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Provider: University College London Hospitals NHS Foundation Trust Good

Reports


Inspection carried out on 8 - 11 March 2016 plus unnanounced visits between 18 - 25 March 2016

During a routine inspection

University College London Hospitals NHS Foundation Trust (UCLH) is an NHS foundation trust based in London. It is made up of University College Hospital (UCH) and Elizabeth Garrett Anderson Wing, UCH at Westmoreland Street, UCH Macmillan Cancer Centre, the National Hospital for Neurology and Neurosurgery, the Hospital for Tropical Diseases, the Royal London Hospital for Integrated Medicine, the Royal National Throat, Nose and Ear Hospital and the Eastman Dental Hospital.

The trust has an annual turnover of approximately £930 million and employs around 7600 staff.

In partnership with University College London, UCLH has major research activities and is part of the UCLH/UCL Comprehensive Biomedical Research Centre and the UCL Partners academic health science centre.

The trust is also a major teaching trust offering training for nurses, doctors and other health professionals in partnership with various universities and UCL Medical School.

Our key findings were as follows:

  • Overall we rated University College Hospitals NHS FoundationTrustas good.
  • We rated surgery, critical care, maternity and gynaecology, services for children, and outpatients anddiagnostic imagingas good. We rated urgent and emergency care and medical care as requires improvement.
  • 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.
  • Inmaternity and gynaecology we saw examples of outstanding practice including the integrated “ one stop” service providing an efficient diagnosis and treatment facility.
  • 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 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.
  • 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 should:

  • 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 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.
  • 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


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