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Queen Elizabeth Hospital Requires improvement

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Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 August 2017

We undertook an announced inspection at the Queen Elizabeth Hospital as part of a planned comprehensive inspection of Lewisham and Greenwich NHS Trust from 7-10 March 2017.

Queen Elizabeth Hospital (QEH) is part of Lewisham and Greenwich NHS Trust. The trust was formed in October 2013 by the merger of Lewisham Healthcare Trust and the Queen Elizabeth Hospital Greenwich (following the dissolution of the South London Healthcare Trust by the Trust Special Administrator). The trust provides acute and community services for more than 526,000 people living in the boroughs of Lewisham, Greenwich and Bexley.

In February 2014 QEH had a planned inspection using our new comprehensive methodology and was rated overall as requires improvement.

Due to CQC receiving increased number of complaints and concerns being reported by patients, relatives and staff, we undertook a further inspection of the emergency department and medical services at the Queen Elizabeth Hospital in June 2016. We rated both services as requires improvement.

This most recent inspection was carried out to determine whether the hospital had made progress following their 2014 comprehensive inspection and 2016 focussed inspection.

We rated Queen Elizabeth Hospital as requires improvement overall. Initially some progress was made following the inspection in 2014, but since then the trust has found it hard to sustain any further improvements.

We rated safe, effective, caring, responsive and well-led as requires improvement.

Maternity and gynaecology and outpatients and diagnostic imaging services were rated as good.

Five services, urgent and emergency services, medical care, surgery, critical care and services for children and young people were rated as requires improvement and end of life care was rated as inadequate.

Our key findings were as follows:

  • The hospital had systems for reporting incidents, but we found learning from incidents was variable and not fully embedded across all services.

  • Medical and nursing staffing levels were not always in line with national guidance. There was a shortage of consultants on the critical care unit and in services for children and young people.

  • Completion rates for mandatory training for both nursing and medical staff did not always meet the trust standard.

  • In some services we observed non-compliance with infection prevention and control practices, hand hygiene, and the environment some patients were cared in had limited space and potentially compromised their safety.

  • Medical patients who were cared for in surgical wards were not always reviewed by the medical team. Staff described significant difficulties in reaching the medical team responsible for these patients.

  • The majority of the services we inspected were providing effective care. However, surgery was rated requires improvement and end of life care was rated inadequate.

  • The hospital performed worse than the England average in some of the national surgical audits.

  • The uptake of appraisals was variable and in surgery the uptake was low.

  • We found many good examples of multidisciplinary working, but there were also poor interactions between some teams.

  • The majority of the services we inspected carried out audits, but in end of life care we found limited audit activity or benchmarking to assess the effectiveness of the service. The end of life care pathway was also inconsistently applied.

  • In the majority of services we inspected we found staff were caring and compassionate. However, in medicine and end of life care we found that staff did not always demonstrate a caring approach to patients and did not always maintain patients’ privacy and dignity. Feedback from patients in these services was variable.

  • Patients described staff as ‘friendly’, ‘helpful’ and ‘attentive’, but patients on some medical wards described staff as ‘rude’ and ‘abrupt’ and said they experienced long waits for staff to respond to their call bells.

  • In the majority of services patients were involved in discussions about their care and treatment. In medical care some patients told us they were not always provided with information or told why for example their medicines had been changed.

  • Patients were not always treated in a timely manner and within national access standards.

  • Some patients experienced long waits in the emergency department, had their surgery cancelled and were delayed in being discharged from critical care due to a lack of available beds.

  • The hospital had a high ‘did not attend’ (DNA) rate for outpatient appointments, higher than the England average.It was also not meeting the operational standard of 93% for people being seen within two weeks of an urgent GP referral for suspected cancer.

  • There were not always sufficient staff to meet the individual needs of patients, for example those requiring one to one support.

  • Mixed sex breaches sometimes occurred in critical care and surgery and the location of the gynaecology clinics and early pregnancy unit was not sensitive to the needs of some women.

  • Complaints were not always responded to within the agreed timescales. Additionally, oversight of agreed actions resulting from complaint investigations was limited.

  • All of the services we inspected had systems to monitor the quality and safety of the care they provided, but we found they were not always effective or proactive.In some services there was low attendance at some of the meetings, sometimes due to insufficient staff.

  • Services had risk registers, but not all of the risks identified during the inspection were recorded on the registers and some risks, critical care and services for children and young people, had been on the register for up to three years without any action being taken. We also found a lack of ownership of the registers in some services with no evidence that risks were regularly reviewed.

