health care groups within the organisation.
The trust has a dedicated end of life care ward which is in the medical health care group. The
ward specialises in caring for patients in their anticipated last days of life and supporting
patients on end of life pathways to be discharged to their preferred place of care. The teams
work in close collaboration with the trust’s discharge team and community providers.
The trust has enlisted the support of the Ann Robson Trust butterfly volunteers who support
patients and relatives at end of life.
The trust has strong links with two hospices in west Essex and east Hertfordshire.
The bereavement team supports recently bereaved families with the process of registering
patient deaths and other practical information and offers advice for bereavement counselling.
The trust’s mortuary at Princess Alexandra Hospital provides suitable storage facilities for the
deceased and work closely with the Essex and Hertfordshire coroners service.
During our inspection we spoke with 36 members of staff including, consultants, matrons,
health care assistants, volunteers, junior doctors, staff nurses, ward managers, the mortuary
manager, bereavement officers, patient journey coordinators, the chaplain, sisters and
discharge support nurses. We looked at 37 do not attempt pulmonary resuscitation forms
(DNACPR) and spoke with two patients and two relatives.

Mandatory training
All nursing staff in the end of life care team had completed their mandatory training.
All members of the specialist palliative care team (SPCT) took part in mandatory and statutory
training to ensure they were trained in safety systems, process and practices such as basic life
support, dementia awareness, values and behaviours, conflict resolution and equality, diversity
and human rights. The trust set a target of 90% for the completion of mandatory training. This
target was met and completed at 100% (see the table below).
End of life care awareness training was given as part of the mandatory trust induction
programme, where the SPCT delivered a three-hour awareness session during the staff induction
training program. Topics included, what the SPCT was, Do Not Attempt Cardio-pulmonary
Resuscitation (DNACPR) forms, preceptorship training and end of life care symptoms
management. Mortuary and bereavement team and the chaplaincy team also delivered training
as part of the trust’s induction programme.
The mortuary manager and bereavement services completed mandatory and statutory training.
Data provided by the trust showed that the team was 100% complaint.
End of life care awareness training was given as part of the mandatory trust induction
programme, where the SPCT delivered a three- hour awareness session during the staff
induction-training program. The mortuary and bereavement team and the chaplaincy team also
delivered training as part of the trust’s induction programme.
The team on Gibberd ward had prioritised the training topics to ensure staff were competent to
care for dementia and end of life care patients. The trust set a target of 95% compliance with
mandatory training. Data from the trust dated March 2019 showed that on Gibberd ward
completion rates for nursing staff varied. There was 79% compliance in fire-general awareness,
70% infection control training, 76% hospital life support training, 70% infection control training
and 96% for Mental Capacity Act (MCA) training.

nursing staff in the end of life care department at Princess Alexandra Hospital is shown below:
As of October 2018
In Princess Alexandra Hospital’s end of life care department, the four members of qualified
nursing staff had completed all 10 mandatory training modules for which they were eligible.
in the end of life care department at Princess Alexandra Hospital is shown below:
As of October 2018
In Princess Alexandra Hospital’s end of life care team, the one member of medical staff had
completed all 10 mandatory training modules for which they were eligible.
The SPCT provided a range of training to clinical staff. There was a commitment from the trust end
of life care department to ensure that relevant clinical staff attended end of life care training. For
example, we were told by senior staff that end of life care champions were released from their
clinical areas to attend meetings and training days.
Safeguarding
Safeguarding systems processes and practices were developed, implemented and
communicated to staff. All SPCT staff were up to date on their safeguarding training
Specialist palliative care staff and those delivering end of life care had a good understanding of
safeguarding in the context of their roles and were aware of safeguarding policies and
procedures. They were aware of their responsibilities and knew who to contact should a
safeguarding concern arise. Staff were able to give us examples of what would constitute a
safeguarding concern, such as domestic abuse. Staff told us they would escalate any
safeguarding concerns to the trust’s safeguarding lead or their manager.
The trust had a safeguarding adult and a safeguarding children’s policy and all staff we spoke
with told us they could access these policies through the trust’s intranet.
The trust set a target of 95% for the completion of safeguarding training modules, apart from
prevent health WRAP training, where the target was 90%. 100% of the SPCT staff had
completed Safeguarding Adults Level 2 and Safeguarding Children Level 2 which exceeded the
trust target.
nursing staff in the end of life care department at Princess Alexandra Hospital is shown below:
As of October 2018
In Princess Alexandra Hospital’s end of life department, the four members of qualified nursing
staff had all completed all three safeguarding training modules for which they were eligible.
staff in the end of life care department at Princess Alexandra Hospital is shown below:
As of October 2018
In Princess Alexandra Hospital’s end of life care department, the one member of medical staff
had completed all three mandatory training modules for which they were eligible.

There were infection control and prevention systems in place to keep patients safe.
All staff on the SPCT had completed the trust’s infection control training level 1 and 2. All Staff in
the mortuary and bereavement team had completed the trust’s infection control training Levels 1 to
3. With a target of 95% on Gibberd ward 70 % of staff on the ward hard completed infection
control training.
Infection control procedures in the mortuary were followed. Hand washing facilities, overshoes and
PPE were available in the post mortem areas. This was in line with the trust’s standard infection,
prevention and control policy. We did not observe the decontamination process following a post
mortem during our visit. However, the mortuary manager explained the decontamination process
after the post mortem of a patient with an infectious disease.
Gibberd ward was visibly clean and uncluttered. Dated, “I am clean” stickers were visible on
equipment to signify that it was clean and ready for use. Staff adhered to trust policies and
guidance on the use of PPE guidance to help prevent the spread of infection. During our visit on
the ward we observed cleaning staff mopping and wiping down beds in empty side rooms after a
patient move.
Clinical waste bins had the correct bin liners. On Gibberd ward we noticed that two full sharps bins
had not been signed or dated and the date they were first in use was not recorded. This meant
that staff could not track when the bins were ready for disposal to avoid risks of infection. We
escalated this to the Matron.
We reviewed the mortuary cleaning and decontamination policy issued March 2017 and it detailed
cleaning and disinfecting methods used by the mortuary department. We noted that the mortuary
team followed the policy ensuring that infection and contamination was avoided.

