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University Hospital Lewisham Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 August 2017

University Hospital Lewisham is a district general hospital providing a full range of services including emergency department, medical, surgery, critical care, maternity and gynaecology, services for children and young people, outpatients and diagnostic imaging and end of life care. It serves the population of the London Borough of Lewisham and the wider area of south east London. Community health services for adults and children and young people are also provided for Lewisham.

We carried out a comprehensive announced inspection at the hospital between 7- 10 March 2017 as part of our planned acute hospital inspection programme. We carried out further unannounced inspections during March 2017.

We rated critical care, and services for children and young people as good. We rated urgent and emergency services (A&E), medical wards, surgery, maternity and gynaecology, outpatients and diagnostic imaging, and end of life care as requires improvement.

In addition we rated community services for adults as good and community services for children and young people as outstanding.

We rated effective care and caring as good and safe care, responsive care and leadership as requires improvement.

We rated University Hospital Lewisham as requires improvement overall.

Our key findings were as follows:

  • In some areas, safeguarding training rates and mandatory training rates fell well below the trust’s target.
  • There were significant shortages of medical, nursing and allied health professional staff in most departments which were having an impact on delivery of care and patient safety. Although the trust was actively trying to recruit into vacant posts there was limited evidence of success.
  • In some areas, principally surgery, medicines management processes were not in line with hospital policy or national guidance.
  • In medical care, infection control processes, including waste management and adherence to the control of substances hazardous to health guidance, was variable.
  • In surgery, we observed numerous breaches of Infection Prevention and Control (IPC) policy, potentially placing patients at significant risk of infection.
  • In maternity and gynaecology we found the cleanliness of the environment and some equipment to be of a poor standard, even where green ‘I am clean’ stickers had been used to show that surface areas and equipment had been cleaned that day.
  • In outpatients the environment in general diagnostic imaging was not fit for purpose.
  • Whilst care was in line with relevant National Institute for Health and Care Excellence (NICE) and other national and best practice guidelines, there was a risk to clinical outcomes and patient safety due to maternity guidelines not being merged across the Lewisham and Greenwich sites and some guidelines also being out of date.
  • The hospital was not providing responsive care in all areas.
  • Emergency and urgent services (ED) did not meet the wait to treatment time of one hour during the 12 months from October 2015 to September 2016.
  • The hospital breached the admit or discharge within four hours of arrival each month between December 2015 and November 2016
  • Waiting times for treatment were well above the England average.
  • There were insufficient systems in place to manage the fundamental issues of capacity and flow within the ED. ED performance was below the objectives set out in the delivery plan.
  • In medical care, referral to treatment (RTT) times was not met in rheumatology where 80% of patients were seen within the target of 18 weeks.
  • Cancer treatment times did not meet the national two-week standard in relation to lung cancer. In November 2016, 61% of patients were seen within two weeks.
  • There were higher than national average numbers of delayed discharges due to problems with access and flow within the hospital. Bed occupancy was also higher than the national average which could limit the service’s ability to provide a bed in the event of an emergency.
  • In critical care there were higher than national average numbers of delayed discharges due to problems with access and flow within the hospital. Bed occupancy was also higher than the national average which could limit the service’s ability to provide a bed in the event of an emergency.
  • In outpatients and diagnostic imaging, many patients complained about the waiting times in the outpatient clinics.
  • The hospital took significantly longer than their target to investigate and respond to complaints which were not responded to in a timely manner.
  • There was limited cross site working with Queen Elizabeth Hospital (QED) For example ED staff did not support each other across sites when there was capacity to do so
  • There was a lack of shared working across the trust within outpatients and diagnostic imaging.
  • There were issues around local leadership at the hospital. For example on some of medical wards, staff said they were demoralised which they attributed to high vacancy rates, increased workloads, being constantly moved around to cover other wards, and a lack of support from matrons who staff thought should have been doing more to support them.
  • Staff across medical wards reported a culture where they were not valued, or respected by matrons.
  • There was no documented strategy for the critical care service, and there were concerns around the medical leadership and governance arrangements.
  • There was no clinical ownership of the risk register within the surgical directorate.
  • In services for children and young people, there were low levels of attendance at governance and safety boards which reduced opportunities for sharing of information to the appropriate people.
  • In surgery, the leadership team were unaware of the issues with medication within theatres.
  • The leadership team in maternity had overlooked basic issues of cleanliness and infection control.
  • Some BME members of staff that we spoke with felt opportunities for staff development, promotion, training and support wasn’t always afforded to them in the same way that it was given to their Caucasian counterparts.

However:

  • Staff were caring and compassionate and patients were treated with dignity and respect.
  • Emotional support was provided by the chaplaincy or multi-faith services.
  • Patients expressed a positive view of the care and treatment they received.
  • Interactions between staff and patients were individualised, caring and compassionate. Patients and their relatives felt they were treated with dignity and respect. However there were aspects of caring in medical care wards that required improvement.
  • There were good examples showing that the needs of people living with mental health issues were being addressed. For example, in ED the child and adolescent mental health services (CAMHS) transformation had improved care with the majority of referrals being seen on the same day (Monday to Friday).
  • In medical care, there were various initiatives to increase awareness of dementia through the hospital’s dementia strategy.
  • In maternity and gynaecology there was good support from The Kaleidoscope Team which worked with vulnerable women and those with mental health needs.
  • There was a positive incident reporting culture, and learning from incident investigations was generally shared with staff in a timely manner in ED, critical care and services for children and young people.

