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University College Hospital & Elizabeth Garrett Anderson Wing Good

Inspection Summary


Overall summary & rating

Good

Updated 15 August 2016

University College Hospital (UCH) is a teaching district general hospital situated in the London Borough of Camden in Central London. It includes the Elizabeth Garrett Anderson Maternity Wing and is part of the University College London Hospitals NHS Foundation Trust. It has close association with University College London (UCL).

The hospital has720 in-patient beds, 12 operating theatres and houses the largest critical care unit in the NHS. The Emergency and Urgent Care department sees approximately 171000 patients per year.

UCH is a major teaching hospital and is closely associated with the UCL Medical School. It is also a major centre for medical research.

In 2015 the urology department moved to the University College Hospital site in Westmoreland Street which had formerly been the Heart Hospital.

We carried out this inspection as part of our comprehensive acute hospital inspection programme for NHS acute hospital trusts. We had earlier inspected this hospital in November 2013 but we did not at that time formally give a rating for the hospital and its core services as we were at that time still in the pilot stage of our new and current methodology.

The announced part of the inspection took place between 8-11 March 2016, and there were further unannounced inspections which took place between 18 – 25 March 2016.

Our key findings were as follows:

  • Overall we rated University College Hospital as Good.
  • We rated surgery, critical care, maternity and gynaecology, services for children, and outpatients and diagnostic imaging as good. We rated urgent and emergency care, and medical care as requires improvement. Because specialist palliative care is provided through a service level agreement by a third party provider we have not reported on that service.
  • Overall we rated effective, caring, responsive and well- led as good and safe as requiring improvement.
  • The organisation had a long-standing model of tripartite management (nursing, medical and general management), reporting to a Medical Director. The organisation had a clear vision and ambition for specialist care and research. Local services, i.e. emergency care for the local population, also featured in the Trust strategy and it was noted that capital investment had been identified to the support the development of the Emergency Department.

We saw areas of good andoutstanding practice including:

  • There was outstanding local leadership in critical care with high levels of staff and patient engagement.
  • In maternity and gynaecology we saw examples of outstanding world class practice, notably the One Stop first trimester Down’s syndrome Screening clinic with immediate Fetal Medicine referral, the gynaecology Integrated ‘One Stop’ Diagnostic and Testing service, and the see and treat service in colposcopy.
  • We found all staff overwhelmingly to be dedicated, caring and supportive of each other within their ward and division.
  • We saw high levels of support given to staff in an innovative environment with good examples of innovation and best practice.
  • Improvements had been made to the environment inthe emergency department (ED)removing patients doubling up in cubicles which had been noted in the previous inspection.
  • We found patient feedback when treatment had been given to be overwhelmingly positive.
  • In surgery, staff demonstrated good knowledge of reporting, investigating and learning from incidents.
  • There were on-going improvements in the use of the World Health Organisation (WHO) five steps to safer surgery checklist.
  • We saw staff treating and caring for patients with compassion, dignity and respect.
  • There was good multi-disciplinary working in surgery and a strong focus on improvement at all levels.
  • In critical care there were effective systems in place to protect patients from harm.
  • Safe numbers of staff cared for patients using evidence based interventions.
  • Staff at all levels in critical care had a good understanding of the need for consent and systems were in place to ensure compliance with deprivation of liberty safeguards.
  • In maternity and gynaecology, staff were competent in their roles with good levels of collaborative working across the service.
  • In services for children, care and treatment reflected current evidence based guidelines.
  • In end of life care, the specialist palliative care team were knowledgeable, skilled and highly regarded.
  • In outpatients and diagnostic imaging, patients were treated with dignity and their privacy was respected.

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

  • Despite improvements in the layout of the emergency department, the recent ED redesign to address the increasing demand for its services was failing to meet patient needs at the time of our inspection.
  • Patients in ED experienced significant delays in initial assessment.
  • Incidents in ED were going unreported due to staff pressure.
  • The ED did not meet Royal College of Emergency Medicine (RCEM) recommendations that an emergency department should provide consultant presence 16 hours per day 7 days per week.
  • In ED, early warning scores , sepsis screening and pain management were not being consistently recorded in patient records.
  • Mandatory training targets were not being met consistently.
  • Staff in ED complained that their concerns were not being listened to.
  • We were not assured that the leadership of the ED were providing sufficient or timely information to trust senior management on the concerns that staff had identified in relation to the service redesign.
  • In medical care, risks identified were not being recorded on risk registers.
  • Documentation and patient records across medical wards was inconsistent and sometimes of poor quality.
  • Patient outcomes on medical wards were variable.
  • In outpatients and diagnostic imaging the trust had performed mostly worse than the England average in 2014-15 for the percentage of people seen by a specialist within 2 weeks from an urgent referral made by a GP.
  • The trust also performed worse than the England average in relation to 31 and 62 day targets from referral to treatment.
  • The trust performed consistently worse than the England average for diagnostic waiting times in 2014-15.

