- NHS hospital
The Royal Free Hospital
All Inspections
10 January 2023
During an inspection looking at part of the service
The Royal Free Hospital (RFH) is part of the Royal Free London NHS Foundation Trust. The hospital provides a range of elective (planned) and emergency surgical services to people mainly living in the Hampstead area of the London Borough of Camden. The Royal Free Hospital business unit provides predominately specialist surgery. Surgical specialities are arranged across several divisions alongside medical specialties, where shared care is common.
In most divisions, the surgical services deliver across regional or supra-regional geographies and have similar models of care. In the network services division, individual patients are often cared for by several of the surgical specialities for example, breast and plastic surgery or dermatology and plastic surgery.
The divisions with surgical specialities are as follows:
- Liver and Digestive Health: hepato-pancreato-biliary surgery; liver transplantation; colorectal and general surgery: gastroenterology, endoscopy and hepatology
- Nephrology, Urology and Renal Transplantation: renal surgery; urology; renal transplantation; nephrology
- Cardiovascular: vascular surgery and cardiology
- Network Services: plastic surgery; ophthalmology; breast surgery; dermatology
- Trauma and Orthopaedics managed by Barnet Hospital but ward managed under Royal Free Hospital nursing team
- Anaesthetics, theatres and ICU; including pre-operative assessment; day surgery ward
- Private practice: all surgical specialities
The Royal Free London NHS Foundation Trust has three hospitals. We inspected the Royal Free Hospital only because the majority of the never events happened at this site. The inspection focused on the safe and well-led key questions which enabled the inspection team to assess the safety, quality and the culture of the service.
We carried out a short notice announced focused inspection because we had concerns about the quality of care in surgery. We saw an increase of serious safety incidents meeting the threshold of a never event in comparison to the previous years. Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers. We were also concerned about the culture within the service.
We did not rate this service at this inspection. The previous rating of requires improvement remains.
We did not inspect other locations or core services provided by the trust as this was a risk-based inspection. We continue to monitor all services as part of our ongoing engagement and will re-inspect when appropriate.
See the surgery section for what we found.
24-25 May 2021
During an inspection looking at part of the service
We carried out this unannounced focused inspection of the maternity service to follow up on concerns we identified during our last visit in October 2020 when we rated the service overall as inadequate. Overall, during this inspection, we rated safe and well-led as ‘requires improvement’. Effective, caring and responsive were not rated on this occasion and stayed as ‘good’.
How we carried out the inspection
During our inspection we visited the combined antenatal and postnatal ward, the labour ward, birthing centre, triage, day assessment unit, fetal medicine unit, close observation maternal assessment (CLOMA) and antenatal clinics. We spoke with 23 staff members including student midwives and junior doctors, band 6-8 midwifes, consultants and leadership team. We looked at 15 sets of notes, attended morning handover, cross site huddle and governance meeting. Due to the COVID-19 restrictions some interviews took place via video conferencing technology.
You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.
27 October 2020
During an inspection looking at part of the service
We carried out an unannounced (staff did not know we were coming), focused inspection of the Royal Free Hospital in response to concerns about maternity service. The concerns related to the maternity service’s response in relation to a serious incident. Because this was a focused inspection our inspection activity focused only on parts of the safe and well led key questions. This means we did not look at all key lines of enquiry in each of the domains.
During our inspection we visited the combined antenatal and postnatal ward, the labour ward, birthing centre, triage, day assessment unit, fetal medicine unit and close observation maternal assessment. We spoke with 17 staff members including student nurses, band 6-8 midwifes, doctors and leadership team. We looked at three sets of notes.
Our rating of this service went down. We rated it as inadequate because:
- Systems and processes to manage safety incidents were not always reliable or effective. The service response following serious incidents was sometimes insufficient and not timely. Learning from incidents was not always effectively embedded.
- The service did not have patient safety information leaflets available in other languages which meant women who had a limited understanding of English were at higher risk of missing warning signs about their own and their babys’ health. The service did not have readily available patient information explaining how to raise concerns or make a complaint.
- Staff without appropriate high dependency training looked after women that required enhanced care. The process of checking resuscitation trolleys was insufficient.