  • Some staff did not feel involved in discussions or plans for their service and we received variable feedback on how well the hospital engaged with staff, the working culture and morale.

  • Cross site working was happening to different degrees in each service, but was still at a relatively early stage.

However:

  • Many staff we spoke with had attended safeguarding training for children and adults and knew the action to take if they suspected abuse.

  • Emergency equipment, including resuscitation trolleys, were maintained and we saw evidence of regular safety checks.

  • We also found care and treatment was informed by evidence based guidance and staff could access guidelines via the intranet. .

  • Nutritional risk and screening tools were used to assess and monitor patients’ nutritional needs. Nursing staff had worked with the catering team to provide more flexible mealtime options for patients with dementia or reduced appetites. In maternity mothers received one to one and group support with breast feeding.

  • Staff had a good understanding of consent process and recognised when the best interests of the patients had to be considered.Staff obtained consent from children and young people and parents involving both the child and the person with parental responsibility in obtaining consent where appropriate.

  • Maternity service had a range of expertise and specialist support available for all women.

  • Some progress had been made in meeting the needs of patients living with dementia including increased activities, improvements to the environment and the introduction of a team volunteers who were being trained in working with people with dementia, which included providing enhanced care.

  • Translation services were available and a multi-faith spiritual team was available to provide support within the hospital.

  • Staff were positive about the local managers and felt they were approachable and supportive.

  • Staff told us there was an open culture and they felt able to report concerns.

We saw several areas of outstanding practice including:

  • The uniquely designed door handles that had been installed on the doors to the neonatal and oncology units demonstrated the service was focused on reducing the risk of infections.

  • Tiger ward had provided additional support to families and patients by introducing an informal coffee morning open to all patients on their case load and not just receiving treatment.

  • The speech and language therapy manager had implemented a risk feeding protocol following a successful research pilot project. This resulted in demonstrable outcomes for patients, including a 10% reduction in the admission of patients with dysphagia through more effective feeding regimes. As part of the project new guidance was issued for patients and staff and a risk feeding register was implemented to help the multidisciplinary team track patients cared for under the new protocol.

  • Staff in the Trafalgar Clinic provided care and treatment for patients in a nearby prison. Each patient’s records were maintained on the service’s electronic patient record system. This meant when a patient left the prison service, there was no disruption in care or treatment because clinical staff always had access to this. In addition, if the patient moved out of the area, the electronic records could easily be shared with pharmacists and health workers in the offender resettlement programme. This meant patients received continual care and were at reduced risk of developing health problems associated with an interruption to antiretroviral therapy.

  • In the two years prior to our inspection, sexual health and HIV services recruited up to 50% of the participants for the trust’s whole clinical trial and research portfolio. This resulted from a policy of proactive and early-adoption participation that was part of a two-year strategy to improve participation in research in other hospital departments and services.

  • In critical care there was a dynamic programme of research and development enabled by the full time appointment of a research nurse working with doctors including consultants. Examples of research studies completed in the past year included a study exploring the relationship between family satisfaction and patient length of stay, and a pilot study looking at the improved physiotherapy outcome measure by the use of cycle ergometry in critical care patients. The trust recognised only a small sample size was used for each study.

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

Importantly, the trust must:

  • Review and improve the systems for monitoring and improving the quality and safety of care including attendance at key meetings in ED, surgery, critical care, services for children and young people and end of life care.

  • It must ensure all risks are included on the risk register and are regularly reviewed and updated and carry out audits to monitor the effectiveness of treatment and care. ED, surgery, critical care, services for children and young people and end of life care.

  • Ensure all risk assessments are carried out on patients in critical care.

  • Ensure medical and nursing staffing levels are in line with national standards in services for children and young people, ED and end of life care, to provide safe continuity of care for patients.

  • In surgery, ensure that patients are cared for in areas that are appropriate to their needs and have sufficient space to accommodate all equipment and does not compromise their safety and staff have the relevant skills and knowledge to care for them.

  • The children’s service should review the consultant cover provision to ensure it meets national standards and provide more continuity for patients in the neonatal unit.

  • Ensure patients requiring end of life care receive appropriate and timely care.

In addition the hospital should:

  • Work to share and embed learning from incidents in all services and across sites.

  • Ensure staff comply with infection prevention and control policies and procedures.

  • Ensure the ED has a separate room for the storage of medicines and medicines are stored safely in all areas.

  • Ensure staff working on medical wards and in end of life care have the values and attitude necessary to treat patients, their relatives and visitors with dignity and respect. This includes staff treating them in a caring and compassionate way at all times.

