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King George Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 22 June 2018

Our rating of services stayed the same. We rated them as requires improvement because:

  • We inspected Urgent and Emergency services during this inspection as we wanted to see what improvements and changes had been made to the service. We rated the service overall as requires improvement, although the rating for effective improved from requires improvement to good.
  • We inspected Medical care (including older people’s care) and found the service had improved from requires improvement to good since out last inspection in 2016. The rating for effective improved to good.
  • We inspected Surgery and found the service had overall improved from requires improvement to good since our last inspection in 2016. However, the rating for well led went down one rating to requires improvement.

Inspection areas

Safe

Requires improvement

Updated 22 June 2018

Effective

Requires improvement

Updated 22 June 2018

Caring

Good

Updated 22 June 2018

Responsive

Requires improvement

Updated 22 June 2018

Well-led

Requires improvement

Updated 22 June 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 7 March 2017

Outpatients and diagnostic imaging services were in transition. The strategy for these services was in development. There were a number of new senior managers who had introduced new quality assurance and risk measurement systems. However, these were not fully embedded.

Hand gel dispensers were in situ across outpatients and diagnostic imaging but we did not observe staff or patients using them.

The percentage of patients who did not attend (DNA) their appointment was above the England average. Staff told us they were not confident of meeting the national indicator for patients waiting over 18 weeks by their target date of March 2017. The trust’s performance for the 62 day cancer waiting time was consistently below the England average. Appointments cancelled by the hospital were also higher than the England average.

Some staff in the diagnostics and imaging team said there was a lack of clarity around their roles and responsibilities.

However, there had been an 88% reduction in the overall backlog of patients waiting over 52 weeks since May 2016.

Staff were aware of how to report incidents and could clearly demonstrate how and when incidents had been reported. Lessons were learnt from incidents and shared across the trust.

The trust had changed their patient records system and introduced the electronic patient record (EPR).

There were appropriate protocols in place for safeguarding vulnerable adults and children. Staff were aware of the requirements of their roles and responsibilities in relation to safeguarding.

Patients’ and staff views were actively sought and there was evidence of improvement and development of staff and services. Staffing levels and skill mix were planned to ensure the delivery of outpatient, diagnostic and imaging services at all times. All new staff completed a corporate and local induction. . Staff were competent to perform their roles and took part in benchmarking and accreditation schemes.

Medicines were found to be in date and stored securely in locked cupboards. Staff were able to describe the procedure if a patient became unwell in their department and knew how to locate the major incident policy on the intranet.

All the patients, relatives and carers we spoke with were positive about the way staff treated people. There was a visible person-centred culture in most departments. Patients and relatives told us they were involved in decision making about their care and treatment. People’s individual preferences and needs were reflected in how care was delivered.

Work was in progress to conduct a demand and capacity analysis to enable the service to develop a model whereby the hospital could assess and effectively manage the demands on the service. The hospital was using a range of private providers to assist in clearing the backlog of appointments.

Patients attending outpatients and diagnostic imaging departments received care and treatment that was evidence based. The service was monitoring the care and treatment outcomes of patients who were receiving outsourced care from providers in the private sector.

Outpatients, diagnostic and imaging services had introduced extended clinics seven days a week to clear patient waiting list backlogs.

There was a formal complaints process for people to use. Complaints information, as well as patient experience information was fed into the trust governance processes and trust board with formal reporting mechanisms.

Most local managers demonstrated good leadership within their department. Managers had knowledge of performance in their areas of responsibility and understood the risks and challenges to the service. There was a system of governance and risk management meetings at both departmental and divisional levels.

Maternity and gynaecology

Updated 18 December 2013

Maternity and family planning services were safe and effective.  Patients reported that midwives were caring and responsive and staff were positive about the service they provided.

Systems were in place for reporting and reviewing incidents to ensure that appropriate action was taken. Midwives used comments and complaints to improve women’s experiences of care and had responded proactively to these.

