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The Royal Free Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 May 2019

Our rating of services went down. We rated it them as requires improvement because:

  • We rated safe, responsive and well-led at this hospital as requires improvement and we rated effective and caring as good.
  • We rated three of the five services inspected, during this inspection, as requires improvement overall.
  • Many of the issues identified during the previous inspection, which impacted on the safety and responsiveness of the service, had not been yet been addressed by the hospital’s leadership team.
  • Mandatory training for staff in key skills, including safeguarding, fell below the trust’s target for compliance.

  • Staff did not consistently follow best practice when prescribing, giving, recording, storing and disposing of medicines. Documentation indicated patients did not always receive the right medication at the right dose at the right time. Medicines management was inconsistent and audits repeatedly found areas of unsafe practice in relation to documentation and storage. Medicines were not always stored securely and managed appropriately.

  • Services did not always have sufficient numbers of staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. Nurse vacancy rates and turnover rates were significantly higher than trust targets and services relied on temporary staff to fill shifts.

  • Standards of nursing documentation were inconsistent and persistent concerns about the performance of agency nurses had not been addressed. The impact of short staffing and lack of specialty team cover at weekends was evident in the inconsistencies and errors we found in some patient documentation, including important medicine administration records. There was a hybrid system of record keeping: part paper, part electronic which led to some delayed or missed information being available to clinicians.

  • We were not assured that there were effective systems and processes in place to prevent avoidable patient safety incidents from reoccurring. Although the hospital generally managed patient safety incidents well, evidence of completed actions in response to serious incidents, was not always robust. There were gaps in the outcomes divisional teams thought they had achieved and the information understood or used by staff delivering care.

  • Equipment was not always well looked after or safely maintained. Not all equipment was up to date with planned preventative maintenance and staff in some services reported frequent equipment failures. This did not meet recommended standards. There were a number of incidents reported relating to the loss or missing surgical instruments after an operation. Whilst instruments were checked at the end of an operation, some instruments would be missing when arriving at the sterile services department.

  • People did not always have prompt access to the service when they needed it. Waiting times from referral to treatment and decisions to admit patients were not always in accordance with best practice recommendations. There was an increase in the number of patients being cared for overnight in the recovery area in the operating theatres due to a lack of suitable beds. Delays in theatres meant patients sometimes had to wait a long time on the day of their procedure. Long waits in A&E were a regular occurrence due to lack of capacity to meet service demand.

  • Best practice guidelines for care and treatment of patients with additional support needs were not consistently followed. Staff did not always use or access specific communication aids for patients with a learning difficulty and were unfamiliar with hospital passports. Some staff said they regularly struggled to meet the needs of patients with mental health conditions whilst they were waiting for a mental health bed placement. Some staff told us their training was insufficient to meet patient needs.

  • Whilst the trust had effective systems for identifying risks and planning to reduce them, risks were not always being dealt with in a timely way. Some department level risks had not been identified or adequately addressed. Not all risks identified during our inspection were on the hospital’s risk register; therefore we were not assured that senior leaders had appropriate oversight of these issues.

  • Whilst the majority of staff felt the culture of the organisation had improved and described the leadership team as accessible and supportive, there remained a culture of bullying within the operating theatres.

However:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

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

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff delivered care and treatment in line with national guidance.

  • Staff worked together as a team to deliver effective, patient-centred care and improve patient outcomes. Treatment was planned and delivered in line with current evidence-based guidance and patients were supported by staff to take ownership of their own recovery.

  • Staff treated patients with kindness, dignity and respect. Patients were involved as partners in their care and were supported by staff to make decisions about their treatment.

  • Most staff felt well supported by managers and told us that they encouraged effective team working across the hospital. Senior staff were visible, approachable and supportive. Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. Most staff spoke positively about their local leadership and line management and said relationships were supportive.

  • The trust was committed to improving services by learning, promoting training, research and innovation. Staff were positive about the support they received to challenge existing practice and try out new ideas.

