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Newham University Hospital Requires improvement

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

We are carrying out checks at Newham University Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 28 April 2017

Newham University Hospital, in Plaistow, East London is part of Barts Health NHS Trust, the largest NHS trust in the country. The hospital offers a range of acute services to a population of approximately 300,000 people living in the London Borough of Newham. The hospital has approximately 344 inpatient beds, with over 1548 staff working there. The services the hospital provide include The Gateway Surgical Centre that offers elective surgery and diagnostic procedures in many different specialties, as well as housing the Trust's sports injuries clinic and fracture clinic.

Newham is deprived, coming third out of 326 of local authorities, with 80% of the local population having a minority ethnic background. The population is predominantly young, with the majority of residents aged between 20 and 39.

As part of an inspection we carried out in 2014/15 of Barts Health NHS Trust, we inspected Newham University Hospital in January 2015 and rated the hospital overall as inadequate. Since 2015, significant changes were made to the leadership of the organisation at both an executive and site based level. We therefore recently returned to inspect Barts Health NHS Trust to follow up on our previous findings where we had found a number of concerns around patient safety and the quality of care. In July of this year we carried out an inspection of Whipps Cross Hospital and The Royal London Hospital, and returned to inspect Newham University Hospital on 1 November 2016.

We returned on this occasion to carry out a focused, unannounced inspection of five core services: Medicine (including older people’s care), Surgery, Maternity & Gynaecology, End of Life Care and Services for Children.

Our key findings were as follows:

Are services safe?

  • Insufficient consultant cover in maternity resulted in less than 50% of women in labour with a consultant present on the labour ward. Staff told us this meant patients were waiting longer for pain relief and treatment.

  • Maternity services lacked enough appropriately skilled midwives to meet the demand of a high proportion of complex cases. Despite this, staff did their best to ensure they provided the best care.

  • Systems were in place to ensure that incidents were recorded, and staff were predominantly familiar with the process. However, incidents were not always investigated in a timely way. In maternity services there was a backlog of more than 150 incidents waiting to be reviewed. Whilst incidents related to end of life care were not easily identifiable.

  • Learning from incidents was not consistently shared amongst staff. However, in medical care, we found root cause analyses were comprehensive and senior consultants had begun to develop a tracking system for factors that contributed to such incidents.

  • There was insufficient consultant cover in end of life care services.

  • At the previous inspection in May 2015, the security of babies in maternity services had been identified as a risk because of insufficient staff to monitor access to the unit. Although approval had been given, security measures had not been implemented and this remained a concern.

  • There were low levels of training amongst certain groups of staff in Level 2 safeguarding adults and safeguarding children.

  • Compliance levels with the World Health Organisation (WHO) surgical safety checklist were inconsistent, especially in The Gateway Centre.

  • We found that infection control procedures were not followed for safe storage of deceased patients in the mortuary. We found that the mortuary area was dirty and there were no daily cleaning check lists available for completion by staff.

  • Mortuary fridge temperatures were not routinely checked. There was no policy to determine correct transfer of deceased patients in the event of a fridge breakdown

  • Sluice rooms on surgery wards were not always locked and chemicals were easily accessible.

  • Hazardous waste was not always managed in line with national and international best practice safety guidance, including in storage and access control.

However:

  • There were no surgical site infections for knee and hip replacements between October 2015 and June 2016.

  • Medical care services reported no never events between October 2015 and September 2016.

  • There were improvements in the number of maternity patients with management plans in their notes. Use of the modified early obstetric warning score (MEOWS) chart was at 97%.

  • The hospital and community midwifery team worked proactively to support women to breastfeed and provided continuing support to women at home. The percentage of women breastfeeding remained high.

  • There was good compliance with infection control training on surgical wards.

  • On medical wards staff demonstrated consistent infection control practices in relation to hand washing, decontamination of the use of personal protective equipment and adherence to the bare below the elbow policy.

  • Risks to children and young people were assessed, monitored and managed on a day-to-day basis; and risk assessments were child-centred, proportionate and reviewed regularly.

  • There were business continuity and major incident plans in place. Senior staff were aware of the plans and were able to explain their roles in the event of an interruption to normal service.

Are services effective?

  • Between March 2015 and February 2016, patients had a higher than expected risk of readmission than the national averages for both elective and non-elective medical admissions.

  • In the 2015 National Lung Cancer Audit, 64% of patients were seen by a cancer nurse specialist. This was lower than the audit minimum standard of 80% and all measurements in the audit were below national targets. General hospital performance had deteriorated since 2014.

  • Performance in the national lung cancer audit indicated the hospital had deteriorated in standards, including a 26% reduction in the number of patients who were seen by a cancer nurse specialist.

  • Some staffing issues in maternity services impacted on women receiving timely pain relief.

  • Results from the patient-led assessment of the clinical environment (PLACE) indicated significant deficiencies in the provision of appropriate nutrition for patients living with dementia. However, the dementia and delirium team had introduced improved monitoring of food and fluids for patients living with dementia as well as improvements to staff competencies, training and resources.

  • Rainbow Ward was unable to deliver adequate pain management for patient controlled analgesia (PCA) and nurse controlled analgesia (NCA).

  • Patient Reported Outcome Measures (PROMs) were worse than the England average for most measures.

  • The trust contributed to the National Care of the Dying Audit (NCDA). The trust was below the England average on three out of the five clinical indicators and only achieved one out of the five organisational key performance indicators (KPI).

  • An audit of the use of the Compassionate Care Plan (CCP) undertaken by the specialist palliative care team showed that only 8 (28.6%) out of 28 sets of patient notes had a documented CCP in their notes.

