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This service was previously managed by a different provider - see old profile

We are carrying out a review of quality at The Royal London Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Good

Updated 5 April 2019

Inspection areas

Safe

Good

Updated 5 April 2019

Effective

Good

Updated 5 April 2019

Caring

Good

Updated 5 April 2019

Responsive

Requires improvement

Updated 5 April 2019

Well-led

Good

Updated 5 April 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 12 February 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

Following our last inspection in July 2016, we issued six actions the provider should take to improve. During this inspection, the service had dealt with or shown improvement for some of the previously reported concerns. But we also found:

•We were not assured that all risks were identified and action plans in place to address identified risks. There was a divisional medicines risk register which fed into the corporate risk register. However, we identified ligature risks on ward 10E, but these were not identified on the divisional risk register. Senior staff on the ward were not aware of whether there was a ligature risk assessment in place.

•During our previous inspection we found that staff did not consistently record observations relating to an elevated NEWS score. During this inspection we found that staff on some wards were still inconsistent in their recording of NEWS scores.

•During our previous inspection we reported that we had found inconsistent recording of patient information in several areas. During this inspection we found the hospital had taken action in the form or regular audits to address shortfalls in record keeping. However, recording was still inconsistent on some wards.

•Staff on ward 10E were unaware of whether there was a ligature risk assessment for the ward. We requested the wards ligature risk assessment from the trust, but this was not received.

•Medical staff had not met the trust’s 85% standard for six out of 24 subjects, this included rates of basic life support training at 59%. This meant there was a risk of medical staff not having up to date skills in resuscitation and basic life support.

•We found issues in regards to equipment being stored securely. We found the door to a medical room which stored medicines on ward 13E open.

•During our previous inspection we found there were significant gaps in understanding and practice in relation to the control of substances hazardous to health (COSHH). During this inspection we found there were still gaps in relation to the safe storage of COSHH.

•Improvements were required in the management of medicines on some wards. We found: disorganisation within medicine cupboards, medicines not placed in their correct locations and not returned to pharmacy as appropriate, patients own drugs (POD), these are medicines bought in by patients from home, stored in a medicines trolley, overstocked controlled drugs (CD) cabinets and duplication in ordering, and fridge temperatures not being recorded accurately.

•Delayed transfers of care from April 2018 to August 2018 were stable, but the rates were high at between 28% in July 2018 and 35% in May 2018.

•Ward staff on 10E said they could not meet the psychological and emotional needs of patients diagnosed with personality disorders as these patients were not supported by the Mental Health Liaison Service.

•There were 3,298 patients moving wards at night across 13 wards within medicine at the hospital.

However, we also found:

•Staffing levels across most services had shown improvement.

•Staff delivered care and treatment in line with national guidance and standards and reviewed trust policies to ensure they were always up to date.

•There was extensive of evidence of well-structured, multidisciplinary engagement and professional development that contributed to a better skilled workforce.

•There was a demonstrable focus on ensuring safeguarding was a key focus of every member of staff and of all care delivered in the hospital. This was evident from the highly visible, proactive work of the safeguarding team to increase training and discussions and to update the trust policy in a way that would be useful to staff.

•Patients and their relatives described staff that were kind, attentive and friendly. Patients told us staff included them in discussions about their care and that staff adapted communication styles to enable their understanding.

•Staff at all levels of responsibility were empowered and confident and were positive about a new working environment and culture that recognised their contribution. This was a significant improvement from our last inspection in 2016.

Services for children & young people

Good

Updated 12 February 2019

Our rating of this service improved. We rated it as good because:

•There was now a clear policy for children aged 16 – 18 on adult wards and children’s services now had full oversight of all incidents involving these patients.

•At the last inspection we found the clinical audit process was not robust. Matrons now regularly reviewed outcome data such as hand hygiene and medicines management audits and shared these results at clinical governance meetings.

•In the previous inspection we found that there was no dedicated dietetic support in the neonatal unit. This had now improved and there was now a dedicated full-time dietitian on the neonatal unit.

•Children and young people’s pain was managed effectively. The service used pain assessment tools including tools for children who were unable to communicate verbally.

•There was good multidisciplinary working within children’s services and the neonatal unit. Records demonstrated input from a full clinical team of doctors as well as physiotherapists, play specialists and dietitians.

•The service took account of the individual needs of children and young people. The service now had a clear learning disabilities pathway and the use of a learning disability hospital ‘passport’ was also encouraged.

