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Provider: Imperial College Healthcare NHS Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 December 2014

Imperial College Healthcare NHS Trust provides acute healthcare services to a population of around two million people across North West London and provides specialist services to patients nationally and internationally. It provides acute services from five locations including St. Mary’s Hospital, Charing Cross Hospital, Hammersmith Hospital, Queen Charlotte and Chelsea Hospital and Western Eye Hospital. The trust employs around 10,000 staff.

Imperial College Healthcare NHS Trust is one of the largest NHS trusts in England and together with Imperial College London forms an academic health science centre. It hosts NIHRBiomedical Research Centre and is part of the network of twenty Experimental Cancer Medicines Centres (ECMC) across the UK.

We carried out this inspection as part of our comprehensive inspection programme of all NHS acute providers and we inspected four of the five locations including St. Mary’s Hospital, Charing Cross Hospital, Hammersmith Hospital and Queen Charlotte and Chelsea Hospital. We did not inspect Western Eye Hospital.

Overall, this trust was rated as requires improvement. We rated it good for providing effective care and for being caring. We rated it requires improvement for providing safe care, being responsive to patients’ needs and being well-led.

Our key findings were as follows:

Safe:

  • The standard of cleanliness, infection control and hygiene was inconsistent across the organisation; with some areas demonstrating robust processes for ensuring cleanliness was maintained but one particular area demonstrating very poor standards of cleanliness and hygiene.
  • The trust had a system in place for receiving and confirming compliance with patient safety alerts sent by the central alerting system (CAS). There was a nominated CAS liaison officer who acknowledged and updated the statuses of alerts, however, the arrangements for monitoring the management of safety alerts was not adequate; for example, local policies were not always updated following the receipt of patient safety alerts.
  • The safety culture was seen to be embraced by the majority of staff; however there had been history of some ‘silo’ working. The divisional structure was reported to be reducing the silo working and encouraged cross-divisional learning, although these changes were in the early stages.
  • Nurse staffing levels were not sufficient with a significant reliance on bank and agency staff, with some shifts remaining unfilled. This was especially applicable to the adult medicine wards.

Effective:

  • Clinical outcomes were either better than expected or in line with the national average. The HSMR and SHMI were better than the national average.
  • The trust took part in local and national audits and clinical audits demonstrated that outcomes for patients after heart attack and stroke were better than the national average.
  • Patients were given information about pain and pain relief was effectively managed and patients’ nutritional and hydration needs were assessed and monitored appropriately.
  • There was a clear commitment to multidisciplinary team working between all staff involved in patients’ care and the divisional directors leading the four clinical divisions were committed to improving cross-divisional and cross-site multidisciplinary team working to improve care through improvements in pathways across the trust.

Caring:

  • Patient’s feedback and observations during the inspection demonstrated that patients were treated with dignity and respect. Patients and relatives told us that they were treated with compassion and considered their individual care needs.
  • Patients felt involved in their care and informed to ensure they had a key role in their care and treatment.
  • The Friends and Family Test results showed the average scores for both inpatients and A and E were better than the national figure for 2012/13, however for maternity the average score was marginally below the national average.

Responsive:

  • The surgical department had a significant backlog of patients who were awaiting elective surgery; however, the trust did provide trust-wide plans to reduce the backlog. Referral to treatment times in some specialties had breached national targets on an on-going basis.
  • The clinical impact of cancellations and delays in surgery and theatre use and productivity were not consistently monitored by the surgical teams
  • The trust was not meeting its target for sending out appointment letters to patients within 10 working days of receiving the GPs referral letter consistently. Some patients were not receiving their appointment letters nor did so after the date of their appointment.
  • When considering peoples individual needs such as learning disability support, translation services or care for patients living with dementia, there were shortfalls in how the needs of different people are taken into account.
  • Complaints management wasn’t meeting the trusts internal completion target of 85% within 25 working days. Complaints were not consistently seen as an opportunity to learn; for example there was no process for recording informal complaints received by staff on wards which would assist in identifying trends and inform learning.

