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King George Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 2 July 2015

Barking, Havering and Redbridge University Hospitals NHS Trust is a large provider of acute services, serving a population of over 750,000 in outer North East London. The trust covers three local authorities; Barking & Dagenham which has very high levels of deprivation, and Havering and Redbridge which are closer to the national average. Havering has a relatively elderly population by London standards.

King George Hospital is in Ilford. It is a modern local hospital providing acute and rehabilitation services for residents across Redbridge, Barking and Dagenham and Havering and some services to patients from South West Essex.

We inspected the trust in October 2013, and found there were serious failures in the quality of care and concerns that the management could not make the necessary improvements without support. I recommended to the Trust Development Agency (TDA) that the trust be placed in special measures in December 2013.

Since the inspection a new executive team has been put into place including a new chair, new members of the board, a chief executive, medical director, deputy chief executive, chief operating officer and a director of planning and governance. The executive team has been supported by an improvement director from the TDA.

The trust developed an improvement plan ('unlocking our potential') that has been monitored and contributed by all stakeholders monthly and published. The purpose of this re-inspection was to check on improvements, apply ratings and to make a recommendation on the status of special measures.

Overall, this hospital requires improvement. End of life care services were rated as good, its Outpatients and diagnostic imaging service were rated as inadequate and all other services were rated as requires improvement. Of the five key questions that CQC asks, we rated the hospital as good for caring. We rated the hospital as requires improvement for safe effective, responsive and well-led.

Our key findings were as follows:

  • Improvements had been made in a number of services since our last inspection.

Safe

  • Safety was not a sufficient priority. There was a backlog of serious incidents and the quality of investigations into serious incidents lacked detail to ensure failings were understood and lessons were learned.
  • There were insufficient systems, processes and practices to keep patients safe. Lessons were not learned and improvements were not made when things went wrong.
  • Recruitment had been on-going however there was not always enough medical and nursing staff to meet the needs of patients.
  • The management of medicines needed improving to ensure safe management and administration.
  • Patient safety could be compromised due to the layout and the inadequate alarm system in the Phlebotomy clinic in Outpatients.

Effective

  • Radiology staff felt that their competencies for CT scanning were not appropriately maintained.
  • Patients' needs were assessed and care and treatment was delivered in line with evidenced-based guidance.
  • Patient outcomes were varied.
  • Pain relief and nutrition and hydration needs were assessed and met.
  • Consent, Mental Capacity Act 2005 and Deprivation of Liberty Safeguards were well understood by the majority of staff and part of a patients plan of care.

Caring

  • Some national surveys have found that staff were not always compassionate. In response, staff had focussed on involving patients, keeping them informed and treating patients with dignity and respect.
  • During our inspection we saw and heard of compassionate and kind care and emotional support being provided.

Responsive

  • Urgent and emergency, children and young people and outpatients services were not responsive to patients' needs.
  • The emergency department was not meeting the national four-hour waiting time target introduced by the Department of Health.
  • The hospital was persistently failing to meet the national waiting times target. Some patients were experiencing more than 18 weeks from referral to treatment time (RTT).
  • Speech and language therapists were not trained to care for patients who had tracheostomies.

Well-led

  • The trust are not committed to delivering all the measures in their published clinical strategy, which impacted on the delivery of services and the needs of patients, and staff morale.
  • The new executive team was making improvements. The board was visible and engaging with patients and staff.
  • The leadership and culture were open, transparent and focussed on improving services.
  • The governance structures did not ensure that responsibilities were clear and that quality, performance and risks were understood or managed.