Importantly, the trust needs to:

  • Examine its streaming process in ED and seek to engage ED staff in developing a system that meets the needs of patients in ED.
  • Significantly reduce average time spent per patient in ED.
  • Shorten the time to initial assessment of patients in ED.
  • Ensure full incident reporting, investigation and learning takes place
  • Examine emergency cover in ED to ensure it meets College of Emergency Medicine recommendations.
  • Ensure that any risks of alleged and potential bullying are understood and ensure that the trust takes action where that bullying is known or arises.
  • Ensure consistent and full recording or early warning scores, sepsis screening and pain management.
  • Ensure mandatory training targets are met consistently.
  • Ensure that all risks identified are noted on the risk register.
  • Examine recording of patient records and ensure improvements to meet consistent best standards across all wards.
  • Examine effectiveness of treatment across medical wards to comply with national guidelines to improve patient outcomes.
  • In medical care and all areas ensure that care of patients living with dementia or learning disability goes beyond mere identification and devise clear care pathways to meet the needs of these patients.
  • Review the policy on admitting paediatric patients in critical care including the management of paediatric patients on the adult critical care unit to assure delivery of safe and effective care.
  • Ensure all staff (including medical and nursing) working in paediatric outpatients receive and have regularly updated level 3 safeguarding training
  • Make necessary improvements on patient waiting times for treatment including referrals and emergency referrals from GPs.
  • Ensure improvements to diagnostic waiting times.
  • Review performance against the 31 day target from diagnosis to first definitive treatment, produce and improvement action plan and monitor performance against that action plan.

The above list is not exhaustive and the trust should examine the report in detail to identify all opportunities for improvement when determining its improvement action plan.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 15 August 2016

Effective

Good

Updated 15 August 2016

Caring

Good

Updated 15 August 2016

Responsive

Good

Updated 15 August 2016

Well-led

Good

Updated 15 August 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 15 August 2016

  • Staff were competent in their roles and undertook appraisals and supervision. We saw good examples of multidisciplinary team (MDT) working in the maternity service. Staff worked collaboratively to serve the interests of women across hospital and community settings.Access to medical support was available seven days a week. Community midwives were on call 24 hours a day to facilitate the home-birth service.
  • We saw examples of outstanding world class practice, notably the One Stop first trimester Down’s syndrome Screening clinic with immediate Fetal Medicine referral, the gynaecology Integrated ‘One Stop’ Diagnostic and Testing service, and the see and treat service in colposcopy. Surgical management of miscarriage under local anaesthetic in the Early Pregnancy Unit and integrated multi-disciplinary working within the Fetal Medicine Unit were also examples of outstanding practice.
  • Feedback from patients and those close to them was positive. Overwhelmingly we received feedback that care was excellent and compassionate. Women reported being treated with dignity, respect and kindness during all interactions and patient-staff relationships were very positive.

Medical care (including older people’s care)

Requires improvement

Updated 15 August 2016

  • Senior staff lacked oversight of some issues within the service and risks we identified were not recorded on the relevant risk register; for example risks relating to the electronic prescription charts.Staff reported incidents, however feedback and learning from these was variable and senior staff did not complete on-going follow up of actions identified as a result of investigations.
  • Documentation across the wards was not completed to a satisfactory level; there were many incomplete assessment and care bundle forms and records without patient identifiable information. We also saw evidence some patients were not escalated appropriately when deteriorating and a lack of systematic identification of sepsis patients.
  • Patient outcomes were variable, including more deaths than expected in some clinical areas and a higher risk of readmission for some specialties. We saw evidence of some practice which was not in line with current recommendations, and variable safety thermometer results. Additionally a number of patients were seen to be receiving oxygen therapy without a prescription.
  • Patient feedback was mainly positive and we observed many positive interactions between staff and patients. However there were occasions when patient privacy and dignity was not fully maintained.

Urgent and emergency services (A&E)

Requires improvement

Updated 15 August 2016

  • Improvements had been made tothe environment in EDsince the previous inspection in November 2013. However staff were struggling to effectively cope with arecently introduced streaming system for patients. Patients experienced significant delays in initial assessment and treatment.Many staff told us that since the introduction of the new working model their concerns were not listened to.
  • The ED did not meet the College of Emergency Medicine (CEM) recommendation that an emergency department should provide emergency cover 16 hours a day, seven days a week.
  • Although staff demonstrated an open and transparent culture about incident reporting and patient safety some adverse incidents went unreported because staff did not have the time to complete an incident report.
  • Early Warning Scores (NEWS), sepsis screening, and pain management were not consistently recorded in patient records.
  • Nursing and medical staff were not meeting the trust targets for some significant mandatory training courses, including safeguarding.