The maintenance and use of equipment kept patients safe, syringe drivers were maintained
and used appropriately.
The trust had a cleaning policy in place, we reviewed that was issued on 28 July 2017. Within the
policy was a schedule for the collection and removal of waste across the trust. Before disposal
clinical waste bags were to be tagged and placed in designated areas for disposal. The policy also
detailed a list of actions to be completed by staff in preparation for room decontamination.
Gibberd ward was a purpose built 27 bedded ward that provided care for patients in receipt of end
of life care and those who were living with dementia. Patients on end of life care also received
care across the hospital. Most dementia patients were bedded in bays on the ward separate to
patients on end of life care who were cared for in side rooms for privacy in their last days of life.
Staff we spoke with on told us that syringe drivers were readily available, and they had not
experienced incidents of delays in accessing them. Staff on wards with end of life care patients
told us that they were trained to use syringe drivers.
A Contract was in place to ensure syringe drivers were calibrated and serviced. We reviewed a
selection of syringe drivers and those in use by end of life care patients had a planned
preventative maintenance (PPM) schedule. We noted that PPMs were tested and in date.
20 additional fridge spaces were housed in a mobile unit outside the mortuary. Access to the
mobile unit was restricted and CCTV was used. A wheel lock was in use to immobilise the unit to
mitigate the risk of the unit being moved. The trust continued to monitor the unit via CCTV.
The mortuary used UKAS temperature mapping which continuously monitored and recorded fridge
temperatures on a computer system. Fridges were connected to an alarm system that would
sound should the fridge temperatures drop below the required temperature. Fridge faults were
reported to the mortuary and maintenance teams who were available 24 hours a day.

Staff identified and responded appropriately to changing risks to patients at the end of life.
Daily board rounds were attended by discharge coordinators, consultants, junior doctors,
occupational therapist, physiotherapist, pharmacist and matrons. During board rounds staff
reviewed the care of patients at the end of life. We observed two board rounds where staff
discussed patient risk and identified control measures to mitigate that risk.
SPCT nurses would attend wards were patients had been identified as being at the end of life to
help prioritise referrals to Gibberd ward or Hospices and triaged them according to their needs and
risks.
Treatment Escalation Plans (TEPs) were used to support clinicians in planning, documenting
individualised ceilings levels of treatment for patients in their last days of life. We reviewed 15 sets
of patient care records and found that TEPs had been appropriately completed. The TEPs we
reviewed demonstrated that patients at the end of their life had a clearly documented ceiling of
treatment. This reduced the risk of inappropriate escalation of patients and inappropriate
continuation of treatment.
The trust used a version of the National Early Warning Score (NEWS) system. The NEWS system
is a way of standardising the identification and assessment of acute illness and deteriorating
patients. We reviewed five sets of patients’ notes and all the early warning indicators were
regularly checked assessed and appropriately calculated.
Individualised care plans were in use on wards to help plan end of life care for patients who were
expected to die within days or hours. The plans ensured that care was tailored to patient needs.
We looked at two individualised care plans and they included the assessment of risks such as risk
of falls and pressure damage.
Nurse staffing
Nursing staffing levels and skill mix in the SPCT were in line with National Guidance.
Medical cover was seen to sufficiently meet needs of patients.
Staffing levels in the SPCT were in line with national guidance (the Association of Palliative
Medicine for Great Britain and Ireland, and the National Council for Palliative Care recommends
there should be a minimum of one specialist palliative care nurse per 250 beds).
The SPCT were supported by palliative and end of life care ward champions, whose roles included
raising awareness of EOLC processes, and educating and supporting staff.
At the time of our inspection, there were no vacancies in the specialist palliative care nursing
establishment.
Please note that care should be taken when interpreting the nursing staffing data as the small
number of staff may have inflated the rates.
Planned vs actual
numbers for the end of life care core service as of March and October 2018. All of the staff were
within the trust’s specialist palliative care team.

Specialist palliative care team 3.0 3.4 88.2% 4.0 5.0 80.0%
As of October 2018, the nursing staffing fill rate within end of life care at Princess Alexandra
Hospital was 80.0%. This was lower than the rate of 88.2% as of March 2018 and largely due to
an increase of 1.6 WTE planned nursing staff.
During our inspection, we were told that the SPCT had no vacancies and were a fully
established team. The team consisted of one WTE Band 8b clinical nurse specialist, who was
the clinical lead, 3.4 WTE Band 7 specialist palliative care nurses and a Band 6 end of life care
facilitator. A palliative care coordinator had also recently been recruited. The current planned
establishment was identified as sufficient to deliver the service over six days and we were told
that there were plans to review this again with the view to staffing a seven-day service.
Vacancy rates
-3.8% for nursing staff in end of life care, indicating that the service was over established. This
was lower than the trust target of 8%. All staff were within the trust’s specialist palliative care
team.
Turnover rates
27.9% for nursing staff in end of life care. This was higher than the trust target of 12%. However,
it should be noted that this related to a single member of qualified nursing staff leaving the team.
All staff were within the trust’s specialist palliative care team.
Sickness rates
14.4% for nursing staff in end of life care. This was higher than the trust target of 3.5%. All staff
were within the trust’s specialist palliative care team.
The ward matron on Gibberd ward told us that due to staff shortages the same agency staff were
requested on a long-term basis.
During our inspection the end of life care leads told they did not use bank or agency staff within
the specialist palliative care team.
The table below shows the numbers of nursing hours in end of life care at Princess Alexandra
Hospital from December 2017 to November 2018 that were covered by bank and agency staff or
left unfilled.
Over this time period, 84 working hours were filled by bank staff and no hours were covered by
agency staff to cover sickness, absence or vacancy for qualified nurses. There were 12 hours
that were unable to be filled by either bank or agency staff.
Over the same time period, there were no working hours that were filled by bank or agency staff
or that were unable to be filled for non-qualified nursing staff.

Not filled by bank
Staff group Bank usage Agency usage
or agency
Hours Hours Hours
Qualified staff 84 0 12
Non-qualified staff 0 0 0
All nursing staff 84 0 12
Medical staffing
The trust employed a substantive palliative care consultant who had been in post since November
2017. Two palliative care consultants provided the 0.4 WTE hours between them, as part of a
service level agreement with a local hospice.
The Royal college of Physicians recommends between 1.56 and 2.0 WTE palliative care
consultants per population of 250,00. This is also cited by National Institute for Health and Care
Excellence (NICE) guidelines for end of life care in adults (QS13). The Princess Alexandra
Hospital served a population of approximately 350,000, meaning around 1.4 WTE consultants
were required and therefore the trust meets the QS13 guidance.
Out of hours, consultant support was available through switchboard from the on-call palliative
medicine consultant provided in conjunction with the local hospice
Planned vs actual
Princess Alexandra Hospital reported the following whole time equivalent (WTE) medical staff
numbers for the end of life care core service as of March and October 2018. All of the staff were
within the trust’s specialist palliative care team.

