Chelsea and Westminster Hospital NHS Foundation Trust

The Chelsea and Westminster Hospital is part of Chelsea and Westminster Hospital NHS Foundation Trust. It is an acute hospital and provides accident and emergency (A&E), medical care, surgery, critical care, maternity, children and young people’s services, end of life care and outpatient services, which are the eight core services always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection.

The Chelsea and Westminster Hospital is a 430-bed general hospital, based in Kensington, North West London. The hospital employs over 3,000 staff. It provides a range of elective and non-elective inpatient surgical and medical services as well as a 24-hour adult and paediatric A&E departments and an Urgent Care Centre and outpatient services. It also provides specialist services including burns, high-risk obstetrics and neonatal care for patients from London, the South East and further afield.

As well as inspecting the eight core services at Chelsea and Westminster Hospital, we also inspected: the HIV and sexual health services at the Kobler Clinic and John Hunter Clinic for Sexual Health, located in the St Stephen’s Centre next to Chelsea and Westminster Hospital; the West London Centre for Sexual Health (WLCSH), which is located at Charing Cross Hospital in Hammersmith; 56 Dean Street and Dean Street Express (at 34 Dean Street), which are both sexual health clinics located in Soho, central London.

The team included CQC inspectors and analysts, doctors, nurses, Experts by Experience and senior NHS managers. The inspection took place on 9 and 10 July 2014 with unannounced visits on 21 and 25 July 2014.

Overall, we rated this hospital as requires improvement. We rated it good for providing caring services, but it required improvement for providing safe, effective and responsive care and for providing services that are well-led.

We rated HIV and sexual health as outstanding; critical care and maternity as good, and A&E, medical care, surgery, children and young people’s services, end of life care and outpatient services, as requiring improvement.

Our key findings were as follows:

