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The Royal London Hospital Requires improvement

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Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 December 2016

The Royal London Hospital in Whitechapel, East London is part of Barts Health NHS Trust, the largest NHS trust in the country, serving 2.5 million people across Tower Hamlets and surrounding areas of the City of London and East London.

The Royal London Hospital is a major teaching hospital. It offers a range of local and specialist services, which includes one of the largest children's hospitals in the UK and one of London's busiest paediatric Accident and Emergency departments. It is home to London's air ambulance, and is one of the capital's leading trauma and emergency care centres and hyper-acute stroke centres. Tower Hamlets is in the most deprived quintile of the 326 local authority districts, with about 37.9% (19,800) children living in poverty. The population includes 55.0% Black, Asian and Minority Ethnic (BAME) residents.

We returned to inspect this location (and the Whipps Cross Hospital location) to follow up on our previous inspection of Barts Health NHS Trust in 2014 and 2015 where we found a number of concerns around patient safety and the quality of care. Following the last inspection, significant changes were made to the leadership of the organisation at both an executive and site based level.

We inspected eight core services: Urgent & Emergency Care, Medicine (including older people’s care), Surgery, Critical Care, Maternity & Gynaecology, End of Life Care, Services for Children, and Outpatients & diagnostic services. Overall, we rated this hospital as requires improvement. The critical care service was rated as good; maternity services as inadequate and the remaining core services as requires improvement.

Our key findings were as follows:

Safe:

  • Nursing staff vacancies across the hospital and theatre staff vacancies impacted on staff morale and in some case the quality of patient care.

  • A shortage of midwives meant that maternity wards were at times inadequately covered. There was also a low level of maternity consultant cover.

  • Baby security was not robust, with poor compliance to the wearing of baby name bands.

  • The infant abduction policy had not been promulgated to staff. However, the policy assumed the use of an electronic baby tagging system which was not in use in the hospital.

  • At the time of our inspection reception staff were inappropriately involved in the streaming of patients coming in to the emergency department.

  • At the time of the inspection and during the unannounced we found the medications cupboards on critical care were left open. All staff who had swipe card access to the unit including non-clinical staff such as domestic staff could access the medications room

  • There were frequent problems with insufficient availability of sterile equipment in theatres.

  • There was insufficient numbers of recovery staff with high dependency or advanced life support competencies to safely care for high acuity, high risk patients.

  • Medicines management was on the whole safe. But there were observed incidents where medicines were unsecured.

  • Infection prevention and control procedures were adhered to and monitored in most areas.

  • We generally saw good evidence of learning from incidents.

Effective:

  • We found poor understanding of the Mental Capacity Act 2015 and Deprivation of Liberty Safeguards (DoLS) amongst staff in services for children and young people, and how it applied to their roles.

  • Overall pain relief was well managed, however staff access to syringe drivers that delivered pain relief for end of life care patients was complicated by low stock levels.

  • Evidenced based care and treatment was provided.

  • We found good examples of local auditing as well as participation in national research that facilitated quality care.

  • Established multi-disciplinary working and seven day working was in progress across all services, except for end of life care where a weekend face-to-face service was not provided.

  • The use of paper based and electronic information in some departments meant that there were communication errors with patients, where appointments were duplicated or referral information was misplaced.

Caring:

  • Most staff were caring and compassionate in their delivery of care. We found the delivery of care on critical care outstanding.

  • Most patients and relatives were satisfied with the care and support they received and felt that staff took the time to include them in decisions about their care. Inconsistencies related to high workload, short staffing and the presence of agency staff.

  • Patients had their dignity and privacy respected. However, there was not a robust policy in place to protect children from sharing rooms with others of the same sex.

  • The compassionate care plan had been introduced in response to the withdrawal of the Liverpool Care Pathway

Responsive:

  • We found that surgery services were inadequate in their response to patient’s needs. The flow within the surgery system from admission, through theatres, wards and discharge was not managed effectively. There were consistent problems with bed management and bed availability, which caused late theatre start times and short notice cancellations of surgical procedures.

  • The average bed occupancy was consistently equal to or above 95%.

  • The average length of stay for elective and non-elective patients was worse than the England average.

  • The average length of stay for medical inpatients was higher than the England average.

  • The trust was not meeting national waiting time targets and had stopped reporting. However, the trust had implemented a full referral to treatment (RTT) recovery programme to address this, which included collaborative working with stakeholders to resolve the issue.

  • The percentage of patients with suspected cancer being seen by a specialist within two weeks of urgent GP referral was worse than the England average.

  • There was a two week backlog of outpatient appointments waiting to be booked. Some patients waited for over a year for follow up appointments.