We saw several areas of outstanding practice including:

  • The values of the trust - passion, responsibility, innovative, drive and empowerment (PRIDE) were well known and embedded in the culture of the people working at the trust.
  • The new executive team were visible and engaged.
  • There was lots of involvement from the local community and voluntary organisations. The foyer had lots of people giving information for patients and visitors about services in the local area.
  • Patients referred for cardiology appointments were seen within seven days.
  • The critical care outreach team provided a ‘critical care follow up outpatient’s clinic’ for patients who required support after leaving hospital. This ensured patients were making progress in the months following their admission.
  • The critical care outreach team had devised a tracheostomy discharge checklist for patient’s leaving the hospital with a tracheostomy. The checklist supported teaching key competencies to patients, family and carers in how to support a person with a permanent tracheostomy.
  • We observed the critical care team supporting patients and their families with their individual needs in a flexible, thoughtful, patient, considerate and caring manner; this support and care extended through to their colleagues.
  • The end of life care service was patient focussed and end of life care needs was well understood by the majority of staff from all staff groups.

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

Importantly, the trust must:

  • Have clear governance with integrated systems and processes to support staff to provide care and treatment safely.
  • Ensure serious incidents are understood, investigated and lessons are learned promptly.
  • Review systems for sharing good practice across the divisions and trust wide.
  • Ensure compliance with all national guidelines and trust policies for medicines management.
  • Improve the service planning and capacity of outpatients by continuing to reduce the 18 week non-admitted backlog of patients as well as ensure no patients waiting for an appointment are coming to harm whilst they are delayed, reduce the did not attend, hospital cancellation and hospital changes rates and improve the 31 day cancer wait target.
  • Improve the IT systems so they are up to date and the IT strategy is implemented and supports clinical staff to carry out their duties.
  • Ensure all services for neonates, children and young people are responsive to their needs.
  • Ensure the radiology is fit for purpose and fulfils its reporting timescales, particularly for CT scans.
  • Continuously review staffing levels and act on them at all times of the day.
  • Include a dietician as part of the critical care multidisciplinary team in line with the core standards for intensive care guidance.
  • Comply with the Duty of Candour legislation.
  • Display the numbers of staff planned and actually on duty at ward entrances in line with Department of Health guidance.
  • Ensure safe management and administration of medicines.
  • Ensure that all incidents including patient falls are accurately reported electronically
  • Ensure that patients who sustain a fall receive a medical review in a timely manner.
  • Ensure that medical outlying patients have an identified medical team to review their care and an agreed escalation plan in place
  • Ensure that speech and language therapists are trained and competent to care for patients who have tracheostomies.
  • Ensure that entries made by medical staff in patient records comply with the expected professional standards
  • Ensure that medical staff in the Emergency Department receive appropriate supervision.
  • Ensure adequate provision of resuscitation equipment in Outpatients.
  • Ensure compliance with COSHH regulations.
  • Ensure patient records are kept securely and that patient confidentiality is maintained.
  • Ensure radiologists are confident and competent when performing CT scans.

In addition the trust should:

  • Consider increasing the target rates for mandatory training.
  • Review the accessibility of the radiology services and consider a duty radiographer structure.
  • Continue to improve patient record availability at outpatient clinics.
  • Review the environment in Outpatients to improve the waiting and reception areas.
  • Consider ways to increase multidisciplinary team working within critical care.
  • Consider ways to engage patients in providing feedback.
  • Review the number of medical staff cover for the medical wards at night.
  • Review the staffing levels on Ash Ward.
  • Ensure that junior medical staff are aware of the trust's complaints procedure.
  • Ensure that nurses understand the importance of the recommendations stated by the speech and language therapy team.
  • Consider ways to increase multidisciplinary team working within critical care.
  • The hospital should review its response to major incidents including equipment, staff training and practical testing.
  • The Emergency Department should review its poor performance in FFT scores and develop a plan for improvement.
  • The Emergency Department should ensure that all staff are fully consulted upon, and aware of future plans for the department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 2 July 2015

Effective

Requires improvement

Updated 2 July 2015

Caring

Requires improvement

Updated 2 July 2015

Responsive

Requires improvement

Updated 2 July 2015

Well-led

Requires improvement

Updated 2 July 2015

Checks on specific services

Maternity and gynaecology

Updated 18 December 2013

Maternity and family planning services were safe and effective.  Patients reported that midwives were caring and responsive and staff were positive about the service they provided.

Systems were in place for reporting and reviewing incidents to ensure that appropriate action was taken. Midwives used comments and complaints to improve women’s experiences of care and had responded proactively to these.