  • The end of life CQUIN audit undertaken in August 2016 looked at 17 deceased patient notes. These showed that only 6 patients (35.3%) had their preferred place of care (PPOC) documented and only one patient was transferred to their PPOC.

  • Not all the patient records we reviewed had pain assessments recorded, despite having diagnosed conditions which often cause pain and discomfort.

  • Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) audits for the period January 2016 to October 2016 showed that 66.6% (201) forms were completed incorrectly.

  • Levels of training in Mental Capacity Act and Deprivation of Liberty Safeguards were 74.4% which was below the Trust target of 90%

However:

  • Medical services presented a comprehensive programme of 73 audits, pilot programmes and benchmarking exercises that took place in 2015/16, which staff used to establish compliance with national best practice guidance. Learning from audits was evident and staff demonstrated a commitment to on-going improvements.

  • The hospital achieved a B grading in the Sentinel Stroke National Programme in March 2016, reflecting effective practice.

  • Procedures and policies were up to date and reflected recent evidence for best practice and NICE guidelines in CYP services.

  • Performance in the 2015 Heart Failure Audit was better than the national average for all four standards relating to inpatient care and in three of the seven standards relating to discharge. This included higher performance than the national average in multidisciplinary working, including in referrals to cardiology follow up and the heart failure liaison service.

  • Outcomes for women and their babies in maternity services were within national guidelines.

  • The maternity service was working towards level 3 of the UNICEF UK Baby Friendly Initiative to promote good care for new-born babies.

  • There was a weekly hospital palliative care multidisciplinary meeting. Medical staff, nurses, social services and the chaplaincy attended this meeting.

  • The hospital performed higher than the national average in the national British Thoracic Society Smoking Cessation Audit, with smoking status documented in 90% of records compared with 80% nationally.

  • Multidisciplinary working and information sharing between wards and departments was effective.

  • Surgical pathways were delivered in line with referenced national clinical guidance.

  • There was effective pain management provision available in surgery.

  • There were good continuing professional development opportunities for staff.

  • All eligible nursing and medical staff had in-date revalidation at the time of our inspection.

Are services caring?

  • We observed kind and compassionate care given to patients. Children, young people and parents were observed to be treated with dignity, respect and kindness during interactions with staff and relationships with staff were positive.

  • However, in medical services, scores relating to privacy, dignity and wellbeing assessed in the patient-led assessment of the care environment audit (PLACE) indicated a sustained decline of 25% in scores between 2013 and 2016, with 2016 results ranging from 45% to 80% for individual wards.

  • The majority of patients we spoke with were happy with the care and treatment they received. However, women using maternity services commented that at times there was a lack of respect, care and compassion and that midwives were often abrupt.

  • Women using maternity services described good support around the choice of place of birth, including home birth and partners were welcome to stay.

  • The trust had developed a Compassionate Care Plan to replace Liverpool Care Pathway for end of life care patients. However, we did not see evidence that this document was embedded across the trust.

  • Palliative care patients were not prioritised for side rooms and there was a lack of facilities for dying patients and their relatives.

  • The results from the bereavement survey undertaken between January and September 2016 showed that only 8% (1) of the respondents rated their overall experience as excellent, and only 15% (2) rated their experience as good.

  • There was a poor response rate to the Friends and Family Test. Albeit, that recommendations rates were generally high.

Are services responsive?

  • Although 140 additional bed days had been provided in September 2016 and October 2016 to meet winter pressure demand, the hospital could not fully staff these

  • The trust suspended reporting on all 18-week referral to treatment target (RTT) waits from September 2014 and had not resumed reporting at the time of this inspection.

  • There was variation within surgical specialisms about length of time taken to respond to complaints.

  • Staff reported regular difficulties meeting demand in the maternity unit. This caused delays, including in planned induction of labour and in elective caesarean sections.

  • The recovery facilities in theatre were not child friendly due to an absence of a recovery bay with appropriate décor.

  • Emergency readmissions for non-elective patients under the age of one year and children between the age of one and 17 years were worse than the England average.

However:

  • Between April 2015 and March 2016 the average length of stay for non-elective medical patients was 3 days, which was lower than the national average of four days.

  • The hospital had implemented a patient flow coordinator role that worked proactively with a dedicated discharge consultant to prioritise medical discharges at weekends.

  • The Greenway Centre provided daily walk-in appointments with a 60-minute target for each patient to be seen. Staff in the endoscopy unit were able to see patients who urgently needed a procedure but who had mixed up their appointment time.

  • In response to the needs of the local population, a dedicated overseas team provided support and liaison for patients with complex needs around immigration, refugee or asylum status.

  • An enhanced care bundle had been introduced to each inpatient ward area that provided staff with a care pathway and contacts to help those with complex social needs.

  • Flow within the surgery system was well managed and theatre utilisation was around 84%.

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

  • There was a substantial decrease in the percentage of surgical patients not treated within 28 days.

  • There was an enhanced recovery programme and joint school for patients booked to have a hip or knee replacement.

  • Between April and October 2016, 97% of end of life care patients had been seen by the specialist palliative care team within 24 hours of referral.

  • Complaints were dealt with effectively, with learning identified, implemented and shared. Staff apologised to patients where a mistake had been made and offered a resolution to the problem.

  • West Ham Ward was not a purpose built paediatric ward. However, The Rainbow Unit rebuilding project would provide modern inpatient and outpatient facilities for children and young people and was due to open in February 2017.

Are services well led?

  • There were concerns about the categorising and length of time the trust took to complete incident reports and serious case reviews. Targets were not being met and there were concerns about the processes for managing incidents. There was a lack of evident assurance that learning was properly followed up and embedded.

  • The risk register in maternity services did not reflect all the current risks. For example, it did not include the low levels of consultant cover in maternity services or the possible risks to patients.