  • The nutrition and hydration needs of patients were met, though this was enabled by the support of relatives in some busy departments.

  • Sexual health and HIV services demonstrated a detailed understanding of the needs of the local population and formed community partnerships, developed research and adapted services to address these.

  • Outcomes for mothers and babies in maternity services were better than the national average.

Well led:

  • There were a number of innovations, particularly in trauma, where the hospital remains a world leader.

  • Changes to the leadership structure of the trust, including at site level, were beginning to make a positive impact. Most staff spoke optimistically of the new leadership structure.

  • Governance and risk management was better managed.

  • In some services there was a lack of understanding of the vision and strategy of the organisation.

  • Despite a general improvement in morale, a perceived negative culture of bullying and inequality was still prevalent in some services.

We saw several areas of outstanding practice including:

  • There was a very strong record of innovation in the hospital’s trauma service and the trust was internationally recognised as an innovator and leader in research in this field.

  • The emergency department was the only centre in the country and one of only two in Europe to offer the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) treatment for patients.

  • The emergency department had introduced a ‘Code Black’ protocol for patients who had severe head injuries. This was the first of its kind in the country and meant that appropriate patients had care led by neurological surgeon from the first time that they arrived in the department.

  • Staff in sexual health and HIV services were highly research active and used findings from in-house research and collaborative partnerships to drive improvements in care and patient outcomes.

  • We found the Adult Critical Care Unit delivered outstanding care. The service had also developed a programme of learning to ensure best practice and improve patient care for a frequently changing medical workforce.

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

Importantly, the trust must:

  • Urgently improve security in the maternity services.

  • Ensure that there are enough midwives on the delivery suite to provide safe care for all women.

  • Ensure that the level of consultant cover on the delivery suite meets the recommendations made by The Royal College of Obstetricians and Gynaecologists.

  • Ensure the proper and safe management of medicines on the critical care.

  • Ensure sufficient numbers of suitably qualified, competent and skilled staff are effectively deployed to meet the needs of patients in all clinical settings.

  • Ensure sufficient availability of sterile surgical equipment in theatres at all times to ensure the safety of service users and to meet their needs.

  • Ensure there are enough recovery staff suitably trained in high dependency support and advanced life support to safely care for post-operative patients at all times.

  • Improve bed management, theatre management and discharge arrangements to facilitate more effective flow of patients from theatres onto wards to ensure patients are not held in recovery for inappropriate lengths of time.

  • Ensure there are sufficient numbers of suitably qualified, skilled and experienced staff to meet the needs of patients across all core services.

In addition the trust should:

  • Ensure that patients arriving in the emergency department are assessed within 15 minutes of arrival, and that all staff involved in the streaming of patients coming in to the emergency department are appropriately trained.

  • Ensure that patients are admitted, transferred or discharged within four hours of arrival in the emergency department.

  • Ensure that consultant cover on critical care during nights and weekends meets the Faculty of Intensive Care Medicine Core Standards consultant to patient ratio.

  • Make arrangements to ensure staff in critical care side rooms have easy access to a call alarm should they require assistance when looking after patients.

  • Consider ways to increase multidisciplinary ward rounds on critical care so they are happening on a daily basis.

  • Review trust incident governance processes to ensure learning from incidents is shared systematically across all trust sites.

  • Improve trust recruitment processes to facilitate more rapid employment of new members of staff and reduce staff vacancies on wards and theatres.

  • Improve compliance and awareness of trust infection prevention and control policies and processes to ensure all staff understand how to label and dispose of clinical waste safely.

  • Improve awareness of major incident plans, policies and protocols for all staff groups and grades.

  • Ensure all staff have completed mandatory training and understand the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS).

  • Ensure that staff appraisal rates are improved and all staff have timely clinical supervision.

  • Take further action to improve and address the perceived culture of bullying and harassment.

  • Ensure that equal opportunities for BAME staff are addressed.

  • Ensure that all staff who wish to undertake additional qualifications relevant to their role are supported to do so.

  • Ensure learning outcomes from incident reporting are effectively disseminated to staff.

  • Ensure nurse to patient ratios are managed in relation to the individual needs of patients.

  • Ensure that temporary staff, including agency nurses and volunteers, are suitably qualified.

  • Ensure that pain scores are consistently recorded and there is always access to syringe drivers for the delivery of pain relief in end of life care patients.

  • Take further steps to improve the patient experience of nursing care on wards

  • Improve systems to ensure the nutrition and hydration needs of all patients are met.

  • Ensure a hospital palliative care lead nurse is available 7 days a week to meet the hospital palliative care team’s managerial and supervisory needs

  • Investigate the introduction of enhanced recovery after surgery protocols to help patients achieve early recovery after surgical procedures.

