All inspections: The Royal London Hospital

We inspected the Maternity service at The Royal London Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the Maternity service on the 17th of August 2022, looking only at the safe and well led key questions.

Bart's Health NHS Trust provide maternity services from five locations these are the Whipps Cross University Hospital, The Royal London Hospital, Newham University Hospital and two standalone birth centres The Barkantine and Barking birth centre.

The Royal London Hospital is in the heart of Whitechapel London. Services are aimed at a diverse population with areas of social deprivation and included antenatal, fetal medicine, consultant led labour ward and the Lotus birth centre, postnatal and community midwifery services to the local population. From August 2021 to July 2022 there were 5,140 babies born at the hospital.

We also inspected 3 other Maternity services run by Barts Health NHS Trust. Our reports are here:

Barking Birth Centre – https://www.cqc.org.uk/location/R1H41

The Barkentine Centre – https://www.cqc.org.uk/location/R1HX7

Whipps Cross University Hospital – http://www.cqc.org.uk/location/R1HKH

Our rating of this hospital went down. We rated it as requires improvement because:

Our ratings of the Maternity service changed the ratings for the Royal London Hospital overall. We rated safe as requires improvement and well-led as requires improvement and the Royal London as requires improvement.

In September 2021 we carried out an unannounced follow-up inspection of diagnostic imaging at the Royal London Hospital. The inspection was to investigate if the trust had addressed warning notices we had issued following an inspection of diagnostic imaging in May 2021.

The warning notices issued in May 2021 related to Key Lines of Enquiry (KLOEs) in the safe and well led domains. At this inspection we found:

The provider has complied with the warning notices issued in June 2021. The provider had made improvements to ensure that diagnostic imaging services had more oversight of staffing rotas and risk assessments.

This service has not previously been inspected and rated as a standalone service. As this inspection was a follow up inspection and we did not inspect all key lines of enquiry, we did not rate the service from this inspection.

See the diagnostic imaging section for more information on what we found.

How we carried out the inspection

We visited all areas of the diagnostic imaging service. This included visiting all treatment rooms and waiting areas. We spoke with 25 members of staff which included departmental and divisional managers, speciality leads, radiologists, superintendent radiographers, radiographers, radiography assistants, and senior hospital and trust leadership. We reviewed documents that related to the running of the service including staffing rotas, policies, standard operating procedures, equipment, meeting minutes, incident investigations, as well as additional evidence provided by the trust post-inspection.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/whatwe-do/how-we-do-our-job/what-we-do-inspection.

We carried out this unannounced focused inspection because we received information giving us concerns about the safety and quality of the diagnostic imaging service.

The concerns related to aspects of the safe and well led domains which were the focus of this inspection. We did not inspect any other of the services at the Royal London Hospital because the concerns did not relate to any other parts of the hospital.

This service had not previously been inspected and rated as a standalone service. As we did not inspect all key lines of enquiry, we did not rate the service from this inspection.

See the diagnostic imaging section for what we found.

How we carried out the inspection

We visited all areas of the diagnostic imaging service. This included visiting all treatment rooms and waiting areas. We spoke with 35 members of staff which included departmental and divisional managers, speciality leads, radiologists, superintendent radiographers, radiographers, radiography assistants, and senior hospital and trust leadership. We reviewed documents that related to the running of the service including staffing rotas, policies, standard operating procedures, equipment, meeting minutes, incident investigations, as well as additional evidence provided by the trust post-inspection.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/whatwe-do/how-we-do-our-job/what-we-do-inspection.

Our rating of services stayed the same. We rated it them as requires improvement because:

We inspected six core services at this inspection. They were urgent and emergency services, surgery, medical care (including older people’s care), services for children and young people, outpatients and dental services.

We rated dental services as good overall and outstanding in the effective, caring and well-led domains. We rated outpatients and medical care as requires improvement. All other core services inspected at this visit were rated as good. When aggregating the overall rating for the hospital, we also took into consideration the services we did not inspect, which were maternity, end of life care, diagnostic services and critical care.