Medical care (including older people’s care)

Requires improvement

Updated 7 March 2017

Hospital environments were not always ideal. Some wards were reported and observed to have high levels of noise and heat. There was a lack of bedside televisions or radios across the wards. There were breaches in the fire resisting compartmentation across the hospital site, which had been caused by previous contractors drilling holes for data cables and services.

Although we observed good infection control practices on inspection, rates of both MRSA and Clostridium difficile infections were high. Infection prevention and control audits, as well as hand hygiene audit results, showed consistently poor compliance in some wards and departments.

Although nursing staffing levels had improved since our last inspection in March 2015, some wards still had significant vacancy and turnover rates. On these wards, there was a reliance on bank and agency staff to fill vacant shifts.

There was a reliance on locum doctors across the service, apart from in cardiology. This affected continuity of patient care, particularly out-of-hours. Medical staff across the service were failing to meet trust targets for completion of mandatory training.

For non-elective admissions, the standardised relative risk of readmission was high, particularly for geriatric medicine. Patient outcomes in care of the elderly were limited by the lack of consultant geriatricians to lead improvements within the service. Junior doctors in geriatric medicine reported lower overall satisfaction than the national average in the 2015 National Training Survey. There was also poor performance in measures such as availability of clinical supervision out-of-hours and regional teaching. Although 2016 survey results showed significant improvement, some issues still remained.

Medical and nursing staff completion rates in basic life support were below the trust target, due to a lack of external training sessions.

There was still a backlog of National Institute for Health and Care Excellence (NICE) guidance that was awaiting confirmation of compliance across the trust. The trust performed worse than the previous year in a number of national audits.

Some principles of good record keeping were not being followed. Fluid charts were not always filled out and medical entries were sometimes illegible and unsigned.

The pathology service was understaffed and unable to provide effective cover out-of-hours.

The pathways for patients with cancer were not always clear. The trust was consistently failing to meet national indicators relating to 62-day cancer treatment. There was poor communication with tertiary centres, which caused delays with patients requiring tertiary treatment or diagnosis at other specialist hospitals. The trust performed slightly below the national average in the National Cancer Inpatient survey 2015.

The trust was not meeting 18-week national indicators for non-urgent referral to treatment (RTT) times.

Staff across the hospital told us that they could not always discharge patients promptly due to capacity issues within the hospital or community provisions had not been put into place. Some patients and relatives felt that more could be done to involve them in their care, especially surrounding discharge.

Patients were not always able to be located on the specialist ward appropriate for their condition, although management of these patients had improved since the previous inspection. The number of patients moved four or more times per admission had increased, although the trust later told us that this data was inaccurate. In some wards, such as Ash, Gentian and Gardenia ward, bed moves were consistently occurring out of hours (between 10pm and 6am).

Patient information leaflets were not standardly available in languages other than English. Although face-to-face and telephone translation services were available, many staff were not familiar with how to access these.

The Patient Advice and Liaison Service (PALS) did not always respond to complaints in a timely manner. There were no leaflets detailing how to access PALS and make a formal complaint on Gentian ward at the time of our inspection.

However, there was a significant improvement in both the reporting of incidents and the sharing of lessons learned from these across the hospital. Staff were aware of their responsibilities with regards to duty of candour requirements, confirming there was an expectation of openness when care and treatment did not go according to plan. The governance structure had been revised to provide a greater level of accountability and oversight of risk.

Nursing staff demonstrated an awareness of safeguarding procedures and how to recognise if someone was at risk or had been exposed to abuse. They knew how to escalate concerns and were up-to-date with appropriate levels of training.

Patients were assessed for a variety of risks on admission to the wards, using nationally recognised tools.

Medicines management had improved, with new processes in place to ensure the safety of patients. Much work had been done since the previous inspection to ensure that discharges were not delayed due to unavailability of take home medications.

Nursing and medical staff completed a variety of local audits to monitor compliance and drive quality improvement. Staff told us that these led to meaningful change across the service. Both local and national audits were overseen by a committee. In the National Diabetes Inpatient Audit (NaDIA) 2015, the hospital scored better than the England average for nine indicators out of sixteen indicators.