Inspection areas

Safe

Requires improvement

Updated 10 May 2019

Effective

Good

Updated 10 May 2019

Caring

Good

Updated 10 May 2019

Responsive

Requires improvement

Updated 10 May 2019

Well-led

Requires improvement

Updated 10 May 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 10 May 2019

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

  • Many of the issues identified during the previous inspection, had not yet been fully addressed by the service.
  • The impact of short staffing and lack of specialty team cover at weekends was evident in the inconsistencies and errors we found in patient documentation, including important medicine administration records.
  • Although staff had access to care guidelines and tools, failure to follow these had led to serious incidents. We also observed a lack of agency staff knowledge of them during our inspection. This meant there was no robust overarching system to check compliance with trust policies.
  • Processes and systems did not effectively or consistently support staff to deliver care or to excel in their roles. This included a mandatory training system that was not fit for purpose, multiple risks and gaps in the IT system and a significant lack of equity in how staff engagement processes were delivered.
  • Healthcare assistants (HCAs) had highly variable support and experiences working in the hospital. While some HCAs reported good local working relationships the majority we spoke with said they felt ignored by the trust with a lack of opportunity and respect. This was corroborated by ward managers.
  • The trust had not effectively addressed issues of bullying and harassment and feelings of intimidation caused by a very hierarchical working environment. There were inconsistencies in the progress senior divisional staff said they had made in this area and information a significant number of staff gave us.
  • Standards of medicines management overall were good although we and found examples of poor stock management that placed patients at risk and that were not adequately rectified by local teams.
  • Governance and leadership systems were not functioning well for specialist teams that provided care to a range of wards, including for clinical practice educators and allied health professionals.
  • Standards of nursing documentation were inconsistent and persistent concerns about the performance of agency nurses had not been addressed.

However, we also found areas of good practice:

  • Safeguarding processes in NHS wards were clearly embedded. The safeguarding team provided a highly specialised service across all medical care areas and had implemented an action plan to meet the requirements of the 2018 intercollegiate guidance on adult safeguarding.
  • The high-level isolation unit (HLIU) reflected the successful outcome of a specialised, multi-professional project to establish a unit and highly skilled team to meet the needs of patients with life-threatening and rare infections. HLIU was one of only two such units in England and the matron and their team had established robust standard and emergency operating procedures, including a six-hour activation time from the first point of escalation.
  • Divisional lead nurses had established detailed guidance on staffing levels for each ward using evidence-based assessments from the National Quality Board safe staffing levels. Along with local initiatives to improve recruitment, this helped to stabilise teams.
  • Multidisciplinary working was clearly embedded in care delivery and patients were treated by a range of clinical nurse specialists and specialist consultants. Teams had opportunities for shadowing and rotations that enabled them to develop skills and build relationships in other areas.
  • Specialist clinical teams and ward teams based staff training and service development on the changing needs of their population group and demonstrated a focus on holistic care to improve outcomes.
  • The hospital performed well in 18-week referral to treatment times with five specialties better than national averages.
  • Systems were in place to coordinate access, flow and discharge between strategic and clinical teams. This included a schedule of meetings and response actions led by discharge and flow coordinators, operations managers and consultants.
  • There was evidence of learning from incidents, complaints, patient feedback and staff engagement although this differed significantly between wards, teams and specialties.
  • Each ward or specialty had developed a vision and strategy in alignment with the overarching trust and divisional objectives and goals. Governance committees maintained oversight and clinical staff were involving in projects and initiatives to drive progress.

Services for children & young people

Good

Updated 15 August 2016

The trust met the Royal College of Paediatrics and Child Health (RCPCH) standards for paediatric consultant staffing levels but nursing levels on the children’s ward were not always complaint to the Royal College of Nursing (2013) standards.

The special care baby unit generally met the British Association of Perinatal Medicine standards (2011) for staffing neonatal units.