Well-led:

  • There had been some instability at executive leadership level over recent years, which had resulted in a number of changes being made; the current CEO had been in post since April 2014. Since being appointed the CEO had made changes to the executive team and portfolios had been clarified to ensure there were clear lines of accountability and a robust clinical governance structure.
  • Since appointment the CEO had spent a significant amount of time working on the wider strategic vision for North West London in conjunction with developing the clinical strategy with staff, in particular the divisional directors.
  • Whilst board level and divisional clinical leadership demonstrated collaboration and alignment to effectively lead the trust and make necessary improvements, the leadership at a more local level at each hospital was markedly varied; with some areas demonstrating good leadership but other areas requiring significant improvement.
  • There was a clear drive to empower and develop leaders through five leadership programmes.
  • The trust had clear values that had been developed in conjunction with staff, however despite some improvements in staff engagement, there was recognition that engaging with staff was an area for improvement and there were clear plans in place to address this amongst all staff groups.
  • Communication generally was recognised to have significantly improved since the appointment of the CEO through staff forums, regular visibility and personal feedback. In addition, the substantive appointment of the whole executive board resulted in a sense of ‘optimism’ about the future stability of the trust.
  • The executive team, the non-executive directors and the divisional directors all recognised the trust was relatively early in the start of a journey to improve standards, standardise processes and improve engagement across all locations.
  • Whilst there was a clear governance reporting structure in place there were inconsistencies in its application across divisions and records held at a trust level were not always consistent with those being held at a local level; such as statutory and mandatory training and appraisal rates.
  • The staff had a clear sense of pride in their work and a commitment to support the clinical strategy for the trust
  • The sustainability of trust services and pathways of care were considered as part of the wider strategy for the trust and “Shaping a Healthier Future ” programme for the whole of North West London. These proposed reconfigurations were not reviewed as part of the inspection as they were not in place and remained under consultation.

In addition to the above, we saw specific areas of outstanding practice:

  • The trust hosts a NIHR Biomedical Research Centre and has a strong focus on translational research participating in and leading national research projects. An example of this is the evaluation of magnetic resonance imaging to predict neurodevelopmental impairment in preterm infants..
  • The impact of the new CEO on all staff groups through staff forums and regular visibility and the evident optimism among staff for the future with a permanent executive team in place.
  • The leadership programmes available to staff, which aimed to ‘drive exceptional performance through engaged people, create inspirational leaders and effective managers whilst ultimately improving patient experience’. These programmes were clearly set out in five separate courses from ‘Foundations’ to ‘Certificate in Medical Leadership’
  • Some of the clinical services we inspected achieve nationally leading outcomes for patients. Examples include the Trauma Centre at St Mary’s Hospital and the stroke service at Charing Cross Hospital.

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

Importantly, the trust must:

St Mary’s Hospital

  • Improve the standards of cleanliness of premises and equipment.
  • Increase the number of cases submitted to the audit programme for the World Health Organization (WHO) surgical safety checklist to increase compliance with the ‘Five steps to safer surgery’.
  • Develop and implement systems and processes to reduce the rate of patients who do not attend their outpatient appointment or surgical procedure.
  • Review the level of anaesthetic consultant support and/or on-call availability to ensure it is in line with national recommended practice.
  • Review the arrangement for medicines storage and ensure medicine management protocols are adhered to.
  • Ensure all staff are up to date with their mandatory training.
  • Ensure all equipment is suitably maintained and checked by an appropriate person.
  • Ensure adequate isolation facilities are provided to minimise risk of cross-contamination.
  • Ensure consultant cover in critical care is sufficient and that existing consultant staff are supported while there are vacancies in the department.
  • Review the divisional risk register to ensure that historical risks are addressed and resolved in a timely manner.
  • Review the provision of the paediatric intensive care environment to ensure it meets national standards.
  • Review the provision of services on Grand Union Ward to ensure the environment is fit for purpose.

Charing Cross Hospital

  • Correct the problems associated with the administration of appointments which was leading to unnecessary delays and inconvenience to patients.
  • Address the high vacancy rates for nursing staff and healthcare assistants in some medical wards, and the level of medical staffing out of hours for the intensive care unit (ICU) and level 2 beds.

Hammersmith Hospital

  • 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.
  • Reduce the significant backlog of patients who are awaiting elective surgery in the surgical department.

Queen Charlotte and Chelsea Hospital

  • Review the staffing levels and take action to ensure they are in line with national guidance.
  • Review the capacity of the maternity and neonatal units to ensure the services meet demands.
  • Review the divisional risk register to ensure that historical risks are addressed and resolved in a timely manner.