Specialist palliative care team 1 0.2 500% 1 1.4 71.4%
As of March 2018, the medical staffing fill rate within end of life care at Princess Alexandra
Hospital was 500.0%, based on one WTE staff member in post compared with only 0.2 WTE
planned. However, by October 2018, the number of planned staff had increased to 1.4 WTE
staff with one WTE in post, giving a fill rate of 71.4%.
Vacancy rates
-25.0% for medical staff in end of life care, indicating that the service was over established. This
was lower than the trust target of 8%. All staff were within the trust’s specialist palliative care
team.
Turnover rates

0.0% for medical staff in end of life care. This was lower than the trust target of 12%. All staff
grades.
Sickness rates
0.8% for medical staff in end of life care. This was lower than the trust target of 3.5%. All staff
From December 2017 to November 2018, Princess Alexandra Hospital reported no medical bank
and locum staff usage or shifts left unfilled in end of life care.
Records
Records were well maintained and kept securely. Information was available for staff to
deliver safe care and treatment to patients at the end of life.
Patients approaching the end of their life had an anticipated last days of life plan in place. The aim
of the care plan was to ensure that dying patients and their families received the best level of care
and support during the last days of life. We reviewed five care plans and all of them showed
discussions with relatives and family, individualised care plans and Treatment Escalation Plans
(TEP). One record was sparse and did not contain a holistic assessment and another record did
not have a Do Not attempt Pulmonary Resuscitation (DNACPR) form filled out where is should
have been.
TEPs were used to support clinicians to discuss, plan and document individualised ceilings of
treatment and care for patients in their anticipated last days of life. In the wards were visited TEPs
were used regularly. We reviewed 17 patient care records and found the TEPs had been fully
completed by staff.
Nursing staff used a comfort rounding tool to assess patients in the last days and hours of life. The
comfort rounding tool is a prompt for nursing staff to undertake and monitor a patient for mouth
care, comfort, hydration, safety and pain. The tool is also used to ensure patients are repositioned
for comfort.
The SPCT reviewed the Individualised care plan for the anticipated last days of life record to audit
compliance with documentation and recording for ceilings of care.
The SPCT made detailed entries within patient’s multidisciplinary team records. Documentation
was clear and concise and considered all aspects of patient care. SPCT documentation followed
the hospitals ‘COMPASSION’ acronym for assessing and documenting care. The ‘COMPASSION’
acronym stood for: communication, observations, medications, pain, activities of daily living, skin,
safeguarding, spirituality, invasive devices, oral and nutrition.
The mortuary manager explained that on admission to the mortuary as individual mortuary number
was assigned to each patient. Stickers with the number were printed out and attached to a wrist
band for the patient to wear. The mortuary number was added to a register that was updated each
time a patient was admitted. We reviewed mortuary records, which were accurate and matched
the mortuary occupancy at the time of our inspection.
In the areas were visited, we saw that patient records were securely and safely stored to protect
confidentiality.
Medicines
There were systems in place for the safe management and administration of medicines
During our inspection, we visited Gibberd ward, a ward set up to provide care for patients with
dementia and those requiring end of life care. Medicines on the ward were stored securely in
locked cupboards in a locked room that was only accessible by authorised staff.
We observed patients being administered medicines by syringe drivers during our inspection and
saw that monitoring of the administration of medicines was appropriately monitored on forms
provided.
Medicines were secured in a lockable wall mounted cupboard that was only accessible by
authorised staff. The controlled drugs cupboard on Gibberd ward was locked securely and all
stock levels were accurately documented. The cupboard was locked when not in use and keys
held by one authorised member of staff.
On Gibberd ward, medicines requiring refrigeration were stored within the recommended
temperature range, and daily monitoring of refrigerator temperatures was conducted. We reviewed
the temperature monitoring record, and entries were correctly completed from September 2018 to
the day of our inspection. Ambient room temperatures were also correctly monitored. Staff told us
that the protocol when refrigerator temperatures were out of range was to notify the pharmacy
team.
Patients receiving end of life care medicines were prescribed anticipatory medicines (medication
that was prescribed for use on an as required basis) to manage common symptoms that can occur
at the end of life. Medication was prescribed in advance to promptly manage any change in the
patient’s pain or other symptoms.
We reviewed four prescription charts and found that allergies were clearly recorded, regular
medicines prescribed included the dose, route, frequency and were signed by the prescriber.
During our inspection we found a bottle of medication that had been drawn up and left unattended
in a treatment room. The time that the medication had been drawn up was not written on the
medication bottle. Also, there was no record of who drew the medication and whether it had been
checked by a second member of staff. We escalated this to the nurse in charge of the ward and
we were assured that this was not usual practice for staff on the ward. That once administered
medication in stored and or disposed of correctly.
Incidents
There were systems and processes in place to report incidents and staff told us they were
encouraged to do so.
Incidents were reported through the trust’s electronic reporting system. Ward staff we spoke with
knew how to report incidents using the trusts electronic reporting system. Staff gave examples of
incidents requiring escalation.
The trust held daily serious incident group (SIG) meetings. Incidents were discussed, graded
according to severity and action plans were made. Following the SIG meetings staff were informed
of the incidents and learning points were shared to avoid them happening again.
Any incident relating to end of life care was referred to the End of Life Improvement Programme
Steering Group for discussion and sharing. The group met monthly and incidents were discussed
when they occurred. We reviewed meeting minutes dated October 2018 to March 2019 and we
were satisfied that incidents were discussed, and appropriate plans of action were made to resolve
them.
Staff in all roles supporting palliative and end of life care services understood the duty of candour
requirement. The duty of candour is a regulatory duty that related to openness and transparency
and requires providers of health and social care services to notify patients (or relevant persons) of
‘certain notifiable safety incidents’ and provide reasonable support to that person. Staff described
incidents when the duty of candour was used to inform the relevant persons following an error.
Never Events
never event.
From February 2018 to January 2019, Princess Alexandra Hospital reported no never events for
end of life care.

In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents
(SIs) in end of life care which met the reporting criteria set by NHS England from February 2018
to January 2019.