  • The hospital senior management team did not have sufficient oversight of the mortuary as it was managed centrally from Royal London Hospital by the Clinical Support Services which operated trust wide.

  • The trust had an End of Life Care Strategy 2016 - 2019, which was based on the 5 priorities of care for the dying. This had been ratified by the trust on the 19th October 2016. However staff we spoke with were not aware that the strategy had been ratified by the trust and many nursing staff knew nothing about it.

  • Many staff told us that culture and morale was much improved since the time of the last CQC inspection in Jan 2015. However, medical staff spoke variably of morale and working culture, including individuals who said they were concerned about the long-term impact of morale because of high levels of sickness and vacancies in nursing teams.

  • A small proportion of staff said that there were pockets of bullying and harassment in existence.

  • There was limited evidence of consistent and structured leadership on some wards, including on Tayberry ward and Silvertown ward. On Tayberry ward there was evidence staff did not always feel safe because of short-staffing and the volume of work.

  • Medical staff did not always feel they were recognised for their skills, supported to develop or had access to appropriate management support.

  • Staff engagement in the most recent NHS staff survey was lower than the national average.

  • Although some services such as the endoscopy unit and Greenway Centre conducted their own patient engagement programmes, there was limited evidence information from engagement was used at a hospital-wide level.

However:

  • There was a clearer governance structure with clearer lines of management accountability across services at Newham University Hospital, following Barts Health NHS Trust introduction of a new leadership operating model in September 2015. Many staff reported this as a positive and effective change.

  • A quality improvement programme that included monthly monitoring of staff engagement, safety improvements, patient feedback and access and flow performance, had led to an increase in staff engaged through social media, over 1000 staff engaged through face-to-face meetings and a 6% increase in compliance with staff training between March 2016 and June 2016.

  • Individual specialist teams were empowered to establish new policies and improve existing policies as a result of patient engagement

  • Although some difficulties remained in gaining the support of midwifery staff affected by changes the trust had imposed, morale among many midwives had improved since the last inspection.

We saw several areas of outstanding practice including:

  • Safeguarding practices in the Greenway Centre were highly specialised and staff proactively developed these to meet the increasingly complex needs of the local population. This included multidisciplinary specialist input and monthly tracking of patients with specific needs, including through the provision of advocates who spoke Romanian or Portuguese.

  • Staff took innovative steps to improve engagement with patients living with diabetes. For example, to improve the care of young people with diabetes, staff introduced remote video chat appointments. This reduced the number of wasted appointments and patients gave very positive feedback about the flexibility this afford them.

  • Staff introduced innovative measures to improve access and flow, particularly at a weekend. This included the implementation of consultant-led discharge ward rounds and a new patient flow coordinator post. In addition staff had negotiated 24-hour, seven-day-a-week access to a social worker that meant complex discharges could be planned outside of the previous Monday to Friday model.

  • An overseas team provided dedicated support to patients cared for on an inpatient basis who had complex needs relating to immigration, asylum or refugee status.

  • There was a clear, sustained focus on offering opportunities to student nurses and medical trainees. Feedback from site visits by sponsoring universities were consistently good with continuous levels of compliance against quality markers for developmental education.

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

Importantly, the trust must:

Services for children

  • The trust must ensure incidents are investigated in a timely way and in accordance with published guidance. 12 (2)(b)

Maternity

  • The trust must ensure steps are taken to provide additional consultant posts to mitigate the risks and meet the care and treatment needs for women and babies at NUH. 18 (1)

  • The trust must ensure that measures to ensure the security of babies in maternity services are implemented. 15 (1)(b)

  • The trust must ensure the backlog of incidents awaiting review are addressed; and serious incidents are correctly identified. 17 (2)(a)(b)(f)

  • The trust must ensure learning from incidents, complaints and peer reviews is used for the purposes of continually evaluating and improving services.17 (2)(e)(f)

  • The trust must ensure staff are clear about their roles and responsibilities under legislation around capacity and deprivation of liberty. 11(3) & 13(5)

End of Life Care

  • The trust must ensure that reporting processes are able to identify, review and learn from information that relates to the end of life care it provides such as through complaints, incidents and satisfaction surveys. 17(1)(2)(a)(b)

  • The trust must ensure that the Compassionate Care Plan it has developed is embedded across the hospital. 9(3)

  • The trust must ensure that it meets the national guidance [‘Commissioning Guidance for Specialist Palliative Care: Helping to deliver commissioning objectives’ (Dec 2012.)] which recommends a minimum requirement of 1 whole time equivalent consultant in palliative medicine per 250 hospital beds (NUH has 344 beds). 18(1)

  • The trust must ensure that systems and processes are in place to enable proper management and oversight of the mortuary to be assured. 17(1)

  • The trust must ensure that standards of cleanliness and hygiene are maintained in the mortuary. 15(1)(2)

  • The trust must ensure that the premises and equipment within the mortuary are properly maintained and fit for purpose. 15(1)(c)(e)

  • The trust must ensure there are systems in place to determine appropriate transfer of deceased patients in the event of a fridge breakdown. 17(1)

  • The trust must ensure that pain for patients at the end of life, is properly assessed and treated.9(3)(a)(b)

  • The trust must ensure that Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms are completed correctly. 9(1)(a)(b), 11(1)

  • The trust must ensure that due consideration is given to the privacy and dignity of patients at the end of life in relation to facilities available for them and their relatives. 10(1)(2)(a)

  • The trust must ensure that systems are in place to effectively monitor the effectiveness of services provided to the dying patient in relation to its fast track process and patients’ preferred place of care. 17(1)(2)(a)

In addition the trust should:

Medical care

  • The trust should ensure learning from infection prevention and control audits is communicated to all staff.