•The service now focused on the improvement of transition from paediatric to adult services. There were now specialist nurses including a clinical nurse specialist for adolescents who supported young people transitioning for paediatric to adult services.

•The children’s outpatient clinics were flexible with appointment times and offered clinics later in the day so older children did not need to miss a full school day.

•The hospital play team visited all children and had created daily schedules for children which were tailored to their individual needs.

•Although the new divisional leadership team had just been formed, they had a formalised, clear vision and strategy for the service. Staff were also aware of the vision of the service.

•Risks we raised at our last inspection which were not on the risk register had been addressed. The risk register also reflected the risks we identified during the inspection.

•Similar to our last inspection, there was good local leadership and managers were visible and approachable.

•The hospital engaged with young people in the design of services.

•The culture within children’s services had improved since the last inspection. There was a positive, open and honest culture within the teams across paediatrics at the children’s hospital which valued staff and was based on shared values.

•Staff knowledge of the duty of candour had improved since the last inspection.

However, we also found:

•Mandatory training levels for medical staff remained low especially for basic life support training and level 3 children safeguarding training.

•Some policies on the trust intranet were not in date such as information governance and the trust’s safeguarding children policy.

•We were unable to find a deteriorating child policy on the trust intranet however paper paediatric early warning score charts contained instructions for the management and escalation of patients.

•There was a lack of overarching consultant oversight on the day care unit. Children were seen by multiple specialist consultants and the matron escalated clinical issues to an on-call consultant but there was no dedicated medical lead for the unit with oversight of acute medical problems.

•The service was in the process of transitioning from paper to electronic records. There were inconsistencies and gaps in records due to the use of both paper and electronic notes.

•There were two public access lifts to the children’s hospital. Similar to the last inspection, parents commented that they were sometimes late for appointments because of the queue for the lift.

•Parents and visitors commented that they were not confident of the lift system and had experienced the lift stall or break down.

•Patients and families said that the Wi-Fi access rarely worked and children found it difficult to do schoolwork or access social media to keep in touch with friends and family.

•There was still a lack of signage and signposting to children’s wards, neonatal unit and clinics.

•Staff knowledge of the trust ‘We Care’ values was variable.

Critical care

Good

Updated 15 December 2016

Patient and relative feedback was positive about the care provided. Staff were frequently described as caring and professional. Patient privacy and dignity was maintained. Staff provided emotional support to patients and relatives and could signpost to services within the organisations as well as external organisations for additional support. Flexible visiting was available on request.

We saw good evidence of learning from incidents. Patients received evidence based care. Suitable processes and development opportunities were in place to ensure nursing staff were competent.

The environment was clean and staff complied with infection prevention and control guidelines. However, medicines were not stored safely and securely. Drug cupboards were left unlocked and access to the medications room was not adequately secure.

Multidisciplinary working was effective, albeit that there were not sufficient numbers of allied health professionals, including physiotherapists and occupational therapists, to meet recommended standards.

Patient flow was hindered by a lack of bed availability elsewhere in the hospital. There was a significant number of delayed and out of hours discharges.

Staff spoke positively of the leadership and this was reflected in the culture across the service.

End of life care

Good

Updated 5 April 2019

Surgery

Good

Updated 12 February 2019

Our rating of this service improved. We rated it as good because:

•The leadership team had sufficiently addressed the concerns identified at our previous inspection.

•There was a significant improvement in theatre utilisation, bed management, bed availability and a focus on improving patient access and flow.

•There were effective processes for incident reporting, investigation and evidence of improved shared learning from incidents.

•Staffing levels had improved in wards and the operating theatre department. There were low vacancy rates and less reliance on temporary staff to cover gaps.

•There was an improved supply and availability of surgical instruments with no recent cancellations of surgery attributed to lack of equipment.

•Surgical pathways were planned and delivered in line with referenced national clinical guidance. There was a clinical audit programme which informed service development.

•Staff had the required knowledge, skills and competencies to carry out their roles effectively. Managers appraised staff performance and provided developmental support.

•Patients gave consistently positive feedback about the quality of care they received.

•Staff felt the culture of the organisation had improved and described the leadership team as accessible and supportive. Equal opportunities for BAME staff had been addressed.

•The service promoted learning and development, and research and innovation. Staff were positive about the support they received to challenge existing practice and try out new ideas.

However, we also found:

•Compliance with mandatory training for medical and dental staff did not meet the trust target.

•There was a hybrid system of record keeping: part paper, part electronic which led to some delayed or missed information being available to clinicians.

