The Queen Victoria Hospital (East Grinstead)

Updated 23 May 2019

Queen Victoria Hospital NHS Foundation Trust is a leading specialist centre for reconstructive surgery and rehabilitation, helping people who have been damaged or disfigured through accidents or disease. Queen Victoria Hospital NHS Foundation Trust provides a specialist burns and plastic surgery service to both adults and children. Patients are admitted from the south east of England including south and east London. The trust also provides ‘hub and spoke’ specialist services at other hospitals in the south east of England, bringing Queen Victoria Hospital NHS Foundation Trust staff with specialist skills to remote hospital locations. The hospital provides a minor injuries unit and community services for people living in and around East Grinstead and is situated on the outskirts of the town.

Queen Victoria Hospital NHS Foundation Trust has 65 beds (including nine paediatric beds, and five critical care beds) 13 operating theatres and employs over 900 staff. The hospital works in partnership with major trauma centres in south London and Brighton.

Queen Victoria Hospital NHS Foundation Trust was one of the first foundation trusts and has 7,600 public members across Sussex, Kent and Surrey.

At our last inspection we rated the hospital overall as ‘good.’

Updated 23 May 2019

• There were arrangements to keep service users safe from abuse which were in line with relevant legislation. The majority of staff had received training, were able to identify who might be at risk of potential harm and knew how to seek support or advice.
• The hospital was providing safe care. There were sufficient staff to meet the needs of patients although some services were heavily reliant on a temporary workforce. Recent recruitment campaigns both locally and overseas had been successful.
• The critical care unit had improved it’s out of hours medical cover since our last inspection. At the time of our last inspection one doctor out of hours was needed in multiple places at once including in theatre and attending to unwell patients. This inspection there had been a change in policy to ensure surgery had finished before the other medical staff would leave the hospital.
• Services were delivered by staff that were competent, trained and supported by their managers, to provide safe and effective care. The trust provided regular training and development opportunities for staff. The trust invested in research, for example, there was specialist research nurses in burns and plastics.
• Staff kept themselves, equipment and the premises clean. Staff demonstrated good hand hygiene practice and safe disposal of sharps and waste. Staff complied with national and trust processes to control and prevent the spread of infection.
• Medicines were stored, prescribed and given correctly and medicines fridge temperatures checked.
• Patients were given enough food and drink to meet their needs. The hospital had recently extended the range of teas available to include ginger and peppermint teas to hydrate patients suffering from post-operative nausea or gas. Pain levels were assessed, and patients received adequate pain relief.
• Staff understood and complied with the relevant consent and decision-making requirements of legislation, including the Mental Capacity Act, 2005.
• Staff provided compassionate and respectful care. Staff provided emotional support to patients and relatives and involved patients and those close to them in decisions about their care and treatment. During our inspection, we heard many examples of staff going ‘the extra mile’ to provide compassionate care that exceeded expectations.
• The hospital provided care and treatment in accordance with evidence-based guidance. Staff were aware of clinical guidance for patients with specific needs or diseases.
• There was an audit program that covered many areas of practice in the critical care unit. The unit looked for areas to improve. There was a positive culture to learning from things when they went wrong or went well.
• The hospital made improvements following learning from complaints and patient feedback. We saw managers fed back complaint learning to staff in staff newsletters. However, the trust did not always respond to complaints within the timeframe set out in the trust’s policy.

However:

• The hospital did not meet the British Burn Association National Burn Care Standards. This was because, as a specialist trust, the hospital did not provide the usual range of hospital services such as general surgery, mental health liaison and paediatric medicine. To reduce these risks, the trust had service level agreements with a nearby acute NHS trust to provide these services in a timely way, 24 hours a day, seven days a week.
• The critical care unit was not fully meeting the Guidelines for the Provision of Intensive Care Services 2015 but there had been an improvement since the last inspection. At the time of our last inspection critical care had no intensive care consultants but now had intensive care consultant cover Monday to Friday. However, the unit still lacked this cover out of hours and at weekends.
• Nursing agency usage was higher than was recommended for a critical care unit. The unit had a target of a maximum 50% usage, but the recommended level was a maximum of 20%.
• There were significant numbers of registered nurse vacancies predominantly in theatres and critical care and heavy reliance on temporary staff. However, the trust had systems and processes to mitigate the risk, for example a limit to how many agency staff could be allocated to each theatre. These services used regular agency staff to provide consistency and continuity.

