You are here

The Queen Elizabeth Hospital Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 16 December 2020

Our rating of services stayed the same. We rated the trust as inadequate at our previous inspection, in July 2019. We rate at core service level only when completing focused inspections. Therefore, any changes in core service ratings are not represented by the trust wide ratings table.

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

  • Compliance with mandatory and safeguarding training was not in line with trust targets across most areas and clinical staff groups. This includes life support training for nursing and medical staff working within the emergency department.
  • Anaesthetists compliance with PROMPT (Practical Obstetric Multi-Professional Training) was significantly below the trust target.
  • Within the emergency department, facilities did not always promote peoples safety.
  • Resuscitation equipment was not always checked in line with trust guidance (on Stanhoe ward). Staff did not routinely remove aprons and gloves when leaving a clinical area within diagnostic imaging.
  • Despite active recruitment, there remained pockets where nursing, medical and allied health professional staffing numbers were below the recommended establishment. This also applied to end of life care, where palliative care consultant numbers remained lower than guidance.
  • Staff did not always keep detailed records of patients’ care and treatment when completing records for end of life care patients. This included the completion of mental capacity assessments.
  • Although staff were aware of the requirement to report clinical incidents and knew what constituted a clinical incident, staff did not report all incidents that might impact the service or patient safety.
  • Performance with regards to referral to treat times were not always in line with national targets.
  • People could not always access the service when they needed it and received the right care promptly.
  • Leaders in the service had a vision for what it wanted to achieve but this was not formalised in a vision and strategy.
  • There was increased staff engagement processes in place to communicate with staff. However, leaders acknowledged that there was further work required to engage effectively with all staff groups.
  • Although effective governance processes and risk management systems were in place these were not fully embedded within diagnostic imaging. Across other services, not all staff groups were regularly represented at meetings.
  • There were pockets within some services where the culture required further investment.
  • Audit programmes were not always clear which meant that oversight of performance and monitoring was not always clear.
  • Leaders had the skills and abilities to run the service, although had not been in place long enough to demonstrate a sustained improvement in performance.

However:

  • Clinical environment was well maintained and suitable to the needs of services. • Staff had access to equipment at the time of need and there were robust processes in place to ensure that equipment was safe to use and serviced regularly. • Infection control and prevention was well managed. Staff ensured that patients and their visitors were safe from communicable infections. Hand hygiene was encouraged, and staff managed clinical waste well.
  • Patients risks were assessed and monitored regularly. When necessary, patients were escalated, and action taken swiftly to prevent deterioration.
  • Staffing was maintained with the use of agency and locum staff. All areas actively recruited staff and where possible developed their own staff to ensure that there were sufficient numbers to meet demands.
  • Patients records detailed care and plans of treatment. With the exception of medicine services, records were held securely, accessible and shared when patients moved between departments or services.
  • Medicines were prescribed, administered and stored in line with guidance.
  • Safety incidents were recorded and investigated. Learning was shared across departments and the trust. Staff were aware of duty of candour and knew when to apply it.
  • We saw patients treated with respect and dignity. Staff were compassionate and included patients and their relatives in decision making.
  • Where possible, services were developed with patients in mind. Departments were accessible.
  • Local leadership teams were passionate about their services. They were visible and respected.
  • Services had or were in the process of developing services strategies that aligned to the trust strategy and vision. All services had plans in place of how they were going to develop.
  • Staff were largely positive about their roles and the services in which they worked. They spoke positively about their peers and the support they received.
  • Staff felt able to escalate concerns.
Inspection areas

Safe

Inadequate

Updated 16 December 2020

Effective

Inadequate

Updated 16 December 2020

Caring

Requires improvement

Updated 16 December 2020

Responsive

Requires improvement

Updated 16 December 2020

Well-led

Inadequate

Updated 16 December 2020

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 16 December 2020

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

  • Staff mandatory and safeguarding training compliance did not meet the trust target and the service did not have enough support staff on all wards to provide the right care and treatment.
  • On Stanhoe ward, staff had not completed appropriate resuscitation equipment checks.
  • Patient records were not always stored securely.

However:

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients to plan and manage services and all staff were committed to improving services continually.