Patient’s needs were assessed, and care and treatment delivered in line with evidence-
based guidance to achieve effective outcomes.
We reviewed the trust’s End of Life strategy (2017 -2020) which referred to various national
standards and guidance; such as Ambitions for Palliative and End of Life Care: A national
framework for local action 2015-2020; Leadership Alliance for the Care of Dying people (2014)
and National Institute for Health and Care Excellence (NICE) (2017). Quality standard – Care of
dying adults in the last days of life end of life care for adults (QS144).
The Individualised care plan for the anticipated last days of life recognised that priorities for care
according to the Leadership Alliance for the Care of Dying People: A national framework for local
action 2015 -2020. The Leadership Alliance for the Care of Dying People promotes a consistent
approach to end of life care through five key principles.
The care plan was used across the trust in all adult wards. The individualised care plan for the
anticipated last days of life document guided clinicians through a series of prompts to discuss the
patient’s personal and clinical needs, preferences, and the amount of intervention required. It
guided clinicians to consider the emotional, psychological and spiritual support needed.
We reviewed four individualised care plan records, which included recognition of dying, symptom
control, and assessment of nutrition and hydration needs.
The trust undertook audits across a variety of areas, including Do not attempt pulmonary
resuscitation (DNACPR) form completion and Treatment Escalation Plans (TEPs) within all adult
areas, Individualised care plan for the anticipated last days of life, SPCT response time to referrals
and preferred place of death (PPD).
Following our inspection, we received data from the trust regarding PPD, DNACPR and TEP
audits. The DNACPR audit dated January 2019 had audited 42 DNACPR form across the trust.
The audit showed that compliance with the trust’s full DNACPR form completion was 95.1%. This
had improved by 53% since June 2018. The audit also demonstrated 92% of the forms audited
demonstrated evidence of a completed MCA. Of the forms audited, 100% were signed and
countersigned by a senior clinical decision maker.
The TEP audit dated March 2019 showed that 88% of TEPs were countersigned by a senior
doctor or the senior doctor involved with the TEP discussion, which had been documented on the
communication sheet.
The SPCT dashboard showed that from September 2018 to February 2019 43% of patients had
their PPD recorded.

Patient’s nutrition and hydration needs were identified and met in relation to national
guidance for caring for patients in the last days and hours of life.
The trust used the Malnutrition Universal Screening Tool (MUST) to identify patients at risk of
malnutrition. Nutrition and hydration were considered under ‘COMPASSION’ documentation tool
and the last days of life care plan. Patients were encouraged to eat and drink as and when they
could and for as long as they are able to in their last days of life.
Patients and family members, we spoke with one patient and their relative during lunch and they
advised that they were happy with the food on offer at the trust.
Throughout our inspection, we saw patients had drinks within easy reach and were routinely
offered fluids throughout the day.
The Individualised care plan for the anticipated last days of life included a comprehensive list of
nutrition and hydration considerations. This included prompts for nutrition and hydration
assessment at every patient review, mouth care, swallowing difficulties and respecting the dying
person’s choice to eat and drink. Staff we spoke we spoke with showed a good understanding of
the importance of nutrition and hydration.
Pain relief
Pain was assessed and managed and there were assessment processes in place for
patients who have difficulty communicating.
The trust had guidelines for the management of pain for patients in their last days of life. These
guidelines were available as flow charts on the wards we inspected. They were also available
through the trust’s intranet so staff had easy access to them.
Pain was assessed as part of the last days of life hourly comfort rounding. Pain assessment
formed part of the ‘COMPASSION’ daily assessment tool used by nursing staff and was part of the
last days of life care plan. Throughout our inspection, we saw evidence of patient’s pain was
assessed and appropriate relief was administered to patients in receipt of palliative and end of life
care.
Staff used the Abbey Pain Scale to access the pain levels for patients who could not verbalise
their pain.
Anticipatory prescribing (medications that are prescribed for use on an ‘as required’ basis to
manage common symptoms that can occur at the end of life) followed the NICE guidelines for
symptom control.
We reviewed 17 medication administration records for patients with TEPs in place and anticipatory
medication was prescribed in all records.
Staff on the wards we inspected told us that the SPCT consultants were able to provide guidance
on the most effective and appropriate treatments and care at the end of life, for example,
management of nausea, vomiting and secretions.
Where appropriate, patients had a syringe driver, which delivered measured doses of medication
over 24 hours. On the wards we visited, all qualified nursing staff were trained in using syringe
drivers and symptom management.
Patient outcomes
Patient’s care and treatment outcomes were monitored through trust participation in the
local end of life care audits. Outcomes were identified, and improvements were made.
The trust participated in the End of Life Care Audit: Dying in Hospital published in March 2016 by
the Royal College of Physicians, the trust met two of the five clinical outcomes. These included
documented evidence that the patient was given an opportunity to have concerns listened to (84%
meets the national score) and 67% (national score was 66%) documented evidence in the last 24
hours during a holistic assessment of the patient’s needs, specifically regarding an individual plan
of care. In relation to the End of life care audit, an action plan was developed to address the
outcomes the trust was not meeting. The action plan for the audit was included within the trust’s
end of life improvement plan, which meant there was regular oversight of the actions and
performance of the service.
The trust participated in local audits to measure patient outcomes. The audit assessed the
individualised care plan for the anticipated last days of life compliance with documentation and
recording of ceilings of care. Information provided by the trust was from the trust stated.
Referrals to the Specialist Palliative Care Team
Between April 2018 and March 2019, 703 referrals were made to the Specialist Palliative Care
Team (SPCT), of these referrals 398 (57%) had a cancer diagnosis and 224 (32%) had a non-
cancer diagnosis. A diagnosis was unknown for 81 patients who were referred.
Competent staff
The service ensured that staff had the skills, knowledge, and experience to deliver
effective care, support, and treatment.
All new staff were provided with three hours of palliative and end of life care training during their
mandatory corporate induction. The SPCT played an active role in developing the training
programme with input from the chaplaincy and bereavement team. Data from the trust showed
that 42 nurses working across the trust had received syringe driver training in the last 12 months.
Porters who transported deceased patients to the mortuary received training by the mortuary
department. The mortuary manager told us that porters with access to the mortuary were trained
on the specific booking in process, infection control standards and the safe movement of
deceased patients.
Palliative and end of life care champions were in place on every ward throughout the hospital. End
of life champions attended additional training sessions, which included shadow sessions at a local
hospice or with the hospital SPCT. The trust had recruited 40 end of life care champions who had
received training around communication with dying patients and their families.
The SPCT did not currently run bespoke communication training within the trust, however they had
included practical sessions on how to communicate with patients and families.
As part of the trust’s end of life care strategy, an education strategy was in place to enable
collaborative working with other palliative care providers to develop, education programmes
across all settings.
Appraisal rates
From April to October 2018, 90.0% of staff within the end of life care department at Princess
Alexandra Hospital received an appraisal compared to a trust target of 90%.

