Lewisham and Greenwich NHS Trust

This is the second comprehensive inspection of Lewisham and Greenwich NHS Trust; our first being carried out in 2014. At that inspection, we rated the trust as requires improvement across each of the five key questions; safe, effective, caring, responsive and well-led.

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 focused inspection.

Following this most recent inspection, we have again rated the trust as requires improvement across the five key questions and requires improvement overall.

We rated both of the main locations as requires improvement overall.

Community services was rated as outstanding overall; this was attributable to the effective care and leadership of children, young people and family community services provided in the borough of Lewisham.

In light of the concerns which existed with regards to the emergency care pathway at Queen Elizabeth Hospital, a system wide risk summit was convened shortly following the announced inspection period. Stakeholders across the health economy committed to work with the trust to address the concerns including patient flow across the emergency pathway. A subsequent visit to the trust on 19 May 2017 by a small team of inspectors and a specialist advisor for emergency medicine confirmed that a number of changes had been made to the emergency pathway. This included increased monitoring of the quality of care provided within the emergency department; improved access to physical beds as compared to trolley's, so as to reduce the risk of patients developing pressure damage; improving ownership and relations of the challenges faced by those working in the emergency department. The trust acknowledged that significant work was still required across the emergency care pathway however representation of key members of the health system were present on 19 May 2017 and all were committed to working together to improve outcomes for patients. 

Our key findings were as follows:

• Despite a period of three years since our last comprehensive inspection, there remained areas of unresolved risks and areas for significant improvement. This included the acute emergency pathway at Queen Elizabeth Hospital. In part, a lack of decisive decision making by the trust leadership team contributed to a lack of overall progress across the organisation.
• 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.
• The provision of end of life care across the organisation was inadequate. There was variation in the level of understanding of services provided to patients.
• 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.
• 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.
• 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.

We saw several areas of outstanding practice including:

• 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 risk registers and are regularly reviewed and updated and carry out audits to monitor the effectiveness of treatment and care. The trust must introduce mechanisms designed to assure the board that any mitigations instigated are implemented and reviewed regularly.
• Ensure all relevant risk assessments are carried out on patients.
• Ensure medical and nursing staffing levels are in line with national standards and service specifications.
• 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.
• Ensure patients requiring end of life care receive appropriate and timely care.
• Improve patient flow across the organisation.

In addition the hospital should:

• Work to share and embed learning from incidents in all services and cross site.
• Ensure staff comply with infection prevention and control policies and procedures.
• 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 patient records are stored and held securely in one document.
• 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 the environment and waiting times for women using the gynaecology service
• Ensure patients who are at the end of their life, and their relatives, are afforded 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.
• 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

Chief Inspector of Hospitals

Overall rating for this core service GOOD

We rated safe, effective, caring, responsive and well led as good.This was because

• Staff used trust wide systems to report and record safety incidents. These were escalated and investigated appropriately and learning was shared.
• Staff used patient risk and care assessments to identify and respond to risks. There were daily discussions of complex patients.
• Community staff were knowledgeable about safeguarding procedures and knew who they would report any concerns to.
• Community nursing staff had access to specialised equipment to meet patients’ needs when required.
• The service had a number of policies and procedures in place which were based on the national institute for health and care excellence (NICE) or other nationally or internationally recognised guidelines.
• Patients had their pain assessed and monitored depending on their needs. There were processes for obtaining pain relief for patients if required.
• Patients were assessed for their nutrition needs and action plans with referrals to appropriate health care providers were made.
• Staff had received an annual appraisal and had opportunities for their personal development as a result. There were numerous examples of staff being trained and developed, and while some training had been on hold previously, this was no longer the case.
• Staff sought consent before undertaking any care interventions. Records showed evidence that consent was gained for care and treatment.
• Staff were clear about their roles and responsibilities regarding the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.
• Patients we spoke with were positive about the staff that provided care and treatment. They told us they had confidence in the staff and the advice they received.
• We observed the way patients were treated, both in the home and in clinic settings. We observed staff using a respectful, compassionate and kind approach; patients gave positive feedback about the care they had received and the manner, which it had been given to them.
• Patients and relatives we spoke with confirmed that they felt involved in their care. Patients told us the staff had explained their treatment options to them, and they were aware of what was happening with their care.
• The friends and family test (FFT) for Lewisham adult community services for the period November 2015 and October 2016 showed that 98% of patients would recommend the service.

• Most services were achieving the 18 week referral to treatment targets pathway. There were many examples of teams working responsively and collaboratively to meet their patients’ needs and to provide care within the patients’ home environment.

• Patient equality and diversity was taken into account, Patient information could be provided in different languages. Staff could access translation services as and when required.
• The service provided a range of specialist therapeutic interventions

• The service worked closely with commissioners, local authorities, people who used services, primary care services and other local providers to ensure it understood the needs of the population it served in order to plan and deliver services.
• Governance structures were in place within adult community services. There were local governance meetings that fed into neighbourhood meetings and Divisional governance meetings.. Clinical dashboards and performance checkpoint reports were used to monitor of incidents, complaints, risks and performance.
• Risks were identified on the risk register and local risk logs and action was being taken to mitigate the risks. For example, staff in community sexual health services identified that a lack of laboratory capacity and challenges with the electronic records system meant there was a risk patients would not receive test results in a timely manner. This involved the intermittent failure of the text message system. In response an IT analyst was working with the systems team to identify and resolve the issue and an alternative communication strategy had been temporarily implemented. Most staff were aware of what concerns were included on the divisional risk register.
• The vision and strategy for community services for adults was closely aligned to the trusts to wider vision and strategy.
• Staff we spoke with told us that they felt valued and respected; and said there was an open and transparent culture.
• There were opportunities for further learning and development. Staff told us they were motivated and they were able to progress.

