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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.

Reports


Inspection carried out on 18 July 2017

During an inspection to make sure that the improvements required had been made

Newham University Hospital, East London is part of Barts Health NHS Trust, the largest NHS trust in the country, serving 2.5 million people across East London.

The hospital provides maternity services to women in the London Borough of Newham and the Barking ward of the London Borough of Barking and Dagenham. The unit delivers around 6,500 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 November 2016. We did not conduct an in depth review of evidence against each of our five key questions and key lines of enquiry, hence we have reported our findings under two domains: safe and well-led.

Gynaecology services were not inspected on this visit.

Our key findings were as follows:

  • Whilst there had been improvements and some progress against the previous requirement notice issued for governance and assurance in the maternity unit, there was still a need to improve and strengthen governance structure and reporting systems.
  • Staffing issues continued to impact the delivery of care. Although there had been some staff recruitment, there continued to be shortages of midwifery staff at the time of our inspection. This included a shortfall in the number of experienced midwives. Whilst consultant cover had increased to 98 hours on the labour ward, out of hours cover was overstretched leading to delays in care.
  • At the last inspection we had raised concerns about record keeping. The most recent cardiotocography (CTG) audit in February 2017 highlighted there were continuing problems with CTG record keeping, including incomplete documentation of risk factors, and failure to consistently comply with correct procedures for filing CTG documents. The trust had introduced measures to address the issues raised; however,it was unclear how CTG record keeping and oversight had improved as further auditing was yet to take place.

  • At the previous inspection in November 2016, the security of babies in maternity services had been identified as a risk because of insufficient staff to monitor access to the unit. At this inspection the trust had implemented the electronic baby tagging system which had increased security. Further work was required to ensure all visitors to the maternity wards were monitored and signed in appropriately.
  • Systems were not effective enough in monitoring the outcomes of audits and incident reports.

  • Plans were in place to monitor and drive improvements throughout the maternity service, however progress was slow.
  • Since the last inspection, some improvements had been made in assessing and monitoring the quality of the service with systems in place to improve engagement with staff.
  • Most staff commented there had been improvement since the last inspection with the leadership much more visible and visiting the units on a regular basis.
  • The trust had made progress in revising the governance team structure for women’s services, and progress on improving governance leadership with a new obstetric lead for clinical governance appointed in May 2017.
  • There was an effective training programme for midwifery staff, although some midwives emphasised the lack of time they had to engage with this.
  • Trainee doctors continued to be well supported and had opportunities to put their learning into practice.
  • 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
  • The service had a plan for continuous improvement in the management of infection prevention and control, and we saw good results from infection control audits. Women told us they were satisfied with the standard of cleanliness

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Take steps to ensure sufficient numbers of appropriately skilled staff are deployed to meet the needs of the service.
  • Ensure that women receive timely treatment and pain relief, and that out of hours medical cover is effective in responding to and meeting the changing needs and circumstances of people using the service.
  • Ensure all overdue serious incident reports are reviewed, actions are completed, learning is disseminated in a timely way, and processes are in place to effectively monitor progress.
  • Ensure learning from incidents is used for the purposes of continually evaluating and improving services.
  • Ensure that patient records, including cardiotocography (CTG) documentation, are comprehensively and consistently completed and that processes are in place to evaluate this

In addition the trust should:

  • Ensure processes are properly utilised so that mothers and babies are kept continuously safe from unauthorised access to the units.
  • Ensure delivery suite coordinators have supernumerary status with sufficient allocated time and resources to carry out their oversight and support role.
  • Further consider funding for staffing a second obstetrics theatre to improve waiting times for caesarean.

  • Take further action to ensure compliance with the trust’s target of 90% completion of mandatory training, including safeguarding training.

Professor Ted Baker

Chief Inspector of Hospitals

Inspection carried out on 1 November 2016

During an inspection to make sure that the improvements required had been made

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 carried out on 20-23 January 2015

During a routine inspection

Newham University Hospital is part of Barts Health NHS Trust and provides acute services to a population of approximately 308,000 people living in the London Borough of Newham.

Barts Health NHS Trust employs around 15,000 whole time equivalent members of staff with approximately 889 staff working at Newham University Hospital.

We carried out an announced inspection of Newham University Hospital between 20 and 23 January 2015. We also undertook unannounced visits to the hospital on 31 January, 2 and 4 February 2015.

