We carried out a focussed, unannounced inspection at Royal Sussex County Hospital (RSCH) on 12 October 2017. The purpose of the inspection was to ensure the trust had appropriate measures in place regarding the Control of Substances Hazardous to Health Regulations.We did not inspect a specific core service we focussed on one key question, “Are services safe?” We did not look at the other key questions relating to effectiveness, caring, responsiveness and well-led as this was a focussed inspection.Our findings did not affect the ratings we gave the hospital after our inspection in April 2017, when Royal Sussex County hospital was rated as requires improvement overall. References to ratings in this report relate to this earlier inspection.

For full details of the inspection undertaken in April 2017 please visit /www.cqc.org.uk/location/RXH01

Our main findings were as follows:

• Housekeeping assistants had a good knowledge of the Control of Substances Hazardous to Health cleaning products they used and had recently received refresher training.

• Although nursing staff received Control of Substances Hazardous to Health training as part of their mandatory training programme, the three nurses we spoke with were not clear about their responsibilities in relation to Control of Substances Hazardous to Health.

• The trust had removed green coloured water jugs (which were implemented to support people with dementia) and only clear jugs were in use. This meant it was possible to see the liquid inside the jug.

• The trust had instructed all the codes on the cleaning cupboard doors to be changed however, we found not all door lock codes had not been changed.

• Ward areas had information folders and generally staff knew where these were located. However, the content of the Control of Substances Hazardous to Health folders we reviewed was not always complete. Control of Substances Hazardous to Health risk assessments or data sheets were not available in cleaning cupboards.

• There was not a system in place which gave assurance that Control of Substances Hazardous to Health information had been read and understood by staff using the substances.

• Substances subject to Control of Substances Hazardous to Health legislation were not always stored securely. We found products stored in unlocked utility rooms and kitchens and access codes were written in close proximity to digital locks. There were unattended cleaning trolleys containing hazardous substances.

• There were cleaning products in use, which had not gone through the trust’s procurement policy.

There were areas of poor practice where the trust needs to make improvements.Importantly the trust must:

• Ensure all products that are subject to Control of Substances Hazardous to Health regulations are stored securely.

• Introduce systems which give assurance that information relating to substances subject to Control of Substances Hazardous to Health is available in work areas, that this information is complete and accurate, and that staff have understood it.

• Ensure nursing staff are aware of the regulations and their responsibilities with regard to safe storage and use of Control of Substances Hazardous to Health products.

In addition, the trust should:

• Consider how Control of Substances Hazardous to Health substances are kept securely on cleaning trolleys.

• Consider alternatives to the digital lock system to control access to cleaning cupboards.

Edward Baker

Chief Inspector of Hospitals

The inspection team included an advisor with specialist knowledge of infection control, and five inspectors. During the inspection we spoke with 44 staff, in a range of roles, including matrons, maintenance engineers, healthcare support workers, housekeepers, nursing staff, consultants, doctors, directors, managers and contractors. We also observed care and spoke with 19 patients and visitors. We visited a sample of elderly care and rehabilitation wards, orthopaedic, surgical and maternity wards. We also visited the eye hospital and the children’s hospital site.

On the day of our inspection we found that the hospital was clean and procedures were in place to prevent and control the spread of infections. We spoke with many patients who were generally very positive about the standards of cleanliness. Most commented that they had observed staff wash their hands frequently, and made use of gloves and aprons when necessary. For example one patient told us," It’s definitely clean, the bathrooms area is always clean which is amazing on a maternity ward”.

We found some areas of the hospital where the fabric of the building had become compromised. This presented a continual challenge for staff in their attempts to maintain acceptable levels of cleanliness. The provider had in place appropriate policies that assessed environmental risks and maintained the premises in order to ensure that people’s rights to privacy, dignity, choice, autonomy and safety were protected.

We took the opportunity to speak with many women during our visit and found that they were generally very complementary about the care and dedication of the staff looking after them. We were told that communication was good, staff referred to individual birth plans and women felt supported and listened to. A woman and her partner told us that they were aware that there was a virtual tour of the maternity unit on the hospital’s website. We spoke with women attending antenatal appointments, during labour and on the post natal ward. All told us that they were very happy with the care they had received. One person commented, “It was really good.” Another said “I feel really supported and safe here”.