The standardised relative risk of readmission for all elective procedures was slightly lower than expected when compared to the England average. This meant that patients were less likely to require unplanned readmission after non-emergency procedures, suggesting that the hospital’s care and discharge arrangements were appropriate.

Patients were cared for in a caring and compassionate manner by staff throughout their hospital stay. Most medical wards performed in line with the national average in the NHS Friends and Family Test (FFT). Patients’ privacy and dignity was maintained at all times. The hospital facilitated a number of forums and listening events to engage patients in the development of the service.

The trust performed above the national average in measures relating to training and appraisals in the NHS staff survey 2015. The majority of staff received annual appraisals on their performance, which identified further training needs and set achievable goals. The trust was supporting nurses with the revalidation process. For all specialties apart from geriatric medicine, the trust scored above the national average for most measures in relation to first year medical doctors in training (2015 National Training Survey).

There was evidence of effective multidisciplinary working within wards and across departments. All members of staff felt valued and respected by their colleagues.

Psychological support for patients was easily accessible and timely. Patients were routinely assessed for anxiety and depression on admission. The chaplaincy team offered comprehensive spiritual support to all patients, regardless of religious affiliation.

People with complex needs, such as those living with dementia or a learning disability, were well considered and cared for within the hospital. Staff made reasonable adjustments to improve their experience of the service and supported them throughout their inpatient stay. Information and environments had been adapted to make them more suitable for these patients.

The trust had developed a clinical vision and strategy and communicated this to staff of all levels, enabling them to feel involved in the development of the service. Most nursing and medical staff thought that their line managers and the senior team were supportive and approachable. The chief executive and divisional leads held regular meetings to facilitate staff engagement.

Staff had awareness of what actions they would take in the event of a major incident, including a fire. Regular drills were held to ensure staff were adequately trained in the event of emergencies.

Urgent and emergency services (A&E)

Requires improvement

Updated 7 March 2017

Lack of resuscitation training was rated as high on the corporate risk register and compliance rates for resuscitation training were low for both doctors and nurses.

No paediatric staff grade nurse had in-date advanced paediatric life support training.

Whilst the trust told us it confirmed all training done by locum staff on their induction checklist, it was unable to supply CQC with a record of all training done by locum staff, including resuscitation, sepsis and safeguarding training.

There was poor recognition of and response to patients with suspected sepsis.

There were poor levels of hand hygiene compliance.

The air handling unit in paediatrics and minor injuries had been out of order for at least three weeks prior to our inspection. This made it difficult to regulate safe temperatures within which to store drugs.

There was a 59% vacancy rate amongst medical staff and the lack of senior medical staff was rated as high on the corporate risk register. This resulted in a high dependency on the use of locum staff, who whilst fully qualified as doctors may not have worked in an emergency department previously.

In addition, there was a shortage of paediatric nurses which was also rated as high on the corporate risk register.

The ED failure to comply with the four hour standard was rated as extreme on the corporate risk register. Ambulance turnaround time did not meet the national handover indicator for 64% of the time between June 2015 and May 2016.

However, staff told us that they were encouraged to record incidents and said there was good sharing of learning from incidents through e-mail, meetings and training days.

Junior doctors felt well supported by senior doctors.

Walk-in patients were effectively streamed and some were redirected back to their GP.

Staff were compassionate towards patients and there was a frail and older persons advice and liaison team as well as dementia champion nurses in the ED.

There was a designated observation ward which was used to assess the community support needs of vulnerable patients before being discharged.

Patients told us they felt staff informed them of what was going on and staff told us they knew who the departmental leadership team and the executive board were.

Since the last inspection in May 2015 improvements had been made to the department’s clinical governance and risk management processes.

Surgery

Requires improvement

Updated 2 July 2015

There was a backlog in investigating serious incidents and, at the time of our inspection, 12 were over the 45 day target. The trust was taking positive action to investigate these.

