You are here

Inspection Summary


Overall summary & rating

Good

Updated 8 January 2016

Great Ormond Street Hospital for Children NHS Foundation Trust is one of four dedicated children's hospital trusts in the UK. The trust operates from a single site in central London. It is the largest paediatric centre in the UK for intensive care, cardiac surgery, neurosurgery, cancer services. nephrology and renal transplants. Children are also treated from overseas in their International and Private Patients’ (IPP) wing. There are more than 50 different clinical specialties at Great Ormond Street Hospital (GOSH). Together with the UCL Institute of Child Health, it forms the UK’s only academic biomedical research centre specialising in paediatrics. Its status as a Specialist Children’s Hospital means that most of the children treated are referred from other hospitals or overseas.

We carried out this inspection as part of our comprehensive acute hospital inspection programme adapted for dedicated children's hospitals. The trust was rated as low risk in the CQC intelligent monitoring system. The inspection took place between 14 and 17 April and unannounced inspections took place between 1 and 3 May 2015. We also inspected the Children and Adolescent Mental Health Services ( CAMHS) provided by this trust as part of our inspection.

Overall this trust was rated as Good. We rated it outstanding for being effective and caring. We rated it good in providing safe care. We rated it requires improvement for being responsive to patients needs and in being well-led.

We rated medical care and end of life care as outstanding. We rated critical care, child and adolescent mental health services and transitional services as good. We rated surgery, and outpatients and diagnostic imaging as requires improvement.

Since our inspection, the trust alerted us to long-standing problems with the reliability of their patient information systems, which affected the validity of the trust’s reporting of referral to treatment (RTT) times. This had the potential to delay the admission of patients waiting for non-emergency treatment. We have reflected these problems in our assessment of services in this report.

Our key findings were as follows:

  • All staff working at the hospital were extremely dedicated, caring and proud to work for the hospital.
  • We saw high levels of care, professionalism and innovative treatment of patients who had been referred for care by other hospitals.
  • The culture was very open and transparent. Parents and children were kept fully involved in their treatment. There was an evident commitment to continually improve the quality of care provided. Children and young people were involved in decision making as far as possible.
  • We saw good examples of duty of candour in practice. Staff were very open when things had gone wrong, expressed full apology and offered full support to parents, children and carers.
  • The new Chief Executive was very visible, had shared his vision for the trust and had gained the early respect of staff members.
  • The executive team were well known to members of staff and patients and did regular walkabouts on the wards.
  • There was outstanding care demonstrated in all departments where there was a tangible level of staff working together in pursuit of excellence of care. All supported the mission statement of the trust which was " the child first and always".
  • When decisions were made to stop treatment, this was done thoroughly and with good governance via the ethics committee and always with maximum consultation with parents or carers.
  • The reporting of incidents was fully embraced by all members of staff we spoke with. Incidents were thoroughly investigated and learning obtained and shared with all staff across the hospital.
  • End of life care was embedded in all clinical areas of the hospital and not seen as the sole responsibility of the palliative care team.
  • Where the trust had completed a refurbishment or rebuild, the facilities were modern, extremely child friendly and conducive to excellent patient care and dignity. There remained some wards, not yet refurbished, rebuilt or relocated where the environment was less good. The hospital recognised this and was in the middle of a total refurbishment/rebuild project.

We saw several areas of outstanding practice including:

  • Clinicians from other hospital services delivered specialist training on physical health issues for CAMHS staff. In return CAMHS staff provided training and expertise to other departments across the hospital, for example on learning disabilities and autism.
  • Because the hospital is treating many patients that could be treated at very few hospitals in the UK it is developing ground breaking clinical guidance which it is sharing with clinical colleagues in the wider medical community.
  • The hospital has developed a pocket-sized guide to help staff working with children with learning disabilities.
  • The Feeding and Eating Disorders Service (FEDS) received 100 % approval in the latest Friends and Family test with 93% saying they were extremely likely and 7% saying they were likely to recommend the service.
  • The Psychological Medicine team provided an outreach service across the country where necessary.
  • Staff in CAMHS were actively involved in research in their specialist areas including Autism and Feeding and Eating disorders.
  • CAMHS introduced a screening tool for mental health problems and the psychological medicine team conducted a study to improve the understanding of the patient experience, diagnosis, treatment and outcomes regarding non-epileptic seizures in children.
  • The FEDS and MCU (Mildred Creak Unit)teams developed a policy around re-feeding syndrome to increase understanding of the issue.
  • In critical care there were excellent mortality and morbidity meetings, and robust safety monitoring of all patients.
  • The Intensive Care Outreach Network(ICON) and Clinical Site Practitioners (CSP) are part of the hospital at night service and hold responsibility for any deteriorating child 24 hours a day, seven days per week.
  • In pharmacy services the chief executive receives monthly reports of prescribing errors; a daily check ensures all electronic prescriptions are screened before the end of each weekday (Monday to Friday)and patients are informed by text message when prescriptions are ready.
  • In transitional care young people feel empowered by the Young Persons' Forum.
  • Joint transitional care clinics are held with on-going hospital providers.
  • In outpatients weekly education sessions were protected to ensure staff maintained currency in mandatory areas and had the opportunity to take part in further specialist training from a clinical educator