• We found that staff were caring and compassionate and treated patients with dignity and respect.
• Patients told us their experiences of care were good. The NHS Friends and Family Test results, however, were below (worse than) the national average for inpatient wards and above the national average for A&E.
• National data indicated that the trust was similar to other trusts for reporting incidents but was potentially an under-reporter of patient safety incidents resulting in death or severe harm. We found that incidents were reported, investigated and appropriate action taken in most cases. But learning was not always shared across the trust. Incidents were under-reported in outpatient areas and some areas had not undertaken appropriate investigations. Serious untoward incidents took a long time to investigate with only 36% being reported within the 45 day standard. Staff in a few areas identified that there could be a blame culture when reporting serious untoward incidents.
• The trust was clean and infection control practice was observed. Most staff followed the trust’s infection control policy, including being bare below the elbows, and observed hand hygiene. Infection control rates were within an acceptable range for Clostridium difficile (C. difficile) but were higher than the expected range when compared to other trusts for MRSA in 2013/14 – but there had been no cases reported from April 2014.
• The NHS Safety Thermometer, a monthly snapshot audit of the prevalence of avoidable harms, including new pressure ulcers, venous thromboembolism (VTE or blood clots), catheter urinary tract infections (UTIs) and falls. The hospital was lower than the national average in all areas except for the incidence of pressure ulcers in surgery, which was higher than average. The information was monitored throughout the hospital but the results were not displayed for the public in clinical areas.
• The National Early Warning Score (NEWS) was used effectively to identify deteriorating patients. Care pathways were being used to standardise care for patients who were acutely ill. Seven-day services had been developed in emergency care and mortality rates were lower (better) than the expected range.
• Not all staff had appropriate knowledge of the Mental Capacity Act 2005 and deprivation of liberty safeguards to ensure that patients’ best interests were protected. There was guidance for staff to follow on the action they should take if they considered that a person lacked mental capacity.
• Nursing staffing levels had been reviewed and assessed using the Safer Nursing Care Tool in some areas but had not been completed across the trust. Some staff involved in this work were not clear about what tool had been used and some staff indicated that that the trust had taken a ‘one size fits all approach’ and had not taken the complexity of patients into consideration. Some staff also reported that there could also be an unresponsive culture when they tried to report significant concerns. There had not been a board report to demonstrate appropriate application of the Safer Nursing Care Tool across the organisation. Nurse recruitment was a recognised as a priority for the trust, as some wards were below establishment. Around 85 nurses and midwives had been recruited and it was intended that they would be in post by the end of the year. Bank (overtime), agency and locum staff were used to fill vacancies where possible but some areas, including the acute assessment unit (AAU) and children’s services did not always have safe staffing levels.
• Medical staffing levels did not meet national recommended standards in A&E and palliative care medicine. However, there was a comparatively higher number of consultant staff in other specialities, which was improving access to specialist care.
• Agency nurses did not have access to the electronic patient records, including risk assessments, prescription and administration records. Therefore, the electronic system could only be updated by a permanent member of staff, which resulted in delays in the records being updated. The agency staff also had to rely on information provided at handover to identify the risks for the patients they were caring for. Care records were not adequately completed and were not always personalised.
• The trust had a major incident procedure, which most staff were aware of. Most staff had participated in training in how to respond to major incidents.
• Staff had access to a range of mandatory training and attendance was monitored electronically and by paper. However, completion of this training was below the trust’s targets. Staff were supported to access training, there was evidence of appraisal but the clinical supervision was not well embedded. The profile of nursing and midwifery needed to be raised, there were examples, where staff were qualified and experienced to delivery care, such as ordering tests and prescribing, but were restricted from doing so.
• The trust had a learning disability ‘passport’ in which key information about how the individual should be supported was documented. However, this document was not widely used in the trust and many staff were unaware of it.
• Most medicines were stored safely but some were not appropriately locked or stored at correct fridge temperatures. The trust used an electronic prescription and medication administration record (MAR) chart for all patients apart from those in the intensive care unit (ICU), neonatal intensive care unit (NICU) and A&E. Agency staff could not access this system. The trust had a system where a medicines chart was manually printed, which agency nurses signed when they gave out medicines; the electronic system was then updated by a permanent member of staff. We saw that this caused delays in updating electronic records and also saw a delay in medication being administered. On one ward the electronic prescription and administration record for patients being cared for by an agency nurse had not been updated to confirm that medicines had been given correctly two hours beforehand. An audit of missed medicine doses in October 2013 on the AAU found that 30% of doses recorded as being missed (not being given within two hours of due time) were due to bank/agency staff being unable to sign into the IT system. It was also reported that, due to their high workload, nurses had not signed for the administration until later in the shift which extended beyond the two-hour critical window and therefore, again, counted as a missed dose. The audit report recommended that all agency staff should be given a log-in by 31 May 2014 but, when we inspected, we found this had not happened.