Access and flow issues, such as theatre cancellations, bed management and supporting discharge were generally well managed. However, there was a referral-to-treatment backlog at the trust, which meant the trust was breaching national targets for these. The trust leadership was focused on addressing key risks to the service: reducing the backlog to outpatient appointments, improving referral-to-treatment times for surgery, and improving the IT infrastructure. We found a governance structure in place that provided leadership, quality checking and improvement. Many members of staff made comments on the improvements to the culture of the service.

We found good cleanliness, infection control and hygiene practices in place. Appropriate arrangements were in place for recording the administration of medicines. We found good evidence to demonstrate the trust’s adherence to evidence-based care and treatment. However, some audits had been abandoned and others had not been completed to the expected deadline.

Patients received effective pain relief through ongoing monitoring and specialist support. Nutrition and hydration needs were being appropriately assessed and monitored. Patient care was supported by competent staff who received annual appraisals. It was also supported by teams from a variety of disciplines. Patients and relatives we spoke with were happy with the care and treatment they had received.

We observed positive and respectful interactions between patients and staff. We found that patients’ individual care needs were being met and quality of care audits monitored that care met individual patient need.

Intensive/critical care

Requires improvement

Updated 2 July 2015

Patients and relatives spoke highly of the care and treatment they received in the Intensive Treatment Unit and High Dependency Unit. They told us they were kept updated about their family member’s progress using language they understood. Visitors to the ward were made to feel welcome and were encouraged to support their family member if they felt able to.

There were insufficient critical care beds available for the population served by the Barking, Havering and Redbridge University Hospitals NHS Trust in comparison with other London trusts. Capacity was high at an average of 95%. It was estimated that critical care bed shortages affected 100 to 200 patients across the trust each month, with patients experiencing cancellations of planned procedures and significant waits in A&E (or in the recovery unit) while waiting for ITU beds.

Changes in the acuity of patients and reduced staffing levels meant patients were not always supported on a one-to-one basis, as per national guidance. Despite the bed shortages and staffing levels, we saw that staff continually assessed the safety of the patients and only supported patients on the ward or in the recovery unit if it was staffed appropriately, ensuring the safety of the patients.

Staff were aware of how to support patients and their families’ individual needs. Staff spoke passionately about providing the best care they could to achieve the best results for their patients. Patient outcomes and mortality rates were within expected ranges when compared to similar services.

Care and treatment was delivered by trained and experienced nursing staff. There was a clear reporting structure and staff told us they felt supported and confident in their role.

Temporary and newly-qualified staff had to achieve a set of core competencies prior to working with patients on an individual basis. Junior medical staff spoke positively of the support and learning they received from consultants.

There was little evidence of multidisciplinary team approach. Physiotherapists spoke with consultants and nurses daily about how to support patients, but access to other professionals was carried out on a referral basis.

All the governance meetings took place at Queen’s Hospital and we found that the consultants did not have a strong grasp of governance, risks or concerns relating to the unit.

Most staff were not engaged with the trust’s vision and were unaware of the senior lead’s vision for critical care services. This was affecting morale, which the senior staff on the unit were managing.

The outreach team supported ward-based staff in the early identification of patients who were at risk of deteriorating and who may require an HDU or ITU bed. Critical Care Outreach Team (CCOT) also provided an outpatient clinic to support previous critical care patients in the months after their admission to ensure they continued to progress.

Services for children & young people

Requires improvement

Updated 2 July 2015

Although staff were aware of the incident reporting system, incidents were not always reported. Paediatric resuscitation equipment was not always checked in some areas of the hospital. We found there was a lack of paediatric life support training for theatre staff who may be involved in treating a child or young person whose condition suddenly deteriorated.

Not all records were stored securely and confidentially. There were issues around obtaining records and tracking temporary notes, which meant a full set of notes was not always available.

The service children experienced during visits to the hospital for phlebotomy did not meet their needs. There were limited resources available for children with mental health needs and no paediatric physiotherapist.

Paediatric services had a lack of developed governance systems which meant that risks were not always identified and escalated appropriately within the division to the patient safety team for appropriate management.