• The trust’s admissions policy for surgical patients and critical care patients relied heavily on the individual judgement of the on-call consultant as to whether a patient met the criteria for admission to the hospital. For example, there was no specific criteria for burns patients around the total body surface area affected by the burns. There were also no specific criteria for significant co-morbidities. Comorbidity describes two or more disorders or illnesses occurring in the same person.
• Mandatory training rates including safeguarding and Mental Capacity Act modules for all staff groups did not always meet the trust target of 95%. However, at the time of inspection compliance had improved.
• The trust had struggled to meet both the 18-week referral to treatment and cancer targets. Five specialties were below the England average for non-admitted pathways for referral to treatment times.
• Plastic surgery department, sleep disorder unit and ophthalmology appointment cancellations by the hospital within seven days varied in the reporting period, none met their target. On the day cancellations by the hospital had stayed the same for a period but failed to reach their target.
• Resuscitation equipment within the plastic and burns department and maxillofacial department had some daily and weekly checks missing which was not in line with the trust’s policy.

Updated 26 April 2016

We found that services for children and young people at the Queen Victoria Hospital caring and compassionate and were well led.

We received positive feedback from patients and their parents about the care, facilities and staff on Peanut Ward, and other areas of the hospital used by children.

We saw that emergency equipment and medicines were appropriately stored and checked in line with protocols. Additional patients’ records were managed in accordance with the Data Protection Act 1998. Records were kept securely preventing the risk of unauthorised access to patient information.

The hospital responds well to patients needs and supports children with complex needs in an innovative and caring manner.

Staff work hard to ensure that children who have had body changing surgery are supported through a network of mentors. These mentors are children who have similar life changing surgery.

Updated 23 May 2019

Our rating of this service improved. This was because the service had improved the medical cover and the governance structure. We rated it as good because:

• The unit had a governance structure focused on critical care. This monitored incident trends, unit performance, risks and managed improvement. This was an improvement from our last inspection.
• The unit was visibly clean and infection control was a priority. All staff complied with infection control policy. Cleaning records were clear and showed compliance with national standards.
• Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents. Staff felt supported when doing so.
• Staff managed medicines consistently and safely. Medicines were stored correctly and disposed of safely. Staff kept accurate records of medicines. Medication charts were completed in line with national guidance with allergies clearly recorded and no missed doses. Microbiological samples were taken before administering antibiotic treatment.
• People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation. This was monitored to ensure consistency of practice.
• Feedback from patients we spoke with was always positive and praised staff’s care and availability. People were treated with dignity, respect and kindness during all interactions with staff and relationships with staff were positive. Patients relatives felt they were involved in the care process.
• There was an audit program that covered many areas of practice in the critical care unit. The unit looked for areas to improve. There was a positive culture to learning from things when they went wrong or went well. This included feedback from patients.
• There was a new proactive leadership team which had the respect of their staff. This team had created a positive culture but as they were new to the unit this was not yet embedded.
• The unit had managed to recruit more permanent and bank staff since our last inspection.
• The unit had improved it’s out of hours medical cover since our last inspection. At the time of our last inspection there was one doctor that had to cover out of hours and was needed in multiple places at once including to work in theatre and to attend to unwell patients. This inspection there had been a change in policy to ensure that if the one doctor at night was needed in theatre then there would be another doctor that would be called in to cover the hospital.

However:

• Mandatory training figures submitted showed some of the trust targets were not being achieved, however the trust set a high target of 95% and these figures had improved when we visited the site on inspection.
• There was a departmental policy of not having more than 50% agency on any one shift which had been discussed and approved by senior clinical leads and the managers within the trust. This was a positive step, but was not in line with the 20% usage limit from the Guidelines for the Provision of Intensive Care Services, 2015.
• The unit was not fully meeting the Guidelines for the Provision of Intensive Care Services 2015 but had improved from the last inspection. The unit at our last inspection had no intensive care consultants but now had intensive care consultant cover Monday to Friday but still lacked this cover out of hours and at weekends.
• The unit did not take part in the Intensive Care National Audit and Research Centre which was a national audit program designed for critical care units. However, the unit did take part in the South East Coast Critical Care Network.