In addition, the trust should:

St Mary’s Hospital

  • Improve the handover area for ambulances to preserve patient dignity and confidentiality.
  • Ensure that there is a single source of up-to-date guidelines for A and E staff.
  • Seek ways of improving patient flow, including analysing the rate of re-attendances within seven days.
  • Improve links with primary care services to help keep people out of A and E.
  • Ensure that all patients who undergo non-urgent emergency surgery are not left without food and fluids for excessively long periods.
  • Review the literature available to patients to ensure it is available in languages other than English in order to reflect diversity of the local community.
  • Ensure same-sex accommodation on Witherow Ward to ensure patients’ privacy and dignity are maintained.
  • Ensure learning from investigations of patient falls and pressure ulcers is proactively shared trust-wide.
  • Develop a standardised approach to mortality review which includes reporting to the divisional boards and to the executive committee.
  • Review patients’ readmission and length of stay rates to identify issues which might lead to worse-than-average results.
  • Review the processes for ensuring compliance with statutory and mandatory training and improve the recording system so that there is a comprehensive record of compliance which is consistent with local and trust-wide records.
  • Review the double-checking process for medication to ensure that staff are compliant with trust policies and procedures.
  • Monitor the availability of case notes/medical records for outpatients and act to resolve issues in a timely fashion.
  • Review the provision of adolescent services and facilities to ensure the current provision is able to meet the needs of patients.
  • Ensure that there is sufficient capacity to accommodate parents/carers while their child receives intensive care support.Ensure that the children and young people’s service has representation at board level.

Charing Cross Hospital

  • Take sufficient steps to ensure the ‘Five steps to safer surgery’ checklist was embedded in practice at Charing Cross Hospital.
  • Implement the trust-wide plans to reduce the backlog of more than 3,500 patients awaiting surgical intervention would be tackled.
  • Ensure that all patients who undergo non-urgent emergency surgery are not without food and fluids for excessively long periods.
  • Increase the capacity in the outpatients department to address the increased demand and adequately respond to people’s needs.
  • Assign sole responsibility for the outpatients department to one division so that quality and risk issues could be managed more effectively.
  • Meet its target of sending out appointment letters to patients within 10 working days of receiving the GPs referral letter.
  • Ensure outpatient letters to GPs occur within its target time of 10 days following clinics.
  • Ensure learning from investigations of patient falls and pressure ulcers is proactively shared trust-wide.
  • Reduce the backlog of patients who are awaiting elective surgery.
  • Increase capacity to ensure patients admitted to the surgical services can be seen promptly and receive the right level of care.
  • Avoid cancelling outpatient clinics at short notice.
  • Minimise number of out-of-hours transfers and discharges from the medical wards.

Hammersmith Hospital

  • 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 high 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.

Queen Charlotte and Chelsea Hospital

  • Review the current training matrix for statutory and mandatory training and improve the recording system so that there is a comprehensive record of compliance which is consistent with local and trust-wide records.
  • Ensure that the risk management process within the neonatal division is suitably robust and fit for purpose to ensure risks are assessed, investigated and resolved in a timely manner.
  • Explore how staff can learn from minor incidents and near misses to avoid similar incidents occurring.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 16 December 2014

Overall we rated the safety of services in the trust as requires improvement. For specific information relating to each hospital location, please refer to the reports for St. Mary’s Hospital, Charing Cross Hospital, Hammersmith Hospital and Queen Charlotte & Chelsea Hospital.

Whilst the majority of staff demonstrated a positive incident reporting culture, there were some staff that were not always encouraged to proactively report incidents. In addition, there was a variation in reporting by staff group; with doctors proportionately under reporting. Learning and improvements from incidents was seen in many areas of the trust, however there was a tendency to share learning locally rather than proactively sharing learning trust wide. The safety culture was seen to be embraced by the majority of staff; however there had been history of some ‘silo’ working. The divisional structure was reported to be reducing the silo working and encouraged cross-divisional learning, although these changes were in the early stages.

The standard of cleanliness, infection control and hygiene was inconsistent across the organisation; with some areas demonstrating robust processes for ensuring cleanliness was maintained but other areas demonstrating poor standards of cleanliness and hygiene. Processes for ensuring cleanliness and infection control practices were maintained to a high standard were not consistently followed by all areas, and this was especially noted within the ED at St Mary’s Hospital. Medicines management was good in the majority of areas; however there were areas which demonstrated standards of medicines management and storage fell below the acceptable levels. The trust infection rates for Clostridium difficile and MRSA were slightly worse than the average range for England, even taking into account the trust size and the national level of infection. All cases were investigated and senior managers described that most actions to address root causes of each case had been implemented. Equipment was not consistently checked and maintained throughout the trust.

Records were well maintained in many clinical areas; however there were examples of record keeping that fell below the required standard. The WHO checklist was not consistently completed in accordance with national standards and there had been two never events that had involved the WHO checklist not being comprehensively completed. There had been four never events in the organisation in the previous 12 months, with one being immediately prior to the inspection.