Staffing on Clover Ward was not always sufficient. However, specialist nurses were brought in as necessary to provide cover. Although an acuity and dependency tool was available to calculate ward staffing levels, the data was not always updated on the system.

Observation of interaction between staff and patients was very positive. Parents told us they were involved in discharge planning and told us they were very happy with the attention their children received while staying on Clover Ward.

End of life care

Good

Updated 2 July 2015

Patients were involved in care planning and decision making. Staff were respectful and treated patients with compassion. Specialist palliative care team members were visible, competent, and knowledgeable. Staff we spoke with were aware of how to report an incident or raise a concern.

Medicines were managed appropriately. Nurses were able to describe safeguarding procedures and how these were used to protect patients from abuse. There was a sufficient number of staff who received appropriate training. There were systems in place that helped to reduce inappropriate hospital readmissions and complaints were responded to appropriately.

There were systems in place for the routine monitoring of the quality of the service and the specialist palliative care team management had developed appropriate strategies and objectives to ensure continuous service improvement. Staff worked well as a team.

The hospital performed worse than the England average in the National Care of the Dying Audit. The trust’s policy did not clearly specify in which cases staff were required to complete do not attempt cardio-pulmonary resuscitation (DNACPR) forms or how long after the admission they had to complete them. End of life services provided at the hospital were limited, with teams being based at another hospital managed by the trust.

Outpatients

Requires improvement

Updated 7 March 2017

Outpatients and diagnostic imaging services were in transition. The strategy for these services was in development. There were a number of new senior managers who had introduced new quality assurance and risk measurement systems. However, these were not fully embedded.

Hand gel dispensers were in situ across outpatients and diagnostic imaging but we did not observe staff or patients using them.

The percentage of patients who did not attend (DNA) their appointment was above the England average. Staff told us they were not confident of meeting the national indicator for patients waiting over 18 weeks by their target date of March 2017. The trust’s performance for the 62 day cancer waiting time was consistently below the England average. Appointments cancelled by the hospital were also higher than the England average.

Some staff in the diagnostics and imaging team said there was a lack of clarity around their roles and responsibilities.

However, there had been an 88% reduction in the overall backlog of patients waiting over 52 weeks since May 2016.

Staff were aware of how to report incidents and could clearly demonstrate how and when incidents had been reported. Lessons were learnt from incidents and shared across the trust.

The trust had changed their patient records system and introduced the electronic patient record (EPR).

There were appropriate protocols in place for safeguarding vulnerable adults and children. Staff were aware of the requirements of their roles and responsibilities in relation to safeguarding.

Patients’ and staff views were actively sought and there was evidence of improvement and development of staff and services. Staffing levels and skill mix were planned to ensure the delivery of outpatient, diagnostic and imaging services at all times. All new staff completed a corporate and local induction. . Staff were competent to perform their roles and took part in benchmarking and accreditation schemes.

Medicines were found to be in date and stored securely in locked cupboards. Staff were able to describe the procedure if a patient became unwell in their department and knew how to locate the major incident policy on the intranet.

All the patients, relatives and carers we spoke with were positive about the way staff treated people. There was a visible person-centred culture in most departments. Patients and relatives told us they were involved in decision making about their care and treatment. People’s individual preferences and needs were reflected in how care was delivered.

Work was in progress to conduct a demand and capacity analysis to enable the service to develop a model whereby the hospital could assess and effectively manage the demands on the service. The hospital was using a range of private providers to assist in clearing the backlog of appointments.

Patients attending outpatients and diagnostic imaging departments received care and treatment that was evidence based. The service was monitoring the care and treatment outcomes of patients who were receiving outsourced care from providers in the private sector.

Outpatients, diagnostic and imaging services had introduced extended clinics seven days a week to clear patient waiting list backlogs.

There was a formal complaints process for people to use. Complaints information, as well as patient experience information was fed into the trust governance processes and trust board with formal reporting mechanisms.

Most local managers demonstrated good leadership within their department. Managers had knowledge of performance in their areas of responsibility and understood the risks and challenges to the service. There was a system of governance and risk management meetings at both departmental and divisional levels.