- The trust did not always formally apologise when things went wrong. There were no written records that families and patients received an apology which is not in line with the trust’s policies and the statutory Duty of Candour. The Duty of Candour regulation sets specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong.
- The service did not have a clear vision and strategy. We were not assured the leaders understood and managed the priorities and challenges the service faced. We were not assured senior staff had a sufficient understanding of what the risks and issues were. The leaders and staff did not always display a good understanding of their population.
- The governance processes did not always enable the service to timely assess, monitor and improve the quality of care provided. The risk management approach was applied inconsistently. There was no robust and effective process to manage risks. There was poor accountability for ensuring the identified actions were implemented.
- The service was not always able to collect reliable data and analyse it due to issues with the electronic patient record system. The service had ongoing issues with computer connectivity to the WiFi network on the labour ward which meant notes could not always be recorded contemporaneously..
Following the inspection, we took immediate enforcement action as a result of our findings. We issued a Warning Notice, on the 13 November 2020, under Section 29A of the Health and Social Care Act 2008. We required the trust to make significant and immediate improvements in the quality of healthcare it provides.
11 December to 10 January 2019
During a routine inspection
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.
18 July 2017
During an inspection looking at part of the service
We undertook an unannounced focused inspection in the critical care department of the Royal Free Hospital which is operated by the Royal Free London NHS Foundation Trust.
The inspection was conducted because the Care Quality Commission (CQC) had received anonymous information that the implementation of a new patient record IT system (CCCIS) had meant patients had been harmed, and was creating an ongoing a risk to patient safety.
During our inspection we found no evidence that patients had been harmed or were at a higher risk of harm as a result of the implementation and use of the new IT system.
At the point of our inspection, we found staff had ceased to use the critical care clinical information system (CCCIS) in early July 2017 in its full capacity as a result of the safety concerns being raised by individuals with the trust. Our inspection therefore focused on how the project had been managed and implemented and the resulting service. Some elements of the CCCIS were still in use, including electronic prescribing and access to diagnostic imaging.
We have not rated any part of this inspection because of its specific focus which did not include all areas of our ratings assessment model.
The summary of our key findings of our inspection were:
- No patients had been harmed as a result of implementing the new IT system. The mortality rate in the 12 months prior to our inspection was significantly better than the national average.
- Although incident tracking and documentation was consistent, there were variable approaches to resolving safety concerns. In addition not all staff felt the incident investigation system was effective.
- A key risk to the safety and sustainability of the service related to short staffing, including a 29% vacancy rate in the nursing team and a 26% vacancy rate amongst junior doctors.
- A dedicated project team had worked with clinical staff who had undertaken additional training to support the pilot scheme of a new CCCIS.
- There was evidence of a responsive approach to risk management during the CCCIS pilot although a significant number of clinical staff disagreed with this.
- Care and treatment was benchmarked against national standards through a programme of local audits and contribution to national audits, including the intensive care national audit and research centre. There was evidence staff improved care policies and protocols as a result of audit outcomes.
- We found evidence of significant and persistent disagreement and conflict between staff at different levels of responsibility. The senior leadership team had not demonstrably addressed this nor implemented timely strategies to reduce pressure on affected staff.
Our key findings were:
- Although incident tracking and documentation was consistent, there were variable approaches to resolving safety concerns. In addition not all staff felt the incident investigation system was effective.
- A key risk to the safety and sustainability of the service related to short staffing, including a 29% vacancy rate in the nursing team and a 26% vacancy rate amongst junior doctors.
- A dedicated project team had worked with clinical staff who had undertaken additional training to support the pilot scheme of a new critical care clinical information system (CCCIS).
- There was evidence of a responsive approach to risk management during the CCCIS pilot although a significant number of clinical staff disagreed with this.
- During the early implementation phase, on-site support for clinicians had been provided on a 24-hour basis by nurses and pharmacists who were trained as ‘super users’.
- Care and treatment was benchmarked against national standards through a programme of local audits and contribution to national audits, including the intensive care national audit and research centre. There was evidence staff improved care policies and protocols as a result of audit outcomes.
- The mortality rate in the 12 months prior to our inspection was significantly better than the national average.