received staff rate target (Yes / No)
Support to scientific,
3 3 100.0% 90.0% Yes
Qualified healthcare scientists 3 3 100.0% 90.0% Yes
Medical staff 1 1 100.0% 90.0% Yes
Qualified nursing staff 2 3 66.7% 90.0% No
Total 9 10 90.0% 90.0% Yes
Please note that care should be taken when interpreting the appraisal completion rates due to
small numbers of staff.
The one eligible member of medical staff had received an appraisal. Although qualified nursing
staff failed to meet the appraisal completion target of 90%, this equates to only one of the three
members of staff not receiving an appraisal.
Staff teams and services worked together across the organisation to deliver effective end
of life care.
Staff on Gibberd ward told us that board rounds were held to discuss patients in a multidisciplinary
setting to discuss patients in receipt of palliative care. Multiple professionals contributed to the
care and discharge process including, consultants, nurses, discharge coordinators, occupational
health therapists and discharges nurses and the SPCT.
Multidisciplinary team (MDT) meetings were held and attended by the hospital SPCT nurses,
consultants, allied health care professionals and members of a local voluntary sector that provided
carer support. During our inspection we observed a board round where staff contributed to the
needs of each patient and their family/carer.
Staff we spoke with were aware of how to contact the SPCT and were positive about the input and
care delivered by the team.
Referrals to the SPCT came from different professional, including nursing, medical and allied
health professional. Nursing staff were confident enough to refer the SPCT and to ask for advice
and support.
Ward staff and managers told us that the specialist palliative care team attended the ward when
referrals were made for advice and support when requested to do so.
All the wards we inspected had a dedicated discharge coordinator and that attended daily
handover sessions.
The trust had a system in place to highlight patients who were at the end of their lives. Patients in
receipt of end of life care were identified by a ‘purple butterfly’ magnet on each ward’s white board.
This helped members of the MDT identify end of life care patients during board rounds.
Seven-day services
The trust did not provide a seven-day face to face service to support the care of patients at
the end of life
The SPCT provided a Monday to Saturday 9am to 5pm service. Staff could access a palliative
care consultant out of hours through the switchboard. This does not meet best practice guidelines.
Hoverer, the SPCT told us a further review to increase staffing to support a seven-day service was
put on hold until the next financial year and further review of funding would be put forward as
business planning for 2019 -2020.
The hospital chaplaincy service had chaplains of various denominations that could be contacted to
provide support for patients and families 24 hours a day, seven days a week.
The bereavement team provided a service between 08.30am to 4.30pm Monday to Friday.
Mortuary staff were on site during the day, Monday to Friday 8.00am to 4.30pm. Mortuary staff
had a 24-hour emergency on call system and could be contacted through the hospital’s
switchboard out of hours.
Porters has access to the mortuary 24 hours a day, seven days a week, to allow prompt transfer of
deceased patients from clinical areas to the mortuary.

Staff supported patients to make informed decisions about their care and treatment. They
knew how to support patients who lacked capacity to make their own decisions or were
experiencing mental ill health.
Training in Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) was
covered within the trust’s safeguarding adults’ level 2 training module. A specific course in MCA
and DoLS was available to staff that wanted to enhance their safeguarding skills but was not
offered as part of the trust’s standard training package.
MCA and DoLS guidance was available on the trust’s intranet along with other associated
documents such as the trust’s consent policy, dementia policy and safeguarding adults at risk
policy.
The trust had a mental capacity policy that set out the legal requirements of the MCA. The policy
stated An assessment of mental capacity for important decisions such as a Do Not Attempt
Cardiopulmonary Resuscitation (DNACPR) form should be completed when a DNACPR is set in
place for a person who lacks mental capacity. We reviewed 37 do not attempt cardio pulmonary
resuscitation (DNACPR) forms. Of the 37 forms 13 had documented that the patient did not have
mental capacity and therefore required a mental capacity assessment. Of the 13 that required a
mental capacity assessment nine mental capacity assessment forms were completed and clearly
documented. This was an improvement from our last inspection where we viewed 37 DNACPR
forms and out of those 23 had documented that the patient did not have mental capacity. This
meant these patients should have had mental capacity assessments completed.
The trust conducted DNACPR audits and the aim was to ascertain compliance with the trust’s
DNACPR policy. The results of the audit dated February 2019 showed that 93% of DNACPR
forms had a completed MCA. 69% of DNACPR forms had been reviewed by a senior nurse and
Gibberd ward had 84% compliance and other wards were 100% complaint.
At the time of our inspection none of the patients at the end of life or receiving palliative care had
an active DoLS in place. Staff we spoke with had a good understanding of DoLS and were able
to provide rationales for not applying for DoLS when asked.
qualified nursing staff and medical staff in end of life care at Princess Alexandra Hospital is
shown below. The completion target for this module is 95%.
As of October 2018
Medical staff 1 1 100.0% 95% Yes
The 95% training target for the safeguarding adults level 2 training was meet by both qualified
nursing and medical staff in end of life care at Princess Alexandra Hospital.
(Source: Routine Provider Information Request (RPIR) – Training tab)r