At this inspection we found that:

•There were effective governance procedures in place to underpin the provision of services. A leadership structure supported the delivery of services. Leaders demonstrated that they understood challenges as well as being able to celebrate the successes.

•The incident reporting culture was well embedded and staff were encouraged to report incidents and learn from them. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

•There was extensive evidence of well-structured, multidisciplinary engagement.

•Staff at all levels were confident and positive about the working environment and culture which recognised their contribution. This was a significant improvement from our last inspection in 2016 and staff offered numerous examples of how the work culture had improved.

•We observed nursing, medical, healthcare assistant and allied health staff provide compassionate and considerate care to patients. Patients and their relatives described staff as kind and friendly. Patients we spoke with told us that they felt staff included them in their care and that consultants explained things clearly.

•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.

•The environment and areas we visited were generally visibly clean and tidy and staff followed the trust’s infection control policy.

•The culture within children’s services had improved since the last inspection. There was a positive, open culture which valued staff and was based on shared values. The service took account of the individual needs of children and young people.

•The recording of information within patient records included good completion of risk assessments and pain scores. However, the service was in the process of transitioning from paper to electronic records and there were some inconsistencies and gaps in records due to the use of both paper and electronic notes.

However, we also found:

•Referral to treatment times were below their intended targets. Information regarding referral to treatment times was difficult to access or fully understand how the hospital was working to improve this.

•Access to services and patient flow continued to be a challenge for the emergency department. Patients were often waiting for long periods before staff moved them to an appropriate ward or department once a decision to admit and been made.

•We identified ligature risks on one ward that had not been identified in risk assessments.

•Medicines were not always stored securely and managed appropriately.

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

•There was still a lack of signage and signposting to children’s wards, the neonatal unit and clinics. There were two public access lifts to the children’s hospital and parents commented that they were sometimes late for appointments because of the queue for the lift. Parents and visitors also 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.

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.

It provides maternity and gynaecology services to the population of Tower Hamlets in east London. The hospital also provides specialist maternity services to women from other hospitals within the Barts Health NHS Trust, and fetal medicine to women from a wider geographical area. The unit delivers over 5,000 babies every year, and numbers are increasing each year.

This was an unannounced inspection. Its purpose was to follow up on concerns about the maternity services identified at previous CQC inspections in January 2015 and July 2016 respectively. Gynaecology services were not inspected on this visit.

Our key findings were as follows:

Staff told us that cultural issues identified in 2015 continued to have a negative impact on patients and staff. Although some managers were taking action to address bias and unprofessional behaviours they felt that changes were not rapid or effective enough.
Not all systems to identify, manage and capture risks and issues had improved. Mother and baby security had been identified as a risk in 2015 and although improvements had been made in physical security, it was not always effective in preventing unauthorised access to the delivery suite Staff told us unauthorised people were still able to access wards.
Arrangements for governance and performance management did not always operate effectively. There remained inconsistencies in the way some data was collected and reported, which impacted on its accuracy and reliability. The service did not always follow trust policy on incident reporting, categorisation and ensuring outcomes were promptly actioned. Systems were not always effective in monitoring the outcomes of incident reports.
Improvements had been made to staffing levels and there were enough midwives on wards during the day and at night. However, the number of clinical midwives was still below establishment. This resulted in inefficiencies on the delivery suite and the postnatal ward and meant some women did not get timely care. Consultant cover on the labour ward averaged 81 hours per week between November 2016 and April 2017, which was below the trust target of 98 hours.
Communication between managers and maternity staff and midwives, which had deteriorated at previous inspections, had improved. The majority of staff were positive about changes, but they identified some cultural issues and ineffective management styles as barriers to change.
In September 2016 we followed up on serious concerns about baby security identified on inspection in July 2016. A system to ensure that all mothers and babies had name bands had lapsed only two months after implementation. During this inspection we saw improvements had been made. All mothers and babies were wearing name bands and staff made twice daily checks which were recorded. We viewed three months of audit records which confirmed this.
Women who had given birth at the hospital’s birth centre were very happy with the way staff treated them, and appreciated the continuity of care they had from midwives. However, we otherwise received a mixed response from women and their partners. Some women and families we spoke with reported poor experiences that included not being treated with dignity and respect and having no continuity of care.
All of the clinical areas we visited were visibly clean and well maintained, with display boards detailing cleanliness and safety information.
There were specialist teams to support women who may require additional support or those with specific needs.
Some systems to identify, manage and capture risks and issues had improved. A site specific maternity risk register was in place. Action plans to address concerns from previous inspections had mitigated and reduced some risks.