Medical care (including older people’s care)

Good

Updated 22 June 2018

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

  • During our previous inspection in September 2016 we reported that some wards had excessive levels of noise. During this inspection we found wards to be calm and quiet.
  • During our previous inspection the trust there were issues with the fire resisting compartmentation across the hospital site. During this inspection we found repairs had been completed and the fire risk addressed.
  • During our previous inspection in September 2016 issues were identified with the recording of patients. During this inspection we found patients records were mostly legible, contemporaneous, and reflected the care and treatment patients received.
  • During our previous inspection in September 2016 we noted there was a backlog of NICE guidance updates. During this inspection we found the backlog had been addressed and policies and procedures we viewed were up to date.
  • The endoscopy unit had achieved Joint Advisory Group (JAG) accreditation.
  • Staff involved patients and those close to them in decisions about their care and treatment. Staff treated patients with dignity and respect. Emotional and psychological support was available to patients and their families.
  • During our previous inspection we found the average length of stay for medical elective patients was higher than the England average. This had improved and from September 2016 to August 2017 the average length of stay for medical elective patients was lower than England average.
  • Outliers were prioritised at bed meetings; and a daily rota identified which medical staff would review outlying patients.
  • The trust took an average of 27 days to investigate and close complaints, this was in accordance with the trust’s complaints policy,
  • Both the specialist medicines and care of the elderly divisions had governance processes including risk registers for the management of risks and dashboards to enable the monitoring of divisional key performance indicators (KPI).
  • Staff spoke positively about the culture of the service describing it as a friendly place to work, and said there was a ‘no blame’ culture in response to incidents to facilitate staff learning and service improvements.

However,

  • During our previous inspection in September 2016 we found poor compliance with mandatory training for medical and dental staff. Medical and dental staff were still not meeting the trust’s standards for any mandatory training modules.
  • Safeguarding training figures showed that medical/dental staff were failing to meet the trust standard for level 2 safeguarding for both adults and children; and nursing staff were not achieving the trust standards for level 3 safeguarding adults training.
  • Staff were not always compliant with infection control practices.
  • We found temperatures were still excessively hot on most wards and staff were unaware of how temperatures on the wards were regulated.
  • There were high levels of bank and agency nursing staff and locum doctors. This posed a risk to the consistency of patient care.
  • During our previous inspection in September 2016 we found non-elective admissions, the standardised relative risk of readmission was high. During this inspection we found this risk was still higher than expected.
  • Patients in Clinical Oncology (Previously Radiotherapy) had a risk of readmission for elective admissions which was higher than expected
  • Some staff did not demonstrate awareness of consent, the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. Although workshops were being rolled out to staff across the hospital. We also found issues remained with Deprivation of Liberty Safeguards documents being updated in patient records in a timely manner.
  • The average length of stay for medical non-elective patients was higher than the England average.
  • The 18 week referral to treatment (RTT) rate for six specialties was below the England average.
  • Senior managers told us there were weaknesses in the relationship between the divisional clinical leadership and the trust’s executive board. The divisional director for acute medicine frequently used managerial time to cover clinical shifts.

Urgent and emergency services (A&E)

Requires improvement

Updated 22 June 2018

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

  • Our main concerns related to patients attending the department with mental health issues. Staff did not understand their roles under the Mental Health Act 1983. Nurses had not received formal training in mental health triage and in observations and assessments of risk to be carried out before mental health professionals arrived. Staff were not familiar with the trust policies on restraint of violent and aggressive patients, or the appropriate recording of restraint or rapid tranquilisation. They did not record such incidents consistently on the incident recording system, so there was no way to audit the frequency or safety of these procedures
  • The use of paper records and several different computer systems caused both duplication of work and sometimes made it hard for clinicians to see the full patient picture.
  • Frontline staff continued to feel that changes were made without involving them, and that non-clinicians developed plans without drawing on the practical experience of clinical staff.
  • There continued to be a shortage of permanent consultants and middle grade doctors, despite active recruitment having led to some improvement since the last inspection. Although many shifts were filled, mainly by regular locum doctors, some shifts remained unfilled which led to delays in assessing and treating patients.
  • The department did not meet the national standard to admit, discharge, or transfer 95% of patients within four hours. At the time of our inspection, about 82% of patients were discharged within the standard time, which was a similar level to that at the previous inspection, so performance had not worsened.