Compassionate care
The service ensured that patients were treated with kindness, respect, and compassion,
and that they were given emotional support when needed.
Throughout our inspection we observed patients treated with compassion, dignity and respect.
Medical and nursing staff we spoke to were aware of the importance of treating patients and their
visitors in a sensitive manner. All staff we spoke with genuinely wanted to provide the best care
possible to patients at the end of their life.
We observe staff taking time to interact with end of life patients, their friends and families. In
particular “Butterfly Volunteers” who were care of the dying companions. Butterfly Volunteers sat
with patients and provide support to family member. Butterfly volunteers sat with patients who had
had no family present so that they did not die alone. We reviewed the SPCT dashboard and in
February 2019, 43 first time visits and 45 return visits were made to patients by butterfly
volunteers.
We observed that patient’s privacy and dignity were respected. Staff on the wards and members
of the SPCT were seen to respond in a compassionate, timely and appropriate way when patients
were distressed or in pain.
During our inspection, we saw that patients at the end of their life and their families were treated
with compassion, dignity and respect. We observed staff interacting with patients and family
members and saw that this was done with kindness and a with a focus on the needs of the
individual.
Care after death honoured patient’s spiritual and cultural wishes. Members of the chaplaincy,
mortuary, bereavement and porter teams treated the deceased with respect and demonstrated an
understanding of the needs of the bereaved. The mortuary manager told us that staff worked
closely with family members regarding care after death.
Maternity gift boxes containing candles, a scroll, a teddy bear and a special message were given
as mementos in the circumstances of the death of a child.
There was a separate quiet room within the mortuary were family could sit and wait to enter the
viewing room prior to viewing their loved one.
Staff told us of a wedding that was conducted, where patients at the end of their life had wanted to
be married before they died.
Emotional support
Staff understood the impact that a patient’s care, treatment, or condition had on their
wellbeing and on those close to them, both emotionally and socially.
Emotional support for patients at the end of life and those close to them was available from the
specialist palliative and end of life care team, the chaplaincy, bereavement team, and ward-based
staff.
Members of the end of life care team had been trained in advanced communication skills and ward
based staff had also received training in communication through a variety of training programmes
based around end of life care.
We observed staff supporting a family following the death of a loved one. We saw that staff gave
them the time they needed to say their goodbyes and were focused on providing support to them
and each other.
The bereavement team understood the importance of emotional support. Members of the
bereavement team were qualified bereavement councillors and offered support to bereaved
families. Staff in the mortuary and bereavement team told us they gave relatives the space and
time to grieve and say goodbye to their loved ones. Staff gave relatives a guidance document that
detailed what to expect and the next steps following a loved one’s death. Staff also sign posted
relatives to relevant information and support. For example, assistance with funeral costs and
bereavement counselling.
Butterfly volunteers were trained to sit with dying patients and support relatives. In some cases,
they acted as a go between with staff and relatives to ensure that patient needs were met.
Patients were supported to be actively involved in making decisions about their care.
There were effective systems in place to support advance care planning and staff on the wards
were familiar with this process. The specialist palliative care team provided support in advance
care planning for patients, relatives and staff on the wards. Patients and relatives told us they felt
involved in their care at the end of life.
Patients’ preferred place of care and their individual choices and preferences were primary focus
when planning care. The individual plan of care for patients at the end of life included sections to
record decisions and conversations with patients and their loved ones.
Staff told us that relatives could stay overnight with provisions such as foldaway beds and toiletry
packs. On Gibberd ward relatives had access to kitchen facilities and a lounge area separate from
the ward or side room.
The trust conducted a bereavement survey, to determine the care provided in the last few days of
life and experience of that time. The most recent survey was conducted in December 2018 and of
the 30 respondents, 22 (75%) said they felt that they were involved in the decision-making process
were their loved one was concerned. 27 (90%) of the 30 respondents said that they had been
given the opportunity to talk with doctors involved in their loved one’s care.
We reviewed 30 sets of medical and nursing care records and they showed that discussions
between clinicians and patients and those close to them. In some cases, the views of the family
were detailed, while other stated that the family member understood and agreed with the plan.

Patients at the end of life were generally nursed in side rooms and there were facilities
available for relatives to stay overnight.
The preferred place of death for patients was recorded on the individualised care plan for the
anticipated last days of life. This was monitored by the specialist palliative care team (SPCT).
Data submitted by the trust showed that between January 2018 and December 2018 100% of
patients on the fast track database had a recorded preferred place of care (PPC).
The discharge team told us that the main reason for delays in discharge was due to delays in
sourcing care in the community and this impacted some patients not achieving their preferred
place of care or death.
The wards we inspected provided portable beds for those relatives wishing to stay with their loved
ones. Access to the car park, food and drink were also free for friends and family.
Friend and family could visit patients on end of life care at any time, there were no visiting
restrictions.
Data received from the trust showed that from September 2018 to February 2019 384 patient
referrals were received and accepted by the SPCT. 70% of these referrals were responded to on
the same day and 22% of referrals were responded to within 24 hours.
The service took account of the individual needs and choices of different patients.
The chaplaincy told us that wedding ceremonies, baptisms and special religious services had
been organised for patients and staff within the hospital.
The multi-faith Chapel was open 24 hours a day, seven days a week. We saw prayer mats for
people with Muslim faith were available and copies of the Holy Bible and Koran as well as other
multi-faith books.
Staff described providing paints and crayons to try and comfort a little girl as she visited her
mother who was at the end of her life.
A variety of leaflets were available on the wards including information about coping with dying,
chaplaincy and spiritual care and what to do following bereavement.
The SPCT told us that a ‘purple butterfly’ would be used instead of the previous ‘golden hand’
symbol. The ‘purple butterfly’ would be placed on patient doors or curtains, to communicate to staff
that the patient was receiving end of life care. Awareness of end of life patients was also
communicated during handovers.
During our inspection, the SCPT staff received tote bags with the purple butterfly printed on them,
they were distributed throughout the trust and to be used as “bereavement bags” for patient
property to be given to bereaved families. This was a new initiate that had been funded as part of
the quality improvement initiative.
The SPCT provided a ‘comfort pack’ to families and relatives who had to stay overnight to be with
a dying loved one. A comfort pack contained a toothbrush and toothpaste among other overnight
body care and hygiene essentials.
The service had a system in place to access telephone and face to face translation and interpreter
services.
The mortuary had a viewing room for families and friends and a private quiet space should they
wish to spend time with the deceased.
The bereavement team told us that they could facilitate rapid access to death certificates and the
release of the deceased back to their families when requested. By streamlining the process, the
bereavement team enabled families to observe religious traditions, for example being buried within
a certain length of time following death.
Access and flow

Patients could access care in a timely way. The special palliative care team would generally
visit the patient on the day of referral.
Data received from the trust stated that in the last 12 months from April 2018 to March 2019, 530
out of 730 patients (70.7%) were seen within 24 hours of their referral to the SPCT.
We reviewed the Specialist Palliative and End of Life Team Annual Report 2017/2018. Data from
the report showed that 60% of patients referred to the SPCT had cancer.
Further data from the trust covering September 2018 and February 2019 specifically, showed that
221 patients out of 356 were referred to the SPCT with cancer.
Data from the trust showed that between September 2018 and February 2019, 56% of patients
discharged died in their recorded preferred place of death.
The trust had systems and processes in place to monitor the rapid discharge process. The fast
track discharge for patients in the last days and weeks of life (last two to four weeks of life) was
coordinated by the discharge team. All the wards we visited had a discharge coordinator that
attended board rounds to identify any patients that required fast track discharge and would
coordinate with the discharge team.
Data from the trust showed that in September 2018, 34 of patient referrals were discharged using
Fastrack verses 37 in January 2019 and 40 in February 2019. Senior staff told us that the fast
track discharge process worked well and on average patients were discharged on the same day or
within 24 hours.
Staff told us that referrals discharge took five to six days. Ward staff told us discharge delays from
to the patients’ preferred place of death were usually due to families changing their minds and the
lack of availability of community palliative beds.