Overall, this hospital is inadequate. We found that urgent and emergency care was good, but surgery, critical care, maternity and gynaecology services, services for children and young people and outpatients and diagnostic imaging all required improvement. We found that medical care and end of life care was inadequate and significant improvement is required in these core services.

Care at this hospital was good overall. However, the hospital requires improvement in order to provide an effective and responsive service in order to meet the needs of patients. The hospital was inadequate in being safe and well-led by the senior management.

Our key findings were as follows:

Safe

  • Staff in the emergency department consistently completed paediatric early warning scores.
  • Whilst inpatient wards were displaying safety thermometer information, not all were displaying in areas accessible to patients, their families and carers; planned and actual nurse and healthcare assistant staffing numbers and who was in charge for each shift, in line with NHS England guidance.
  • Safeguarding arrangements were in place and were followed in most circumstances, although we identified some instances where this was not the case.
  • Suitable arrangements existed for reporting and investigating incidents, and most staff were familiar with the reporting system.
  • Medicines management was variable, but in the main was safe.
  • Infection control principles were adhered to and monitored in most areas apart from hand hygiene auditing in some surgical theatres.

Effective:

  • The emergency department had good processes in place to ensure that patients received evidence-based care and treatment.
  • Pain relief was mostly well managed, but systems to ensure that children received adequate pain relief were not comprehensive.
  • Multidisciplinary working was in place and appropriate, but seven-day working was not fully in place across all disciplines.
  • Patient outcomes were at or better than the national average across most surgical specialties.
  • The outcomes for women and their babies in maternity services were within expected limits.
  • Trainee doctors were generally well supported in maternity services and had wide-ranging opportunities to put their learning into practice.
  • Most staff were competent and had received the appropriate level of training.
  • The nutrition and hydration needs of patients were being managed.
  • Patients were largely given sufficient information about their treatments and had the opportunity to discuss any concerns.
  • Processes were in place to assess and manage risk, which were promoted by close multidisciplinary working.

Caring:

  • Staff were mostly caring and friendly 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 overwhelmingly 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 emergency department consistently met 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.
  • All ambulances were able to hand over to staff in the emergency department within 30 minutes of arriving.
  • Staff were familiar with the complaints process, and posters directed patients to contact the Patient Advice and Liaison Service to raise concerns. However, complaints were not always managed in a timely or appropriate manner.
  • Patient flow was mostly well managed, although transfers between trust sites and the availability of some services that were no longer provided at Newham University Hospital caused some concern for patients and staff.
  • Women were able to discuss the type and place of birth they wanted at antenatal appointments, and community care was responsive to their needs.
  • There was open access for relatives visiting patients who were dying. Car parking rates for those spending long periods visiting were preferential.
  • 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:

  • There were examples of good local leadership at Newham University Hospital, and staff felt supported by their immediate line managers. However, the trust-wide senior managers did not support local managers well.
  • Some visions and strategies were in place; however, they were not being realised.
  • Governance and risk management was monitored in some instances, but improvements were not consistently made.
  • Patient satisfaction among women using the maternity service had increased.

We saw an area of outstanding practice:

  • The Gateway Surgical Centre’s design, layout, forward planning, engaged staff and integrated care with members of the multidisciplinary team were outstanding.

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

The trust must:

  • Ensure governance and risk management processes are robust and embedded throughout the hospital.
  • Ensure, where appropriate, that intensive care and hospital risk registers reflect any risks in relation to the safety of patients and/or quality of care.
  • Make sure that staff are aware of and adhere to local and national guidelines, to ensure patients receive safe care.
  • Improve the leadership and direction of the end of life care service.
  • Ensure that staffing establishments meet the acuity and dependency levels of areas such as the coronary care unit.
  • Address the significant shortages of medical and midwifery staff which sometimes compromised the care and treatment delivered to women.
  • Ensure nurse staffing levels and the skill mix on some surgical areas are always appropriate to meet the needs of patients, to ensure safe, effective, caring and responsive care is provided.
  • Provide a minimum of 14 hours a day consultant cover in the emergency department, in line with the College of Emergency Medicine recommendation.
  • Recruit band 5 nurses to the full establishment of the critical care unit, so that patient care is not adversely affected.
  • Comply with The Misuse of Drugs Regulations 2001 in relation to the security of the keys for the controlled drugs cabinet on the medical wards and the condition of the controlled drugs record book on the surgical areas.
  • Ensure arrangements are in place for the safe storage of intravenous fluids in line with best practice guidance.
  • Ensure that nurses record the date and time they commence intravenous fluids for central venous lines and arterial lines.
  • Make sure staff are aware of their responsibilities under the Mental Capacity Act and have suitable arrangements in place for obtaining and acting accordance with the consent of service users, or acting in accordance with the best interest principles of the Act.
  • Ensure nursing records are completed fully and accurately to ensure patient safety.
  • 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.
  • Make sure all nursing staff on the medical wards are competent to care for the patients they are caring for.
  • Ensure that all relevant ward staff receive training specific to managing patients at the end of their lives.
  • Improve processes/referrals for safeguarding children in the emergency department.
  • Improve multidisciplinary working in the emergency department and paediatrics.
  • Listen to staff concerns regarding bullying and harassment and take action to improve the culture of the organisation.
  • Ensure national guidance for the care and treatment of surgical patients is always followed.
  • Support staff must to obtain the necessary qualifications to meet the core standards for intensive care units.
  • Make sure all staff have appraisals as required.
  • Ensure reasonable adjustments are made for people with disabilities who access surgical services.
  • Share the hospital’s vision with all staff.
  • Reduce patient waiting times in outpatient clinics.

The trust should:

  • Use the modified early warning score consistently to assess patients whose health may be deteriorating and update the electronic patient record with modified early warning score and PEWS scores.
  • Provide leaflets in other languages for the local population.
  • Improve feedback on and learning from incidents, so that staff are aware of incidents that have occurred and so that appropriate recommendations are put in place to learn from them.
  • Ensure cleanliness and infection control standards are adhered to consistently across the whole hospital.
  • Keep up to date with equipment checks.
  • Keep policies and procedures up to date.
  • Consistently obtain feedback from patients and take action to improve the service based on this feedback.
  • Meet the particular needs of vulnerable patients, particularly those living with dementia.
  • Ensure complaints are responded to in a timely fashion and improvements are made following these complaints.
  • Reduce the gap between recommended staffing levels in relation to the number of births and the current establishment in maternity. This relates both to midwives and obstetricians, and also to the availability of theatre staff to support obstetric surgery.
  • Manage the risk to timely care and treatment of women in the maternity service that results from current staff deployment, particularly out of hours.
  • Improve the environment for children in the operating department, as it is not child-friendly.
  • Consider providing up-to-date training in children’s resuscitation, as none of the staff in the operating theatre are trained in this.
  • Review the level of resuscitation equipment for children undergoing surgery.
  • Review pain relief for children, as the systems to ensure that children have adequate pain relief are not comprehensive.
  • Review how the children’s service is led, as the service is disjointed with no overall direction or strategy.
  • Review its plans to move non-elective children's surgery to The Royal London Hospital, as some medical staff are not convinced that this move is the best option for the service.
  • Provide patients with clear and up-to-date information on waiting times in outpatient clinics.
  • Ensure the adequate availability of hand-gel sanitiser in outpatient clinics.
  • Have a coordinated outpatient booking system.
  • Monitor performance targets in the outpatient department and reduce the overbooking of clinics to avoid clinics overrunning, especially the West Wing clinic.
  • Make sure administration staff are regularly supervised and thus better supported.
  • Share performance data with staff to increase awareness and improve practice.
  • Develop mechanisms to obtain feedback from patients and relatives about their experience on the unit and improving the unit.
  • Continue to recruit nursing and medical staff on the critical care unit.
  • Look for ways to improve the facilities for relatives and friends on the critical care unit.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 5-6, 11 and 14 November 2013

During a routine inspection

Newham University Hospital is in Plaistow, East London, and serves the people of Newham and other areas. It provides a full range of inpatient, outpatient and day care services as well as maternity and accident and emergency departments. It also has a dedicated stroke unit for rehabilitation following initial urgent treatment. The area the hospital serves has the third most deprived local authority (out of 326 local authorities) and has been identified as one of the top 50 most deprived areas in the country.