However:

• There were significant vacancies across the adult community services. The overall vacancy rate was 38%.
• Completion of mandatory training with the adult community services was 77% which was below the trusts target of 85%.
• The response rate to the staff survey was low at 15%. The staff friends and family test (FFT) for Lewisham adult community services for the period December 2015 to September 2016 showed that 71% of staff would recommend the trust to friends and family as a place to receive care or treatment and 63% of staff would recommend it as a place to work.

Overall rating for this core service Outstanding

We rated community children and young people’s (CCYP) services outstanding because:

• Community children and young people’s safety performance was monitored and when something went wrong there was a process in place to review or investigate incidents involving all relevant staff, children and young people (CYP) and their families. Lessons were learned and communicated widely to support improvement in other areas as well as services that were directly affected.
• There were clearly defined and embedded systems and processes to keep children and young people safe and safeguarded from abuse. Staff received up-to-date training in safeguarding to an appropriate level. Staff took a proactive approach to safeguarding; and took steps to prevent abuse from occurring, and responded appropriately to any signs or allegations. There was active and appropriate engagement in local safeguarding procedures and effective working with other relevant organisations.
• Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
• Staffing levels and skill mix were planned, implemented and reviewed to keep children and young people safe at all times. Any staff shortages were responded to quickly to ensure staff could manage risks to CYP who used services. However, there was a freeze on the recruitment to the School Nursing Service (SNS) team due to tendering of the service.
• Risks to CYP were assessed, monitored and managed on a day-to-day basis. Staff recognised and responded appropriately to changes in risks to CYP who use services. Risks to safety from service developments, anticipated changes in demand and disruption were assessed, planned for and managed effectively.
• Outcomes for CYP who used services were consistently better than expected when compared with other similar services. CYP care and treatment was planned and delivered in line with current evidence-based guidance, best practice and legislation, including the Healthy Child Programme (HCP). This was monitored to ensure consistency of practice.
• There was a truly holistic approach to assessing, planning and delivering care and treatment to CYP who used services. The safe use of innovative and pioneering approaches to care and how it was delivered were actively encouraged. CYP had comprehensive assessments of their needs, including consideration of their mental health, physical health and wellbeing, and nutrition and hydration needs.
• All staff were actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking, peer review, and research were proactively pursued. Including health visitors achieving level 3 United Nations Children’s Fund (UNICEF) baby friendly accreditation for breastfeeding. Accurate and up-to-date information about effectiveness was shared internally and externally and was understood by staff, and used to improve care and treatment and CYP outcomes.
• The continuing development of staff skills, competence and knowledge was recognised as being integral to ensuring high quality care. Staff were proactively supported to acquire new skills and share best practice.
• Staff, teams and services were committed to working collaboratively and had found innovative and efficient ways to deliver more joined-up care to CYP. For example, at Kaleidoscope children were cared for by a multidisciplinary team (MDT) of dedicated and skilled staff.
• There was a holistic approach to planning people’s discharge, transfer or transition to other services, which was done at the earliest possible stage. Arrangements fully reflected individual circumstances and preferences.
• The systems to manage and share the information that was needed to deliver effective care were fully integrated and provided real-time information across teams and services.
• Consent practices and records were actively monitored and reviewed to improve how CYP and families were involved in making decisions about their care and treatment.
• Parents spoke highly of the care CYP received and told us they felt involved in their children’s care. We observed a number of examples of compassion and kindness by staff.
• The trust received confirmation on the 17 March 2017 that they had been successful in their tender to continue to provide HVS and FNP services. However, a third sector provider had been commissioned to provide SNS services.
• CCYPS were planned and delivered in a way that met the needs of the local population. The CCYPS service planning emphasised delivering services in a range of settings to maximise reach into communities.
• The needs of CYP were taken into account when planning and delivering services. The CCYPS model bridged health and social care. The aim of the service model was to improve CYPs outcomes and experience through bringing existing community services from health and social care into a more combined way of working. CYP care and treatment was co-ordinated with other services and other providers.
• Complaints handling policies and procedures were in place. All complaints to the service were recorded. Information on the trust’s complaints policy and procedures was available on the trust’s internet website.
• CCYPS local leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care. The CCYPS was undergoing a significant reorganisation of services. Managers and team leaders demonstrated a clear understanding of their role and position in the trust. However, we found that some staff were unclear about the long term strategy for SNS and community nursing services.
• Governance and performance management arrangements were proactively reviewed at a local level and reflected best practice.
• Local leaders had an inspiring shared purpose, strove to deliver and motivate staff to succeed. Comprehensive and successful leadership strategies were in place to ensure delivery and to develop the desired culture.
• There were high levels of staff satisfaction across all equality groups in CCYPS. Staff were proud of CCYPS as a place to work and spoke highly of the culture. There were consistently high levels of constructive engagement with staff, including all equality groups. Staff at all levels were actively encouraged to raise concerns.
• There was strong collaboration and support across CCYPS and a common focus on improving quality of care and people’s experiences.
• The leadership drove continuous improvement and staff were accountable for delivering change. Safe innovation was celebrated. There was a clear proactive approach to seeking out and embedding new and more sustainable models of care. For example, Kaleidoscope in Lewisham provided a “one stop shop” for children with complex needs. CCYPS were also involved in a number of research projects with both London based and National research units.

However, we also found:

• There was a lack of security on the main entrance at Kaleidoscope.
• CCYPS there were 66.61 (81%) whole time equivalent (WTE) nursing staff in place which was less than what was determined by the trust to provide effective and safe care. There was also a freeze on recruitment to the community nursing team and school nursing service (SNS) due to tendering. However, this was mitigated by the use of bank staff.
• The tendering process had an impact on staff morale, especially in regards to SNS.