Updated 26 April 2016

This a small MIU with c11,000 attendances each year and we found that Cleanliness, infection control and hygiene were meeting the standards expected. And that staff were reporting incidents in a timely manner. There had been no never events or serious incidents reported in the last year.

Mandatory training rates were variable with only 46% of staff having had mental capacity act training, which is not acceptable.

Staffing levels were adequate to cover the unit and staff were suitably qualified. There was a system in place to monitor staff competencies and ensure they had the right skills to treat patients who attended the unit.

All patients we spoke to were positive about the treatment they received and reported that staff were professional, caring and courteous. All patients were triaged by an emergency nurse practitioner within 15 minutes of arrival at the department and a priority allocated.

The department was well-led and there was regular contact with senior managers. However environment compromised confidentiality in the reception area and patients’ privacy and dignity in treatment cubicles.

Updated 23 May 2019

• Staff understood how to protect patients from abuse. Most of the staff had training in recognising the signs of abuse and how to apply their knowledge.

• The service controlled infection risk well. We observed staff following national guidance on infection control and prevention. For example, we observed staff decontaminating their hands immediately before and after every episode of direct contact or care.

• Staff completed and updated risk assessments for each patient. Safety huddles were held every morning in each outpatient department. All staff working in the outpatient clinics met at the same time every day to discuss current safety issues relating to the premises, patient care and other relevant issues that could impact on patient safety.

• The service had suitable premises and equipment and looked after them well. The design, maintenance and use of facilities and equipment kept people safe. Equipment was maintained and monitored to ensure it was fit for use.

• Staff kept detailed records of patients’ care and treatment. People’s individual care records, including clinical data was written, stored and managed in a way that kept people safe.

• The service followed best practice when prescribing, giving, recording and storing medicines. Medicines in outpatients were managed safely and stored in a lockable cupboard.

• The department provided care and treatment based on national guidance. Speciality clinics operating within the outpatient department followed relevant national guidance and participated in national and local audits.

• The service made sure staff were competent for their roles. The trust figures showed below target figures, however; compliance for appraisal rates exceeded the trust target in the departments we visited.

• 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.

• Staff cared for patients with compassion. People were treated with compassion, kindness, dignity and respect, when receiving care. Staff communicated with people in a way that supported them to understand their care and treatment.

• The department was clearly signposted and we observed staff helping to direct patients to where they needed to go. We observed staff interacting with patients in a way that was supportive and helpful.

• Advice and guidance for non-urgent GPs referrals were in place, this allowed GPs access to consultant advice prior to referring patients into specialist clinics.

• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. There was evidence of learning and improvement from complaints, but response times were not in line with the trust policy.

• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. There was a trust wide vision for ‘delivering excellence’ and a strategy detailing ‘outstanding patient experience, world class clinical service, operational excellence, financial sustainability and organisational excellence’. All departments we visited were aware of the vision and were committed to achieving it.

• The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. Data security standards were being implemented by the trust which underpinned its cyber security strategy in 2017/18. They achieved the Cyber Essentials accreditation in February 2018 and Cyber Essentials Plus in March 2018.

• The Compliance in Practice inspection process as a quality improvement initiative was being used by the trust.

• The trust had an onsite psychological therapies team who supported patients and staff who were experiencing mental health or emotional difficulties.Access to the team was reported to be timely and efficient.

• The sleep disorder centre was one of the six largest centres in the UK, it admitted up to 42 patients for inpatient studies in a week, there were 15 outpatient clinics per week, and day case admissions for therapy each weekday.

  However:

• Resuscitation equipment within the plastic and burns department and maxillofacial department was subject to daily and weekly checks but there were some gaps in the recording of these.

• Complaint response time was not in line with the trust policy of 30 days.

