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Hammersmith Hospitals Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 December 2014

Hammersmith Hospital is part of Imperial College Healthcare NHS Trust. It is an acute hospital and provides medical care, surgery, critical care, services for children and young people, end of life care and outpatient services. These are six of the eight core services that are always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection. The accident and emergency department was going to close the week following our inspection to be replaced with an urgent care centre; therefore we made the decision not to inspect it. The other core service that is not provided by this hospital is maternity and family planning. Maternity and neonatal services for this trust are reviewed in our inspection report for Queen Charlotte’s & Chelsea Hospital.

Hammersmith Hospital has 346 beds and is based in the London Borough of Hammersmith and Fulham. The hospital provides a range of elective and non-elective inpatient medical and surgical services as well as outpatient services.

The team included CQC inspectors and analysts, doctors, nurses, experts by experience and senior NHS managers. The inspection took place between 2 and 5 September 2014.

Overall, we rated this hospital as ‘requires improvement’. We rated effective and caring as ‘good’ but safety, responsive and well-led as ‘requires improvement’.

We rated services for children and young people and end of life care as ‘good’ but medicine, surgery, and critical care as ‘requires improvement’. We rated outpatients as ‘inadequate’.

Our key findings were as follows:

Safe:

  • Patients were asked for their consent before procedures were carried out and staff knew how to report concerns related to alleged abuse or neglect.
  • The specialist palliative care team (SPCT) involved family members in decisions that related to patients’ care and treatment.
  • Most areas were clean and there were good infection prevention and control measures.
  • Staff had received safeguarding training, was able to identify potential abuse, and were aware of how to report this.

Effective

  • Pathways used for the assessment and management of patients’ medical conditions were informed by appropriate national guidance.
  • Patients were given pain relief when needed, prescribed in line with their individual requirements.
  • There was good communication and multidisciplinary team involvement among all staff involved in patients’ care and treatment.
  • Pain relief was well-managed and the nutritional needs of patients were catered for.

Caring

  • Staff were caring and compassionate and spoke to patients in a dignified manner.
  • The privacy and dignity of patients were respected.

Responsive

  • The provision in theatres was satisfactory. The surgical admissions lounge was a suitable environment and allowed for patient comfort, dignity and confidentiality.
  • Single side rooms were available on wards for patients receiving end of life care and people’s spiritual needs were met.

Well-led

  • Local line management of staff was good, supportive and visible.
  • Staff worked well as a team and were motivated to do their job.
  • There was an open and accessible culture that created positive teamwork among staff.
  • Translational clinical research is embedded in some clinical services with close working relationships with academic departments of Imperial College.
  • However, there were also areas of poor practice where the trust needed to make improvements.

The trust must:

  • Correct the high number of vacant nursing and healthcare assistant posts on the medical wards.
  • Address the problems associated with the administration of outpatient appointments which was leading to unnecessary delays and inconvenience to patients.

The trust should:

  • Improve patient transport from the outpatients department so that patients are not waiting many hours to be taken home.
  • Improve the management of medicines on the medical wards.
  • Ensure patients’ records are always appropriately completed.
  • Ensure learning from investigations of patient falls and pressure ulcers is proactively shared trust-wide.
  • Ensure cleaning of equipment is always carried out.
  • Improve access to the one pain clinic that is available in the trust.
  • Reduce the number of out-of-hours transfers and discharges.
  • Monitor the clinical impact of cancellations and delays in surgery.
  • Ensure that surgical patients are not cared for in inappropriate areas such as in the theatre overnight.
  • Improve the responsiveness of the outpatients department with regards to clearing the backlog of GP letters from the gastroenterology clinic and reducing the waiting times for patients to get an initial appointment.
  • Avoid cancelling outpatient clinics at short notice.
  • Ensure there is accurate performance information from the outpatients department.
  • Ensure that quality and risk issues in the outpatients department are managed effectively.
  • Consider reviewing the processes for the capturing of information to help the service to better understand and to measure its overall clinical effectiveness.
  • Consider reviewing the current arrangements for the provision of children’s outpatient services to ensure there is parity across the hospital campus.
  • Consider reviewing the operating times of the David Harvey Unit to ensure the service is accessible to the local population to which it serves, at the right time of day.