Women were happy to talk with us and confirmed that they were generally very happy with their care. They said they been provided with enough information and had their treatment fully explained with them. One woman commented, “I wanted to be quite flexible on the day.” Another told us that they had brought their birth plan in when they were due to give birth, and staff had referred to it during her labour. They all told us that they would recommend the unit to friends.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

People who use this hospital 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, wherever possible. We spoke to many patients and were told that people felt able to express their preferences and that as far as practicable and in accordance with their wishes and individual care plans, people were enabled and encouraged to make choices about their daily lives.

As part of our compliance review of The Royal Sussex County Hospital we visited Accident and Emergency departments, Chichester, Donald Hall, Bristol, Fleming and Lister, Albion, Solomon, Vallance, Jowers and Lewes wards. All units and wards were found to be well managed and the staff we spoke with were confident and competent in their roles. The environment was found to be clean and generally well maintained.

Patients in all areas of the hospital appeared to be safe, generally comfortable and well cared for. This was supported by positive comments from patients and their relatives and also evident from direct observation of individuals being supported in a professional, sensitive and respectful manner. We were told by one patient that “the staff are all so kind and friendly and the care they provide is second to none”. Another told us that “we feel very involved with the hospital and we are kept informed about what is happening”.

As far as practicable and in accordance with their wishes and individual care plans, people were telling us that they were enabled and encouraged to make choices about their daily lives and the care they were to receive.

• Our rating of this service improved. We rated it as good because:
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.
• The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. The service used information to improve the service.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to monitor and prevent the spread of infection.
• The service had suitable premises and equipment and looked after them well. Staff carried out risk management strategies in unsuitable premises and kept patients safe. The service had systems to provide assurance that information relating to Control of Substances Hazardous to Health (COSHH) was available, complete and accurate, and staff understood it.
• The service gave, recorded and stored medicines safely. Patients received the right medication at the right dose at the right time.
• Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
• Staff understood how to protect patients from abuse and the service worked well with other organisations to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• The service provided mandatory training in key skills to all staff and made sure everyone completed it.
• We found staff responded well to the deteriorating patient and there was effective sepsis management.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Staff carried out comprehensive assessments to meet people’s needs and improve their health. This included consideration of clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs. They used special feeding and hydration techniques when required. They adjusted to patients’ religious, cultural and other preferences.
• Staff of different professions worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Outcomes for patients were good. The service performed well in audits such as the quarterly Sentinel Stroke National Audit programme. On a scale of A-E, where A is best, the trust achieved grade A in the latest audit, August 2017 to November 2017.
• The service made sure staff were competent for their roles. Staff had the right qualifications and skills to carry out their roles effectively and in line with best practice. Staff received timely supervision and appraisals of their work performance and they had access to learning and development, including mandatory training.
• Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to information they need to assess, plan and deliver care to people in a timely way. When there are different systems to hold or manage care records, these were coordinated.
• Staff in most areas we inspected 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 understood and monitored the use of restraint and used less restrictive options where possible.
• The service had a strong, visible person-centred culture. Despite staff and financial challenges, staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Relationships between people who use the service, those close to them and staff were strong, caring and supportive. These relationships were highly valued by staff and promoted by leaders.
• We saw staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Feedback from people who use the service, those who are close to them and stakeholders was continually positive about the way staff treat people. People described that staff “go the extra mile” and the care they received exceeds their expectations.
• Staff provided emotional support to patients to minimise their distress. Staff were aware of the impact on patients and carers of the care and treatment they provided.
• Staff involved patients and those close to them in decisions about their care and treatment. Patients were satisfied with the information they had been given and was explained in a way they could understand.
• Staff highly valued people’s emotional and social needs and we saw these were not only embedded in their care and treatment, but they went over and beyond to innovate the “Small Acts of Friendship” programme to help elderly patients retain dignity, social activity, mobility and well-being whilst in hospital.
• The service planned and provided services in a way that met the needs of local people. We saw flexibility, choice and continuity of care were reflected in the services.
• The service had done everything within their remit to improve access and flow. Initiatives such as discharging patients before midday, regular and effective monitoring and managing of medical outliers and the service had recruited a new manager to help with the flow. The service also monitored delayed transfers of care and worked with system partners to improve the position. Capacity to deal with the demand could be fully realised once the trust’s 3Ts project is completed.
• Staff provided coordinated care and treatment with other services and other providers.
• The service took account of patients’ individual needs. Staff accounted the needs of different people when planning and delivering services. For example, on the grounds of age, disability, gender, gender reassignment, pregnancy and maternity status, race, religion or belief and sexual orientation.
• Staff made reasonable adjustments and removed barriers when people find it hard to use or access services.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. It was easy for people to complain or raise a concern and they were treated compassionately when they did so. There was openness and transparency in how complaints were dealt with. Complaints and concerns were always taken seriously, listened to and responded to in a timely way. The service made improvements to the quality of care as a result of complaints and concerns.
• The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. The leadership structure was clear and staff knew their reporting lines and responsibilities.
• The trust had a vision for what it wanted to achieve and workable plans to turn it into action with involvement from staff and patients. Staff could clearly explain what the vision was and were actively engaged in training for the strategic patient first approach to working. Staff could clearly explain why they thought this was a positive initiative to improve patient care.
• The trust used a systemic approach to continually improve the quality of its services and safeguarding its standards of care by creating an environment in which clinical care would flourish.
• The culture was significantly different to previous inspections. Staff displayed a ‘can do’ attitude to any challenges they faced. All disciplines of staff had a shared focus and purpose to ensuring patients received the best possible care and experience. Staff morale was good, and staff were positive about the overall leadership of the trust.
• We saw good local ward and department leadership. Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff we spoke with described they were valued and how they felt there was a culture of collective responsibility between teams and services.
• Staff were engaged, supported and felt valued by senior staff. There was a supportive culture of learning and education and staff told us that this was a real focus and they felt invested in.
• The service engaged with patients, staff, the public and local organisations to plan and manage appropriate services.
• Staff understood candour, openness, honesty and transparency and challenged poor practice. The service had mechanisms to support staff and promote their positive wellbeing. Behaviour and performance inconsistent with the values were identified and dealt with swiftly and effectively, regardless of seniority.
• The service had an effective process to identify, understand, monitor and address current and future risks. They escalated performance issues to the relevant committees and the board through clear structures and processes. We saw clinical and internal audit processes functioned well and had a positive impact on quality governance, with clear evidence of action to resolve concerns.
• The trust managed financial pressures so that they did not compromise the quality of care.

