Imperial College Healthcare NHS Trust

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 NIHR Biomedical 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