Outstanding practice included:

My Body Back maternity clinic was set up with project volunteers for women contemplating pregnancy or who are pregnant. It was a charitable voluntary service for women who had experienced rape and sexual trauma. The clinic provided advice about pregnancy and birth by empowering women to develop their birth plans and strategies in preparation for labour and birth.
The service had won an award for the use of manual and vacuum aspiration enabling miscarriage to be managed under local anaesthetic without needing to go to theatre. This reduced waiting times and uncertainty for women.

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

Importantly, the trust must:

Ensure all security systems and processes are properly utilised and staff are aware of their responsibilities in this area to ensure mothers and babies are kept safe from unauthorised access to the units.
Review all overdue serious incident reports and ensure that all required actions are completed and learning is disseminated in a timely way.
Ensure governance processes for monitoring and reviewing serious incidents are applied correctly so that serious incidents are addressed in a timely way in future.
Ensure there are sufficient numbers of experienced midwives to supervise and support less experienced staff and safely manage the level of acuity of women on the labour and postnatal wards.
Ensure that all relevant staff complete children and adult safeguarding levels two and/or three to ensure compliance with the trust target of 90% completion.
Ensure that the level of consultant cover on the delivery suite meets the trust target of 98 hours.

In addition the trust should:

Consider introducing the NHS maternity safety thermometer to more accurately assess risk specifically associated with maternity care.
Ensure delivery suite coordinators have supernumerary status with sufficient allocated time and resources to carry out their oversight and support role.
Take further action to ensure compliance with the trust’s target of 90% completion of mandatory training.
Consider auditing the percentage of women presenting in labour seen by a midwife within 30 minutes so as to be better assured that all women are appropriately risk assessed and seen by the relevant professional in a timely way.
Assess demand for written information in languages other than English.
Take further action to address the perceived culture of bullying and harassment amongst midwives.
Take further action to improve cultural awareness of staff.

Professor Ted Baker

Chief Inspector of Hospitals

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

The Royal London Hospital in Whitechapel, East London is part of Barts Health NHS Trust and provides acute services to a population of approximately 242,000 living in Tower Hamlets and surrounding areas of the City of London and East London. The hospital serves a highly deprived population with a higher than average proportion of ethnic minority population, with Bangladeshi being the largest single group with 30% in Tower Hamlets.

The trust employs around 15,000 staff with approximately 1703 nursing and midwifery staff based at the hospital.

We inspected this location in a direct response to the concerns we found at Whipps Cross University Hospital, another hospital run by the trust and concerns raised by a number of sources including members of the public and commissioners. We spoke with approximately 150 patients and relatives and over 350 members of staff.

Overall, we rated this hospital as 'inadequate'. The critical care service was rated as good however we found that urgent and emergency care, medical care including care of older people, surgery, maternity and gynaecology services and outpatients and diagnostic imaging all required improvement. We found that services for children and young people and end of life care was inadequate and significant improvement is required in these core services.

In order to provide safe, effective and responsive care that is well led to the needs of patients, this hospital requires significant improvements.

Our key findings were as follows:

The organisational structure of the Clinical Academic Groups did not always facilitate robust and effective governance arrangements and visible local leadership.
Hospital specific performance information was not always available and senior leaders did not have the information they needed to be assured about the quality and safety of the service being provided.
There was a culture of bullying and harassment and we have concerns about whether enough is being done to encourage a change of culture to be open and transparent.
The trauma and emergency service provided excellent outcomes for patients.
Staffing was a key challenge across all services. there was a high use of bank and agency nursing staff and locum medical staff who were not always familiar with the hospitals policies and processes and did not always have access to IT systems that held patient information.