Professor Sir Mike Richards Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 16 December 2014

Effective

Good

Updated 16 December 2014

Caring

Good

Updated 16 December 2014

Responsive

Requires improvement

Updated 16 December 2014

Well-led

Requires improvement

Updated 16 December 2014

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 19 October 2017

Surgery

Requires improvement

Updated 16 December 2014

We found evidence of good outcomes for patients who underwent surgery at Hammersmith Hospital. There was a backlog of patients waiting for elective surgery with some patients who had experienced long waits for their surgery. The trustdid provide a plan to reduce the backlog of patients waiting for elective surgery. We found preoperative assessment for some surgical specialties was not managed effectively, which often led to cancellation of elective procedures. Data submitted by the trust showed a high rate of procedure cancellation.

The trust had not taken sufficient steps to ensure the ‘five steps to safer surgery’ – from the World Health Organization (WHO) surgical safety checklist – was embedded in practice across Hammersmith Hospital, due to the low numbers of WHO checklist audits. We identified that surgical wards had a low number of nursing vacancies; they regularly reviewed skills mix and used a low volume of agency staff. The majority of staff received mandatory training and further specialist training was available to a wide variety of staff. Infection control procedures and practices were adhered to and regularly monitored.

Procedures and treatments within surgical services followed national clinical guidelines. Pain relief was effectively managed and most nutritional needs of patients were assessed and catered for.

Patients spoke positively about their care and treatment at the hospital. They told us staff were caring, compassionate and professional. Results from the NHS Friends and Family Test were better than the England average, and a high number of patients would recommend this hospital to their family and friends.

Intensive/critical care

Requires improvement

Updated 16 December 2014

Critical care services at Hammersmith Hospital required improvement. We were concerned with bed capacity and staffing arrangements. Capacity was stretched and staffing levels were either not appropriate or not taking into account other arrangements in the hospital. Some aspects of safety requirements were not always adhered to. However, there was good patient feedback and good outcomes for patients.

Services for children & young people

Requires improvement

Updated 16 December 2014

Both the children’s outpatient department and the David Harvey Ambulatory unit were clean and tidy and there were processes in place to regularly monitor the standards of cleaning. There were procedures in place to manage the deteriorating neonate, child or young person. Whilst medical records were kept safely, there was an emerging theme that clinicians did not always have access to full sets of clinical notes or referrals in-time for clinics.

Children’s services followed national evidence-based care and treatment and carried out a small selection of local audits to ensure compliance. However, there was no auditing of care in which the service could be benchmarked either locally or nationally.

Children and those close to them, such as their parents or carers, were involved in the planning of care and treatment and were able to make individual choices on the care they wished to receive. People spoke positively about their experience of using the David Harvey Unit, which during 2013/2014 received a very low number of complaints.

Whilst the department had embraced the wider “Connecting Care 4 Children” initiative, there was little vision or future strategy for the department. There was no evidence to demonstrate that there had been consideration to alleviating the pressures of the over-subscribed outpatient department located at St Mary’s Hospital.

End of life care

Good

Updated 16 December 2014

There was an inconsistent approach to the completion of ‘do not attempt cardiopulmonary resuscitation’ (DNA CPR) forms. In line with national recommendations, the Liverpool Care Pathway for end of life care had been replaced with a new end of life care pathway framework that had been implemented across the hospital. Action had been taken in response to the National Care of the Dying Audit for Hospitals 2013, which found the trust did not achieve the majority of the organisational indicators in this audit, but there was no formal action plan. However, the majority of the clinical indicators in this audit were met.

There was a recently developed end of life strategy and identified leadership for end of life care. The end of life steering group reported to executive committee. The specialist palliative care team (SPCT) were visible on the wards and supported the care of deteriorating patients and pain management. Services were provided in a way that promoted patient centred care and were responsive to the individual’s needs. Referrals for end of life care were responded to in a timely manner and the team provide appropriate levels of support dependent on the needs of the individual.

There was clear leadership for end of life care and a structure for end of life care to be represented at board level through the director of nursing.

Outpatients

Good

Updated 31 May 2017