  • The trust should ensure interpreting services are readily and proactively provided to reduce the safeguarding risk associated with relying on relatives and friends to interpret clinical care.

  • The trust should ensure the nutritional and hydration needs of patients are met. This includes patients with complex needs including dementia, co-morbidities and where they are cared for as a medical outlier.

  • The trust should ensure premises and equipment are clean and secure in relation to the control of substances hazardous to health.

  • The trust should ensure staffing levels are actively monitored and reflected accurately in daily safer staffing meetings. This means the senior nurse in charge on each ward should agree with the staffing level reflected by the site manager in the safety briefing.

  • The trust should ensure staff are supported to work safely and effectively through the provision of consistent and structured support.

  • The trust should ensure nurses have access to training and professional development in line with their career plans and/or professional development plan.

  • The trust should ensure staff who wish to undertake additional qualifications relevant to their role are supported to do so.

Surgery

  • The trust should ensure there is clear differentiation between adult and paediatric resuscitation equipment on the resuscitation trolley.

  • The trust should ensure there is good compliance with all steps of the World Health Organization surgical safety checklist.

  • The trust should ensure that referral to treatment time is evidenced.

  • The trust should ensure that all staff have level 2 safeguarding training and safeguarding children.

  • The trust should ensure all staff have training in Mental Capacity Act and Deprivation of Liberty Safeguards.

  • The trust should ensure that there is better feedback about incidents to surgery staff and that there is shared awareness of the top three departmental risks.

  • The trust should ensure sluice room doors on surgical wards are kept locked and all chemicals are locked away in a cupboard.

  • The trust should endeavour to recruit to anaesthetic staff grade vacancies.

  • The trust should improve upon data collection of appraisal rates.

  • The trust should improve upon Patient Reported Outcome Measures (PROMs) measures.

Services for children

  • The trust should ensure infection prevention and control on Rainbow Ward always complies with the trust’s policies for infection prevention and control.

  • The trust should ensure expressed breast milk is stored separately from other products.

  • The trust should address maintenance issues in a timely way, ensuring thorough investigation and repairs.

  • The trust should ensure CYP services should have a robust plan and system of clinical audit in place to monitor adherence to evidence based practice.

  • The trust should ensure staff on the NNU make themselves aware of the UNICEF Baby Friendly accreditation programme, a global accreditation programme to support breast feeding.

  • The trust should ensure Rainbow Ward delivers adequate post-operative pain management of children.

  • The trust should ensure there are facilities for parents to prepare or purchase food.

  • The trust should ensure there is a range of information leaflets for children and their parents or carers across both Rainbow Ward and the NNU.

  • The trust should improve recovery facilities in theatres to ensure areas for children are child friendly with appropriate décor.

  • The trust should improve on emergency readmissions for non-elective patients under the age of one year and children between the age of one and 17 years.

  • The trust should develop a long-term local strategy for CYP services.

  • The trust should ensure the agendas for governance meetings always reflect the governance meetings terms of reference.

  • The trust should ensure identified risks are always included on the trust’s risk register in a timely way, and record actions the service is taking to mitigate risks clearly on the risk register.

Maternity

  • The trust should ensure further recruitment to providing sufficient number of appropriately skilled midwives to meet the needs of the service.

  • The trust should consider funding for staffing a second obstetrics theatre to improve waiting times for caesarean

  • The trust should ensure better working relationships across the maternity service; fostering better communication and morale.

  • The trust should ensure that midwifery staff are supported to attend the role specific training programme.

End of Life Care:

  • The trust should ensure that medical and nursing files are easy to navigate and in order.

  • The trust should give consideration to all services that link in to the overall vision of end of life care, such as chaplaincy and therapies, in its draft business case to increase staffing.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 28 April 2017

Effective

Requires improvement

Updated 22 May 2015

Caring

Good

Updated 22 May 2015

Responsive

Requires improvement

Updated 22 May 2015

Well-led

Requires improvement

Updated 28 April 2017

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 28 April 2017

There was insufficient consultant cover resulting in less than 50% of women in labour with a consultant present on the labour ward. Staff told us this meant patients were waiting longer for pain relief and treatment.

Out of hours medical cover at all levels was overstretched, leading to delays in care. The trust had not approved the proposal to fund additional consultant posts at the time of our inspection.

Although there had been some staff recruitment there were shortages of midwifery staff at the time of our inspection. Many midwives were inexperienced and midwives were overstretched. The trust had recruited additional nursing staff from overseas that were expected to be in post by the end of October 2016. Seventeen newly qualified band 5 nurses had been recruited but that still left 14 whole time equivalent (WTE) vacancies across midwifery services. The service had submitted a paper to the trust board outlining the case for further recruitment. Several staff told us that the lack of appropriately skilled midwives meant they were often spread thinly and this could impact on women’s care.

There were concerns about the management of incidents and serious incidents. There was a backlog of more than 150 incidents waiting to be reviewed, which had led to a delay in learning. However, the trust were working closely with commissioners to review overdue serious incidents and incidents, with a plan for completion by December 2016.

Trust guidelines for the reporting of serious incidents and root cause analyses were being followed. However, not all incidents were correctly identified as a serious incident. We saw examples where similar outcomes had been categorised differently and the reason given by the trust did not follow their own policy.

There was only one staffed obstetric theatre. Many staff commented on the difficulties this caused for women such as having to wait longer for a caesarean. This was raised as a concern at the last inspection. In response a bid had been put forward for funding for staffing a second theatre; however this had not progressed. Staff were dependent on operating time being available and nursing and medical staff being available to use the second theatre.