Safe

There was not always enough nursing and medical staff to ensure safe care. However there was a high fill rate on bank and agency which meant when it was identified that staff were needed they were provided. Whilst some areas were displaying safety thermometer information, they were not displaying planned and actual nursing and nursing assistant/healthcare assistant staffing numbers and who was in charge for each shift in the clinical area that was accessible to patients, their families and carers, in line with NHS England guidance.
There was not sufficient information documented in patients records to ensure safe quality of care.
Patients needs were not always assessed and responded too.
Safeguarding arrangements were in place and were followed in most circumstances, although we identified some instances where this was not the case.
Most staff were familiar with the incident reporting system. However lessons learnt were not always known or widely shared with staff. Within surgery there had been three Never Events relating to wrong site surgery within a three month period and not all staff were aware of the learnings from these incidents. At the time of our inspection there were 100 incidents overdue for investigation in the children's and young people service.
The WHO Surgical Safety checklist was not sufficiently audited.
Medicines management was variable, but overall was safe.
Infection control principles were adhered to and monitored in most areas apart from hand hygiene auditing in some surgical theatres.

Effective:

Most staff lacked an understanding of the Mental capacity Act 2015 and Deprivation of Liberty Safeguards (DoLs) and how it applied to their roles.
Evidence-based care and treatment was provided. However some guidelines and policies were out of date regarding children and young people and end of life care.
There was lots of multidisciplinary working, and seven-day working was in progress across all disciplines. The services had good joint up working with mental health specialists.
Patient outcomes were at or better than the national average across most medical and surgical specialties.
Overall pain relief was well managed.
The nutrition and hydration needs of patients were met.
Patients were largely given sufficient information about their treatments and had the opportunity to discuss any concerns.

Caring:

Staff were caring and compassionate and interacted well with patients.
Most patients and relatives were satisfied with the care and support they received and felt that staff listened to them and were compassionate.
Patients had their privacy and dignity respected.
Information was available to people and shared with them so they could be fully informed about their care.
Chaplaincy and bereavement services demonstrated a caring and compassionate approach to working with people.

Responsive:

The average bed occupancy from April to December 2014 was 95%. This impacted on the flow of patients throughout the hospital. Patients were cared for in recovery, or transferred out of critical care for non clinical reasons.
The emergency department was not meeting the national four-hour waiting time target. This target was introduced by the Department of Health for NHS acute hospitals in England, and sets a target that at least 95% of patients attending emergency departments must be seen, treated, admitted or discharged in under four hours.
The hospital was persistently failing to meet the national waiting time targets. Some patients were experiencing delays of more than 18 weeks from referral to treatment (RTT). The trust had suspended reporting activity to the department of health and had started a recovery plan.
Patients well enough to leave hospital experienced significant delays in being discharged because of documentation needing to be completed.
Operations were often cancelled due to a lack of available beds.
Complaints were not always managed in a timely or appropriate manner.
Bereavement services were well organised and responsive to people’s needs.
Plenty of information was available to patients in written form; however, this information was only provided in English, and not in the language of the predominant population served by the hospital.
Translation services were available when required.

Well-led:

Performance dashboards and information was unreliable. Senior staff did not always have the information they needed to have oversight of the services they led.
There were some examples of good local leadership, and most staff felt supported by their immediate line managers. However, the trust-wide senior managers did not support local managers well.
Governance and risk management was monitored in some instances, but improvements were not consistently made.
Innovation was prevalent in the trauma and emergency centre.
The financial position of the trust impacted on the volume of innovation, improvement and sustainability initiatives of the services.