  • Ensure that documentation, such as pressure ulcer risk tools, are consistently used across all services.

  • Ensure robust and consistent infection prevention and control measures are in place across all services.

  • Ensure the removal of all potential ligature risks throughout children’s services that would be a safety concern for young people at risk of self-harm.

  • Ensure the development of a learning disability pathway in children’s services, as well as ensure that staff have consistent access to input from specialist learning disabilities support.

  • Ensure that a robust policy is in place to protect children and young people from sharing rooms with others of the same sex..

  • Continue to reduce Referral to Treatment backlogs.

  • Ensure improvements to diagnostic waiting times.

  • Improve provision of patient literature in community languages.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 15 December 2016

Effective

Requires improvement

Updated 15 December 2016

Caring

Requires improvement

Updated 15 December 2016

Responsive

Requires improvement

Updated 15 December 2016

Well-led

Requires improvement

Updated 15 December 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 13 October 2017

Medical care (including older people’s care)

Requires improvement

Updated 15 December 2016

Although notable improvements had been made in clinical care, leadership and governance, not all of the safety issues raised at our last inspection had been addressed. A rolling programme of staff recruitment was in place, but overall numbers of registered nurses had decreased with high levels of agency nurses in some areas. The availability of specialist medical staff at weekends was inconsistent.

Patients were mostly treated with kindness and compassion. However this was inconsistent across the service and related to high workload and short staffing. Standards of infection prevention and control were variable and in some areas fell below standards. Auditing processes were in place but there was limited evidence of sustained improvement. Incident reporting took place, though learning outcomes were not consistently communicated to staff.

We found that multidisciplinary working contributed positively to patient assessment, safety and outcomes. Collaborative working between departments led to improved working relationships. Service planning was developed by staff who understood the changing needs of the local population. Several services offered 24 hours a day, seven days a week cover. Sexual health and HIV services demonstrated a detailed understanding of the needs of the local population and formed community partnerships, developed research and adapted services to address these.

Staff were inconsistent in their opinion as to how supportive the hospital’s senior team was, and a number of staff across the service told us they felt the trust behaved in a biased manner when considering promotions and complaints

There were a number of areas of innovation in staff development, research, service expansion and quality improvement and sustainability.

Urgent and emergency services (A&E)

Requires improvement

Updated 15 December 2016

At the time of our inspection, we found that reception staff were involved in the streaming of patients coming in to the emergency department. Patients arriving by ambulance did not consistently receive an assessment within 15 minutes of arrival, and the department had been consistently below the national target of seeing and treating 95% of patients within four hours of arrival.

Nursing staff vacancies within the department remained high. However, we found good multidisciplinary team working and a culture of mutual respect and trust. A continuous programme of clinical and professional development was demonstrated. The environment was clean and 24 hours a day, seven days a week working was in place.

Pressure ulcer risk tools were not in use and patients at risk of developing pressure ulcers were nursed on trolleys due to a lack of hospital beds. Pain scores were not consistently recorded. However, tools to monitor the deteriorating patient were in use across the department.

Staff treated patients with dignity and respect. Patients we spoke with were positive about the care they received. Patients and their relatives told us that they felt informed and involved in their treatment plans. Staff also commented that they were supported by their peers and management.

Patients received evidence-based care and treatment. The service was involved in a number of research projects that it recruited patients to. The service undertook a large number of clinical audits throughout the year and could show evidence of learning and improvement. Clinical incidents were appropriately investigated and learning was fed back to the staff.

Surgery

Requires improvement

Updated 15 December 2016

There was some evidence of progress since the previous CQC inspection. However, there remained a number of serious, cross-cutting risks and issues that were longstanding and unresolved and the service had not adequately addressed some concerns.

There were high levels of nursing and theatre staff vacancies across the service that impacted on the quality of care patients received. Patients told us some agency staff demonstrated a less caring approach. There were not enough recovery staff suitably trained in high dependency support and advanced life support to safely care for patients in theatre at all times. Patients frequently remained in recovery after surgery for unacceptable lengths of time. Most patients we spoke to said that they had been well informed about their treatment.

We found that surgery services were inadequate in their response to patient’s needs. The flow within the surgery system from admission, through theatres, wards and discharge was not managed effectively. There were consistent problems with bed management and bed availability, which caused late theatre start times and short notice cancellations of surgical procedures. There were inefficiencies and under usage of operating theatres and the service was not meeting all of its targets.