However:

• Patients could not always access services when they needed them. Data provided to us by the trust showed there was 902 black breaches as Royal Sussex County hospital between September 2017 and August 2018. 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. The trust accounted the black breaches to challenges with hospital capacity and flow.
• The percentage of patients in the emergency department waiting between four and 12 hours from the decision to admit until being admitted was worse than the national average.
• Patients referred on a cancer pathway were not always treated within 62 days of referral from their GP. The trust was performing worse than the England average in this area.
• The trust participated in the 2017 Lung Cancer Audit and the proportion of patients seen by a Cancer Nurse Specialist was 64.6%, which did not meet the aspirational audit standard of 90%. The figure had improved since 2016 when it was 60.0% and we saw the trust had an action plan to address this issue. The trust worked with another NHS provider to roll out a streamlined rapid access pathway for new referrals in late 2018/early 2019. The pathway was compliant with National Optimal Lung Pathway.
• Surgical patients sometimes stayed longer than their required recovery time in theatre due to a lack of bed availability in critical care and ward areas.
• In outpatients, critical care and surgical wards and theatres, there were some pieces of equipment that had not been serviced in line with schedule. Fire risk assessment in wards level 8a East and 8a West had identified actions and on both wards, these actions were only partially complete.
• In the surgery core service, there was some inconsistency in recording why medications were not administered. Out of eight charts checked, four showed no documentation of reasons for not administering drugs by using the suggested code, which meant a lack of information when reviewing treatment.
• The trust did not comply with all elements of Guidelines for the Provision of Intensive Care Services, 2015. Coverage from the critical care outreach team was not provided 24 hours a day, seven day a week and there was not a critical care pharmacist.
• No staff in outpatients had received training in the Mental Health Act 1983.
• The patient led assessment of the care environment audits for dementia and disability scored significantly worse than the national average across four outpatients areas that were assessed. The trust wide dementia strategy did not have any outpatient related actions.
• The leadership and governance structures did not provide consistent and visible support to staff working in outpatients, although arrangements were in place to appoint to key management vacancies and address this moving forward.