We saw several areas of outstanding practice including:

Senior staff were trialling the Multidisciplinary Action Training in Crises and Human Factors initiative (MATCH). This was a framework within which Never Events and Serious Incidents could be discussed in an environment characterised by mutual respect and in which lessons learnt could be quickly introduced without damaging personal relationships. It was reported that initial results had been very promising. However, staff reported that whilst there had previously been plans to introduce this across the Trust, the financial pressures meant this was on hold.
The hospital is a pioneer in trauma care. 25% of the patients attending the trauma service as an emergency had penetrative wounds, which is significantly higher than any other UK trauma centre. However, the survival rate at the hospital was better than the national average and the service had regular national and international visitors wanting to learn from the service. The service had worked with the Armed Forces whilst on combat operations and had taken specific learning from this and applied it to the service.
In particular, the Trauma service in conjunction with military colleagues had developed the concept of the ‘platinum ten minutes’ based upon techniques used to help save the lives of soldiers in combat situations. Through the use of fluid, plasma, active surgical intervention and rapid assessment at the scene more patients were arriving at hospital alive.
The Royal College of Physicians audit of stroke care rated the hospital as 97.5% for patient experience from diagnosis to rehabilitation - the highest result in London.
A surgeon had become the first in the UK to broadcast online a live surgical procedure using a pair of Google Glass eyewear. The procedure was watched by 13000 surgical students around the world from 115 countries and they also had the opportunity to ask the surgeon questions.
In the week following the inspection the service was running an initiative entitled “Stepping Into the Future”. This was a trial run of a new operating model that, it was hoped, would help relieve some of the flow and access issues in the service. Initiatives that would be tried would include ring fenced surgical elective beds, no non-clinical cancellations on the day, surgery not starting without an available ITU/HDU bed, and trauma and orthopaedics to concentrate on emergency admissions only.

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

Importantly, the hospital must:

ensure safety is a sufficient priority in all services.
ensure all services are well-led.
take further action to improve and address the perceived culture of bullying and harassment.
address the capacity issues across the hospital.
ensure performance dashboards and information are reliable and service specific. Senior staff must have the information they need to have oversight of the services they lead.
address the lack of data specific to services at the hospital.
ensure governance and risk management processes are robust and embedded throughout the hospital.
ensure incidents are investigated promptly and the learning from incidents, complaints and never events is shared across the services.
ensure audits are carried out to identify areas for improvements and implementation is monitored.
ensure all policies are based on current and best practice guidelines.
urgently improve security in the maternity services.
ensure staff carry out and document assessments of patient's needs to ensure the planning and delivery of care meets their needs.
ensure nursing records are completed fully and accurately to ensure patient safety.
ensure there are sufficient numbers of suitably qualified, skilled and experienced medical staff to met the needs of patients. In particular in maternity and children's services.
ensure there are sufficient numbers of suitably qualified, skilled and experienced nursing staff to met the needs of patients. Staffing levels must meet the Royal College of Nursing staffing guidelines and the Core Standards for Intensive Care Units.
take definitive action to reduce the Referral to Treatment Time and ensure accurate reporting.
reduce the number of cancelled procedures and operations.
ensure the induction process for agency staff working in critical care needs to be consistent and monitored.
ensure all staff have an understanding of their responsibilities under the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. Staff in Urgent and emergency services clearly understood their role however other services were not clear.
ensure there is enough surgical equipment for children.
ensure the do not attempt cardio-pulmonary resuscitation (DNA CPR) form and the new DNA CPR policy are clear and in keeping with any recent ruling or guidance.
ensure that all relevant ward staff receive training specific to managing patients at the end of their lives.
ensure there is a policy on the consistent use of opioids.
reduce patient waiting times in outpatient clinics.

The trust should:

ensure all staff follow infection prevention and control guidance in all medical services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The Royal London is a teaching hospital that offers a full range of local and specialist services, including one of the largest children's hospitals in the UK and one of London's busiest children’s accident and emergency departments. The hospital is part of Barts Health NHS Trust, which brought together the former Barts and the London NHS Trust, Newham University Hospital NHS Trust and Whipps Cross University Hospital NHS Trust in April 2012.