However:

  • The trust had made improvements in many areas where we had concerns at our previous inspection. In particular they signifcantly improved training in both resuscitation and sepsis recognition and management. On this inspection there was evidence that both adult and paediatric nurses and locum doctors had undertaken training or were booked on training in the during the year. Sepsis screening within an hour was consistently high at this site. NHS England had recently commended the trust for being one of the trusts which had seen the greatest improvements in performance in assessing and treating sepsis within its emergency departments.
  • We inspected at an extremely busy time of year. The volume of patients was preventing the hospital from seeing, treating and discharging patients within the standard time, as was the situation in many London hospitals. However we considered patients were safe while waiting for treatment and they were kept informed about waiting times and the reasons for this.
  • Staff worked effectively with each other and with other teams within the hospital such as the medical assessment unit, the frailty unit and the paediatric ward.
  • Safeguarding was well managed, particularly in relation to children.
  • Feedback from patients and families was very positive and we saw staff manage bereavement with sensitivity and compassion.

Surgery

Good

Updated 22 June 2018

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

  • There was a positive incident reporting and investigation culture.
  • Monthly performance reports monitored harm free care. There was good evidence of acting on identified risks and good analysis at safety briefings and safety huddles.
  • All wards reported zero infections for MRSA and C-diff.
  • Equipment was kept in good order and was appropriately stored. Theatres were clean and well organised.
  • Medicines were stored appropriately and securely.
  • Staff were trained in safeguarding and had a clear understanding of what constituted a concern and how to escalate this.
  • The surgery division was meeting the trust target of 90% for mandatory and compliance rated training.
  • Pain relief was being managed effectively and the development of nursing competency documents included pain management.
  • A practice development nurse had been newly appointed within the surgery division which had traditionally been a corporate role. Practice educators have also been appointed to theatres to support staff learning and training. Meaningful work had been carried out to scope compliance with training and competence.
  • There was an effective multidisciplinary team working environment and multidisciplinary input in theatres, recovery and the wards.
  • There were good response rates to the friends and family test. Results were very positive and all fifteen patients and five relatives we spoke with told us staff were caring and compassionate.
  • Complaints were appropriately investigated and reviewed and staff worked with patients to resolve any issues as they arose.
  • There were numerous assessment processes in place that supported meeting people’s individual needs.
  • Every elective patient received pre assessment at the trust hospital that hosted the specialty. In pre assessment we found that all clinic rooms were being utilised.
  • Compliance against a trust target of 92% for referral to treatment (RTT) was recorded as a 12 month rolling trend rate of 78.5%. However, it also showed the last two month average to be 86%.
  • Patients told us they were given useful information regarding their treatment and what to expect.
  • There were clear lines of accountability within the governance structure that effectively monitored and reported up on performance and risk.
  • There was a clear leadership and staffing structure within the surgery division to manage activity and oversee care.
  • Staff felt there was now visible leadership, which had been highlighted as an area requiring attention in a previous staff survey.
  • There was a positive working culture.

However:

  • The infection control team did not have a system to identify trends in infection and data was trust wide and not broken down by site. There were no records for ordinary streptococcal infection.
  • The adult day unit sometimes had Saturday and Sunday operating lists, so the unit’s ward was opened. With only one trained nurse on duty, there were potential issues around who was supervising the unit.
  • Consent was being taken on the day of surgery for both day cases and major (inpatient) surgery. This could impact on both the patient and theatre schedules if the patient was assessed as lacking capacity.
  • Specialties and divisions confirmed their compliance with NICE guidance by email, which was accepted. Compliance with NICE guidance was not being audited.
  • There was not sufficient medical cover to meet the needs of the surgical wards at weekends or evenings. There was a lack of access to occupational therapy, dietetic, and speech and language therapy services at weekends.
  • Patients told us that medical and ward staff were emotionally supportive. However, there was no dedicated counselling or psychology service available for surgery patients.
  • We found that theatre lists were inefficient. There were a low number of cases being put through. Most clinics did not start on schedule, with late start times and early finishes, which seemed to be accepted as the norm.
  • Relatives and carers were not restricted from staying overnight when this was appropriate. However, there were no makeshift beds or mattresses available to make this more comfortable.
  • There were some parking bays for blue badge holders close to the entrance of the hospital which were free of charge. However, disabled parking bays in the main car park incurred the normal charge and the free parking bays were often full.
  • At the time of inspection, both divisional director and service manager posts had become vacant with no substantive replacement appointed.