Newham University Hospital is part of Barts Health NHS Trust (the trust). Barts Health is the largest NHS trust in England. It has a turnover of £1.25 billion, serves 2.5 million people and employs over 14,000 staff. The trust comprises 11 registered Care Quality Commission (CQC) locations, including six primary hospital sites in east and north east London (Mile End Hospital, Newham University Hospital, St Bartholomew’s Hospital, the London Chest Hospital, the Royal London Hospital and Whipps Cross University Hospital) as well as five other smaller locations.

CQC has inspected Newham University Hospital twice since it became part of Barts Health on 1 April 2012. Our most recent inspection was in June 2013, when we visited the stroke ward and an elderly ward to check that the trust had taken action to address issues identified in August 2012. We issued two compliance actions and asked the trust to provide us with an action plan showing how they would address the shortfalls. As part of this November 2013 inspection, we assessed whether the trust had addressed the shortfalls, and we took a broader look at the quality of care and treatment in a number of departments to see if the hospital was safe, effective, caring, responsive to people’s needs and well-led.

Our inspection team included CQC inspectors and analysts, doctors, nurses, midwives, allied health professionals, patient ‘Experts by Experience’ and senior NHS managers. We spent two 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 a listening event in Stratford Town Hall to hear directly from people about their experiences of care. Prior to the inspection, we also spoke with local bodies, such as clinical commissioning groups, local councils and Healthwatch.

Inspection carried out on 14 June 2013

During an inspection to make sure that the improvements required had been made

We visited the stroke ward and an elderly ward.

At our last inspection we found patients privacy and dignity was not always respected. At this inspection most patients we spoke to told us they felt their privacy and dignity was respected. Patients said, “staff introduce themselves when entering the room and, they say please and thank you” and “staff are friendly and polite and always close the curtains when providing care.”

We found people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Most patients we spoke with felt they were well looked after and had everything they needed. One patient said “everyone’s caring here.”

Staff we spoke to told us they had undergone safeguarding training in 2012 or 2013. Staff were able to describe the different types of abuse, actions they would take and who they would involve and inform.

At our last inspection we found patients were not always supported to eat and drink. At this inspection we observed patients at lunchtime and found they were assisted or supported to eat their meals in a timely manner. Most patients we spoke to told us the food was very good. One person said “they get to choose what they want and there are always things they like on the menu.”

We found staffing levels on the two wards were inadequate to meet people needs. On the day of our inspection most of the patients and staff we spoke to said that both wards were regularly short staffed. Most relatives we spoke to told us they felt there were not enough staff on duty. We saw evidence to show that shifts were not always covered. The arrangements for arranging temporary nursing cover for shifts did not always work effectively.

We found staff were not always appropriately supported. We found staff did not always have appraisals and many had not had one in the past twelve months. Although there were regular clinical meetings, there was no evidence that team meetings occurred. Staff did not always have individual meetings with their managers to discuss their work, career and general issues.

At our last inspection we found the patients' personal records were not always accurate and fit for purpose. At this inspection we found that whilst there was still some gaps in recording, improvements had been made. Most patients’ records we checked contained completed weight charts, nutritional screening tables and pressure sore information.

Inspection carried out on 8 August 2012

During a themed inspection looking at Dignity and Nutrition

Patients told us what it was like to be in hospital and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals are treated with dignity and respect and whether their nutritional needs are met.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us.

The inspection team was led by two Care Quality Commission (CQC) inspectors joined by a practising professional and an Expert by Experience who has personal experience of using and caring for someone who uses this type of service.

We spoke to seven patients and three visiting relatives on the medical ward. On the stroke ward we spoke to seven patients and four relatives. One person said, “I am kept informed of changes of my medication.” Another said, “The different tests results are discussed with me.” While another said, “I am updated with how my treatment is progressing”.

People's diverse needs were catered for. A patient of African origin, said “staff understand my needs culturally, as they attend to my skin care and use appropriate creams for my hair.”

Patients made positive comments about the care on the stroke ward and a medical the ward we visited. The views expressed included,” Nurses and doctors are fabulous”, “They cannot do enough for you”, “very good care”, and “An excellent place to come if you need care and treatment.” One person said, “I am kept informed of changes of my medication.” Another said, “the different tests results are discussed with me.” While another said, “I am updated with how my treatment is progressing”.

Patient’s said that their dignity and privacy was respected most of the time but some of the people we spoke to said the curtains did not always close and that people could still see through some of the screens provided.