There was generally good access and flow within the children’s service. Patients received evidenced based care and treatment and good multi-disciplinary working existed between the children’s services, external providers and the child and adolescent mental health service (CAMHS).

The poor post-operative recovery facilities for children exposed them to potential hostile sights and sounds.

Staff were caring, compassionate and respectful and the staff we spoke with were positive about working in the service and there was a culture of flexibility and commitment.

The service was well led and a clear leadership structure was in place. Individual management of the different areas providing acute children’s services were well led. A governance system was in place and we saw that clinical risks identified. Feedback from staff, parents and children and young people was generally good.

We saw that although services provided evidenced based care as identified within evidenced based clinical guidelines, many of these were out of date posing potential risks to patients.

There was an over reliance on agency nurses to fill gaps in the nursing rosters.

Critical care

Good

Updated 10 May 2019

Our rating of this service stayed the same. Overall, we rated the service as good because:

  • At our inspection in 2016, we had identified some concerns including feedback from incidents, timely response to national audits, delayed discharges to the ward. In the 2017 inspection we had identified concerns about the culture and relationships within the unit. There had been improvements in all of these areas.
  • There were effective systems in place to protect people from harm. Learning from incidents were discussed in departmental and governance meetings and action was taken to follow up the results of investigations.
  • Staff were aware of their responsibilities under the mental capacity act and we saw appropriate records were in place in patient’s notes.
  • Feedback from families for the services inspected was mostly positive. Staff respected confidentiality, dignity and privacy of patients.
  • There was good day to day leadership on the ITU, and permanent staff felt valued and supported in their role with opportunities for learning and development.
  • There had been improvements in staff morale since the July 2017 inspection, and there were sufficient junior doctors, progress in other areas had been slow. The unit had been slow to respond to some of the issues raised in the CQC reports and peer review reports

However:

  • Leadership required improvement as there was no shared vision among senior medical staff and little work had been done to assess the views of patients, relatives and other stakeholders and feed this into service development.
  • The assessment and management of risk needed to improve. Not all risks were identified on the risk register and progress to mitigate risk was slow. Some of the risks seen at the previous inspection were still judged to be high risk.
  • There was no capital programme at the time of the inspection for the replacement of obsolete equipment. Staff reported frequent equipment failures and only 61% of equipment was up to date with planned preventative maintenance. This did not meet recommended standards. The trust later sent us a capital replacement programme for 2019-20.
  • Although evidence-based care was built into some of the protocols used, the unit’s own policies and guidelines were in a variety of different formats, many had not been through the trust approval process and were not all up to date. The trust was aware of this and a review process had been started but was not complete at the time of the inspection.
  • The absence of electronic records limited data analysis.
  • There was little written information for patients and their families, and no follow up clinics. This had not improved since the previous inspection.

End of life care

Good

Updated 15 August 2016

They was a dedicated team providing holistic care for patients with palliative and end of life care (EOLC) needs in line with national guidance.

The hospital provided mandatory EOLC training for staff which was attended, a current EOLC policy was evident and a steering group met regularly to ensure that a multidisciplinary approach was maintained.

The Royal Free London NHS Foundation Trust and its staff recognised that provision of high quality, compassionate end of life care to its patients was the responsibility of all clinical staff that looked after patients at the end of life. They were supported by the palliative care team, end of life care guidelines and an education programme.

The palliative care team was highly thought of throughout the hospital and provided support and education to clinical staff. The team worked closely with the practice educators at the hospital to provide education to nurses and health care assistants. Medical education was led by the medical consultants and all team members contributed to the education of the allied healthcare professionals.

The majority of EOLC was provided by clinical staff on the wards. The palliative care service worked as an advisory service seeing patients with specialist palliative care needs, including those at the end of life.

Staff at the hospital provided focused care for dying and deceased patients and their relatives. Facilities were provided for relatives and the patient’s cultural, religious and spiritual needs were respected.