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

Importantly the hospital must:

  • Resume WHO checklist audits in surgery
  • Ensure that there are clear arrangements for reporting transitional care service performance to the board.
  • Ensure that its referral to treatment (RTT) data and processes are robust and ensure that staff comply with the trust's patient access policy in all cases.
  • Ensure greater uptake of mandatory training relevant to each division to reach the trust's own target of 95% of staff completing their mandatory training.
  • Ensure that, particularly in critical care, communication between senior nurses and senior medical staff is enhanced and that the contribution of nursing is fully reflected in the hospital's vision.

In addition the hospital should:

  • Ensure early improvements in the environments of wards which have not been refurbished, rebuilt or relocated.
  • Standardise radiation protection training for junior radiologists to overcome inconsistencies caused by short rotations.
  • Develop a dedicated advocacy service for its Child and Adolescent Mental Health service ( CAMHS).

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 8 January 2016

Effective

Outstanding

Updated 8 January 2016

Caring

Outstanding

Updated 8 January 2016

Responsive

Requires improvement

Updated 8 January 2016

Well-led

Requires improvement

Updated 8 January 2016

Checks on specific services

Medical care

Outstanding

Updated 8 January 2016

Patients in medical care services were protected from abuse and avoidable harm. There were enough trained and experienced doctors, nurses and other staff to react if patients deteriorated.

The service was treating many patients that could only be treated at very few other hospitals if any. Multi-disciplinary teams were well coordinated to ensure the best outcomes for patients.

The patients we spoke with were all very positive about the care they had received. One patient told us, “ It’s better than being in school, I come in three times a week. I love dancing with the staff”. Another patient told us, “ I have to come in for a check up every two years. It's a very good service, the doctors are brilliant and they’re good at listening and explaining things”.

Medical care services at the hospital were very responsive to the needs of patients. We found many examples where staff had made a special effort to meet the needs of patients.

The trust’s core vision of “The child first and always” was well recognised and owned by staff. The newer version of “always welcoming, always helpful, always expert and always one team” was less well recognised. Staff were focused on delivering high levels of care to patients.

Neonatal services

Good

Updated 8 January 2016

The NICU at GOSH had very good systems and processes in place to protect babies from harm and these included reporting and learning from incidents. Nurse staffing levels were in line with national guidance and staff had access to a range of training both internally via the GOSH education department and at local universities. The needs of the babies and theirmothers or carerswere met by skilled and experienced staff including breast-feeding experts. The staff members were accustomed to caring for babies with co- morbidities. Policies were based on NICE and other relevant national guidelines. NICU shares data with the British Association of Perinatal Medicine. There was a formal escalation process in place for managing deteriorating babies and outwith NICU in the high dependency unit care staff have been trained in its use and knew how to effectively use theclinical site practitioner service and the hospital at night team.

The capacity and flow of babies through the NICU was managed by collaborative working with other providers across London and further afield. The team of senior medical team co-ordinated the Intensive Care Outreach Network (ICON) which worked closely with the site practitioner team. Nursing staff felt supported by the senior nursing team and were able to raise concerns without fearof retribution. The staff members we spoke with were fully aware of the new chief executive and his plans for the future direction of the Trust. Interprofessional working was fully embedded within NICU.

Transitional services

Good

Updated 8 January 2016

Young people were being treated with dignity, respect and compassion. Clinical teams supporting care were committed to supporting young people requiring transitional services. We found examples of excellent care pathways for young people with specific long-term health needs transitioning to adult services.

We saw evidence of trust wide “Transition to Adult Health Services Integrated Care Pathway” (ICP) audit and re-audit of “transition arrangements for young people”.However, we found that there was no overall responsibility or leadership for transitional services in the trust at board level.

Surgery

Requires improvement

Updated 8 January 2016

Incidents were appropriately reported, investigated and learnt from. Staff demonstrated good knowledge of safeguarding procedures and gave excellent examples of recognising and reporting abuse. Theatres and ward areas were visibly clean and hygiene checks were taking place. Patient risks were being appropriately identified and acted upon.Five steps to safer surgery checklists were being completed using a laminated wipe clean sheet but observational audits had not occurred since March 2014.

Care and treatment was being reviewed to show that best practice was being achieved through a trust wide forum that included surgical activity. Clinical audit projects were taking place throughout the surgical specialties. Clinical educators were in place throughout theatres and surgical wards to ensure staff were competent and followed best practice. There was good multi-disciplinary team working throughout the surgical wards of the hospital and we found good examples where staff had worked with issues of capacity and consent.

We found many examples to demonstrate that the hospital was delivering compassionate care. Parent feedback unanimously supported this. Parents told us they had a good understanding of the care their child was receiving and felt the hospital involved them in the care their children received.