Statutory and mandatory training levels were inconsistent and there were discrepancies between records and compliance rates locally and those held at trust level. The trust were taking steps to improve the recording of statutory and mandatory training.

The trust had a system in place for receiving and confirming compliance with patient safety alerts sent by the central alerting system (CAS). There was a nominated CAS liaison officer who acknowledged and updated the statuses of alerts; however, the arrangements for monitoring the management of safety alerts were not adequate. Staff told us the medical devices management group had not taken place since February 2014 and the next one was due in November 2014. We were told during the inspection that there was not an identified board member who had personal oversight of all alert compliance, implementation and sign-off or a named individual to lead on the practical implementation of each alert in accordance with national guidance. However, the trust later told us that the medical director was the board level patient safety alert compliance person.

Nurse staffing levels were not sufficient in all areas and there were some instances of shifts remaining unfilled with a significant use of agency staff. Medical staffing was in the majority of areas good. Around 50% of the doctors employed by the trust were specialist registrar doctors who were supported by consultants (30% of all doctors). The number of middle grade doctors was higher than the England average of 39%. The number of junior doctors employed by the trust was lower than the national average. Only 18% of all doctors were junior grades compared to the England average of 22%. The trust advised this was due to the high degree of specialist care provided by the trust.

Effective

Good

Updated 16 December 2014

Overall, we rated the effectiveness of the services in the trust as good. For specific information relating to each hospital location, please refer to the reports for St. Mary’s Hospital, Charing Cross Hospital, Hammersmith Hospital and Queen Charlotte & Chelsea Hospital.

Care pathways, policies and procedures were based on evidence-based guidance and national recommendations. Clinical outcomes were either better than expected or in line with the national average such as outcomes for patients who had undergone major, orthopaedic and vascular surgery were better than the England average. The HSMR and SHMI were better than the national average. Staff were seen to use care pathways for the assessment and management of patients’ effectively.

The trust took part in local and national audits and clinical audits demonstrated that outcomes for patients after heart attack and stroke were better than the England average.

Patients were given information about pain and pain relief was effectively managed in the majority of cases. Patients’ nutritional and hydration needs were assessed and monitored appropriately.

Staff competence and knowledge was good where necessary staff training supported in many cases. There was a clear commitment to multidisciplinary team working between all staff involved in patients’ care and the divisional directors leading the four clinical divisions were committed to improving cross-divisional and cross-site multidisciplinary team working to improve care through improvements in pathways across the trust.

Caring

Good

Updated 16 December 2014

Overall, we rated the caring aspects of services in the trust as good. For specific information relating to each hospital location, please refer to the reports for St. Mary’s Hospital, Charing Cross Hospital, Hammersmith Hospital and Queen Charlotte & Chelsea Hospital.

Patient’s feedback and observations during the inspection demonstrated that patients were treated with dignity and respect. Patients and relatives told us that they were treated with compassion and considered their individual care needs. Patients felt involved in their care and informed to ensure they had a key role in their care and treatment.

The Friends and Family Test results showed the average scores for both inpatients and A&E were better than the national figure for 2012/13, however for maternity the average score was marginally below the national average. In addition, the response rate for inpatient was better than the national percentage, but for A&E and maternity the response rate was lower.

The National Cancer Patient Experience Survey , for which the trust received sufficient response to base measurements for 54 questions, resulted in the trust performing below average in 46 questions, and average in 6 questions. The trust had taken significant steps to make improvements and understand the concerns being raised.

Responsive

Requires improvement

Updated 16 December 2014

Overall we rated the responsiveness of services in the trust as requires improvement. For specific information relating to each hospital location, please refer to the reports for St. Mary’s Hospital, Charing Cross Hospital, Hammersmith Hospital and Queen Charlotte & Chelsea Hospital.

The surgical department had a significant backlog of patients who were awaiting elective surgery; however, the trust did provide trust-wide plans to reduce the backlog. Referral to treatment times in some specialties had breached national targets on an ongoing basis. The clinical impact of cancellations and delays in surgery were not monitored and there was a lack of robust and consistent formal data collection in relation to theatre use and productivity.

There was insufficient bed capacity to ensure patients admitted to the surgical services could be seen promptly. Consequently, staff told us that patients were frequently cared for in inappropriate areas, such as in theatre overnight. There was some effective cross-divisional working to manage bed capacity issues. Whilst there wasn’t a significant number of medical patients who were provided with treatment on non-medical wards due to lack of beds availability, they were often cared for on their speciality ward.

