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Inspection Summary


Overall summary & rating

Good

Updated 15 August 2016

This was the first inspection of The Royal Free Hospital under the new methodology. We have rated the hospital as Good overall. 

We carried out an announced inspection between 2 and 5 February 2016. We also undertook unannounced visits during  the following two weeks.

We inspected eight core services: Urgent and Emergency Care, Medicine (including older people’s care, Surgery, Critical Care, Maternity and Gynaecology, End of life Care, Services for Children and Outpatients and diagnostic services.

Our key findings were as follows:

Safe

There was a good culture of reporting incidents and we saw evidence of changes to practice as a result of investigations, and there were robust systems in place.

There were concerns with infection prevention and control practices, such as variable hand hygiene, staff wearing nail varnish and jewellery and doors left open to patients in isolation.

The safety thermometer data and many patient risk assessments or records, including fluid balance charts, were incomplete.

Departments performed frequent audits such as the theatre checklist and hand hygiene. Audits were analysed and the results cascaded to staff through staff meetings, notice boards and safety briefings.

Staff were aware of the safeguarding policies and procedures and had received training. Most staff understood their responsibilities under the Duty of Candour and were able to provide examples.

Suitable governance arrangements and appropriate incident reporting meant staff learnt from mistakes and near misses to improve care.

A formal early warning system was not consistently to identify deteriorating patients in the ED at the Royal Free site, which could lead to a delay in identifying deteriorating patients.

Effective

Clinical practice was benchmarked against national guidance from organisations such as NICE.

Caring

Staff were caring, compassionate and respectful and the staff we spoke with were positive about working in the hospital.

Caring staff maintained patients’ privacy and dignity and provided emotional support to relatives.

Responsive

The trust’s ED performance on waiting times for treatment was inconsistent but they often met the 4-hour target.

The Hospital and its staff recognised that provision of high quality, compassionate end of life care to its patients was the responsibility of all clinical staff that looked after patients at the end of life. They were supported by the palliative care team, end of life care guidelines and an education programme.

The palliative care team was highly thought of throughout the hospital and provided support and education to clinical staff. The team worked closely with the practice educators at the hospital to provide education to nurses and health care assistants. Medical education was led by the medical consultants and all team members contributed to the education of the allied healthcare professionals.

An interpreting service was available for both in-patients and out-patients within the hospital.

Ambulance turnaround time did not meet the national target of handover. Patients were also not consistently receiving an assessment within 15 minutes of arrival, which was not in line with College of Emergency Medicine (CEM) guidance.

Patients’ individual needs and preferences were mostly considered when planning and delivering services.

The trust had consistently not met the referral to treatment time standard or England average for the past ten months. The time to triage referrals as to their priority varied between specialities and could take as long as 34 days.

There had been a deterioration in performance of the 62 day cancer performance compared to the national standard.

The hospital cancelled 35% of outpatient appointments in the last year. From October to January 34% of short notice cancellations were due to annual leave, which was not in line with trust policy.

There was a lack of bereavement facilities on the labour ward. The designated room for bereaved mothers was a standard labour room and was sometimes used for other patients, such as those with an infection, which meant that women were cared for in the birth centre.

The poor post-operative recovery facilities for children exposed them to potentially upsetting sights and sounds.

Well Led

Patients achieved good outcomes due to receiving evidence-based care from suitable numbers of competent staff who enjoyed their work and were well supported by a visible management team.

There was an appropriate system of governance in surgical care services and arrangements to monitor performance and quality.

The trust promoted and encouraged both local and national innovations to improve patient care and treatment.

We saw several areas of outstanding practice including:

A ‘Foetal Pillow’ had been designed to aid delivery of the baby at caesarean section. The foetal pillow was used to elevate the baby’s head making operative delivery easier.

Particular praise must be given to the volunteers who provided additional caring activities such as massages for patients and supported patients with dementia.

We observed dynamic nursing leaders who supported clinical environments are were essential in the development and achievement of best practice models.

The neonatal unit had level 2 UNICEF accredited baby friendly status where breast feeding was actively encouraged and mothers are given every opportunity to breast feed their babies.

The vigilance and recording of mandatory training and other aspects of post qualifying education by the paediatric practice education team was exemplary.

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

Importantly, the trust must:

  • Take action to ensure compliance with The National Patient Safety Agency (NPSA) alert PSA001 31st January 2011.

  • The trust should ensure the 62 day cancer wait times are met in accordance with national standards.
  • The trust data base of clinical guidelines and procedures hosted via “freenet” must be updated as soon as possible.
  • The recovery area of the operating theatre must be altered to protect children from witnessing upsetting sights and hearing frightening sounds.
  • Nursing staffing levels on the children’s ward must be improved.

In addition the trust should:

  • Clearly define the ‘low risk’ pathway for women identified as suitable for birth centre care.

  • Improve termination of pregnancy pathway.

  • Identify a dedicated bereavement facility for women and families to use in or near the labour ward.