There was a backlog of patients waiting more than 18 weeks for surgery, with cardiac, orthopaedics and plastic surgery under the greatest pressure. Initiatives were in place to work to reduce these numbers. Surgical intake had been staggered to four times a day to reduce waiting times for parents and children.

There were a number of measures in place to meet the needs ofpatients and familiesbut the quality of some building facilities was variable. For example there were drainage problems and toilets on some wards were not at low level and child friendly. Other wards located in newer parts of the building had better environments and there was a plan to relocate all surgery wards to a new building currently under construction, thus remedying existing premises issues.

Systems and initiatives were in place that ensured patients’ individual needs were being met. Meeting the needs of children with a learning disability had been a specific focus of the service and other special needs were also being met.

There were clear visions and strategic priorities, and clear lines of leadership and accountability. We found an open and transparent culture with motivated and compassionate staff.

However we were concerned in relation to the impact on surgical patients following the discovery of unreliable referral to treatment data and inconsistent application of the trust patient access policy.

Intensive/critical care

Good

Updated 8 January 2016

There were systems and process in place to promote safe and effective care. There was a formal escalation process in place for managing deteriorating children and young people. Incidents were reported, investigated and learning took place. Nurse staffing levels were in line with national guidance. Staff had access to a range of training and professional development, ensuring they were competent for their role.

Policies and guidelines were based on NICE and other relevant national guidelines. The service participated in local and national audit including PICANET. The unit’s capacity and flow was managed effectively. There was a vision for the development of the service and identified nursing and medical leadership

Services for children & young people

Good

Updated 8 January 2016

Young people accessing specialist mental health services within the hospital were treated with genuine kindness and respect by highly skilled and experienced staff. Parents told us that the treatment and support their children received for their complex mental health issues was ‘lifesaving’ and offered hope for their future.

All children had personalised and holistic treatment plans with input from a dedicated multi-disciplinary team. Children and parents were involved in the development of care plans and risk assessments. Family therapy, support and psycho-education groups were available for parents and carers.

The environment was clean and safe with a notable calm and contained atmosphere and children had access to a range of therapies and activities. Restraint was minimal and issues of consent and capacity thoughtfully addressed with the involvement of children and their carers. Patient records were thorough and regularly reviewed.

Effective systems were in place for reporting and managing incidents, the learning from these investigations was used to embed positive changes. Feedback was proactively sought to improve the service.

The service was involved in innovative research and the MCU was accredited as Excellent by the Royal Society of Psychiatrists Quality Network for Inpatients CAMHS. The service shared expertise and delivered training to other trust departments.

Staff had access to a range of mandatory training and professional development opportunities.

Governance and risk management processes were embedded into the service. There was effective, supportive leadership across the service. However some staff felt concerned that the current reconfiguration of the service could potentially impact on the quality of specialist treatment delivered. Staff turnover was low, and staff told us they were proud to work in the service.

End of life care

Outstanding

Updated 8 January 2016

Parents we spoke with could not praise the quality of the care and support given by GOSH any higher. One parent wrote in an email, “GOSH and the healthcare professionals involved in our child’s care are leading the world in paediatric care.” All staff across the hospital were found to be compassionate, caring and considerate and wanted to do the best they could for children and their families.

We found that care and treatment was safe, evidenced based and followed accepted standards and professional guidance. There were clear care pathways for children being cared for in the hospital and community and all parties involved in the child’s care were included in these plans.

There was excellent multidisciplinary team working in palliative and end of life care services which included chaplaincy and dedicated psychological and social support teams. An ethics committee safeguarded C&YP interests in the event of a conflict in care and treatment.

Children and their families were given the choice as to whether they wished to receive end of life care at the hospital, at home or in a hospice. The service took into account individual circumstances and needs and supported them in their decisions without judgement.

End of life and palliative care was well-led. The team were thought of highly by colleagues within the hospital and by other professionals from around the world.

The team were passionate about continually improving the service, which included training programmes for nurses and GPs from hospitals

Outpatients

Requires improvement

Updated 8 January 2016

There was a culture of high quality, child centred care delivered by competent staff. E

ffective systems were in place for reporting, investigating incidents using learning to change practice. The environment and clinical equipment were visibly clean and appropriately maintained. Medical records were available but they were not always transported using equipment that was suitably maintained.

There was participation in audits and care and treatment was provided in line with professional guidance. Staff had access to a range of mandatory training and professional development. While not all services operated seven days a week, services were flexible to meet patients’ needs. There was evidence of multidisciplinary team working and systems were in place to coordinate care with other departments in the trust.

Children, young people and their parents received compassionate care and were encouraged to be involved in decisions about their treatment. Feedback was proactively sought to improve the service. Cancellations were minimal and appropriate action taken. The trust was working to remedy the underlying issues which caused delays in clinics. Informal and formal complaints were listened to and action taken to resolve the issue.

There was a vision and strategy for the development of the service. There was identified leadership who were supportive and motivated staff. Governance and risk management processes were embedded into practice and fit for purpose.

However we were concerned in relation to the impact on outpatients following the discovery of unreliablereferral to treatment data and inconsistent application of the trust patient access policy.