Bed occupancy was worse than the England national average and in line with the wider strategy to the North West London ‘Shaping a Healthier Future’ and the trust’s clinical strategy, bed numbers had reduced in some specialties

There had been significant improvements made in the cancer pathway performance over the previous 18 months where the trust had improved from meeting only two of the eight Cancer standards to meeting seven out of eight at the time of the inspection, with projections to meet all eight standards for the next quarter.

In the outpatients department, the trust had not responded consistently responded to the gradual increase in clinic attendances. The number of clinics had not increased in the last two years at St Mary’s despite an increase in patients. Patients were waiting longer for an initial appointment and also waiting longer in clinic. Doctors consistently arrived late for clinics without explanation. The trust was not meeting its target for sending out appointment letters to patients within 10 working days of receiving the GPs referral letter consistently. Some patients were not receiving their appointment letters nor did so after the date of their appointment.

When considering peoples individual needs such as learning disability support, translation services or care for patients living with dementia, there were shortfalls in how the needs of different people are taken into account, for example dementia care plans were not fully implemented at St. Mary’s hospital. Availability of written information available in languages other than English was either limited or non-existent across the trust.

Complaints management wasn’t meeting the trust’s internal completion target of 85% within 25 working days. Complaints were not consistently seen as an opportunity to learn; for example there was no process for recording informal complaints received by staff on wards which would assist in identifying trends and inform learning.

Well-led

Requires improvement

Updated 16 December 2014

The trust’s leadership was rated as requires improvement. For specific information relating to each hospital location, please refer to the reports for St. Mary’s Hospital, Charing Cross Hospital, Hammersmith Hospital and Queen Charlotte & Chelsea Hospital.

There had been some instability at executive leadership level over recent years, which had resulted in a number of changes being made and the current CEO had been in post since April 2014. Since being appointed, the CEO had made changes to the executive team and portfolios were clarified to ensure there were clear lines of accountability and a robust clinical governance structure. In addition, since appointment the CEO had spent a significant amount of time working on the wider strategic vision for North West London in conjunction with developing the clinical strategy with staff, in particular the divisional directors.

Whilst board level and divisional clinical leadership demonstrated collaboration and alignment to effectively lead the trust and make necessary improvements, the leadership at a more local level at each hospital was markedly varied; with some areas demonstrating good leadership but other areas requiring significant improvement.

There was a drive to empower and develop leaders through five leadership programmes, which aimed to ‘drive exceptional performance through engaged people, create inspirational leaders and effective managers whilst ultimately improving patient experience’. Staff described how leadership development and these specific programmes had improved their knowledge confidence as a leader.

The trust had clear values that had been developed in conjunction with staff, however despite some improvements in staff engagement, there was recognition that engaging with staff was an area for improvement and there were clear plans in place to address this amongst all staff groups. Communication generally was recognised to have significantly improved since the appointment of the CEO through staff forums, regular visibility and personal feedback. In addition, the substantive appointment of the whole executive board resulted in a sense of ”optimism” about the future stability of the trust.

The executive team, the non-executive directors and the divisional directors all recognised the trust was relatively early in the start of a journey to improve standards, standardise processes and improve engagement across all locations. This was fundamental to the overall strategy for Imperial Healthcare NHS Trust, which comprised of the trust vision, their strategic objectives, their clinical strategy and their supporting strategies (estates, people, patient transport, informatics, education and research, public and patient engagement). These were aligned with the wider plans for North West London “Shaping a Healthier Future”.

Whilst there was a clear governance reporting structure in place there were inconsistencies in its application across divisions and records held at a trust level were not always consistent with those being held at a local level; such as statutory and mandatory training and appraisal rates. There was an alignment between the executive team and non-executive director responsible for quality on key issues that needed to be addressed and the majority of the board were seen to be visible, especially the new CEO, however some staff expressed a desire to see more of the executive team on an informal walkabout basis.

The staff had a clear sense of pride in their work and a commitment to support the clinical strategy for the trust even where this had a direct impact on their future role, with a commitment from the trust to support staff in their development. Staff demonstrated a culture of multidisciplinary teamwork across locations, however there had been some ‘silo’ working in some areas which had improved since the divisional structure had been implemented.

Whilst being part of the first AHSC demonstrated some evidence of the positive impact on clinical care provided to patients through leading innovations, there was little evidence that being part of a AHSC had an impact on all staff groups and in the day to day running of the hospital or patient experience in an innovative manner. This was recognised by the executive team and there was a clear vision that being part of the AHSC would also have a key role in developing the day to day working practices and patient experience measures.