At the last inspection staff told us they felt like the poor relation to one of the trust’s other acute hospitals even though Newham University Hospital had the larger maternity unit. They perceived the senior leadership as remote and that leaders imposed decisions rather than listening to the concerns and ideas for improvement. At this inspection we found staff repeating the same concerns. Several staff commented that middle managers as well as senior managers were not listening to them.

Mortality and morbidity meetings were held regularly and doctors gave presentations on specific cases. It was not clear how learning was drawn from this or how it influenced future practice because no minutes or actions were recorded.

Some staffing issues impacted on women receiving timely pain relief. Some women had to wait longer than 45 minutes when an epidural anaesthetic was called for, exceeding national guidance. Midwives had to regularly call on operating department practitioners (ODPs) from the main theatres for epidurals, which also delayed pain relief for some women.

At the previous inspection in May 2015, the security of babies in maternity services had been identified as a risk because of insufficient staff to monitor access to the unit. Although approval had been given, security measures had not been implemented.

Midwifery, nursing and medical staff were not up to date with safeguarding adults and safeguarding children’s training. The trust had not met its targets for medicines management and equality and diversity training in midwifery services.

Most staff we spoke with were not clear about their roles and responsibilities under legislation around capacity and deprivation of liberty. Staff responses were variable and several staff thought it was about health and safety issues.

There was an effective training programme for midwifery staff, although some midwives felt they did not have time to develop their skills outside the framework of mandatory training because they were so busy. Trainee doctors were well supported and had opportunities to put their learning into practice

However, we also found:

Staff did their best to ensure they provided the best care they could. A clinical educator had been employed to support recently recruited midwives from overseas to the hospital. The practice development midwife had recently been supported with administrative support to help with maintaining an accurate database of staff training.

The education team had a rolling system for looking at skills gaps and putting in place development opportunities for midwifery staff. There were 12 supervisors of midwives and a preceptorship programme for band 5 and 6 midwives. Supervisors of midwives helped to develop all midwives’ skills and expertise. Several staff commented on the benefit in having a named member of staff to refer to if they had any concerns or queries.

Some women we spoke with were happy with the care they had received. They were treated with dignity and their privacy was respected. Women were informed and involved in their care and treatment.

There was a clear care pathway in the maternity unit, according to women’s clinical needs. Women felt that the level of communication from midwives and doctors was good. They felt listened to and well supported.

The inpatient environment was spacious and clean. Women were involved in choices about their care; there were initiatives to encourage natural birth.

Processes were in place to assess and manage risk. These included the use of team briefings and the World Health Organisation (WHO) surgical safety checklist in obstetric theatre

Medical care (including older people’s care)

Good

Updated 28 April 2017

Annual nurse turnover had stabilised at an average of 9% between March 2016 and May 2016, which was better than the trust target of 14%.

Daily multidisciplinary safety huddles enabled staff to identify patients who were deteriorating, review patients with complex needs and plan for safe and effective discharges.

The hospital achieved a B grading in the Sentinel Stroke National Programme in March 2016, reflecting effective practice.

In response to an increasing number of patients living with dementia and those with needs such as alcohol dependency, a nursing team had introduced an enhanced care bundle. This helped ward staff and other clinicians to provide person-centred care and treatment planning that was adaptable to individual needs.

A patient flow coordinator role and dedicated discharge consultant worked together to plan discharges and ensure each patient had a package of care in place as well as prescribed to take home medicine where needed. This team had established innovative links with local social services, who provided 24-hour seven day cover to help reduce discharge delays by providing a single point of referral for patients with community social needs. The endoscopy unit had reduced the backlog for procedures and six-week-wait breaches by 76% to August 2016 through improved staffing and equipment reliability.

The hospital demonstrated it was responsive to local needs and challenges. For example, a dedicated overseas team provided specialist liaison and support with immigration authorities and the police to help patients with complex immigration, asylum or refugee status needs. This meant patients could be discharged safely without putting them at risk and without blocking bed capacity in the hospital.

Staff spoke positively about the introduction of a ward manager role, which they said helped to stabilise their teams and provide a structured approach to local leadership support. Ward managers had increased their clinical presence to 40% of their workload, which meant they were more visible and readily available to clinical staff.

Performance in the national heart failure audit was significantly better than the national average. This included a 38% higher overall compliance rate with cardiology inpatient care and a 34% higher rate of consultant cardiologist input.

An enhanced care bundle enabled staff to provide person-centred holistic care. The tool could be adapted for patients with a learning disability, living with dementia, at risk of self-harm or at risk of falls. The care bundle could be used with relatives to establish a patient’s normal daily routine and identify factors that could be used to reduce anxiety and distress, such as talking about their favourite topic or providing access to music.

A dementia and delirium team and dementia strategy group had worked with patients and carers to introduce a range of improvements to the hospital environment and services to improve the experience for patients living with dementia. This included improved support for carers and resources for patients that included access to a reminiscence room and use of technology such as sound amplifiers.

There was substantial evidence of continual improvement to services as a result of engaging with patients and the people close to them, including the use of remote video technology to support young adults with long term condition management.

However we also found:

Medical staffing levels were generally consistent although out of hours the number of doctors was significantly reduced. However, the trust did take steps to ensure long-term consultant sickness in neurology was covered by a locum consultant.

Nurse staffing levels were inconsistent and vacancy rates were up to 29% in care of the elderly services. Although a team of healthcare assistants provided support, some staff told us their level of training had been reduced and they were no longer able to provide cannulation, catheter care or wound care, despite their workload being increased as a result of nurse shortages. However, after our inspection the trust said they had not reduced healthcare assistant's opportunities for training.

There was no dedicated junior anaesthetist input into multidisciplinary ward rounds, which meant the pain management team was not able to provide a full specialist service.