Updated 26 April 2016

Patients who used the service experienced safe, effective and appropriate care and treatment and support that met their individual needs and protected their rights. The care delivered was planned and delivered in a way that promoted safety and ensured that peoples individual care needs were met. Patients had their individual risks identified, monitored and managed and the quality of service provided was regularly reviewed.

We found that patients were protected from avoidable harm because there were systems to report, monitor, investigate and take action on any incident that occurred. There were robust systems in place to monitor clinical safety throughout the service such as infection control, slips, trips and falls and manual handling. This included the five steps to safer surgery and the World Health Organization’s (WHO) procedures for safely managing each stage of a patient’s journey from ward through to anaesthetic, operating room and recovery.

The hospital had systems to identify when patients’ condition deteriorated and were becoming increasingly unwell. This enabled staff to provide increased support. Recognised tools were used for assessing and responding to patient risks. Outcomes for patients were good and the departments followed national guidelines. Departments undertook frequent audits such as the theatre checklist and hand hygiene. Audits were analysed and the results cascaded to staff.

Staff were competent and knowledgeable about their specialties on both the wards, the burns unit and in the theatres. However mandatory training was not always up to date for all staff groups.

The general environment was visibly clean and a safe place to care for surgical patients. However there was little monitoring or routine assessment of environmental safety, such as security, COSHH flammable liquids and facilities, however the hospital undertook annual Health and Safety assessments. There was sufficient emergency resuscitation equipment available. This was usually checked appropriately and ready for use in suitable locations throughout the surgical services.

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

The care delivered was measured on a continuous basis to ensure quality and adherence to national guidance and to improve quality and patient outcomes. The trust was able to demonstrate that it continuously met national quality indicators with patient outcomes monitored and reviewed through national and local audits. Medicines management was generally good however remained practice in theatre that did not meet current best practice or comply with national guidelines.

The care was very much multidisciplinary where every healthcare professional’s input was valued and respected. Consultants led on patient care and there were arrangements for supporting the delivery of treatment and care through sharing consultant knowledge and experience, multidisciplinary teamwork and specialists. The hospital had a dedicated pain team that provided specialist pain services to patients. Nursing staff assessed the nutritional needs of patients and supported patients to eat and drink with the assistance of a red tray system and protected mealtimes. Special medical or cultural diets could be catered for.

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

We found that the hospital was not yet offering a full seven-day service. Staffing constraints and availability had yet to be addressed. There was limited routine availability of other support services such as therapies over the weekend and out of hours. Although staff reported few problems with being on call staff into the hospital, not having on site staff available at all times limited the responsiveness and effectiveness of the service the hospital was able to offer.

Patients and their families were treated with compassion, dignity and respect. They had their care needs met by caring and dedicated staff. This positive feedback was reflected in the Family and Friends feedback and patient survey results.

Both patient and stakeholder needs were taken into consideration when planning services. Patients who lived far from the hospital were able to access the specialist services of QVH through the ‘Hub and Spoke’ outreach system. There was innovative use of telemedicine to aid the urgent assessment of injuries, improve patient experience and prevent unnecessary hospital admissions. There were clear admission criteria for burns patients in order to manage the hospital’s relative clinical isolation and noncompliance with the national burns standards in relation to providing essential support services. Service level agreements with other hospitals within the burns network ensured that patients were triaged to the most effective location for their particular physical needs. The effective management of elective and trauma cases meant that operations were rarely cancelled. Complaints were acknowledged, investigated and responded to with information was shared to promote learning and prevent reoccurrence.

The specialist services undertaken by the trust were well-led with clear strategic objectives were in place that were known and understood by the staff. Senior leaders were visible, available and supportive to all staff. There was an effective governance and risk management structure in place with robust clinical governance and reporting arrangements in place. There was clear leadership with staff taking ownership and responsibility for their areas of influence. All staff spoke with passion and pride about working at QVH. The trust promoted and encouraged both local and national innovations to improve patient care and treatment.

Updated 23 May 2019

We inspected burns services and plastic surgery services during this inspection but not surgery overall.