  • Use lessons learned from Barnet Hospital in reducing Caesarean section rates.

  • Undertake a maternity acuity staffing assessment to identify staffing requirements for the merged service.
  • Improve antenatal risk assessments.

  • Ensure the theatre swab, needle and instrument policy is ratified and new practices are embedded in all relevant departments across all sites.
  • Ensure a safer surgery policy is produced and ratified.
  • Ensure appropriate staggering of arrival times with the day surgery unit to minimise the time patients are prohibited from eating and drinking.
  • Ensure ED staff are fully trained and able to identify and support patients living with dementia.
  • Ensure the ED risk register captures and manages all risks.
  • Ensure that there is an electronic system in place to flag patients who may require additional support.
  • Ensure that medical and nursing records are fully completed without gaps or omissions.
  • Ensure that RTT is met in accordance with national standards.
  • Ensure all staff interacting with children have the appropriate level of safeguarding training.
  • Ensure security of prescriptions forms is in line with NHS Protect guidance.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 15 August 2016

Effective

Good

Updated 15 August 2016

Caring

Good

Updated 15 August 2016

Responsive

Good

Updated 15 August 2016

Well-led

Good

Updated 15 August 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 15 August 2016

We saw examples of safety incident reporting systems, audits concerning safe practice, and compliance with best practice in relation to care and treatment.

Staff planned and delivered care to patients in line with current evidence-based guidance, standards and best practice. For example, we observed that staff carried out care in accordance with National Institute of Health and Care Excellence (NICE) and Royal College of Obstetricians and Gynaecologists(RCOG) guidelines.

Patients told us they had a named midwife. The ratio of clinical midwives to births was in mainly in line with the national average of one to twenty eight women.

The trust provided evidence of one-to-one care during labour which is recommended by the Department of Health. Women told us they felt well informed and were able to ask staff if they were not sure about something.

Patients and their relatives spoke highly of the care they received in both the maternity and gynaecology services.

However,

There were three never events involving retained swabs in 2014, 2015 and 2016.

Record keeping was inconsistent and on-going risk assessment in pregnancy was not recorded in patient records.

Patients’ individual needs and preferences were mostly considered when planning and delivering services.

The designated bereavement room was not always available for bereaved mothers and they were therefore sometimes cared for in the birth centre.

Medical care (including older people’s care)

Good

Updated 15 August 2016

Patients achieved good outcomes due to receiving evidence-based care from suitable numbers of competent staff who enjoyed their work and were well supported by a visible management team.

Results from the Friends and Family Test and patient feedback suggested most patients would recommend the service to their loved ones and were happy with the care they received.

Suitable governance arrangement and appropriate incident reporting meant staff learnt from mistakes and near misses to improve care.

We saw evidence of relevant service development and innovation, particularly in the HLIU where equipment design was reviewed after each patient admission. Patients across the country could access the HLIU with a direct consultant referral.

There were concerns with infection prevention and control practices, such as variable hand hygiene, staff wearing nail varnish and jewellery and doors left open to patients in isolation.

The safety thermometer data and many patient risk assessments or records, including fluid balance charts, were incomplete.

Urgent and emergency services (A&E)

Good

Updated 15 August 2016

Staff were proactive in reporting incidents and we saw evidence of learning taking place as a result of incidents.

Learning was shared with all staff via safety briefings and posters were displayed in the seminar rooms. Staff we spoke with were aware of their responsibilities to protect vulnerable adults and children.

The trust’s performance on waiting times for treatment was inconsistent but often met the 4-hour target. The trust has been above the England average for percentage of patients seen within four hours since February 2015.

The department was responding to most complaints within the agreed time frame but staff we spoke with were unable to tell us about any learning or changes implemented as a result of a complaint.

Staff were caring and compassionate, although the design of some accommodation meant that patient’s privacy and dignity were not always protected.

Staff felt supported in their roles and innovative ways were introduced to retain staff. There was an open culture so staff could raise concerns and staff felt the trust was investing in them.

There was clear nursing and medical leadership visibility with the department, and staff felt able to highlight issues to them. The governance arrangement was clear to staff we spoke with and, from the meeting minutes we reviewed, it was clear the leadership team understood the service.

However;

During our inspection, we observed staff did not always wash their hands between seeing patients. Checks on resuscitation trollies and defibrillators were not carried out regularly although we noted the resuscitation trolley to be fully stocked during our inspection.

Patients were also not consistently receiving an assessment within 15 minutes of arrival, which was not in line with Royal College of Emergency Medicine (RCEM) guidance.

There was no formal scoring or early warning system to identify deteriorating patients in the department, which could lead in a delay in identifying deteriorating patients.

The needs of people living with dementia were not always being met as there was no flagging system to identify these patients and some staff had not received training and hence showed a limited understanding of the condition.

The department conducted their own local audits against RCEM standards but did not submit data to the Royal College of Emergency Medicine in 2014-2015. Clinical leads confirmed that this was only a one off year and they were registered for 2015-2016 audits.