The standard of infection control processes, including hazardous waste management and adherence to the control of substances hazardous to health guidance, were variable. This was because not all areas we inspected were clean and there were areas of unrestricted access to waste and chemicals.

Although risk assessments in most records we looked at were comprehensive and completed routinely, there was a lack of consistency where patients had complex needs, where nurse teams were short staffed and where patients were cared for as an outlier.

Staff in some teams said they felt morale was low and decreasing and talked about their worries in relation to increasing workloads and ongoing nurse shortages due to vacancies and sickness.

Urgent and emergency services (A&E)

Good

Updated 22 May 2015

There were arrangements in place for reporting and investigating incidents. Nursing staffing levels were well managed and a recruitment programme was in place. The paediatric area within the department was staffed predominantly with qualified paediatric nurses.

Suitable safeguarding arrangements were in place although there were a small number of examples where trust policy had not been followed and there were inconsistencies in referral of potential non-accidental injuries.

The department was meeting national targets and there were good patient flows through the department. Patients felt well cared for and staff told us they felt supported by their peers and management.

The governance structure worked well at a local level but some meetings lacked detail and routine agenda items were not consistently discussed at meetings.

Consultant cover was less than the College of Emergency Medicine recommendation of a minimum of 14 hours consultant cover a day. Some improvement was needed to ensure accurate records and the monitoring of early warning scores were maintained.

Surgery

Good

Updated 28 April 2017

We found that there was much improvement made in the hospital’s surgical services from the time of our last inspection in January 2015, when four domains were rated as requires improvement and one as inadequate. During this inspection, we found that four domains were good and one required improvement.

There was a new site based management team and a more robust clinical governance structure which meant there was better oversight of risk. Staff expressed a greater level of confidence in management and general morale was high. We found that there were reduced numbers of staff vacancies and better planning of skill mix. Staff reported on a supportive learning environment with good continuous professional development opportunities.

Patient flow was well-managed and there were no surgical site infections for knee and hip replacements and length of stay for elective and non-elective surgical patients was better than the England average.

The majority of patients we spoke with were happy with the care and treatment they received and we observed kind and compassionate care being given.

However, we also found:

There were low levels of training amongst certain groups of staff in Level 2 safeguarding adults and safeguarding children.

Intensive/critical care

Requires improvement

Updated 22 May 2015

The unit was grappling with a range of problems, including vacancies, staff attendance at mandatory training, and improving governance within the unit.

The key issues included nursing vacancies and poor uptake of mandatory training by nurses, which had resulted in the withdrawal of final-year nursing students and a temporary suspension (later lifted) on recruitment until staff were up to date with their training and able to support new staff. Insufficient nurses had completed the post-registration intensive care course, and the unit had experienced difficulties recruiting to the post of clinical educator.

Staff understanding of obtaining patients’ consent and acting in their best interest in accordance with the Code of Practice of the Mental Capacity Act (2005) was not good.

There was 24-hour consultant cover seven days a week and a critical care outreach team. Consultants thought the on-call rota was demanding, and because of capacity issues and nursing vacancies, thought they spent a lot of time managing patient flow through the unit rather than caring for patients.

Nursing staff vacancies and a lack of beds affected patient flow and meant that some patients had their surgery cancelled and others had to be transferred to another unit.

Care was based on national guidance, but there was a lack of awareness of and adherence to guidelines by nursing staff. Outcomes for patients were reported and monitored, but other aspects of governance needed to be improved, including audits.

Multidisciplinary working was in place, the unit had a dedicated pharmacist, dietician and physiotherapist. Staff were positive about their working relationships, but formal meetings between different disciplines were limited.

Other aspects of patient care, such as their nutritional needs and pain relief, were managed well. We observed staff talking to patients in a kind and caring manner, but no mechanism was in place to obtain feedback from patients or their relatives.

Resources for relatives were limited, and visiting times were fixed; however, staff were flexible and relatives could visit outside set times.

The unit did not conform to modern building standards and had a shortage of space. The unit had started to address some of the issues, but progress was slow and some of the changes were reliant on the trust developing a clinical strategy. Within the unit, progress was hampered by the lack of a joined-up approach to improving service and quality and potential further changes to the nursing leadership.

Services for children & young people

Requires improvement

Updated 28 April 2017

The service had systems in place to ensure that incidents were reported. However, incidents were not always investigated in a timely way and in accordance with published guidance.

Infection prevention and control on Rainbow Ward did not always comply with the trust’s policies for infection prevention and control.

Expressed breast milk was stored in the same fridge as other products. For instance, two expressed breast milks were stored in the Rainbow Ward fridge together with a carton of soya milk.

Maintenance issues were not always addressed in a timely way. There were leaks in the ceilings of Rainbow Ward and the Neonatal Unit (NNU) which had not received thorough investigation and repairs. Some senior staff on the NNU we spoke with were unaware of UNICEF Baby Friendly accreditation, a global accreditation programme to support breast feeding.

Rainbow Ward was unable to deliver adequate pain management for patient-controlled analgesia (PCA), nurse controlled analgesia (NCA) and epidurals for the post operative pain management of children.

Parents did not receive food on the ward, unless they were diabetic or breast feeding. There were limited facilities for parents to prepare or purchase food.

There was a limited amount of information leaflets for children and their parents or carers across both Rainbow Ward and the NNU.

West Ham Ward was not a purpose built paediatric ward, conditions for staff in the ward were cramped.

There were a number of comments from staff and patient/relative surveys in 2016 that were negative about the environment on the ward and outpatients department.

The décor of Rainbow Ward did not cater for children and young people and was not child friendly Bay 1 was of particular concern due to its multi-purpose usage and lack of natural light.