• There had been an increase in demand for services, and the capacity in some areas of the trust, such as A&E, experienced difficulties in meeting this additional demand. Staff reported that a contributing factor to this increase was due to the local reconfiguration of services across London. However, as many of these changes had been recently introduced there was no evidence to support this view.
• Patient care in A&E was good but the service was under increasing pressure and attendances were increasing, which was causing delays in assessment and treatment.
• Emergency medical care was well supported by consultant staff. There were good outcomes for medical patients, for example, in stroke care and for heart attacks, but diabetes care needed better coordination.
• Overall, the trust was not meeting the national target of 18 weeks for surgery and patients had longer waiting times for general surgery, trauma and orthopaedics, urology and plastic surgery. Patient outcomes varied and compliance with the Five Steps to Safer Surgery checklist needed to improve.
• Critical care services were good and the outreach team was responsive and supportive of patients in the hospital who required access to specialist critical care.
• The maternity department’s leadership and culture needed to improve to support staff and ensure women did not have interventions that might not be needed.
• The Chelsea Children’s Hospital officially opened in March 2014 and provided bright, modern and child-friendly facilities. The leadership of the service needed to improve its governance arrangements for safety and compliance with national standards of care. The culture in the neonatal unit also needed to improve.
• End of life care standards were being rolled out across the hospital but these needed to be monitored. Overall, the hospital performed well in the National Care of the Dying Audit.
• Waiting times for outpatient appointments were within national waiting times. At times, appointments could be cancelled at short notice and it was difficult for patients to contact the service by telephone.
• We rated the HIV and sexual health services as outstanding.
• Patient discharge was supported by the rapid response teams in A&E and coordinators in other services. However, some patients did report that their discharge from the wards felt “rushed” and there could be long waits, particularly, in the discharge lounge for transport or medication. Providing discharge summaries to GPs was taking longer than 48 hours.
• The hospital at night team was good. Patients were triaged and escalated safely. Junior doctors appreciated that they were only contacted when there was a concern, making their workload manageable.
• The trust had introduced Schwartz rounds (monthly one-hour sessions) for all staff to discuss aspects of the emotional and social dilemmas that arise from caring for patients. Staff who had attended were positive about the learning and emotional support and the focus on improving outcomes for patients.
• The trust was supportive of art and music therapy and there were excellent examples of uplifting art on display, and music was played on Thursday lunchtime in the main corridor of the trust.
• Staff were positive about working for the trust and said it was a friendly and positive place to work, but it was not without its challenges, which were described as concerning IT, human resources, staffing levels and support from leadership.
• The leadership team had created an environment where all members of staff were part of quality project teams. These teams were then given time to undertake innovate projects and research to improve the quality of the service. As a result, a number of staff throughout the hospital had been nominated for the trust’s award for clinical excellence. Staff told us how these projects had led to improvement to services.
• There were examples of the trust’s research that were nationally and internationally recognised.
• Between April and June 2014, 80% of complaints were responded to within 25 days. The main themes of complaints were clinical care, attitude of staff and communication. The main areas were surgery, medicine, maternity and end of life care. The Patient Advice and Liaison Service (PALS) had a target to respond to complaints within 10 days, and patients through local Healthwatch had identified that poor response times, for what were informal concerns, was an issue. Most PALs concerns were about outpatient clinic appointment waits, lack of communication from reception staff, having to arrive for surgery before 7am and the attitude of clinical staff when making a complaint. Staff provided positive feedback about the PALS team in terms of their support.
• Services across London were changing under the ‘Shaping a healthier future’ agenda and the trust was preparing for the increasing demand on its services. The trust had a vision and clinical strategy to provide excellent services that could be sustained, to improve health and to support innovation in healthcare. There were new services for children and a new A&E was planned. The trust had published quality improvement objectives in its quality account. Governance arrangements were complex and it was difficult to identify priorities for action. Information on quality and performance was monitored, but staff did not always own this information and many actions and updates were not available or timely. Safety information was not displayed in ward and clinic areas for patients and the public to see. The trust’s engagement with the public and some specific staff groups needed to improve. Staff felt the chief executive was visible but this was not the same for other members of the board.
• Staff were aware of the trust’s vision. Most service areas had a strategy or transformation plans that identified how the service would develop and build capacity to respond to the predicted increase in attendances and admissions under ‘Shaping a healthier future’.