Medical records and care plans were completed and contained individualised end of life care plans. Most contained discussions with families and recorded cultural assessments. The ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms were all completed as per national guidance. However there were inconsistencies in the documentation in the recording of Mental Capacity Act assessments.

There was evidence that systems were in place for the referral of patients to the palliative care team for assessment and review to ensure patients received appropriate care and support. These referrals were seen and acted upon within 24 hours.

The EOLC service had supportive management and visible and effective board representation. This had resulted in a well led trust wide service that had a clear vision and strategy to provide a streamlined service for EOLC patients.

Outpatients and diagnostic imaging

Good

Updated 15 August 2016

Medical records were available electronically but delays occurred when scanning paper records onto the system. There was no method of recording the number of prescriptions issued.

The trust had consistently not met the referral to treatment time standard or England average for the past ten months. The time to triage referrals as to their priority varied between specialities and could take as long as 34 days.

There had been a deterioration in performance of the 62 day cancer performance compared to the national standard.

The hospital cancelled 35% of outpatient appointments in the last year. From October to January 34% of short notice cancellations were due to annual leave, which was not in line with trust policy.

The outpatient and radiology departments followed best practise guidelines and there were regular audits taking place to maintain quality.

Staff contributed positively to patient care and worked hard to deliver improvements in their departments.

Staff felt supported by their managers and stated their managers were visible and provided clear leadership.

We saw clinical staff were not consistently bare below the elbow at the point of care.

Surgery

Requires improvement

Updated 10 May 2019

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

  • Compliance with mandatory and safeguarding training for medical and nursing staff did not meet the trust target of 85%.
  • The trust had reported eight never events for surgery, four of these occurred at the RFH site.
  • There was a hybrid system of record keeping: part paper, part electronic which led to some delayed or missed information being available to clinicians.
  • Medicines were not always stored securely and managed appropriately in the operating theatres.
  • Staff appraisal figures remained at 72% which was below the trusts 85% target.
  • Patients continued to arrive at 7.30am on the day surgery unit for their operation which resulted in 25% of patients having to wait for their operation until the afternoon.
  • Operating theatre utilisation rates (70-80%) remained low. Performance had improved from our previous inspection of 63% but further improvement remained a high priority for the service.
  • There was an increase in the number of patients being cared for in recovery overnight. The length of stay ranged from 14 hours to 23 hours.
  • Whilst most staff felt the culture of the organisation had improved and described the leadership team as accessible and supportive, there remained a culture of bullying within the operating theatres.

However:

  • Staff awareness of incident reporting had improved.
  • There was effective multidisciplinary team (MDT) working to support patients’ health and wellbeing with good access to services such as pain and tissue viability.
  • Staff recognised the importance of providing good standards of patient care regardless of how busy they were. Most of the patients and relatives we spoke with told us all staff, whether permanent or temporary, were compassionate and caring.
  • There was a clinical audit programme which informed service development. Surgical pathways were planned and delivered in line with referenced national clinical guidance.
  • The trust had carried out an audit in 2018 to review its progress against the seven-day services standards which showed an improvement compared with 2017.
  • The service promoted learning and development, and research and innovation. Staff were positive about the support they received to challenge existing practice and try out new ideas.

Urgent and emergency services

Requires improvement

Updated 10 May 2019

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

  • Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with good practice. The department did not meet the Department of Health’s standard for emergency departments which states that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department.
  • Best practice guidelines for care and treatment of patients with additional support needs were not consistently followed. Nurses and healthcare assistants told us they did not use or access specific communication aids for patients with a learning difficulty and were unfamiliar with hospital passports
  • Mandatory training for staff in key skills, including safeguarding, fell below the trust’s target for compliance.
  • There was low compliance with hand washing before and after patient contact.
  • We found that daily checks of the resuscitation trolley in the rapid assessment and triage (RAT) area were not always carried out.
  • There was inconsistent record keeping for emergency department patients in the adult assessment unit, which was staffed by general medical nursing staff.
  • Staff were unsure about the lines of medical patient responsibility in the adult assessment unit.
  • The department was in the lower UK quartile for three standards in the 2016/17 Royal College of Emergency Medicine (RCEM) moderate and acute severe asthma and consultant sign-off audits.
  • Appraisal rates for nursing and medical staff were not compliant with the trust standard.