Staff in theatres consistently reported problems with the timely supply of complete sterile surgical sets from the trust’s external contractor. Surgeons told us that lack of instrumentation was impacting on their ability to treat patients effectively and was leading to cancellations and inefficient running of theatre lists. For example, surgeons reported a recent example where they did not have access to sets for major trauma, orthopaedic, vascular, arterial or neurosurgery for over 12 hours. ODPs told us they did not feel confident the service would be able to respond if there was a major incident.

The average length of stay for elective and non-elective patients was worse than the England average. Ineffective discharge arrangements across surgery wards impacted on bed availability. However, the trust had focused on reducing ‘Referral to Treatment’ times which were steadily decreasing. There were also appropriate arrangements in place to support those with learning difficulties and those living with dementia.

Barts Health was internationally recognised as a world leader in research and development of trauma care. The Royal London Hospital remains the busiest Major Trauma Centre in the UK, and there was a well embedded multidisciplinary multispecialty workforce.

Intensive/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.

Services for children & young people

Requires improvement

Updated 15 December 2016

We found potential ligature risks throughout children’s services which would be a safety concern for young people at risk of self-harm. We also found examples of where safe guarding concerns were not appropriately acted upon.

There lacked a robust policy to protect children and young people from sharing rooms with others of the same sex.

The service did not have a specific area for the care of young people aged between 16 and 18 years who were generally cared for on adult wards.

There were high levels of nursing staff vacancies across the service. Staff did not receive regular clinical supervision and most staff had not been appraised in the last 12 months.

Children’s services did not have a specific learning disabilities pathway. Wards did not have access to input from specialist learning disabilities support, and the needs of patients with learning disabilities were not always being met.

Staff were encouraged to formally record concerns, and there was a good culture of learning from incidents. We also found effective multidisciplinary working across the service.

Children had access to a number of large, well-resourced playrooms, and age appropriate toys. Each ward had a play specialist available to work with children and provide exercises and playgroup sessions during their stay in hospital.

Patients and family members we spoke with were positive about the staff that were caring for them. Across all children’s and neonatal services we saw patients and family members treated with dignity and respect. However, we found information was not provided in languages other than English.

Children’s services and the neonatal unit did not have formalised plans in place for the future strategy and vision for the division. However, we identified good examples of local leadership, both on the wards and within the new organisational structure for the division. Most of the staff we spoke with stated that the culture of the children’s services had improved since the last inspection.

End of life care

Requires improvement

Updated 15 December 2016

A face to face end of life care service was provided by the hospital palliative care team 9am to 5pm Monday to Friday. However, this was not in accordance with national guidelines, which recommends that palliative care services should provide such services 7 days a week between the same hours.

Staff access to syringe drivers that delivered pain relief was complicated by low stock levels. There was inconsistent completion of pain scoring tools on one ward. There was also inconsistency in the completion of patients’ nutrition and fluid records.

The trust had introduced the compassionate care plan in response to the withdrawal of the Liverpool Care Pathway. Patients received care and treatment that was evidenced based. Although there were no formalised patient outcomes measure in place, work was in progress to introduce the integrated palliative care outcome scale.

Staff were aware of how to report incidents and learning from incidents was shared.

Most patients were positive about the way staff treated them. Most patients told us that their care met their expectations

There was an open and honest culture within the service and morale had improved. Clinical leads were visible, approachable and supportive.

Outpatients

Requires improvement

Updated 15 December 2016

The trust was not meeting national waiting time targets and had stopped reporting. However, the trust had implemented a full referral to treatment recovery programme to address this, which included collaborative working with stakeholders to resolve the issue.

There was a 2 week backlog of appointments waiting to be booked. Some patients waited for over a year for follow up appointments. A recent waiting times audit within clinics showed that over a third of patients experienced delays of more than 30 minutes. However, some clinical staff ensured services prioritised some individual’s needs, such as those living with dementia or physical disability.

The percentage of patients with suspected cancer being seen by a specialist within two weeks of urgent GP referral was worse than the England average.

There had been 5 incidents where patients had suffered harm due to wrong site surgery in dental outpatients. There was lack of evidence to demonstrate feedback and shared learning with other outpatient services within the hospital. In the ophthalmology clinic we found medicines left unsecured.

There were good staffing levels and skill mix was appropriate across the service.

Patients were positive about the care they received and the information provided to them. Patients were treated with kindness, dignity and respect and told us they felt involved in their care and treatment.

The environment was clean. Staff adhered well to infection prevention and control policies, and ensured equipment was clean and well maintained.

Diagnostic imaging provided services for inpatients 24 hours a day, seven days a week.

The leadership and culture of the senior management reflected the vision and values of the trust, delivering safe and compassionate care. There were clear lines of management accountability and most staff worked well as a team.