We noted that risks were discussed regularly, but not all the risks we identified were on the department’s risk register.

Surgery

Good

Updated 15 August 2016

There was a good culture of reporting incidents and we saw evidence of changes to practice as a result of investigations, and there were robust systems in place.

Departments performed frequent audits such as the theatre checklist and hand hygiene. Audits were analysed and the results cascaded to staff through staff meetings, notice boards and safety briefings.

The trust promoted and encouraged both local and national innovations to improve patient care and treatment.

We saw emergency equipment and medicines were appropriately stored and checked in line with protocols.

We spoke to 30 members of staff who were passionate about working at the hospital and showed pride in their work. All staff said they felt supported and senior staff were visible.

Staff were aware of the safeguarding policies and procedures and had received training. Most staff understood their responsibilities under the Duty of Candour and were able to provide examples.

There was an appropriate system of governance in surgical care services and arrangements to monitor performance and quality.

An interpreting service was available for both in-patients and out-patients within the hospital.

Arrangements were in place to support people with disabilities and cognitive impairments. However there was no electronic flagging system currently in place but a business case has been submitted for such a system.

Intensive/critical care

Not sufficient evidence to rate

Updated 20 September 2017

Services for children & young people

Good

Updated 15 August 2016

The trust met the Royal College of Paediatrics and Child Health (RCPCH) standards for paediatric consultant staffing levels but nursing levels on the children’s ward were not always complaint to the Royal College of Nursing (2013) standards.

The special care baby unit generally met the British Association of Perinatal Medicine standards (2011) for staffing neonatal units.

There was generally good access and flow within the children’s service. Patients received evidenced based care and treatment and good multi-disciplinary working existed between the children’s services, external providers and the child and adolescent mental health service (CAMHS).

The poor post-operative recovery facilities for children exposed them to potential hostile sights and sounds.

Staff were caring, compassionate and respectful and the staff we spoke with were positive about working in the service and there was a culture of flexibility and commitment.

The service was well led and a clear leadership structure was in place. Individual management of the different areas providing acute children’s services were well led. A governance system was in place and we saw that clinical risks identified. Feedback from staff, parents and children and young people was generally good.

We saw that although services provided evidenced based care as identified within evidenced based clinical guidelines, many of these were out of date posing potential risks to patients.

There was an over reliance on agency nurses to fill gaps in the nursing rosters.

End of life care

Good

Updated 15 August 2016

They was a dedicated team providing holistic care for patients with palliative and end of life care (EOLC) needs in line with national guidance.

The hospital provided mandatory EOLC training for staff which was attended, a current EOLC policy was evident and a steering group met regularly to ensure that a multidisciplinary approach was maintained.

The Royal Free London NHS Foundation Trust and its staff recognised that provision of high quality, compassionate end of life care to its patients was the responsibility of all clinical staff that looked after patients at the end of life. They were supported by the palliative care team, end of life care guidelines and an education programme.

The palliative care team was highly thought of throughout the hospital and provided support and education to clinical staff. The team worked closely with the practice educators at the hospital to provide education to nurses and health care assistants. Medical education was led by the medical consultants and all team members contributed to the education of the allied healthcare professionals.

The majority of EOLC was provided by clinical staff on the wards. The palliative care service worked as an advisory service seeing patients with specialist palliative care needs, including those at the end of life.

Staff at the hospital provided focused care for dying and deceased patients and their relatives. Facilities were provided for relatives and the patient’s cultural, religious and spiritual needs were respected.

Medical records and care plans were completed and contained individualised end of life care plans. Most contained discussions with families and recorded cultural assessments. The ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms were all completed as per national guidance. However there were inconsistencies in the documentation in the recording of Mental Capacity Act assessments.

There was evidence that systems were in place for the referral of patients to the palliative care team for assessment and review to ensure patients received appropriate care and support. These referrals were seen and acted upon within 24 hours.

The EOLC service had supportive management and visible and effective board representation. This had resulted in a well led trust wide service that had a clear vision and strategy to provide a streamlined service for EOLC patients.

Outpatients

Good

Updated 15 August 2016

Medical records were available electronically but delays occurred when scanning paper records onto the system. There was no method of recording the number of prescriptions issued.

The trust had consistently not met the referral to treatment time standard or England average for the past ten months. The time to triage referrals as to their priority varied between specialities and could take as long as 34 days.

There had been a deterioration in performance of the 62 day cancer performance compared to the national standard.

The hospital cancelled 35% of outpatient appointments in the last year. From October to January 34% of short notice cancellations were due to annual leave, which was not in line with trust policy.

The outpatient and radiology departments followed best practise guidelines and there were regular audits taking place to maintain quality.

Staff contributed positively to patient care and worked hard to deliver improvements in their departments.

Staff felt supported by their managers and stated their managers were visible and provided clear leadership.

We saw clinical staff were not consistently bare below the elbow at the point of care.

Other CQC inspections of services

Community & mental health inspection reports for The Royal Free Hospital can be found at Royal Free London NHS Foundation Trust.