The sustainability of trust services and pathways of care were considered as part of the wider strategy for the trust and “Shaping a HealthierFuture” programme for the whole of North West London. These proposed reconfigurations were not reviewed as part of the inspection as they were not in place and under consultation.

Vision and strategy for this service

  • The trust vision was “being committed to being a world leader in transforming health through innovation in patient care, education and research”
  • The trust values were developed with staff as a set of five, which included, “respect, innovation, care, achievement and pride”. Most staff were able to describe the values and what they meant to them; however some staff were not clear in terms of how these values translated into their work.
  • The trust’s overall strategic vision was part of a wider clinical reconfiguration and estates programme to improve NHS services across North West London “Shaping a Healthier Future”, which was being led by eight clinical commissioning groups across North West London’s eight boroughs. This strategic vision across North West London was fundamental to the future of Imperial Healthcare NHS trust in terms of both clinical care and improvements to the estates across the trust. However, at the time of the inspection it was in the process of being agreed and significant improvements were dependant on this strategy going ahead over the next 3 to 5 years.
  • The strategic vision to address estates challenges in particular were less clear if the wider strategy involved in “Shaping a Healthier Future” did not progress or things that needed to be addressed earlier. However, the trust had spent a significant amount of time working on the strategic vision aligned with “Shaping a Healthier Future” and consequently they were working through the options and requirements to improve Imperial Healthcare NHS Trust specifically in conjunction with the wider vision.
  • The overall strategy for Imperial Healthcare NHS Trust in the longer term comprised of the trust vision, their strategic objectives, their clinical strategy and their supporting strategies (estates, people, patient transport, informatics, education and research, public and patient engagement). These aspects were aligned with the plans for “Shaping a Healthier Future”.
  • Since the new CEO commenced in post there had been a significant amount of work done to ensure staff at all levels were involved, understood and were aligned to the clinical strategy of the organisation.

Governance, risk management and quality measurement

  • There were standardised governance systems and processes in place to manage risk; however these were not always consistently followed across the all locations and divisions, with some areas maintaining local records that were not always feeding into the wider governance system.
  • In addition, the continuous improvement cycle was not being consistently followed due to feedback and learning not always being implemented into practice and actions being taken trust wide.
  • There was a committee structure that demonstrated evidence of escalation and progress of issues, although there were examples of actions not being progressed in a timely manner as per plans.
  • The structure and accountability of clinical governance had been disjointed; however the new CEO recognised this as a priority and realigned the accountability to the medical director in order to give more clarity and consistency to address clinical governance in a robust manner.
  • The Quality and Safety Committee was chaired by a non-executive director who demonstrated good evidence of how clinical governance had improved during the last year, with evidence of triangulation of managing risk through robust challenge and ‘probing’ at the committee combined with regular communication with divisional directors and walkabouts that fed back into aggregation of information with subsequent improvements being made.
  • There were examples of ‘board to ward’ and ‘ward to board’ communication, however this wasn’t consistent across all locations; although there had been a recognised improvement since there had been more stability in the executive team and the new CEO had commenced in post.
  • There had been a change in structure to four clinical divisions, which were clinically led by divisional directors with clear lines of accountability for all aspects of their division reporting into the chief operating officer (CoO).
  • The four divisional directors met with the medical director every week individually and as a group to discuss clinical issues and incidents from that week; which provided a forum for issues to be shared across divisions in a timely manner and actions to be taken at a senior level where necessary. Although there were actions clearly taken as a consequence of these meetings they were not documented and therefore difficult to monitor process and efficacy in a robust manner.
  • Whilst there had been a recognised reduction in ‘silo’ working since the divisional structure had been implemented, there was not a consistent and robust approach for communication across divisions, which had been recognised and was being reviewed.
  • In the majority of cases there was a culture of incident reporting amongst staff groups, however there were some staff groups that were not reporting as consistently as others and there had not been any specific focused work on to improve incident reporting amongst certain staff groups.
  • There was not an effective audit programme in place to align national and local audits and monitor improvements being made in a robust and consistent manner. This had been recognised by the trust and the medical director was reviewing the process in conjunction with the divisional directors at the time of the inspection.
  • There was not a robust system in place for monitoring national guidelines, including patient safety alerts and NICE guidance. This had been recognised by the new medical director since he commenced in post but this had not been addressed at the time of the inspection.
  • The systems in place for monitoring statutory and mandatory training and appraisals trust wide were not consistent with the records being kept locally in the divisions and locations themselves, which demonstrated areas where the board was not able to take assurance from the data being presented to them in these areas.
  • Whilst there were examples of learning from incidents, complaints and compliments this was not consistently shared across divisions or trust wide.
  • As a consequence of the number of recent changes at board level it was difficult to assess the level of challenge present at the board in ensuring governance was managed proactively and in a robust manner; however, the executive team had recently become substantive and there was evidence to suggest that although there were multiple areas where processes needed to be improved to ensure a cycle of continuous improvement was present, this had been recognised by the executive team and they were taking steps to strengthen all aspects of governance and quality improvement.
  • In addition, there was clear evidence that there had been significant improvements made in the processes in the last twelve months, such as the improvements in the management and processes associated with waiting times for patients.
  • The complaints process was being reviewed and improved as the trust was not meeting their own internal target of a response within 25 days in 85% of complaints and the policy was out of date. However, there was clear commitment to improving the complaints process. The CEO only signs complaint response letters that were from MPs or from complainants who specifically asked that the CEO saw their letter.

