All inspections: The Queen Victoria Hospital (East Grinstead)

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.

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

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

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

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

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

Our key findings were as follows:

Safe

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

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

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

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

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

Effective

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

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

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

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

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

Caring

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

In children and young peoples services and Burns and plastics we saw outstanding examples of care toward patients.

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

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

Responsive

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

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

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

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

Well led

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

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

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

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

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

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

We saw several areas of outstanding practice including:

Staff were taking exceptional steps to improve the hospital experience for patients living with dementia. Allowing extra time during assessment, facilitation families in supporting the patient, awareness of the environment and equipment in relation to vulnerable patients and the use of distraction accessories such as ‘twiddle muffs’ demonstrated that the needs of vulnerable patients were taken into consideration and steps taken to personalise their care and treatment.
The burns outreach nurse post was an innovative solution to the problems of dealing with burns in the community. Patients were able to be discharged quicker with continuity of care and treatment.
The hospital’s audit office undertook the task of monitoring and auditing the quality of care and treatment across the trust. The staff demonstrated passion and enthusiasm for improving patient experience through the use of data and audit.

The trust developed and actively uses a Telemedicine Referral Image Portal System which has been developed in collaboration with the London and South East of England Burns Network. Telemedicine is the use of telecommunication and information technologies in order to provide clinical health care at a distance. Telemedicine was chosen as the SE Coast Regional Winner in the 2008 Health & Social Care Awards in the category of “Innovative Information & Communications Technology” and went on to be a runner up at the National awards. This Innovative use of telemedicine allows trained staff to view a burn injury at a distance either in another hospital or via ambulance staff photos and give appropriate advice, assessment and advise transfer to most appropriate location.
Staff within the paediatric service had been instrumental in developing unique aftercare opportunities for patients. One such initiative was called the CREW camp. This stands for challenging, recreational, educational weekend for burns patients which is funded by local businesses and provides educational activity weekends for up to 30 ex patients. A committee of eight staff have been established to run the event which selects nominated children who they consider would get the most benefit from the activities.
The prosthetics department was cutting edge and provided a patient focussed individualised service. Clinicians worked with patients to ensure the best outcomes were achieved. Staff were enthusiastic, dedicated and were committed to continual professional development publishing regularly in professional journals. This meant that patients received the most up to date advancements in prosthetic development.
The patient pathway for head and neck patients was comprehensive. Patients attended a pre-assessment appointment, were allocated a named nurse and visited other departments in the hospital that would be part of the treatment intervention. There was a separate waiting area in outpatients so that patients had privacy whilst waiting to be and seen and a psychology service was available to support the emotional needs of patients coming to terms with life changing body image issues.

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

Importantly, the trust must:

The provider must ensure that all medication in theatre is stored appropriately.
The provider must ensure adequate and safe out of hours medical care.
The provider must ensure all clinical staff have training in the Mental Capacity Act.

In addition the trust should:

Ensure that all COSHH (Control of substances hazardous to health) products should be stored appropriately.
Continue to review how it benchmarks itself against national quality standards.

Review how patients pain is managed specifically when carrying out dressing changes.
Continue its review of governance arrangements so that critical care has its own individual agenda.
`Ensure that departmental risks are identified, recorded and regularly reviewed.
Ensure there are mechanisms in place for staff and patients to raise an alert in an emergency situation in the therapies department.
Ensure all incidents are reported in a timely manner in outpatients.
The trust should ensure the décor is refreshed and updated in outpatient department 1.
Ensure there are adequate facilities for patients attending the hand therapy clinic and that privacy is maintained.
Ensure that staff in MIU have attended all mandatory training.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We undertook this inspection to follow up on concerns that were noted at our previous inspection on the 4/5 of February 2013. These related to the some records that did not contain accurate and sufficient information about the care and treatment provided and the lack of records of the qualifications undertaken by staff, in order to evidence that they had the skills and training to operate radiology equipment.

At this inspection we found that considerable action had been undertaken to address the previous concerns. This included staff undertaking training in records management, regular audits across the Trust to monitor standards of record management and the establishment of a patient document committee. We found that the records we looked at now contained the information necessary in order to protect patients from the risk of unsafe or inappropriate care and treatment.

This was an unannounced inspection which focused on maxillofacial, orthodontic and paediatric services. We looked at both inpatient and outpatient departments for these areas.

Patient feedback across each of the departments we visited was positive about the quality of care and treatment that people had received. Patients told us that they had experienced care that had exceeded their expectations. People said that they felt safe at the hospital. We found evidence that people had been consulted with and wherever possible had been involved in the planning of their own care. Patients had been given accessible information and support to make decisions about their treatments.

We found staff to be competent and experienced. Staff told us that they felt well supported both by their line managers and the wider Trust. Staff said that the hospital operated an open culture and that they felt able to challenge practices and each other.

The Trust had appropriate systems in place for monitoring the services it provided. We saw evidence that where areas had been identified for improvement the necessary action had been taken to secure this.

We looked at a range of records across the hospital. Many records were found to be detailed and accurate, however we identified areas where significant information had not been fully documented. Where there were gaps it was not possible to evidence that the appropriate action had been taken to protect people.

People who use this service said that they felt supported by the staff to receive the care they need. They told us that every effort is made by the staff to help them maintain their mobility, independence and regain confidence to help them live independently when they are discharged. We spoke to many patients who said they felt included in their care, were able to express their preferences and contributed with goal setting for discharge. They were able to make choices in their daily activities and what food they wished to eat.

During our visit we spoke with people on two wards who had been in the hospital between 3 days and 5 weeks and they told us they were very happy with the care provided. In general they were confident that the doctors and nurses made the right decisions about their care and treatment but some were not always sure that they fully understood all the details. They said that when they asked or needed things explained in more detail the ward staff took time to explain things more clearly and were good at making sure people understood about their illness, their treatments and care, even at busy times.

General observations made by inspectors throughout the day found that overall staff talked politely, respectfully and treated patients with dignity when giving treatment or care. When we looked at a selection of nursing records and care plans we could see that these documents clearly recorded what treatment was required and received, together with important references to the patients' ethnicity, religious needs and preferences.

During our visit we saw lunch being served both in the dining area and within the wards. Staff told us that they encouraged people to eat in the dining room whenever possible to help regain mobility and engage with other people. We saw that those people that needed some support and encouragement to eat their meal were treated calmly by staff in a dignified manner and given appropriate equipment to use. People told us they were always asked if they wanted a choice of drinks and that hand washing wipes were available for them to use prior to eating.

We asked people on each ward what they thought of the food, and they all reported that it was of good quality with plenty to choose from. On the day of our visit the food looked appetising and patients were keen to tell us that the food was always hot, well presented and there was an excellent roast dinner on Sundays. One person said 'It's the best hospital food I've had' and another person told us that 'food is excellent here and I am a very fussy eater so not easy to please'.

The Queen Victoria Hospital (East Grinstead)

All Inspections

29 Jan to 27 Feb

During a routine inspection

11 and 12 November 2015 unannonced inspection 23rd November 2015

During a routine inspection

Professor Sir Mike Richards

26 September 2013

During an inspection looking at part of the service

4, 5 February 2013

During a routine inspection

5 April 2011

During a themed inspection looking at Dignity and Nutrition