- We found evidence of significant and persistent disagreement and conflict between staff at different levels of responsibility. The senior leadership team had not demonstrably addressed this nor implemented timely strategies to reduce pressure on affected staff.
- Clinical governance and risk management strategies were well established and effective in service improvement but there was limited evidence they were effective in driving good working relationships or project management.
- Senior divisional staff had instructed external NHS bodies to visit the unit and implement strategies to improve working relationships and leadership.
There were also areas of practice where the trust should consider making improvements:
- The trust should work with all staff groups and their representatives to assess how staff can feel more involved in major changes within the trust.
- The trust should review how governance systems can be made more open and effective in relation to project implementation and conflict management.
Professor Edward Baker
Chief Inspector of Hospitals
2 - 5 February 2016
During a routine inspection
This was the first inspection of The Royal Free Hospital under the new methodology. We have rated the hospital as Good overall.
We carried out an announced inspection between 2 and 5 February 2016. We also undertook unannounced visits during the following two weeks.
We inspected eight core services: Urgent and Emergency Care, Medicine (including older people’s care, Surgery, Critical Care, Maternity and Gynaecology, End of life Care, Services for Children and Outpatients and diagnostic services.
Our key findings were as follows:
Safe
There was a good culture of reporting incidents and we saw evidence of changes to practice as a result of investigations, and there were robust systems in place.
There were concerns with infection prevention and control practices, such as variable hand hygiene, staff wearing nail varnish and jewellery and doors left open to patients in isolation.
The safety thermometer data and many patient risk assessments or records, including fluid balance charts, were incomplete.
Departments performed frequent audits such as the theatre checklist and hand hygiene. Audits were analysed and the results cascaded to staff through staff meetings, notice boards and safety briefings.
Staff were aware of the safeguarding policies and procedures and had received training. Most staff understood their responsibilities under the Duty of Candour and were able to provide examples.
Suitable governance arrangements and appropriate incident reporting meant staff learnt from mistakes and near misses to improve care.
A formal early warning system was not consistently to identify deteriorating patients in the ED at the Royal Free site, which could lead to a delay in identifying deteriorating patients.
Effective
Clinical practice was benchmarked against national guidance from organisations such as NICE.
Caring
Staff were caring, compassionate and respectful and the staff we spoke with were positive about working in the hospital.
Caring staff maintained patients’ privacy and dignity and provided emotional support to relatives.
Responsive
The trust’s ED performance on waiting times for treatment was inconsistent but they often met the 4-hour target.
The Hospital 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.
An interpreting service was available for both in-patients and out-patients within the hospital.
Ambulance turnaround time did not meet the national target of handover. Patients were also not consistently receiving an assessment within 15 minutes of arrival, which was not in line with College of Emergency Medicine (CEM) guidance.
Patients’ individual needs and preferences were mostly considered when planning and delivering services.
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.
There was a lack of bereavement facilities on the labour ward. The designated room for bereaved mothers was a standard labour room and was sometimes used for other patients, such as those with an infection, which meant that women were cared for in the birth centre.
The poor post-operative recovery facilities for children exposed them to potentially upsetting sights and sounds.
Well Led
Patients achieved good outcomes due to receiving evidence-based care from suitable numbers of competent staff who enjoyed their work and were well supported by a visible management team.
There was an appropriate system of governance in surgical care services and arrangements to monitor performance and quality.
The trust promoted and encouraged both local and national innovations to improve patient care and treatment.
We saw several areas of outstanding practice including:
A ‘Foetal Pillow’ had been designed to aid delivery of the baby at caesarean section. The foetal pillow was used to elevate the baby’s head making operative delivery easier.
Particular praise must be given to the volunteers who provided additional caring activities such as massages for patients and supported patients with dementia.
We observed dynamic nursing leaders who supported clinical environments are were essential in the development and achievement of best practice models.
The neonatal unit had level 2 UNICEF accredited baby friendly status where breast feeding was actively encouraged and mothers are given every opportunity to breast feed their babies.
The vigilance and recording of mandatory training and other aspects of post qualifying education by the paediatric practice education team was exemplary.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Take action to ensure compliance with The National Patient Safety Agency (NPSA) alert PSA001 31st January 2011.