Leadership of service

  • There was a leadership and development programme at the trust, which aimed to ‘drive exceptional performance through engaged people, create inspirational leaders and effective managers whilst ultimately improving patient experience’. These programmes were clearly set out in five separate courses from ‘Foundations’ to ‘Certificate in Medical Leadership’ including:

    • Foundation – Introduction to management
    • Headstart – Management into leadership
    • Aspire – The leadership way
    • Horizons – Strategic leadership
    • Certificate in medical leadership – Inspirational leadership

  • Each level of the leadership programme was aimed at different staff groups to proactively develop emerging top leaders with the divisional directors all having attended the certificate in medical leadership.
  • There was evidence of various staff groups attending these courses with a clear focus on supporting development of talent throughout the organisation to provide effective leadership.
  • The CEO had been in post since April 2014 and had made a significant impact on the organisation since commencing in post. Staff at all levels described the positive impact the new CEO had made in such a short period of time, which resulted in staff describing positivity for the future of the trust with a substantive executive team in place.
  • Since commencing in post the CEO had made some significant changes to the executive team, including change of medical director and appointment of deputy CEO (additional role give to COO), which had given confidence to staff at all levels that the leadership the trust required was in place after a period of instability.
  • Whilst board level and divisional clinical leadership demonstrated collaboration and alignment to effectively lead the trust and make necessary improvements, the leadership at a more local level at each hospital was markedly varied; with some areas demonstrating good leadership but other areas requiring significant improvement.
  • The executive team as a whole recognised they were a relatively new team working together and described the support they had in place to ensure they developed effectively as a team.
  • The CEO had done open forums and other forms of staff engagement since appointment and she was well known by staff at all levels for being visible and approachable. In addition, staff reported that if they raised an issue with the new CEO they received a response to their concerns.
  • The divisional directors that led the new structure of the four clinical divisions demonstrated both an alignment and understanding of the issues that needed to be addressed trust wide as well as a constructive level of challenge between themselves. However, as the new divisional structure was a recent change, it was too early to assess the impact of this.
  • The operational management team had been through a complete restructure following the appointment of the CoO, which was embedded at the time of the inspection having led some of the challenges associated with waiting times and processes. The CoO was recognised to have an open leadership style and held general manager forums to provide leadership to operational staff in conjunction with the deputy CoO.
  • The medical director was relatively new in post, however he had been working in the organisation previously and therefore had built up relationships with colleagues prior to being appointed and provided professional leadership to the divisional directors working closely with the CoO and director of nursing (DoN) to address quality issues.
  • The DoN held weekly meetings each Friday to ensure all nursing staff communicated issues in a timely manner and to share good practice between themselves across sites. Videoconferencing was used to ensure different locations were sharing information.
  • The director of people (DoP) provided a key leadership role in staff engagement and there was evidence of good visibility across the organisation to ensure she understood the views of staff and the culture across all locations. There were clear plans to improve staff engagement across all staff groups and ensure the executive team understood the views of staff throughout the trust.
  • The Chair and non-executive directors demonstrated a clear understanding of the strategy of the trust and key issues to be addressed throughout the trust. There was evidence of the non-executives holding the executive team to account in a challenging but supportive manner in more recent months and they were visible throughout the organisation. The chair and non-executive director leading on quality were reported to be visible to staff.
  • There was consistent feedback among all staff groups and levels that the CEO had improved communication and demonstrated the values through significant visibility and commitment.
  • Since the CEO had commenced the executive team portfolios of work, lines of responsibility and accountability relating to their portfolios were much clearer allowing improved systems and processes to become established and embedded.
  • Despite being a relatively new executive team, there was evidence of a cohesive and clear strategy that they were all aligned to; with clear recognition that they were at the beginning of a ‘journey’ to implement the overarching and clinical strategy to make improvements, some of which have been related to longstanding issues.
  • Although some members of the executive team were reported to be highly visible and approachable, the were some of the executive team that staff told us they would like to see more regularly in open forums or informal walkabouts.