  • Ensure medical patients are appropriately reviewed when they are cared for on other wards and that all staff know who is responsible for them and they are contactable.

  • Ensure that in surgery patient records are stored and held securely in one document.

  • Ensure all patient records are complete and accurate including risk assessments.

  • Ensure all patients have their pain assessed and receive analgesia in a timely manner

  • Improve compliance with mandatory training completion rates for modules that are below the trust target in all staff groups.

  • In critical care consider ways to introduce multidisciplinary meetings and ward rounds to review care and treatment of patients.

  • Ensure there are ongoing arrangements for measuring and reporting patient satisfaction in critical care.

  • Review the arrangements for bereavement services.

  • In critical care, ensure formal arrangements for emotional and psychological support of patients and families including access to clinical psychologists are in place.

  • Review and update the operational policy for the critical care outreach team and ensure sufficient staff are deployed every day to provide an effective service.

  • Review the environment and waiting times for women using the gynaecology service.

  • Develop outcomes for gynaecology.

  • Ensure staff working in HIV, GUM and sexual health services are informed and involved in any future plans for the service.

  • Review the provision of care on Hippo Ward to ensure it is adequately staffed and is open long enough to support patient flow.

  • Review the level of cover currently provided by play specialists to make sure that children are supported appropriately.

  • In services for children and young people, encourage attendance at quality and safety board meetings so that information can be shared and discussed effectively.

  • Complete two year follow ups of babies admitted to the neonatal unit as part of the national audit.

  • Ensure patients who are at the end of their life, and their relatives, are ensured privacy.

  • Improve cross site working in all services.

  • Work to reduce the number of cancelled operations and improve referral to treatment times and reduce the ‘did not attend’ (DNA) rate for outpatient appointments.

  • Continue to recruit to medical and nursing vacancies in outpatients and diagnostic imaging

  • Respond to complaints within agreed timescales.

  • Improve communication and working relationships between different staff groups.

  • Provide sufficient staff to care for patients who need one to one care.

  • Identify ways to empower and support staff to make improvements and take the lead in decisions and improvements in their services.

Professor Edward Baker

C

hief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 17 August 2017

Effective

Requires improvement

Updated 17 August 2017

Caring

Requires improvement

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

Good

Updated 17 August 2017

Maternity and gynaecology were rated good because there were systems to monitor and improve the quality and safety of care provided. We saw evidence of reporting and learning from incidents and there were sufficient staff to care for women and their babies. Care was informed by national guidance and outcomes for women using maternity services were monitored.

Staff were caring and responsive to the needs of women and had developed a range of services to meet the varied and complex needs of women who used the service. Women told us that staff answered their questions and were ‘kind’ and ‘patient’.

Women were able to choose where they gave birth.

There was a good cohesive leadership team and which had established

effective links with local and regional commissioners of services, local authorities, GPs and patients to coordinate care for women.

However, the environment for women using gynaecology services was not always appropriate or sensitive to their needs and some women experienced long waiting times.

Medical care (including older people’s care)

Requires improvement

Updated 17 August 2017

We rated medical care requires improvement because, although improved, systems for monitoring the quality and safety of care and reducing the risks to patients were not fully embedded.

Staff did not consistently demonstrate a caring compassionate approach to patients. Patient dignity was not always maintained and patients were not always involved in discussions about their care. Staff were not always able to respond to patient’s individual needs and sometimes found it difficult to obtain additional resources to support patients with complex needs.

Many staff told us there had been an improvement in the leadership and most were positive about the local leadership and support they received from their managers. Some therapy staff felt they were not always recognised as key members of the team and were not always treated with respected or valued by other staff caring for patients.

Care was informed by national guidance and patients were cared for by competent staff. Patients had their pain assessed and received appropriate analgesia. Nutritional assessments were carried out and the speech and language therapists had implemented a new feeding regime which had improved outcomes for patients.

Urgent and emergency services (A&E)

Requires improvement

Updated 17 August 2017

We rated urgent and emergency services requires improvement because the problems we found in previous inspections still existed. There were long waiting times for some patients to be seen by a doctor and for a bed once a decision to admit them had been made. The environment was sometimes very crowded and patients had to be cared for in public corridors albeit with screens around them.

However, we also found staff provided kind, compassionate care and involved patients in discussions about their care and treatment. The majority of patients we spoke with were positive about the care they had received and described the staff as ‘kind’ and ‘professional’.

Both nurses and medical staff told us their received support from senior nurses and doctors and had opportunities for training and development. They were encouraged to raise concerns and staff we spoke with told us they were happy to work in the department.