Complaints relating to the care of patients at the end of life were reviewed by the specialist
palliative care team with a view to learning/ lessons and improving care.
From August 2018 to February 2019 the trust received three complaints about end of life care.
We reviewed an audit of the complaints and the outcomes. Two of the complaints were concerned
with staff communication with relatives. The SPCT had met with the relatives and these concerns
had been resolved. One complaint concerned a relative not being happy with the care their loved
one received. The SPCT was yet to meet with the relative in question to resolve this complaint.
Complaints were discussed as a standing agenda item during ward huddles, governance meeting
and trust end of life improvement programme steering group monthly meetings. Any lessons learnt
from complaints were shared in the SPCT newsletter, The SPCT attended the trust’s healthcare
group meeting where complaints were discussed, and lessons shared as part of a performance
review. Meeting minutes that we reviewed showed that recent complaints concerning end of life
care were discussed and key learning points were shared at meetings.
Staff on the wards gave examples of lessons learnt with regards to communicating with patient
families. For example, making every effort to contact relatives regarding patient conditions. Staff
told us that complaints were discussed at end of life care steering groups and findings were
disseminated to all staff involved.
From December 2017 to November 2018 the trust received nine complaints about end of life care
at Princess Alexandra Hospital (3.8% of total complaints received by the hospital).
Department
complaints of total
Complex care (care of the elderly) and fractured neck of femur 3 33.3%
Cancer services/oncology 1 11.1%
Respiratory 1 11.1%
Cardiology 1 11.1%
Women and children directorate 1 11.1%
Total 9 100.0%
The subjects of the complaints are shown in the table below:
Type of complaint Number of complaints Percentage of total

End of life care 7 77.8%
Total 9 100.0%
From November 2018 to date there were 11 compliments about end of life care at Princess
Alexandra Hospital.
(202 compliments).

Leadership
Leaders were visible and approachable. They had the skills needed and understood the
challenges to quality and sustainability for end of life care services.
Operationally, end of life care leadership across the trust was provided by a lead consultant and a
lead nurse. At an executive level, end of life care was led at an executive level by the Chief
medical Officer and supported by a non-executive director (NED).
Local leadership for end of life in clinical areas was provided by matrons, ward managers and
senior clinical staff with the support from the end of life nurses. Leaders were visible in all areas
we visited as part of our inspection and staff told us that they felt supported by their managers.
Staff told us that at times senior managers visited the wards.
The palliative care consultant and palliative care nurses demonstrated good leadership in the
clinical areas, and staff we spoke with on the wards described them as approachable and
supportive.
The trust’s end of life steering group was chaired by the associate clinical director and attended by
various leads including, the senior bereavement advisor, chief medical officer and the palliative
care and end of life lead. We reviewed minutes dated October, November, December 2018 and
agenda items included update on the new risks on the register and the trust’s improvement plan.
The trust had a service level agreement with the local hospice and consultant cover was managed
through the hospice to help support the lead end of life care consultant.
Vision and strategy