However:

  • Staff worked together as a team to deliver effective, patient-centred care and improve patient outcomes. Treatment was planned and delivered in line with current evidence-based guidance and patients were supported by staff to take ownership of their own recovery.
  • Staff treated patients with kindness, dignity and respect. Patients were involved as partners in their care and were supported by staff to make decisions about their treatment.
  • There was a strong culture of openness, transparency and teamwork within the organisation. Staff felt well supported by managers and told us that they encouraged effective team working across the hospital. Senior staff were visible, approachable and supportive.
  • The introduction of a rapid assessment and treatment area meant there was increased patient streaming provision.
  • There were improved facilities for patients with mental health conditions. Staff knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • There was a robust governance structure with clearly defined areas of responsibility for individual members of medical staff. Staff were encouraged to report incidents and learning was widely shared.

Maternity

Good

Updated 10 May 2019

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated the maternity service as good because:

  • The staff were found to exemplify well the trust’s values of being visibly reassuring, clearly communicating, being actively respectful and being positively welcoming.
  • The Friends and Family Test showed that women were in general very satisfied with the care and treatment provided.
  • The service offered women with uncomplicated pregnancies a number of birthing options. There was the midwife-led Heath Birth Centre, the consultant-led labour ward or care in the community setting.
  • The medical and midwifery staffing levels and skill mix were adequate and were adjusted to reflect the acuity of the patients. Women in labour received one-to-one care.
  • If a serious incident occurred, it was dealt with in accordance with the trust’s procedure.
  • The medical and midwifery staff had received up to date training.
  • Staff were alerted to mothers and babies needing medical intervention by the use of early warning tools.
  • Staff had received training in safeguarding, and were able to recognise abuse and take rapid action.
  • The clinical care was generally equal or better than the England average on most metrics.
  • The service had a consultant on call out of hours.
  • The department had recently introduced an electronic patient record system. In some cases there may have been delays during the transition, but measures had been taken to ensure patient safety.
  • The service followed national guidance, and actively participated in NHS England initiatives to improve care, and sought to demonstrate resulting improvements in care. The service examined patient outcomes and responded fully to any issues found.
  • The rate of emergency caesareans was in line with the England average.
  • The performance of the service was monitored by bringing together a number of critical indicators on a monthly basis in the maternity dashboard spreadsheet, and highlighting any surprising figures. The results for the last three months were displayed on a notice board.
  • Women in labour and in the postnatal stage received effective pain relief.
  • Infant mortality in the department was lower than average.
  • The service was strong in providing assistance for women with complex psycho-social needs, and had a specially trained team to deal with their needs.
  • The service emphasised continuity of care, with the same midwife assisting where possible the low-risk patients in the antenatal, delivery and postnatal stages.
  • The department was strong in helping mothers who chose to breast feed and had achieved the United Nations Children’s Fund (UNICEF) Baby Friendly Stage Three.
  • The service had many collaborative projects with other hospitals in the North London region

However:

  • The management of medicines required some improvements. The service needed to ensure refrigerators used for medicines were maintained at the correct temperature. Resuscitation trolleys needed to be tagged following the daily checks. There needed to be more attention given to the expiry dates of medicines, and out of date medicines needed to be disposed of promptly. All entry and cancellation of controlled drugs in the controlled drug register should be in accordance with the trust medicine policy and procedures.
  • The consent forms were not always filled in and completed correctly.
Other CQC inspections of services

Community & mental health inspection reports for The Royal Free Hospital can be found at Royal Free London NHS Foundation Trust.