Source · CQC inspection

Princess Royal Hospital

Provider University Hospitals Sussex NHS Foundation Trust Type NHS Healthcare Organisation Region South East Last inspected 14 Feb 2024

Overall rating: Requires Improvement View full CQC report

Domain ratings

Five CQC key questions

Safe

Requires Improvement

Effective

Good

Caring

Good

Responsive

Requires Improvement

Well-led

Requires Improvement

Earlier inspection findings

pre-2024 framework · 11 must-do 4 should-do

Must-do actions (11)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 11

Must do

Safe

The trust must ensure appropriate training, in line with guidance, is in place and completed by staff to support patients with learning disabilities, dementia and autism.

Regulation: Regulation 12

⚠ Since July 2022 it is a legal requirement for all staff to receive training in how to interact with people with a learning disability and autistic people. Training attendance for learning disability and autism was low at 42%.

Must-do action 2 of 11

Must do

Safe

The trust must ensure that staff complete mandatory training in line with their role and that oversight of targets is effectively monitored.

Regulation: Regulation 12

⚠ It was not possible to identify mandatory training compliance figures for Princess Royal Hospital. The surgical division was across both Princess Royal Hospital and Royal Sussex County Hospital and the staffing data was not separated into data for each individual hospital.

Must-do action 3 of 11

Must do

Safe

The trust must ensure that medicines are stored according to the manufacturer’s instructions.

Regulation: Regulation 12

⚠ A light sensitive medicine was stored on open shelving and in glass fronted cabinets across multiple locations.

Must-do action 4 of 11

Must do

Safe

The trust must ensure that all guidance documents relating to medicines management are up to date.

Regulation: Regulation 12

⚠ Some of the guidance documents that were in use by staff were out of date. This included guidance about what medicines to continue to administer when a patient was nil by mouth.

Must-do action 5 of 11

Must do

Safe

The trust must ensure there is enough equipment to safely meet the needs of patients.

Regulation: Regulation 12

⚠ The service did not always have enough suitable equipment to help them to safely care for patients. Staff told us there was not enough monitoring equipment or computers on wheels (COWs) on the wards.

Must-do action 6 of 11

Must do

Responsive

The trust must ensure that it responds to all patient complaints as per their policy.

Regulation: Regulation 16

⚠ There was a delay in responding to and resolving complaints and only 33.3% of complaints were closed within the 25-day deadline.

Must-do action 7 of 11

Must do

Safe

The trust must ensure all incidents and near misses are reported and acted on.

Regulation: Regulation 12

⚠ Staff did not report all incidents and near misses. Staff said they tended to only report the more serious incidents as they were often too busy to report the more minor incidents. Review of national data indicated that trust wide from October 2022 to October 2023 the trust reported fewer …

Must-do action 8 of 11

Must do

Safe

The trust must ensure there are enough nursing staff and medical staff to keep patients safe. This needs to include arrangements for the management of patients operated on by Royal Sussex County Hospital surgeons.

Regulation: Regulation 12

⚠ The service did not always have enough nursing and support staff to keep patients safe. It was often difficult to get medical support for the patient if there was a complication after the operation as the operating doctor had left the site. This increased the risk of avoidable harm to …

Must-do action 9 of 11

Must do

Effective

The trust must ensure that guidance documents have been reviewed and are up to date.

Regulation: Regulation 17

⚠ Out of 58 items of NICE guidance relevant to the surgical division, 43 had not had yet had baseline assessments completed which meant it could not be fully assured the service was following national guidance.

Must-do action 10 of 11

Must do

Responsive

The trust must ensure action is taking to improve their compliance with national waiting list targets. And that performance data for the trust can be separated to show site performance.

Regulation: Regulation 17

⚠ People could not access the service when they needed it and had long waits to receive the right care. Waiting times from referral to treatment and arrangements to admit and treat patients were not in line with national standards. Waiting times for treatment were getting longer (worse). Performance data for …

Must-do action 11 of 11

Must do

Well-led

The trust must ensure that workforce data for the trust can be separated to show individual site performance.

Regulation: Regulation 17

⚠ Workforce data for the trust was not separated to show individual site performance, making it impossible to have an accurate assessment of the safety of staffing at Princess Royal Hospital.

Should-do actions (4)

Recommended improvements to enhance service quality.

Should-do action 1 of 4

Should do

Responsive

The hospital should consider improving engagement with patients and their families to increase the response rate of the friends and family test surveys.

Should-do action 2 of 4

Should do

Responsive

The hospital should act to reduce the number of mixed sex breaches.

Should-do action 3 of 4

Should do

Safe

The hospital should act to improve compliance with the Royal College of Radiologists safety checklist.

Should-do action 4 of 4

Should do

Well-led

The hospital should consider how to improve staff confidence in raising concerns to senior leaders.