- The trust should ensure the 62 day cancer wait times are met in accordance with national standards.
- The trust data base of clinical guidelines and procedures hosted via “freenet” must be updated as soon as possible.
- The recovery area of the operating theatre must be altered to protect children from witnessing upsetting sights and hearing frightening sounds.
- Nursing staffing levels on the children’s ward must be improved.
In addition the trust should:
- Clearly define the ‘low risk’ pathway for women identified as suitable for birth centre care.
- Improve termination of pregnancy pathway.
- Identify a dedicated bereavement facility for women and families to use in or near the labour ward.
- Use lessons learned from Barnet Hospital in reducing Caesarean section rates.
- Undertake a maternity acuity staffing assessment to identify staffing requirements for the merged service.
- Improve antenatal risk assessments.
- Ensure the theatre swab, needle and instrument policy is ratified and new practices are embedded in all relevant departments across all sites.
- Ensure a safer surgery policy is produced and ratified.
- Ensure appropriate staggering of arrival times with the day surgery unit to minimise the time patients are prohibited from eating and drinking.
- Ensure ED staff are fully trained and able to identify and support patients living with dementia.
- Ensure the ED risk register captures and manages all risks.
- Ensure that there is an electronic system in place to flag patients who may require additional support.
- Ensure that medical and nursing records are fully completed without gaps or omissions.
- Ensure that RTT is met in accordance with national standards.
- Ensure all staff interacting with children have the appropriate level of safeguarding training.
- Ensure security of prescriptions forms is in line with NHS Protect guidance.
Professor Sir Mike Richards
Chief Inspector of Hospitals
26 February 2014
During a routine inspection
We spoke with 40 patients or their relatives and with 58 members of staff from a range of backgrounds, including medical, nursing and therapy. We looked at 33 sets of records relating to patients and analysed seven complaint responses.
Most of the patients we spoke with were positive about their experiences at the trust. Many told us they felt the staff were caring and had provided them with good support. A few felt there could be improvements. Most patients felt there was enough staff to meet their care needs. When we asked patients if they would feel confident raising concerns, most told us they would feel comfortable doing this.
The following are examples of comments we received from patients:
'Nurses are wonderful, couldn't ask for nicer. Doctors are good as well.'
'The care had been very good. The nurses are very attentive.'
'Everything is right. They took care of me very well. Best hospital.'
'Quality of the care is simply outstanding.'
'Overall it is first class.'
'Not too good. It's a bit noisy sometimes. I've known better hospitals.'
Where people did not have the capacity to consent, the provider acted in accordance with legal requirements. We saw that where they were required, capacity assessments and best interest meetings had taken place.
People experienced care, treatment and support that met their needs and protected their rights. We saw examples of care being planned appropriately and observed staff being very caring towards patients. Some care planning in the services for older people could be more personalised.
People were protected from the risks of inadequate nutrition and dehydration. We observed staff supporting patients with meals.
People were protected from the risk of infection because appropriate guidance had been followed. The wards we visited were mostly very clean.
There were enough qualified, skilled and experienced staff to meet people's needs. In most wards we visited we saw examples of good leadership and motivated staff. On ward 8 East there were a number of vacancies but recruitment was underway.
People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Most staff we spoke with told us they felt adequately trained and supported in their roles.
There was an effective complaints system available. Comments and complaints people made were responded to appropriately. The trust was not meeting their timescales for replying to all complaints although this was being addressed.
29 October 2013
During an inspection looking at part of the service
16 October 2012
During a routine inspection
Overall, we spoke with 58 patients or their relatives and with 46 members of staff from a range of medical, nursing, and therapy backgrounds.
In general, the patients we spoke to were very positive about their experiences at the trust. Most told us they felt the staff were caring and treated them with respect. They felt they were involved in decisions about their care and that there were enough staff to meet their care needs.
Most of the patients we spoke with told us they thought the hospital was clean.
The following are examples of comments we received from patients:
'The staff including the doctors and midwives have all been very friendly.'
'I have been using the service since 2009. The care is not bad I have no complaints.'
'Yes, it is good. I have no concerns.'
'Staff are there when I need them.'