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

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
• The service had suitable premises and equipment and looked after them well. We saw records of daily checks of critical equipment, such as oxygen, suction, call bells and hoists. Equipment received annual servicing and electrical safety testing to ensure it was safe and fit for purpose.
• Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
• The service had 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.
• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.
• 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.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.
• The service provided mandatory training in key skills to all staff. Although not all staff held up-to-date mandatory training, data available at the time of our visit showed mandatory training rates now met the trust target of 95% in some areas.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.
• 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.
• 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 service made sure staff were competent for their roles. Managers appraised staff performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• 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 provided consultant cover 24 hours a day, seven days a week, for any patients needing consultant review. Records we reviewed demonstrated daily medical review of patients.
• The service promoted healthy living with its patients. Staff referred patients for stop smoking services and support to reduce alcohol consumption where relevant.
• 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.
• There was a strong, visible person-centred culture and the service truly respected and valued patients as individuals. Staff were highly motivated and inspired to offer care that was exceptionally kind and promoted people’s dignity.
• Feedback from patients, those close to them and stakeholders was continually positive about the way staff treated people. The trust performed ‘much better than expected’ compared with other trusts in CQC’s 2017 Adult Inpatient Survey. NHS Friends and Family Test data displayed on the wards showed almost all patients would recommend the service to family and friends. There were consistently high recommendation rates, which reached 100% in nine out of 12 months in 2018 on the Burns Unit, and eight out of 12 months on Margaret Duncombe Ward.
• Staff saw patients emotional and social needs as being as important as their physical needs. Staff provided emotional support to patients and those close to them to minimise their distress and help them in their recovery from traumatic events or major surgery.
• Staff were fully committed to working in partnership with people and making this a reality for each patient. The service always reflected patients’ individual preferences and needs in the delivery of care.
• The trust planned and provided services in a way that met the needs of local people, as well as patients from further away that required specialist services. The facilities and premises were suitable for the services being delivered.
• The service took account of patients’ individual needs. Staff acted to meet the needs of different patient groups so they could access the service on an equal basis to others.
• The service treated concerns and complaints seriously and investigated them. They learned lessons from the results and shared these with all staff. We saw examples of improvements following learning from complaints and patient feedback.
• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. They were knowledgeable about the issues and priorities for the quality and sustainability of the service, understood the challenges and how to address them.
• 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. Staff we spoke with at different levels knew the strategic objectives for the service and how they contributed to them.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. All staff we spoke with were highly positive about the caring culture of the trust.
• The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
• The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Staff we spoke with understood the risks to the service, and we saw the service acted to reduce risks.
• The trust collected, analysed, managed and used information well.
• The trust engaged well with patients, staff, the public and local organisations to plan and manage services. They collaborated with partner organisations effectively.
• The trust engaged well with patients, staff, the public and local organisations to plan and manage services. They collaborated with partner organisations effectively.
• The service was committed to improving by learning from when things went well and when they went wrong, promoting training, research and innovation. We saw examples of projects and changes to drive continuous improvement.

However:

• For some surgical specialties, people could not always access the service when they needed it. The trust experienced a decline in referral to treatment performance in 2018. Between September 2017 and August 2018, referral times were better than the England average for the ophthalmology and ear, nose and throat specialties. They were worse than the England average for the plastic surgery and oral surgery specialties.
• We saw chemicals subject to Control of Substances Hazardous to Health (COSHH) regulations, such as floor cleaner, toilet cleaner and a biohazard spill kit stored in unlocked sluice rooms on Canadian Wing on the second day of our visit. We highlighted this issue to a matron, who took immediate action to lock the chemicals away to prevent unauthorised access.
• The service did not meet the British Burn Association National Burn Care Standard C.05: Additional Clinical Services. This was because, as a specialist trust, the hospital did not provide the usual range of district general hospital services such as general surgery, mental health liaison and paediatric medicine. To reduce these risks, the trust had service level agreements with a nearby acute NHS teaching hospital trust to provide these services in a timely way, 24 hours a day, seven days a week as needed.
• The service’s admissions policy for surgical patients relied heavily on the individual judgement of the on-call consultant as to whether a patient met the criteria for admission to the hospital. For example, there was no specific criteria for burns patients around the total body surface area affected by the burns. There were also no specific criteria for significant co-morbidities.
• Mandatory training rates for medical and dental staff were 81%, which did not meet the trust target of 95%.