•Medicines were not always stored securely and managed appropriately.

•Nursing documentation such as individual patient care plans was not always complete and did not always consider emotional and psychological needs.

•Clinical waste bags in the operating theatre department were not always disposed of correctly.

•Length of stay for surgical patients was higher than the national average.

•There was a higher than expected risk of readmission when compared to the England average.

•Referral to treatment times had not been reported between 2014 and 2018. As of September 2018, the surgical service was meeting 81% of the target times for referral to treatment for non- cancer referrals.

•Local audit of patients undergoing cranioplasty showed a high infection rate. A new protocol for peri-operative care has been instituted and the result of re-audit is awaited.

Urgent and emergency services

Good

Updated 12 February 2019

Our rating of this service improved. We rated it as good because:

•Staff understood how to protect patients from abuse. Staff knew how to recognise and report abuse and they knew how to apply it.

•The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

•Staff monitored patients who were at risk of deteriorating appropriately. Early warning scores were in use in both adult and paediatric areas.

•There were good protocols in place for the recognition and management of sepsis.

•There was consistent recording of information within the patient records reviewed. This included good completion of risk assessments and pain scores. The recording of pain assessments had improved since the last inspection.

•The incident reporting culture was well embedded and staff were encouraged to report incidents and learn from them.

•Multidisciplinary working was evident in all areas of the department.

•Staff were professional and care for patients in a caring and compassionate manner. Feedback from patients and relatives was positive.

•There was a positive culture within the department and staff generally felt supported by managers.

•The vision and strategy of the department was still one of striving for excellence which was demonstrated through a continuous programme of clinical and professional development.

However, we also found:

•The paediatric waiting room was still not in sight of the nursing station and checks were not consistently being carried out as we found in the last inspection. This posed a significant risk to children who deteriorate as there is a lack of clinical oversight of the waiting area.

•Some of the paediatric guidelines on the trust intranet were out of date and not reviewed.

•The department was still a negative outlier for the Trauma Audit and Research Network (TARN) mortality. However, the department was working with TARN on improving data collection methods.

•The department did not meet the target to admit, discharge, or transfer 95% of patients within four hours between in any of the 12 months preceding our inspection.

•Patients were still waiting for long periods before staff moved them to an appropriate ward or department once a decision to admit and been made. Access to services and patient flow continued to be a significant problem for the department and patients could experience long waits.

Maternity (inpatient services)

Good

Updated 5 April 2019

Dental hospital

Good

Updated 12 February 2019

This was the first inspection of the dental hospital so there were no previous ratings. We rated it as good because:

•Staff completed training in line with the trusts target for completion rates.

•Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. We saw evidence of multi-agency working in relation to safeguarding.

•The hospital had processes in place for infection control. The environment and areas we visited was visibly clean and tidy and staff followed the trust’s infection control policy. We saw staff used personal protective equipment and sterilised dental instruments in line with guidance.

•Health and safety risk assessments were completed periodically.

•The Radiation protection file was up to date and the hospital were complying with safety regulations relating to this.

•Medicines were stored, checked and managed safely.

•Staffing levels were appropriate to ensure the safety of patients and visitors to the hospital.

•Patient care was delivered in line with evidence-based guidance from the National Institute for Health and Care Excellence (NICE), the Royal Colleges and other relevant bodies. Policies we viewed were reviewed regularly, and new clinical guidelines were disseminated to staff appropriately.

•Patients’ needs were monitored and planned for in an effective way.

•There was excellent multidisciplinary working at all levels within the dental hospital. They had developed innovative and efficient ways to deliver joint up care.

•The hospital shared learning from incidents across the hospital internally and nationally across dental hospitals. Consultants from the hospital were representatives of National dental safety groups

•The hospital had undertaken audits looking at reducing antibiotic use nationally. This included all dental hospitals in the UK and Ireland.

•Lessons were learnt, analysed and investigated when things went wrong. The hospital took part in and lead on local and national safety programmes to share learning. They took the opportunity to learn and share their experiences of safety events with other dental hospitals and the wider dental community.

•Staff worked closely with General dental practitioners, GP’s and community services.

•Staff were involved in promoting national priorities to improve the population’s health and implemented initiatives to support this.

•People were given information relating to health promotion.

•Staff we spoke with demonstrated that they understood the legal requirements of the Mental Capacity Act 2005.

•Patients comments were consistently stating that they felt well supported and were given emotional support.