There was a clear vision and strategy with identified priorities. Quality and sustainability
were a key priority for the trust and the end of life care team.
The trust’s end of life strategy (2017 – 2020) had been developed in line with the trust’s values,
standards and behaviours. The application of the strategy was monitored through the end of life
steering group that met every month.
The trust was part of Hertfordshire and West Essex Sustainability and Transformation Plan (STP)
Palliative and End of Life Care Strategy Group. This involved collaboration and integration with
community specialist palliative care and the local hospice services to help deliver services to meet
the need of local people.
The SPCT were clear about the strategy and vision for palliative and end of life care service with
the philosophy that involved putting quality first as time was precious.
The strategy was in line with the six ambitions for Palliative and End of Life Care: A national
framework for local action 2015 to 2020 (National Palliative and End of Life Care Partnership
2015). The six ambitions stated that, “every person is seen as an individual, each person gets fair
access to care, maximising comfort and wellbeing, care is coordinated, all staff are prepared to
care, and each community is prepared to help.”
Culture
Staff felt positive and proud of the quality of end of life care delivered. There was a culture
of delivering quality end of life care throughout among staff.
Staff we spoke with within the specialist palliative care team and those working on the wards told
us they felt supported to deliver good quality end of life care. End of life care was given enough
priority across the trust. Staff working within the specialist palliative care service were passionate
about end of life care. They consistently demonstrated a focus on patient choice, involvement and
providing support to ensure the last days and hours of life were consistent with the wishes,
choices and preferences of the patient and those close to them. Ward staff were equally
committed to delivering a high standard of end of life care and supporting patients and those close
to them to have the best experience possible.
Senior staff told us they encouraged staff to observe the duty of candour which involved being
open and honest at all times and especially when errors occur.
Mortuary and bereavement staff demonstrated a strong team ethic and a structured working
relationship. The mortuary and bereavement teams demonstrated a willingness to deliver a good
standard of care to the deceased and their relatives.
Butterfly volunteers had been introduced to the trust to sit with patients at the end of their life when
staff and relatives were not able. Staff told us that this level of compassion was an essential
aspect to good quality end of life care.
End of life care champions included medical staff, nurses and healthcare assistants. We spoke
with staff who had been trained as end of life care champions, who felt that they were able to
deliver good quality end of life care
Governance
The structures, processes and systems of accountability supported good quality and
sustainable services.
Palliative and end of life care services operated throughout the trust. The service sat under the
Cancer, Cardiology and Clinical Services Health Care Group. A quarterly end of life care report
was presented to the quality and safety committee, and an annual report was presented to the
trust board.
The SPCT produced a monthly quality assurance dashboard that monitored the performance of
the service.
The trust monitored the end of life service through the end of life steering group, which met
monthly and was chaired by the associate clinical director. We reviewed minutes from steering
group meeting dated October 2018 to March 2019 and found that the risk register was a standing
item. Risks discussed at meetings included shortage of office space and out of hours cover.
Weekly multidisciplinary meetings were held to discuss patients at the end of their life, any delays
in discharge and current plans of care.
The specialist palliative team produced a quarterly newsletter, which h gives highlights of end of
life in the trust and shares the learning from incidents and complaints. The newsletter also raised
awareness of resources and new policies.
Risk registers included identified risks in relation to end of life care and these were
regularly reviewed and actioned.
The trust’s end of life care risk register was submitted as part of the divisional risk register. We
reviewed the SPCT risk register and found that entries were up to date. Examples of risks
included, no seven-day service, inaccurate completion of DNACPR and MCA documents, lack of a
psychologist and inappropriate admissions for end of life care patients form care homes.
During our last inspection the trust achieved six of the eight organisational indicators in the End of
Life care Audit: Dying in Hospital 2016. During this inspection we found that there was an
improvement and that the trust had achieved seven out of eight organisational indicators. The
indicator that they had not achieved was specialist palliative care for at least 9am to 5pm, seven
days a week. Staff in the SPCT told us that they now had an end of life care facilitator who had
recently joined the trust.
There was evidence that risks were being reviewed and updated regularly. Risks listed had control
measures in place and a review date and there was evidence that they were being actioned.
Referrals were sent to the SPCT through an electronic referral system. The team was also
available via telephone.
Staff on the wards that we visited told us that they could easily access information on palliative
and end of life care form the intranet. Staff pointed us to end of life care folders that were kept on
the ward. The folders contained information relating to end of life care, including the referral
process to the SPCT. Staff told us that each ward had a palliative and end of life care information
folder.
Engagement
Staff were actively engaged in end of life care across the trust through the development of
end of life care champions.
Staff were engaged in end of life discussions through training and attendance at the end of life
care meetings and steering groups. In particular, those staff had trained as end of life care
champions. End of life care champions attended regular meetings and training with specialist
palliative care team had the opportunity to engage with and inform the development of the service.
Staff working within the service demonstrated an open and collaborative approach in how the
service was run and developed.
Staff told us that a Bereavement Survey was conducted and handed to relatives to find out if they
felt that they had received the appropriate communication and emotional support from staff.
Results from the trust’s bereavement survey dated December 2018, showed that 73% felt that
they had been involved in the decisions about their deceased loved one’s care. 100% felt that they
were given an opportunity to spend time with their loved one before they died. Comments
included, “Plenty of time. Staff fantastic. Only left when ready. 90% mentioned that they had been
given the opportunity to talk to doctors involved in their loved one’s care.
We reviewed notes from the End of life Steering Group Meetings and noted that a representative
from the Patient Panel was in attendance at all meetings. The patient panel representative
ensured that patient and relative interests were taken into consideration and relayed back and
forth to the Patient Panel.

The trust had systems in place to highlight patients who were at the end of their lives.
The trust had allocated a clinical nurse specialist to be linked with the frailty and emergency
department to identify any patients on the end of life pathway from the community.
An end of life care facilitator was appointed to assist medical teams with identifying patients who
triggered a score of over five on the trust’s electronic patient records system and should be
considered for end of life pathway of care. The facilitator visited wards each morning to monitors
patient observations and records. Discussions were then held with the ward teams to plan patient
care.
Previously to identify patients who were at the end of their life a ‘golden hand’ magnet was placed
next to their bed number on the ward white board. During our inspection SPCT told us that they
had introduced a ‘purple butterfly’ to replace the ‘golden hand’. The purple butterfly magnets were
used for ease of identification during board round discussions. Staff told us that the reason for the
change was due to the introduction of the butterfly Volunteers. The Butterfly Volunteers had a
purple butterfly as their logo, so it was decided that End of Life care services would use the same
purple butterfly across the trust. For uniformity and ease of recognition, purple folders were used
to store patient notes for those on end of life care.
The SPCT reviewed an updated end of life care list daily from the whiteboard reports with names
and patient locations on wards. This ensured an immediate response from SPCT to support ward
nurses, patients and families.
The trust was part of the Hertfordshire and West Sussex Sustainability and Transformation Plan
(STP) Palliative and End of Life Care Strategy Group, which was working on a system wide
locality strategy for end of life care, to care and support people in the last years of their life.

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The Princess Alexandra Hospital NHS

Tel: 01279 444455

Facts and data about this trust

(Source: Trust website)

(Source: Routine Provider Information Request (RPIR) – Context acute tab)

Acute hospital sites at the trust

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 1

Name of acute Details of any specialist services provided at

(Source: Routine Provider Information Request (RPIR) – Sites tab)

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 2

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 4

Staff group BME % Female %

(Source: Routine Provider Information Request (RPIR) – Board Diversity tab)

Vision and strategy

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 5

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 8

Medical and Nursing and

(Source: Routine Provider Information Request (RPIR) – Staff Diversity tab)

NHS Staff Survey 2018 results – summary scores

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 9

Workforce race equality standard

Notes relating to the scores:

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 10

(Source: NHS Staff Survey 2018; NHS England)

Friends and Family test

(Source: Friends and Family Test)

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 12

(Source: NHS Digital)

General Medical Council – National Training Scheme Survey

Survey area RAG

(Source: General Medical Council National Training Scheme Survey)

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 13

• Performance and finance Committee

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 14

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 15

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 16

(Source: Trust Board Assurance Framework – November 2018; trust website)

Risk score Risk score

(Source: Trust Board assurance framework, November 2018)

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 17

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 18

Historical data Projections

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 20

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 21

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 22

• Developing multi-professional neighbourhood teams and build Population Health

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 23

• A new paediatric emergency department

Learning, continuous improvement and innovation

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 24

Complaints process overview

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 25

(Source: Routine Provider Information Request (RPIR) – Complaints tab)

A breakdown by core service can be seen in the table below:

(Source: Routine Provider Information Request (RPIR) – Compliments)

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 26

Accreditation scheme name Service accredited

(Source: Routine Provider Information Request (RPIR) – Accreditations tab)

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 27

• Princess Alexandra Hospital emergency department

(Source: Routine Provider Information Request (RPIR) – Sites tab)

Activity and patient throughput

(Source: Hospital Episode Statistics)

Evidence appendix The Princess Alexandra Hospital NHS Trust Page 28