We chose to inspect Barts Health NHS Trust as one of the Care Quality Commission (CQC) Chief Inspector of Hospital’s first new inspections because we were keen to visit a range of different types of hospital, from those considered to be high risk to those where the risk of poor care is likely to be lower. Barts Health NHS Trust was considered to be a high-risk provider.

One of London’s oldest hospitals, the Royal London was founded in 1740. To support modern healthcare delivery, the old hospital was recently demolished and replaced by new, state-of-the-art buildings. The new Royal London Hospital opened on 1 March 2012.

CQC has inspected the Royal London Hospital twice since 1 April 2012. On our most recent inspections in November 2012 and June 2013, we issued five compliance actions to the trust. As part of our November 2013 inspection, we did not assess whether the trust had addressed these shortfalls, as the deadlines for completing the trust’s action plans had not been reached. These areas will be subject to a further inspection early in 2014.

Our inspection team included CQC inspectors and analysts, doctors, nurses, allied health professionals, patient ‘Experts by Experience’ and senior NHS managers. We spent three days visiting the hospital. We spoke with patients and their relatives, carers and friends and staff. We observed care and inspected the hospital environment and equipment. We held one listening event in Shadwell and heard directly from people about their experience of care. Before the inspection, we also spoke with local bodies, such as clinical commissioning groups, local councils and Healthwatch.

Maternity Services:

Most of the mothers experienced care, treatment and support that met their needs and protected their rights. We were satisfied that people's health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others. However, we found that staff did not always treat mothers using the hospital with dignity and respect and their privacy was not always observed.

There were not enough qualified, skilled and experienced staff to meet mothers' and their babies' needs. In addition maternity staff did not always feel supported and listened to by their senior managers.

Elderly Care:

People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

Patients did not always receive appropriate care and treatment. Staff did not always update patients' care plans when people's needs changed; for example when people had pressure ulcers. Care plans were not always kept up-to-date. There was no sufficient care plan documentation in place to demonstrate that patients' care needs were being met in relation to safe management of their pressure areas. We also found that discharge systems were not always safe. Patients were therefore at risk of being discharged without appropriate support systems in place.

There were staff shortages, which meant that nurses had less time to spend with each patient. In addition, one of the wards did not have a person in charge and the position was vacant. Staff told us that because of shortage of staff they struggled to maintain basic care standards. Although improvements had been made to support staff, they did not always receive appropriate supervision. However, Barts Health had an effective system to regularly assess and monitor the quality of service that people receive. Comments and complaints people made were responded to appropriately.

As part of our inspection we looked at care in Accident and Emergency (A&E) and two elderly medicine wards. We observed staff speaking with patients politely and with respect. Most people who spoke with us were satisfied with the quality of care offered to them.

One person told us, 'nursing care is terrific, ever so kind, nothing is too much bother.' Another patient said, 'nurses treat me well, my treatment is explained (...).'

Patients were able to express their views and were involved in making decisions about their care and treatment. People felt nursing and medical staff were 'kind' and explained treatments to them. Care and treatment was planned and delivered in a way that ensured patient's safety and welfare.

There were effective systems in place to reduce the risk and spread of infection.

Patients and their relatives told us they liked the new building, however they found it confusing because of the lack of signs.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard most of the time. However staff did not always receive appropriate supervision and appraisal.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

The Royal London Hospital

All Inspections

17 August 2022

During an inspection looking at part of the service

8 September 2021

During an inspection looking at part of the service

18 May 2021

During an inspection looking at part of the service

10 - 12 December 2018

During an inspection looking at part of the service

11 September to 11 October 2018

During a routine inspection

8-9 June 2017

During an inspection looking at part of the service

Professor Ted Baker

26 - 29 July 2016

During a routine inspection

Professor Sir Mike Richards

21 - 23, 30 January 2015, 4 and 6 February 2015

During a routine inspection

Professor Sir Mike Richards

7 November 2013

During an inspection

5-7 and 15 November 2013

During a routine inspection

4, 5 June 2013

During a routine inspection

20, 21 November 2012

During a routine inspection

20 March 2012

During a themed inspection looking at Termination of Pregnancy Services