Caring for people with a learning disability

• We looked specifically at the care of people with a learning disability. Monitor, the health regulator for foundation trusts, has a Risk Assessment Framework that has six standards for learning disability care and there should be quarterly reporting against these. The standards include having: a flagging system to identify patients; readily available information agreed with people with a learning disability; protocols to provide suitable support to families or carers; training on learning disability; protocols to encourage representation with trust boards; local groups and relevant forums; and protocols to regularly audit practice. The trust had declared no breaches in the last financial year and full compliance in March 2014.
• We found that there was a lead nurse for learning disability but she was not a specialist and was the lead nurse for women’s services. She had not been given any extra time to do the role and was fitting the work in with her existing job. There was no non-executive director, board lead or governor lead for learning disability. Staff were not aware that the trust had a lead nurse. There was no system to flag patients. There were good resources available, such as the hospital passport and resources on the intranet, but these were not widely used by staff. Easy-to-read information leaflets were not available and there was not a leaflet for consent to treatment. Learning disability training was available and the course was run every two months but this was not well attended by staff. There was a learning disability steering group and carers forum group with learning disability representation. The care of people with a learning disability had not been audited.

We saw several areas of outstanding practice, including:

• The A&E department staff had taken part in a research project to routinely test patients for HIV (with their consent). This had now been embedded practice for over a year and testing had resulted in a higher-than-normal proportion of patients being identified as HIV positive.
• The clinical sterile services department (CSSD) had introduced a metal detector that was used to identify surgical equipment that had been incorrectly discarded into rubbish bags. The aim of this initiative was to promote staff safety and reduce the cost of lost equipment.
• The burns unit had international recognition and published numerous research papers annually that identified best practice.
• The physiotherapy team in intensive care had an impressive research portfolio. For example, they had developed an innovative simulation-based physiotherapy course to improve quality and safety, and a standardised functional score assessment tool to improve compliance with National Institute for Health and Care Excellence (NICE) guidance. The tool is now used in more than 50% of ICUs nationally.
• The female genital mutilation (FGM) service in maternity had achieved a national award for innovation and care.
• The neonatal palliative care nurse had developed national standards on caring for very young babies with life-limiting conditions who need palliative or end of life care on neonatal units. These standards had recently been shared with medical royal colleges and other hospitals for national use.
• The HIV and sexual health services provided outreach clinics at London’s G-A-Y Bar, Manbar and Sweatbox Gay Sauna, and in hostels and community venues to engage with hard-to-reach groups such as the Chinese and Muslim communities, young people and people socially excluded or those who use Supporting People programme services, such as the homeless.
• The HIV and sexual health services gained community engagement through outreach work, taking part in London Pride, publicity stunts such as the Guinness World Record attempt for taking the most HIV tests at G-A-Y Bar on World Aids Day in 2011 and the House of Lords campaign to provide HIV tests for legislators.
• 56 Dean Street and Dean Street Express brought sexual health services to a high street location. Dean Street Express provided fast, self-testing modern facilities for asymptomatic patients.
• Public engagement in the HIV and sexual health services was an integral part of the service and had led to innovation and excellence across London. The service had two patient representatives on a part-time basis, funded by the trust to obtain the views of people using the service to help make positive changes.
• The HIV and sexual health services provided speciality clinics such as: SWISH for people employed in the sex industry; CODE clinic for men who were into harder sex or using drugs during sex; Pearl clinic for people with a learning or physical disability; and cliniQ and the Gold Service for the transsexual community. CliniQ and the Gold Service are the only specialist sexual health clinics in the country for the transsexual community. The model for this service was led by the transsexual community through public engagement.
• The HIV and sexual health services have consistently been shortlisted and won awards for a variety of projects every year since 2007. One of their most recent awards was for the work with the West London African Women’s Service for dedication to improving the care of women living with FGM. The trust had won the BMJ Group Award 2013 for transforming patient care using technology, and the adult sex project of the year at the Brook Sexual Health Awards 2013 for Dean Street at Home and cliniQ.
• The leadership team had created an environment where all members of staff were part of quality project teams. These teams were then given time to undertake innovate projects and research to improve the quality of the service. As a result, a number of staff throughout the trust had been nominated for the trust’s award for clinical excellence. Staff told us how these projects had led to improvement to services.

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

Importantly, the trust must ensure that:

• Patients are cared for in appropriate areas in the accident & emergency (A&E) department so that there is safe monitoring of their condition.
• All staff in A&E receive training in mental health awareness, and when and how to safely restrain patients.
• All staff receive training in the Mental Capacity Act 2005 and its associated deprivation of liberty safeguards.
• Pain scores are recorded and reassessed for all patients in A&E.
• In line with national guidance, consultants in A&E should sign off and agree to the discharge of patients with complex needs.
• There are suitable environments in outpatients areas to ensure accessibility for patients with a physical disability or poor mobility, to promote the privacy and dignity of patients, and protect patient confidentiality.
• Patient records and care plans are accessible by all staff, including agency staff.
• Regular checks of medicines are undertaken, that all medicines are stored safely, and are in date and fit for use.
• Nurse staffing levels are compliant with safer staffing levels guidance.
• A recognised acuity tool is used in all areas and staffing levels and skills mix reflects the findings of these as well as national guidance.
• Appropriate equipment is available and regularly checked and records maintained.
• Compliance with the ‘five steps to safer surgery’ checklist is improved and is embedded in surgical practice.
• The incidences of pressure ulcers in surgery and critical care are reduced.
• A record of the termination of pregnancy (TOP) forms (HSA4) sent to the Department of Health is kept by the trust.
• Compliance with statutory and mandatory training is improved.
• All staff use the incident reporting system, and that feedback is provided and learning from incidents is cascaded and shared. There should be evidence of appropriate action in response to any never event (serious harm that is largely preventable).
• Risks identified on the risk register have appropriate actions to mitigate them, with timely reviews and updates. Information on risks should be owned by the divisions.
• The safety thermometer is embedded across the trust and information on avoidable harms is available and displayed for the public to access.
• The time taken for the root cause analysis investigation of serious incidents improves so that issues are identified quickly to prevent recurrence.
• Clinical guidelines are up to date, in line with national guidance and action is taken as a result of audits.
• Governance and risk management procedures in children and young people’s services improve.
• The trust continues to support staff and investigates and resolves the culture of intimidation and bullying identified in the neonatal unit.
• Staff are aware of and use the trust’s learning disability passport and operational standards for people with a learning disability are appropriately assessed and implemented.
• Do not attempt cardio-pulmonary resuscitation (DNACPR) forms are appropriately completed so that the decision and sign-off is clear and there is appropriate communication with patients, their relatives or carers.
• End of life care standards are appropriately monitored against national standards.
• Patients receiving end of life care are appropriately identified and referred to the specialist palliative care to receive timely support and treatment advice.
• There is an operational policy or guidance for the management of a deceased patient’s belongings.
• Clinical governance arrangements are simplified so that there are effective processes to prioritise and escalate concerns.
• Discharge summaries are sent to GPs in a timely manner and include all relevant information in line with Department of Health guidelines
• Support is given to frontline nursing staff to be involved in change and to ensure there is a just culture.
• Staff in lower pay bands feel they are treated similarly to all staff in the trust.
• Cost improvement programmes are developed and are also reviewed by the board.

In addition, the trust should ensure that:

• Medical staffing levels meet national recommendations in A&E and palliative care medicine.
• Develop the nursing and midwifery profile so that their advanced skills can be used appropriately, this is particularly the case in A&E, maternity and for end of life care.
• Agency staff get appropriate induction when working in the hospital.
• Patients living with dementia are appropriately screened and identified and that staff access the tools and advice available to ensure there is consistent care and support in all areas of the hospital.
• Information on staffing levels, safety and performance activity is displayed and accessible to patients and the public in ward and outpatient areas.
• Discharge is effectively planned and organised and patients are not waiting for long periods of time in the discharge lounge, or waiting after their outpatient appointment.
• Clinical supervision is developed for all staff.
• There is a just culture for all staff when dealing with serious incidents.
• The critical care unit participates in the Intensive Care National Audit & Research Centre (ICNARC).
• There is better multidisciplinary working in maternity and children and young people’s services.
• Governance arrangements in maternity continue to improve.
• All staff follow infection control practices, particularly the bare below elbow guidance in ward and outpatient areas.
• Waiting times meet the national referral time target of 18 weeks.
• Information leaflets and signs are available in other languages where relevant.
• Bereavement support should be appropriately maintained when the officer is on leave.
• Outpatients clinics are not cancelled at short notice and patient waiting times are improved to within 15 minutes of clinic appointments.
• Staff engagement improves so that staff feel listened to and consulted about specific issues that affect service development, particularly in A&E and outpatients; and where job roles are affected for administrative, clerical and support staff.
• Patient and public engagement continues to develop to improve services, including formal approaches for patient feedback across all services.
• Human resources, IT and finance support improve for staff, in terms of payroll and consultation on job roles.

Professor Sir Mike Richards

Chief Inspector of Hospitals