Services for children & young people

Good

Updated 24 July 2019

Our rating of this service stayed the same. We rated it as good because:

  • The service provided mandatory training in key skills. Nursing staff mandatory training compliance was 90% on Rudham ward and 91% on NICU. Staff had safeguarding training and they knew how to recognise, and report abuse to protect patients.
  • The service had suitable premises and equipment, looked after them and controlled infection risk well.
  • Staff kept detailed records of patients’ care and treatment, completed and updated risk assessments for each patient and followed best practice when prescribing, giving, recording and storing medicines. Care and treatment was based on national guidance.
  • The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from harm and to provide the right care and treatment. Managers made sure staff were competent for their roles, appraised staff’s work and performance. Staff of different specialities worked together as a team to benefit patients.
  • 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.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They assessed and monitored patients regularly to see if they were in pain and promoted good health.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care and understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff cared for patients with compassion, provided emotional support and involved patients and those close to them in decisions about their care.
  • The trust planned and provided services in a way that met the needs of local people and took account of patients’ individual needs. Waiting times from referral to treatment were in line with good practice.
  • Managers at all levels in the service had the right skills and abilities to run a service providing care and they promoted a positive culture that supported and valued staff.
  • The service had effective systems for identifying risks, collected, analysed, managed and used information well to support its activities and engaged with patients and staff to plan and manage appropriate services. The service treated concerns and complaints seriously.

However:

  • Mandatory training compliance for medical staff did not meet trust target (90%) for any of the eight modules.
  • Safeguarding children level three training compliance for nursing and medical staff did not meet trust target of 95%. Nursing was 89% and medical staff was 85%.
  • The service did not have enough consultants to meet royal college of paediatric and child health (RCPCH) guidance and consultant handwriting was not always legible in all medical records.
  • Not all nursing staff in NICU handed over care of the babies when leaving the nursery for an extended period of time and one member of nursing staff was heard to use discriminatory language when speaking about a patient with known mental health issues.
  • Staff on Rudham ward did not have a portable telephone call so that they could make confidential calls in a private area away from the nurse’s station.
  • Governance structures were not embedded, not robust and did not give enough consideration to children and young people’s services and did not monitor the progress of the CYP strategy which staff were unaware of.
  • There was no representation of CYP services at the quality and safety committee meetings, mortality review meetings or the mental health governance committee meetings and the service did not have a CYP specific learning disability nurse.

Critical care

Good

Updated 19 September 2014

Patients and their families said that staff were attentive and caring. Staff treated people with kindness, dignity, respect, compassion and empathy, while providing good care and evidence-based treatment. Staff worked well as a team, felt supported by their line managers, and were highly motivated to provide patients with the best care possible.

 

The service had a clear vision and credible strategy to deliver high-quality care and promote good outcomes. The service was actively involved in national and local research and audit projects, and demonstrated innovation through involvement in equipment design. The trust engaged with patients and visitors, and acted on their feedback.

 

The trust’s track record on safety was good. There were reliable systems, processes and practices in place to keep people safe and safeguarded from abuse. The trust learned when things went wrong, and improved safety standards as a result. We were concerned that there were no side room facilities for coronary care patients; however, we were reassured that this was already on the service risk register, and that senior managers were taking appropriate action by looking at ways to resolve this issue.

Some outcomes for people using the service were good compared to other services. There were periods in the past year where bed occupancy levels were above the England average. These capacity issues meant that patients were not always cared for in the most appropriate setting for their needs, and elective surgery got cancelled.

End of life care

Requires improvement

Updated 16 December 2020

Our rating of this service improved. We rated it as Requires Improvement because:

  • Palliative care consultant staffing continued to be a concern but recognised as a nationwide problem. To mitigate any risks there was a clear demonstration of increased ownership for end of life care throughout the trust and clear recognition for the need for palliative care expertise. Consultant staffing from other local trusts were in place and we were assured they were accessible and provided support to care for patients in receipt of end of life care.
  • Patient care records had gaps in the completion of Mental Capacity Act documentation. This was recognised by the trust and an ongoing piece of improvement work was being carried out.
  • Patients did not always receive timely care or treatment in line with their wishes.