Importantly, the hospital must:

  • Ensure effective systems to assess and monitor the quality and safety of the care and treatment in all services across the hospital.
  • Address and improve issues of medicines management in surgery and services for children and young people.
  • Address and improve issues of cleanliness and infection control in medical care, surgery and maternity and gynaecology.

In addition the hospital should:

  • Ensure mandatory training targets are met in all services at the hospital.
  • Improve its recruitment processes to mitigate vacancy levels in medical, nursing and allied health professional staff.
  • Merge maternity guidelines across both major hospital sites and within community midwifery.
  • Address performance targets currently not being met as detailed above.
  • Ensure complaints are dealt with in accordance with trust timeline targets.
  • Ensure that service and department leaders are aware of issues and concerns within their departments and act to rectify them.
  • Identify ways to empower and support staff to make improvements and take the lead in decisions and improvements in their services.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 17 August 2017

Effective

Good

Updated 17 August 2017

Caring

Good

Updated 17 August 2017

Responsive

Requires improvement

Updated 17 August 2017

Well-led

Requires improvement

Updated 17 August 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 17 August 2017

  • We found the cleanliness of the environment and some equipment to be of a poor standard, even where green ‘I am clean’ stickers had been used to show that surface areas and equipment had been cleaned that day.
  • We observed that a number of key items of equipment were out of date for safety testing, such as CTG (cardiotocography) and BP (blood pressure) machines, incubators and resuscitaires.
  • We found that local leadership at the hospital had overlooked the basic issues of poor cleanliness and out of date equipment checks and the potential clinical, infection control and patient safety risks they posed.
  • While the service said it had enough Dopplers to assess babies’ health, these appeared to the inspection team to be not readily accessible.
  • IV (intravenous) fluids were unsecured in all ward areas, such as delivery rooms and emergency trolleys.
  • Mandatory training levels were below the trust’s benchmark of 85% compliance across a number of subject areas.

Medical care (including older people’s care)

Requires improvement

Updated 17 August 2017

Urgent and emergency services (A&E)

Requires improvement

Updated 17 August 2017

  •  Safeguarding training rates and mandatory training rates fall well below the trust’s target in many areas. The number of Black breaches was reported at on a steady upward trend during 2016.
  • The department did not meet the seven day working standard requiring 16 hours consultant presence, seven days a week. Consultant presence in the ED was 15 hours a day Monday to Friday and 14 hours a day at weekends. The ED did not meet the wait to treatment time of one hour during the 12 month from October 201 to September 2016.The ED breached the admit or discharge within four hours of arrival each month between December 2015 and November 2016.
  • There were insufficient systems in place to manage the fundamental issues of capacity and flow within the ED. ED performance was below the objectives set out in the delivery plan.

Surgery

Requires improvement

Updated 17 August 2017

  • There were significant issues with medication management within theatres. Including breaches of CQC regulations and The Misuse of Drugs Regulations 2001.
  • Information governance practices were poor, with patient records being left unlocked and unattended in public areas throughout the hospital.
  • We observed numerous breaches of Infection Prevention and Control (IPC) policy, potentially placing patients at significant risk of infection.
  • There were significant vacancy levels within the service, and high staff turnover.
  • The senior leadership team were unaware of the issues with medication within theatres.

Intensive/critical care

Good

Updated 17 August 2017

  • There was a positive incident reporting culture, and learning from incident investigations was generally shared with staff in a timely manner.
  • The environment was clean, infection rates were low and staff complied with infection prevention and control practices. Nursing staffing levels met national standards.
  • Systems were in place to ensure the safe supply and administration of medicines.
  • Records were safely secured and contained documentation in accordance with national and local standards.
  • Care and treatment was delivered in line with national guidelines and best practice guidance.
  • There was an ongoing programme of clinical audit which included measurements of patient outcomes.
  • Interactions between staff and patients were individualised, caring and compassionate. Patients and their relatives felt they were treated with dignity and respect.

Services for children & young people

Good

Updated 17 August 2017

  • There was strong evidence of good learning from incidents including sharing of methods cross-site to reduce errors across both sites. All areas we saw were clean and regular audits supported this process.
  • Good hand hygiene was maintained rigorously including the introduction of specialist hand gel door dispensers in the neonatal unit to prevent infection. Patients and parents were positive about the compassionate care that they received and we observed kind and respectful care during the inspection.
  • Changes had been made to patient pathways, such as the introduction of ward reviews, and referrals to the hospital at home team which had decreased length of stay. There were a low number of formal complaints made about the service and response rates to complaints received were within the agreed timescales. Since the last inspection there had been clear progress in developing cross-site governance structures, risk management and learning.

End of life care

Requires improvement

Updated 17 August 2017

  • End of Life Care (EoLC) did not appear to have a high profile at trust board level.
  • The trust performed poorly in the End of life care Audit: Dying in Hospital 2016 and most staff whom we spoke with were unaware of the trust’s performance in this.
  • Utilisation of end of life care plans was not fully embedded.
  • There was poor recognition of when a patient was at end of life.
  • Responsibility for end of life care appeared to rest with the Specialist Palliative Care team, rather than being seen as a trust wide responsibility.

Outpatients

Requires improvement

Updated 17 August 2017

  • Many patients complained about the waiting times in the outpatient clinics. They said they had not been given any update information about waiting times.
  • There was a lack of shared working across the trust within outpatients. Not all staff were aware of how to use the electronic reporting system.
  • The environment in general diagnostic imaging was not fit for purpose. Some equipment was in urgent need of replacement.
  • There was a shortage of radiographers and radiologists.