The recovery facilities in theatre were not child friendly due to an absence of a recovery bay with appropriate décor.

Emergency readmissions for non-elective patients under the age of one year and children between the age of one and 17 years, were worse than the England average.

There was a trustwide strategy for children and young people’s services at Newham Hospital, but this was not embedded. There was no long-term local strategy for children and young people’s services.

There were new governance arrangements for children’s services, but these were not fully embedded.

The agendas for governance meetings did not always reflect the governance meeting terms of reference.

Identified risks were not always included on the trust’s risk register in a timely way. Actions the service had taken to mitigate risks were not always recorded on the risk register.

However, we also found:

The hospital reported data on patient harm each month to the NHS Health and Social Care Information Centre (HSCIC) Safety Thermometer. From August 2015 to August 2016, Rainbow Ward and neonatal unit (NNU) had reported 100% harm-free care during this period.

Staffing levels and skill mix were planned, implemented and reviewed to keep children and young people safe. Any staff shortages were responded to quickly and adequately.

Risks to children and young people were assessed, monitored and managed on a day-to-day basis; and risk assessments were child-centred, proportionate and reviewed regularly.

Risks to safety from anticipated changes in demand and disruption were assessed, planned for and managed effectively. Plans were in place to respond to emergencies and major situations.

Staff we spoke with understood their safeguarding responsibilities and knew what to do if they had concerns.

There were sufficient numbers of nursing staff to ensure that shifts were filled. However, this was sometimes based on the use of bank staff.

The were business continuity and major incident plans in place. Senior staff were aware of the plans and were able to explain their roles in the event of an interruption to normal service.

Procedures and policies were up to date and reflected recent evidence for best practice and NICE guidelines.

The children’s service had a practice development nurse who monitored staff training and competence.

There was evidence of multi-disciplinary team working in all children’s and young people’s departments.

Information sharing between wards and departments, and medical and nursing staff was effective.

Parents were involved in giving consent to examinations, as were children when they were at an age to have a sufficient level of understanding.

Children and young people and their primary carer were supported, treated with dignity and respect, and were involved as partners in their care.

Feedback from children, young people and parents was positive about the way staff treated patients.

Children, young people and parents were treated with dignity, respect and kindness during all interactions with staff and relationships with staff were positive.

Staff helped children and young people and those close to them to cope emotionally with their care and treatment.

Children and young people were involved in making decisions.

Admission pathway protocols were in place.

There had been no formal closures to admissions to Rainbow Ward in the previous 12 months.

The NNU had three rooms available for parents staying overnight. The rooms were homely and had en-suite toilet and shower facilities.

Complaints were managed in accordance with trust policy and lessons were learnt. Staff and managers told us that they preferred to resolve concerns “on the spot.”

Staff were aware of the trust’s vision and values.

There was a new governance framework in place and responsibilities were defined.

Department level leadership was effective. Consultants’ roles and responsibilities were defined by the trust’s job planning process.

Staff supported each other well. Staff told us the culture of the service was very focused on meeting the needs of children and young people who used the service.

Staff were provided with information on developments at the trust and information on projects the trust was focusing on such as the new children and young people’s Rainbow Unit.

The Rainbow Unit rebuilding project would provide modern inpatient and outpatient facilities for children and young people, the new ward was due to open in February 2017.

End of life care

Requires improvement

Updated 28 April 2017

The reporting process meant that the trust were unable to identify, review or learn from incidents or complaints that were related to end of life care. There were no risks identified on the risk register that related to end of life care. Minutes of one meeting stated that end of life care incidents were not easy to identify. The trust reported two incidents and zero complaints that related to palliative and end of life care between November 2015 and October 2016. This was raised as an issue at the last inspection.

There were no specific care plans in place for patients receiving palliative and end of life care. The trust had developed a Compassionate Care Plan (CCP) to replace Liverpool Care Pathway (LCP). This was still not embedded across the hospital. This issue was raised as a concern at the last inspection and although progress has been made, further work is needed.

The SPC team had 0.5 of a whole time equivalent (WTE) consultant in post. This did not meet the ‘Commissioning Guidance for Specialist Palliative Care: Helping to deliver commissioning objectives’ (Dec 2012.) which recommended a minimum requirement of 1 WTE consultant in palliative medicine per 250 hospital beds (NUH has 344 beds).

There were poor standards of cleanliness, dignity and upkeep in the mortuary for which the hospital’s senior management team knew little about and had poor oversight of. It was managed centrally from Royal London Hospital by the clinical support services, which operated trust wide.

We found that the mortuary area was not clean. There were no daily cleaning check lists available for completion by staff. This meant the hospital had no assurance that areas were cleaned routinely and in a specific time scale.

There was no policy or guidance in place for how the mortuary should be cleaned to ensure that health and safety requirements were met and that deceased patients were treated with dignity throughout cleaning processes.

Within the mortuary we found that there was a hole in the wall exposing electrical cabling. Staff told us this had been reported in early October 2016. There was no signage on the fridges or in the mortuary to identify correct location of bodies to indicate how many days they had been stored in the fridges.

We found that infection control procedures were not followed for safe storage of deceased patients. Fridge temperatures were not checked between 11th October and 1st November 2016 which meant the trust had no assurance that the body storage facility was at the correct temperature.

There was no policy to determine correct transfer of deceased patients in the event of a fridge breakdown.

Medical and nursing notes were not always easy to navigate, there were loose sheets and they were not in any order.

Barts Health NHS Trust contributed to the National Care of the Dying Audit (NCDA) March 2016. The trust was below the England average on three out of the five clinical indicators and only achieved one out of the five organisational key performance indicators (KPI).