However:

  • The trust worked collaboratively across the local health economy to introduce a new, sustainable end of life care strategy and address concerns raised at the previous inspection.
  • The strategy was widely shared, and staff were engaged in the process of embedding the practical elements to ensure good quality end of life care.
  • There was an executive lead, senior leadership team and clinical ownership and accountability across the trust for end of life care.
  • Patient care records receiving palliative and end of life care contained Recommended Summary Plan and Emergency care Treatment (ReSPECT) documentation with do not attempt cardiopulmonary resuscitation (DNACPR) documented. Staff carried out audits to help ensure good quality completion and compliance.

Surgery

Requires improvement

Updated 16 December 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Leaders and teams used systems to manage performance, however, performance was below targets.
  • Staff mandatory training compliance and medical staff compliance with mandatory safeguarding training was below the trust target. This was as a result of changes to training due to COVID- 19, however, there were plans in place to improve compliance.

However, we also found;

  • There were processes in place to ensure patients were safe when being admitted to hospital for surgical procedures. Staff completed training in mandatory and specialist skills to meet the needs of patients and there were safe numbers of staff working to meet care for patients. Staff used risk assessments to identify any risks and escalated them accordingly. The environment was suitable to meet the demands of the service, equipment was well maintained, and all areas appeared to be clean and tidy. Patient records reflected care that had been given or planned, and they were stored securely. Medicines were managed in line with guidance and administered in a timely manner. Staff were aware of their roles and responsibilities for reporting and managing incidents and teams shared learning.
  • The surgery service leadership team had plans in place to manage activity and included staff in the planning and implementation of service changes. Leads were visible and easily accessible and well thought of by the wider team. There were robust governance processes underpinning activity and staff regularly reviewed performance, challenged findings and held each other to account. Risks were known and mitigation implemented to manage risks effectively. There was largely a positive culture, and staff were proud of their achievements.

Urgent and emergency services

Requires improvement

Updated 16 December 2020

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

  • Staff compliance with mandatory and safeguarding training was generally below the trust targets, although staff were aware of how to protect patients from harm. The environment did not always meet the needs of activity, and some areas were cramped which impacted on staffs ability to maintain safe distances between patients. There were also some staff vacancies within the department although there was no evidence to demonstrate that this impacted negatively on patients care and treatment.
  • Performance within the department did not always meet the national standards with variances in referral to treatment times, arrangements to admit and treat and discharge times.

However, we also found:

  • Infection control and prevention was maintained to protect patients from risks of infection. Clinical areas were visibly clean, and waste was managed appropriately. Patients were risk assessed and escalated appropriately.
  • The service collected information about performance and used it to improve. There was service wide knowledge of risk and plans in place to cope with unexpected events.
  • Patients were treated respectfully and with compassion and kindness. Staff considered individuals needs and supported patients and their families with decision making.
  • There was a positive culture within the department with mutual respect across staff groups. Staff felt supported and able to escalate any concerns or offer ideas on how the service could be improved. There was a shared plan which was aligned to the trust strategy, and all staff understood their roles in achieving the vision. Staff felt supported and valued and worked collaboratively with partner organisations.

Diagnostic imaging

Requires improvement

Updated 16 December 2020

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

  • Staff mandatory and safeguarding training compliance did not meet the trust target. The service did not have enough substantive staff with the right qualifications and skills to cover all shifts. We were not assured that the out of hours staffing arrangement was sustainable and robust to provide safe care and treatment to patients. Staff did not routinely remove aprons and gloves when leaving a clinical area. Staff did not report all incidents that might impact the service or patient safety.
  • Although effective governance processes and risk management systems were in place these were not fully embedded. Leaders acknowledged that there was further work required to engage effectively with all staff groups. Leaders in the service had a vision for what it wanted to achieve but this was not formalised in a vision and strategy.

However:

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients and acted on them. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Most staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients to plan and manage services and all staff were committed to improving services continually.

Maternity

Requires improvement

Updated 16 December 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Mandatory and safeguarding training compliance was lower than the trust target and midwifery staff did not always attend meetings, or have sufficient numbers to enable coordinators to be supernumerary. Anaesthetists compliance with PROMPT (Practical Obstetric Multi-Professional Training) was significantly below the trust target.
  • It was unclear if there was an audit plan in place to monitor performance and inform decisions about service developments. Midwifery representation at governance meetings was not always clear. Some staff felt that the culture required further development.