•There was a co-ordinated approach towards providing good quality care in a way that focussed on patients’ needs.

•We saw that people were involved in the co-ordinating of their care in a meaningful way their feelings were considered and time was taken to ensure they were comfortable with procedures.

•Innovative techniques were used to provide emotional support to patients. For example, the sensory room for children and disabled people.

•The hospital worked extensively with other departments and organisations to ensure patients were involved and engaged with their care and treatment.

•The services provided reflected the needs of the local population

•The dental hospital responded to the needs of patients by providing flexibility with appointments and joint clinic appointments.

•The hospital was fully accessible. The entrance to the building was step-free and there were lifts to access each floor.

•The services were delivered and coordinated to consider people with complex needs.

•The hospital monitored complaints, responded to them and had processes to learn from them.

•The hospital has processes in place to manage people’s information in a safe way.

•There was a holistic understanding of performance, which sufficiently covered and integrated people's views with information on quality.

•There were effective governance procedures in place to underpin the provision of services.

•Roles and responsibilities were clearly defined and there was a sufficient mix of skills and abilities across the staffing levels.

•There was a leadership structure that supported the smooth running and delivery of the service.

•The leaders who we spoke with demonstrated that they understood the challenges the hospital was facing as well as being aware of and able to celebrate the successes.

However, we also found:

•Referral to treatment times were still below their intended targets in some departments. Oral surgery, which made up 60% of the patient tracking list was 73.1%.

•The service was experiencing issues with using technology to communicate with patients and ensuring it was appropriate for patients whose first language was not English.

Outpatients

Requires improvement

Updated 12 February 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

•Outpatient services had transferred from a centralised management structure to site based leadership three weeks before our inspection. As a result, structures and processes were still embedding. The site based leadership team were aware of the challenges but had not yet had the time to address the challenges and make improvements.

•There were limited audit and performance measurement processes in place. The first outpatient’s performance review under site based management was scheduled for two weeks after our visit.

•The trust had only recently returned to reporting on its referral to treatment (RTT) performance in recent months and there was limited information available. RTT improvement was not yet embedded within its governance processes. Performance was currently below the target of 92%.

•We were told that access to the appointment booking system was not restricted; this meant that departments could book onto the list which caused overbooking. Staff told us that it was unclear who had oversight of this within the trust.

•The trust was not adhering to its policy concerning ASI lists in that the trust stated in its ‘Access and management’ policy that ASIs should be resolved within a maximum of five working days for urgent patients and 10 working days for routine patients.

•Prior to the inspection data was requested through the Routine Provider Information Request (RPIR), some of this information was not provided by the trust although it was provided following the inspection.

However, we also found:

•Staff understood how to protect patients from abuse and were aware of their roles and responsibilities for escalating safeguarding concerns. Staff had received training on how to recognise and report abuse.

•Outpatient departments were observed to be clean, furnishings and fittings were in a good state of repair, hand-free waste bins were clean with foot pedals, paper towels were available from enclosed dispensers, environments were free from visible damage (flaking paint or damage services) and work surfaces were free of clutter and visible cupboards were clean.

•Staff highlighted patients who were at risk before coming to the clinic during daily meetings; this enabled them to be prioritised. Stretcher patients were reviewed at the start of each clinic and were allocated a room which could accommodate a stretcher and hoist should this be needed. Patients living with learning difficulties, dementia or other mental health conditions were prioritised and reviewed as soon as possible.

•Evidence of risks were observed, Waterlow scale was documented on an admissions form, if there is an indication that the patient’s pressure areas were at risk. We saw that clinics were flexed, this meant that patients were prioritised and those at higher risk were to be seen more urgently.

•Outpatient staff showed an understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff we spoke with were aware of their duties and responsibilities in relation to patients who lacked capacity. The trust provided training on the Mental Capacity Act and Deprivation of Liberty Safeguards as part of their wider safeguarding training.

•We observed nursing, medical, healthcare assistant and allied health staff provide compassionate and considerate care to patients. All staff we observed introduced themselves and attempted to build a good rapport with patients.

•Patients we spoke with told us that they felt staff included them in their care and that consultants explained things clearly. We observed a patient’s appointment with a consultant and saw that the doctor took time to explain things to the patient and answer their question.

•The hospital was meeting its cancer referral targets between April 2017 to March 2018.

•Staff confirmed that the leadership support within the non-clinical teams and Clinical teams had improved and the structure was clear and confirmed that regular meeting were held and information is cascaded down to all the areas.