Urgent care centre

Updated 14 January 2014

The physical environment of A&E was inadequate and not responsive to the needs of patients, and we had concerns that the current environment and layout could compromise patient safety and requires considerable improvement. The staff in the A&E were caring with patients and supportive of each other, and as a team, through their attitude and practice, they mitigated the impact of the inadequacy of the A&E on patient care. However, at times of intense pressure, we had concerns that staff were disempowered from being able to care for patients appropriately.

We also had concerns about the effectiveness and leadership of the A&E, and the trust’s response to known risks and failures. This includes allowing the pressure on the A&E to increase through routing referred medical and surgical patients through the department.

In the context of the trust, what we found and what staff told us it was felt that the A&E service was not a priority. It is clear that not all staff were aware of the focus of the board in this area.

Surgery

Good

Updated 15 August 2016

  • Staff demonstrated good knowledge of the process of reporting; investigating and learning from incidents. We saw good evidence of local and trust wide learning from incidents that had occurred. There were on-going improvements in the use of the World Health Organisation (WHO) Safer Surgery checklist. Staff demonstrated that this was embedded in their practice and audit data demonstrated this was carried out to a high standard.
  • We saw staff treating and caring for patients with compassion, dignity and respect. Patient feedback was positive. Patient outcomes were monitored through internal and external audits and benchmarked against other services.
  • There was a strong focus on improvement from all levels of staff when results were less them optimum.There was good multidisciplinary team (MDT) working between doctors, nurses and other allied health professionals throughout patient pathways.

Intensive/critical care

Good

Updated 15 August 2016

  • There were effective systems in place to protect patients from harm and a good incident reporting culture.

  • Learning from incident investigations was disseminated to staff in a timely fashion and they were able to tell us about improvements in practice that had occurred as a result.

  • Safe numbers of staff cared for patients using evidence-based interventions. There was good access to seven-day services and the unit had input from a multidisciplinary team.

  • Staff at all levels had a good understanding of the need for consent and systems were in place to ensure compliance with the Deprivation of Liberty Safeguards.

  • There was good local leadership on the unit and staff reflected this in their conversation with us.

  • Staff and patients were engaged in decision making on the unit and provided feedback about the service.

  • The unit was engaged in research a large team of nurses and doctors dedicated to the research programme.

Services for children & young people

Good

Updated 15 August 2016

  • The service had a robust process for ensuring incidents were reported and investigated. All staff were aware of their responsibilities to report and lessons were learnt where incidents had taken place. Patient risks were appropriately identified and acted upon with clear systems to manage a deteriorating child or baby.

  • Care and treatment reflected current evidence-based guidelines, standards and best practice. The services participated in a number of national and local audits to measure their effectiveness and to drive improvements. Performance against the national neonatal audit programme and the national diabetes audit was better than the national average and there was evidence of local action plans to address any issues identified.
  • Pain was being effectively managed and regularly monitored. Nutrition and hydration was being monitored and dietician input was available when needed.
  • Children were cared for in a caring and compassionate manner. Their privacy and dignity was maintained throughout their hospital stay. Fully trained and registered children’s nurses and neonatal nurses throughout the service ensured that children and their families were informed about their care and were fully involved in any treatment decisions. Consent to care and treatment was obtained in line with legislation and guidance.

End of life care

Updated 14 January 2014

We found that the trust was improving support for people at the end of their lives.

The trust had recognised the need to increase the staffing levels in its palliative care team and was taking action to do this.

The trust was no longer using the Liverpool Care Pathway. It had been recently replaced by an interim “Excellent care in the last days of life – Individualised care plan.”

We found that staff were caring and responsive to patients’ needs. There was a good working relationship between the different support services that were available. We received positive feedback from relatives of patients.

However, the trust was not ensuring that the paperwork for patients who had been assessed as not requiring resuscitation (do not attempt resuscitation or DNAR) was always fully completed. We found examples where there was no evidence recorded of discussions with the person or their family members and there was no consultant signature to indicate they had reviewed the order.

We found that the trust was seeking to develop and improve its End of Life service. It had an End of Life Board to provide senior leadership in developing the service at the trust. A five-year strategy for End of Life is currently at draft stage.

Outpatients

Good

Updated 15 August 2016

  • There were systems for reporting incidents and raising concerns. Outcomes from these were shared with staff and used for shared learning. Records were stored securely.Risks were listed on local risk registers which were up to date and reviewed regularly.
  • The environment was clean and hygienic and the department was staffed adequately in order to run all of the outpatient and diagnostic imaging services.
  • There were systems which allowed effective performance monitoring. There were clear lines of management responsibility and accountability within the outpatient’s and diagnostic imaging departments. We observed that staff worked well as a team supporting one another. Staff told us they felt able to raise concerns and discuss issues with the managers of the department.