An audit of the use of the CCP undertaken by the SPC team, showed that only 8 (28.6%) out of 28 sets of patient notes had a documented CCP in their notes.

A hospital survey undertaken in July 2016 to identify awareness of patients approaching end of life was low amongst medical staff and clinical nurse specialists.

The end of life CQUIN audit undertaken in August 2016 looked at 17 deceased patient notes. These showed that only 6 patients (35.3%) had their preferred place of death (PPD) documented and only one patient was transferred to their PPD.

Not all the patient records we reviewed had pain assessments on file, despite having diagnosed conditions which often cause pain and discomfort.

T34 syringe pump training was not mandatory for all registered practitioners working on the wards.

Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) audits for the period January 2016 to October 2016 showed that 66.6% (201) forms were completed incorrectly.

Palliative care patients were not prioritised for side rooms. There was a lack of facilities for dying patients and their relatives; this meant that patients privacy and dignity was compromised.

The results from the bereavement survey undertaken between January and September 2016 showed that only 23% (3) of the respondents rated their overall experience as excellent or good.

The Fast Track process was not routinely audited; without this information, the hospital was unable to monitor their progress or improve.

The trust was not routinely auditing patients’ preferred place of care (PPOC). Without this information, they were unable to monitor their progress or improve.

There were no designated facilities for relatives’ or carers’ overnight accommodation. Wards could provide chairs for relatives who wished to remain at their relatives’ bedsides.

The trust had an ‘End of Life Care Strategy 2016 - 2019’. It had been ratified by the trust on the 19th October 2016. However, staff we spoke with were not aware that the strategy had been ratified by the trust and many nursing staff knew nothing about it.

The trust had a draft business case to increased staffing to improve end of life care and specialist palliative care across the trust. However, this business case had not taken into consideration other services such chaplaincy and therapies and how they would link in to the overall vision of end of life care.

There were no risks identified on the risk register that related to end of life care. However the ‘end of life care key line of enquiry report’ presented to the quality assurance committee meeting in September 2016 highlighted two risks. These related to the recruitment of additional staff for end of life care.

The trust carried out surveys for patient and staff satisfaction. However, these did not specifically identify end of life care results.

However, we also found:

We fed back our immediate concerns regarding the mortuary on 1 November 2016. On 11 November 2016 the trust reported what actions had been taken. An infection prevention and control review had been undertaken on 3rd November 2016, two days after being made aware of our findings, and a deep clean of the environment and equipment carried out. A new cleaning schedule was put in place with weekly reviews for the following four weeks and monthly reviews thereafter. The trust reported that the site management team were assessing the risks and logistics associated with a specialist deep clean of the fridges. On the 18 November 2016 the trust reported that the mortuary was closed on 17 November as a temporary measure for deep cleaning of the fridge to take place, which was scheduled for 23rd November. Contingency plans had been made for all deceased patients to be looked after by a local undertaker. The capital cost to replace the fridge from the current year’s capital budget had been identified and the hospital’s managing director reported that the estates team were sourcing a supplier and establishing the quickest route to replacement.

We were also provided with information regarding leadership and management of the mortuary, giving the hospital greater oversight and management.

There was guidance for prescribing palliative medication and guidance for use of anticipatory medication at end of life.

The trust provided evidence of a maintenance schedule and asset list of syringe drivers including when they were purchased and last service date.

We found that most patients under the care of the SPC team were prescribed anticipatory medication.

We saw that the hospital had recently introduced ‘End of Life Care Wednesdays’; a series of one hour interactive workshops led by the SPC team for all clinical staff.

There was a weekly hospital palliative care multidisciplinary meeting. Medical staff, nurses, social services and the chaplaincy attended this meeting.

The DNACPR forms were stored at the front of the patients’ notes. They were easily identifiable and allowed easy access in an emergency.

We saw that verbal consent to treatment was recorded in all the patient records we reviewed.

Relatives we spoke with told us that the staff communicated with them and their relative in a way that helped them understand their care, treatment and condition. They told us discussions with staff had been handled very sensitively.

We saw staff carrying out care with a kind, caring, compassionate attitude. Staff spoke to patients politely and respected their privacy and dignity, asking for consent to proceed with tasks.

The chaplaincy service visited patients on a daily basis to provided support for patients and their relatives irrespective of their individual faith. They could be called upon 24 hour a day seven days a week.

Between April and October 2016 97% of the patients had been seen by the SPC team within 24 hours of referral.

There were no visiting time restrictions for family and friends visiting a patient in the last days or hours of life. This allowed family and friends un-limited time with the patient.

The trust had a defined management and governance structure for end of life care. The trust’s Chief Medical Officer (CMO) and a Non-Executive Director had specific responsibility for end of life care on the trust board.

The trust had an end of life strategy which identified priorities to improve care and treatment delivered at the last stages of life.

The SPC team attended the trust wide palliative care team meetings which were held monthly.

Outpatients

Requires improvement

Updated 22 May 2015

Many patients complained about the waiting times in the outpatient clinics. They said they had very little information and staff were not always open with them about waiting times.

There was a lack of shared objectives and strategy to achieve an improved outpatient service. Local managers were not well supported by the trust-wide senior managers and there were no clear lines of accountability. Not all staff were aware of the electronic incident-reporting process.

Medicines were stored and administered safely. The department held its own training records, which were up to date and demonstrated that most staff had attended mandatory training.

All the patients we spoke with told us they had been treated with dignity and their privacy had been respected and protected. Patients found staff polite, supportive and caring. They spoke highly of the staff in the outpatients and diagnostic imaging department.

Patients were appropriately asked for their consent to procedures. Medical records were available on most occasions for patients’ clinic appointments. Translation services were available for people who did not speak English.