Surgery

Requires improvement

Updated 17 August 2017

We rated surgery requires improvement because we found many problems that were impacting/ or potentially impacting on the safety and quality of care that patients received.

Reporting and learning from incidents was not happening consistently and staff did not always comply with infection prevention and control policies. Patients were not always cared for in the most appropriate and safe environment and there was little evidence that risk assessments had been carried out and actions put in place to mitigate risks. Some of the risks we identified during the inspection were not reflected on the risk register.

The results of some national audits found surgery performed worse than the England average e.g. national hip fracture audit. Some patients had their surgery cancelled on the same day and some prior to admission due to a lack of available beds. The number of patients who had their surgery cancelled and were not treated within 28 days was worse than the England average.

Staff felt supported by their immediate managers, but felt under constant pressure due to increasing demand and a lack of capacity. Staff across different groups and at different levels told us they did not feel they were involved in decisions about their service.

However, we found that despite working in difficult conditions staff strived to provide compassionate care to patients and involve them in decisions about their care. Patients told us they were aware that staff were busy, but said they were ‘kind’ and ‘attentive’.

Intensive/critical care

Requires improvement

Updated 17 August 2017

Critical care was rated requires improvement because we found the long standing problem of insufficient consultants had not been addressed and was having a significant impact on some aspects of the service.

The lack of consultants meant that the service was not meeting national guidance for patient staffing ratios, there were no regular meetings where all consultants discussed the care of patients, strategy regarding the bed base, patient caseload, recruitment and standards or guidelines.

Although concern about the lack of consultants had been on the risk register since 2016 no action had been taken until an external peer review in 2017 when the trust had started the process to recruit more consultants. Staff were also not carrying out all necessary risk assessments on patients.

In addition, the service had occupancy rates that were consistently greater than the Royal College of Anaesthetists recommendation of 70% critical care occupancy. This could limit the unit’s ability to take emergency admissions due to a lack of bed space availability. Flow and delayed discharges were a significant concern for the service and the unit had more non-clinical transfers than comparator units.

However, we also found that many aspects of care were effective care and staff were kind and caring and treated patients with dignity and respect.

Staff were positive about working on the unit and said the matron was open and approachable. They told us the matron was visible and very supportive.

Services for children & young people

Requires improvement

Updated 17 August 2017

Services for children and young people were rated requires improvement because of concerns about the number of nursing and medical staff in the neonatal unit (NNU). The service also did not meet national guidance for paediatric consultant cover. The number of play specialists had also been reduced which impacted on their availability to support children.

Children and young people who attended the Hippo unit, and had first attended the urgent care centre, sometimes experienced delays in having their observations carried out. Due to the times the service operated they sometimes had to attend the Emergency Department when it closed which prolonged their time in the hospital.

Since the last inspection in February 2014, there had been some improvement in cross site working and governance processes. However, some of the risks, increased number of cots in the NNU, identified during the inspection were not recorded on the risk register or little or no progress had been made. Medical cover was an example of this and discussions had been taking place for three year little progress had been made.

However, children and young people received effective care and staff were caring and competent to perform their roles and responsive to the individual needs of children.

End of life care

Inadequate

Updated 17 August 2017

End of life care was rated inadequate. This was because there were insufficient staff to meet the needs of patients. Patients on the end of life care pathway received a variable standard of care, some medical staff were unsure how to initiate the end of life care pathway and there was little evidence of monitoring of the quality and safety of care provided to patients.

Attendance at meetings to monitor the quality of the service was variable and there was little or no action taken in response to problems identified. There was limited information on the wards about how staff could contact the end of life care team.

We saw some positive caring interactions between ward staff and patients and the mortuary team and bereavement office staff. However, privacy and dignity were sometimes compromised and delayed communication between some hospital teams resulted in delayed or inappropriate care for some patients.

Although some action had been taken since the 2014 inspection we did not see evidence of sustained improvement in the service.

Outpatients

Good

Updated 17 August 2017

Outpatients and diagnostic imaging were rated as good because patients were receiving safe, effective care and the service was well-led. The service needed to improve how it responded to patients.

We found a good culture of reporting incidents and the environment was safe and clean. Equipment had been cleaned and checked. Care and treatment was provided in line with national guidance and regulations. Patients told us staff were kind and said they felt involved in their care with staff providing explanations as needed.

Staff were positive were about their immediate managers and said they supported them and they felt valued. Outpatients and diagnostic imaging had developed a five year strategy for improving the service

However, the service was not always meeting national referral to treatment times and the ‘Did not attend’ (DNA) rate was higher than the England average. Many of the clinics were observed were running late and there was no evidence that this was being monitored.