Intensive/critical care

Requires improvement

Updated 2 July 2015

Patients and relatives spoke highly of the care and treatment they received in the Intensive Treatment Unit and High Dependency Unit. They told us they were kept updated about their family member’s progress using language they understood. Visitors to the ward were made to feel welcome and were encouraged to support their family member if they felt able to.

There were insufficient critical care beds available for the population served by the Barking, Havering and Redbridge University Hospitals NHS Trust in comparison with other London trusts. Capacity was high at an average of 95%. It was estimated that critical care bed shortages affected 100 to 200 patients across the trust each month, with patients experiencing cancellations of planned procedures and significant waits in A&E (or in the recovery unit) while waiting for ITU beds.

Changes in the acuity of patients and reduced staffing levels meant patients were not always supported on a one-to-one basis, as per national guidance. Despite the bed shortages and staffing levels, we saw that staff continually assessed the safety of the patients and only supported patients on the ward or in the recovery unit if it was staffed appropriately, ensuring the safety of the patients.

Staff were aware of how to support patients and their families’ individual needs. Staff spoke passionately about providing the best care they could to achieve the best results for their patients. Patient outcomes and mortality rates were within expected ranges when compared to similar services.

Care and treatment was delivered by trained and experienced nursing staff. There was a clear reporting structure and staff told us they felt supported and confident in their role.

Temporary and newly-qualified staff had to achieve a set of core competencies prior to working with patients on an individual basis. Junior medical staff spoke positively of the support and learning they received from consultants.

There was little evidence of multidisciplinary team approach. Physiotherapists spoke with consultants and nurses daily about how to support patients, but access to other professionals was carried out on a referral basis.

All the governance meetings took place at Queen’s Hospital and we found that the consultants did not have a strong grasp of governance, risks or concerns relating to the unit.

Most staff were not engaged with the trust’s vision and were unaware of the senior lead’s vision for critical care services. This was affecting morale, which the senior staff on the unit were managing.

The outreach team supported ward-based staff in the early identification of patients who were at risk of deteriorating and who may require an HDU or ITU bed. Critical Care Outreach Team (CCOT) also provided an outpatient clinic to support previous critical care patients in the months after their admission to ensure they continued to progress.

Services for children & young people

Requires improvement

Updated 2 July 2015

Although staff were aware of the incident reporting system, incidents were not always reported. Paediatric resuscitation equipment was not always checked in some areas of the hospital. We found there was a lack of paediatric life support training for theatre staff who may be involved in treating a child or young person whose condition suddenly deteriorated.

Not all records were stored securely and confidentially. There were issues around obtaining records and tracking temporary notes, which meant a full set of notes was not always available.

The service children experienced during visits to the hospital for phlebotomy did not meet their needs. There were limited resources available for children with mental health needs and no paediatric physiotherapist.

Paediatric services had a lack of developed governance systems which meant that risks were not always identified and escalated appropriately within the division to the patient safety team for appropriate management.

Staffing on Clover Ward was not always sufficient. However, specialist nurses were brought in as necessary to provide cover. Although an acuity and dependency tool was available to calculate ward staffing levels, the data was not always updated on the system.

Observation of interaction between staff and patients was very positive. Parents told us they were involved in discharge planning and told us they were very happy with the attention their children received while staying on Clover Ward.

End of life care

Good

Updated 2 July 2015

Patients were involved in care planning and decision making. Staff were respectful and treated patients with compassion. Specialist palliative care team members were visible, competent, and knowledgeable. Staff we spoke with were aware of how to report an incident or raise a concern.

Medicines were managed appropriately. Nurses were able to describe safeguarding procedures and how these were used to protect patients from abuse. There was a sufficient number of staff who received appropriate training. There were systems in place that helped to reduce inappropriate hospital readmissions and complaints were responded to appropriately.

There were systems in place for the routine monitoring of the quality of the service and the specialist palliative care team management had developed appropriate strategies and objectives to ensure continuous service improvement. Staff worked well as a team.

The hospital performed worse than the England average in the National Care of the Dying Audit. The trust’s policy did not clearly specify in which cases staff were required to complete do not attempt cardio-pulmonary resuscitation (DNACPR) forms or how long after the admission they had to complete them. End of life services provided at the hospital were limited, with teams being based at another hospital managed by the trust.