However:

  • The service had processes in place to ensure the safety of women and babies. Staff were aware of their roles and responsibilities and completed training specific to the speciality. Infection prevention and control was maintained, and staff ensured that equipment was suitable and serviced regularly. Staff took action to escalate any concerns and ensured records reflected care given. Medicines were stored securely and administered in line with guidance.
  • There had been changes to the leadership of the team and staff felt there had been positive changes to the functioning of the service with staff working more cohesively. Midwifery staff felt supported and involved with changes and service developments. There was a strategy in place which reflected the vision and was aligned to the trusts strategy. There were robust processes in place to ensure good governance.

Gynaecology

Requires improvement

Updated 24 July 2019

We rated the service as requires improvement because:

  • Staff did not always complete mandatory training in line with the trust’s target. The trust target was not met for any of the seven mandatory training modules for qualified nursing and midwifery staff in gynaecology. The module manual handling had the lowest compliance rate of 33% below the trust target of 95%.
  • Medical staff had not completed any mandatory training modules in line with the trust’s target. The trust target was not met for any of the eight mandatory training modules for medical staff in gynaecology. The module adult basic life support had the lowest completion rate of 52% which did not meet the trust target of 95%.
  • The service utilised a high number of locum medical staff and we were not assured that all staff had the appropriate training. The trust was unable to confirm that all medical staff had the relevant ultrasound scanning competency.
  • Not all nurses had the appropriate competencies in place to provide the right care and treatment. Nurses did not hold a recognised post qualification gynaecological course. Whilst competencies were in place the assessor had not completed their own competencies. However, there was access to clinical nurse specialists and midwives for advice and support.
  • The service did not routinely audit the effectiveness of care and treatment and use the findings to improve them. The service did not participate in Royal College of Gynaecology Safer Standards national audits.
  • People could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with good practice.
  • The timeliness of complaint responses did not meet local policy targets. Although the service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • Leaders of the service did not always act on concerns raised in a timely manner. Staff did not feel empowered to improve the quality of care. Staff felt that they would escalate concerns, but no action would be taken.

However:

  • There were systems and processes in place to monitor standards of cleanliness and hygiene. These included up to date policies, cleaning schedules and checklists, infection prevention and control training.
  • There were systems and processes in place for medicine management concerning handling, storage and security of medicines. Staff kept medicines securely in the clinical areas we visited.
  • 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.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. The service took account of patients’ needs.

Outpatients

Requires improvement

Updated 24 July 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Although the service had suitable premises and equipment in most areas and looked after them well some areas did not meet the needs of the service. For example, the diabetic clinic consulting room. This impacted on staff being able to protect patient’ privacy and dignity when delivering care.
  • Outpatient areas did not routinely audit the effectiveness of care and treatment and use the findings to improve them. This had not improved since the previous inspection.
  • Non-admitted referral to treatment pathway rates were below the trust’s operational standard and the England average. This meant that patients were waiting longer for appointments after being referred by their GP.
  • The trust did not routinely collect data on late starting clinics or patient waits in outpatients. Main outpatients had begun to collect this data but had yet to analyse the information collected.
  • Car parking facilities did not always meet demand. Patients reported that they often had difficulty parking when attending for clinic appointments which caused them to be concerned that they would miss their appointment.
  • The outpatient’s department did not have a local vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
  • We were not assured that local risk and performance was monitored appropriately. There was a lack of robust monitoring of referral to treatment times and control audits across all areas of outpatients.
  • The trust did not have processes in place to engage with patients, the general public and local organisations to plan and manage appropriate services. Staff were positive about engagement with local mangers but reported that engagement with the trust senior executive team was inconsistent.
  • There were processes and systems of accountability within clinical business units although these were not always effective. Outpatients were split over a number of different business units. There did not appear to be oversight and shared learning across all outpatient areas.

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.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • The service took account of patients’ individual needs.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. The average time to investigate and close complaints was **. This had improved since the previous inspection
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

Maternity (inpatient services)

Updated 6 March 2019