Culture within the service

  • The culture throughout the organisation was open and transparent, which was reported to have become a specific focus since the appointment of the CEO as a key part of improving patient experience.
  • The staff demonstrated a culture of multidisciplinary teamwork across locations, however there had been some ‘silo’ working in some areas which had improved since the divisional structure had been implemented.
  • There was a culture of research and development and innovation among some staff groups, but this was more prevalent in some hospital services than others.
  • Although the trust was part of the first Academic Health Sciences Centre, there was not a consistent and clear alignment among all staff groups in relation to the impact of this on their day to day working practices.
  • There was a clear culture of staff working with a sense of pride in their work, with a commitment to improve patient care.
  • There was a sense of ‘optimism’ among staff since regarding the future of the trust as a consequence of the CEO commencing in post providing clear leadership in conjunction with the rest of the executive team.

Public and staff engagement

  • The staff survey in 2013 results showed that of the 28 key findings, 4 were in the top 20% nationally and 11 were in the bottom 20% nationally. This included staff feeling motivated at work being in the top 20%, but staff job satisfaction was within the bottom 20% nationally.
  • Whilst there had been evident improvements in staff engagement, there was significant work that needed to be done to embed the improvements and ensure the engagement was improving across all staff groups. The executive team recognised this and there were clear plans in place to address this, including quarterly engagement survey sent out to staff.
  • An element of the sense of optimism amongst staff was due to the engagement with staff regarding the clinical strategy for the organisation.
  • The trust values were known by the majority of staff and they were developed in conjunction with some staff groups.
  • The CEO open forums provided an opportunity for staff to feedback directly raising issues or opportunities for development. Staff reported positively about these forums and the commitment the CEO had demonstrated, to personally respond to staff that raised an issue.
  • The executive team all provided opportunities to engage with staff but it was recognised that these could be improved to ensure staff felt engaged with all of the executive team members.
  • The non-executive team carried out regular walkabouts and some staff were able to describe examples of improvements being made as a consequence of staff raising concerns.
  • The majority of staff were aware of the proposed clinical and overarching strategy including the reconfiguration of services and were able to describe the reasons for the necessity of the changes.
  • Where staff were going to be personally affected by the changes of the reconfiguration in the coming years there were examples of staff describing how they were involved in discussions around the plans and how they were going to ensure patient experience was maintained until the point of change.
  • In addition, where staff were concerned about the future of their job following changes they described a commitment from the trust to ensure they were developed prior to the changes to empower them to secure another post in a proactive manner.
  • The overarching strategy for the clinical reconfiguration of services had been out to consultation and patients were able to comment on the developments.
  • There were examples of patients being involved in the development of services and pathways of care; however this was not consistent across all locations and areas within the trust.

Innovation, improvement and sustainability

  • Research and development and clinical innovation was fundamental part of the trust, particularly through the work linked to the AHSC. This innovation clearly provided opportunities for patients to be involved in clinical trials and have access to leading improvements in healthcare.
  • However, whilst there were many examples of how the AHSC improved clinical care directly there was less evidence that being part of an AHSC had an impact on all staff groups and in the day to day running of the hospital in an innovative manner.
  • This focus on clinical innovation was recognised by the executive team and there was a clear vision that the AHSC has a key role in developing the day to day working practices and patient experience measures, whilst continuing to develop innovations in clinical care through research and development.
  • In addition, innovation at a local level was encouraged among staff groups and there were examples where improvements were made following staff proposing innovations.
  • Whilst improvement in delivery of care were evident during the inspection, there were differences between hospitals which demonstrated aspects of ‘silo’ working where best practice and basic standards were not consistent throughout the trust.
  • There had been significant improvements in the management of the cancer pathway, which involved collaborative working and leadership at a number of levels throughout the organisation to embed and deliver transformation at a clinical level, as well as improve key pathways and processes to ensure any potential breaches in patient pathways can be tracked real time and brought back on track rapidly.The sustainability of services and pathways of care were considered as part of the wider strategy for the trust and “Shaping a Healthier Future” programme for the whole of North West London. These proposed reconfigurations were not reviewed as part of the inspection as they were not in place and under consultation.