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Queen's 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 .

  • We inspected Urgent and Emergency services during this inspection to check if improvements had been made since our last inspection. The overall rating for the service was requires improvement. The rating for effective and caring improved to good. Safe, responsive and well led remained requires improvement
  • We inspected Medical care (including older people’s care) and found the service had improved since we last inspected in 2017. We rated the service good overall. The rating for safe and responsive both improved from requires improvement to good.
  • We inspected Surgery and rated the service requires improvement. The rating for effective improved to good; however the rating for the other domains remained requires improvement.
  • We previously inspected Maternity services in 2015. On this occasion we rated the service overall requires improvement, although the rating for well led improved to good.

Inspection areas

Safe

Requires improvement

Updated 22 June 2018

Effective

Good

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

Critical care

Requires improvement

Updated 2 July 2015

There were insufficient critical care beds available for the population served by the trust in comparison with other London Trusts. Despite four additional beds being made available, capacity has remained high at an average of 95%. It was estimated that critical care bed shortages affect 100-200 patients each month, with cancellation of planned procedures and significant waits in A&E when waiting for a GICU bed.

Incident reporting was variable and staff were unclear about which issues to report. Learning from reported incidents was not always apparent and staff told us there was little change after raising issues. Patient records, including consent and mental capacity assessments, were completed in most cases but we found some gaps in care plans and inconsistency in prescribing resulting in controlled drugs being administered without a valid legal prescription.

There was limited space. This resulted in small bed areas and no space for dedicated hand wash facilities or waste bins for each patient space. There was limited available storage for equipment. In most cases, equipment was cleaned in line with the infection control policy but some areas of the unit were not cleaned to the highest standard.

There was little multidisciplinary team working evident on GICU. Physiotherapists attended handovers but access to other professionals was on a referral basis. On NITU, structured MDT meetings were held for long term patients. Pastoral support was available across critical care 24 hours a day.

The leadership team had a strong vision for future expansion of critical care services but this had not been shared with the ward staff. Staff had a mixed understanding of the vision for critical care and the reconfiguration had left some uncertainty about the future expansion plans.

Care and treatment was delivered by trained and experienced nursing staff who worked in dedicated teams. There was suitable medical cover provided by specialist consultants and junior doctors.

Policies and protocols we observed were based on national guidance and international guidelines. The critical care units completed local audits and evidence based work when no national guidance was available. The GICU participated in a national database for adult critical care. Patient outcomes and mortality were within expected ranges when compared to similar services. The outreach team supported ward based staff in the early identification of patients at risk of deteriorating and who may require an HDU or ICU bed. CCOT also provided an outpatient clinic to support previous critical care patients in the months after their admission and to ensure they continue to progress.

Outpatients and diagnostic imaging

Good

Updated 7 March 2017

There was evidence of significant improvements in outpatient, diagnostic and imaging services. 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.

However , we also found:

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.

We found alcohol hand sanitising gel dispensers in the ground floor outpatients waiting area and diagnostic and imaging department entrance were empty. Staff in the diagnostic and imaging department did not observe best practice guidance on hand washing or using sanitising gel between patients. The first floor outpatients’ department corridor was being used as a waiting area and this created a risk due to patients waiting in the corridor.

Privacy curtains were not being drawn in the main diagnostic and imaging department, and the emergency room in ophthalmology had bays that did not promote patients’ privacy and dignity. Phlebotomy waiting rooms were full and there appeared to be limited space for the phlebotomy service’s footprint to expand.

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 standard for patients waiting less than 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.

Urgent and emergency services

Requires improvement

Updated 22 June 2018

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

  • We were pleased to note improvements in a number of significant areas since the previous inspection and commend the department for these achievements. However, there was still considerable work required to reduce bottlenecks in the system and to assess and treat a higher proportion of patients more quickly.
  • Not all medical shifts were filled despite the use of locum doctors. Significant efforts were being made to improve recruitment and retention, including retention of locum doctors, which had shown some success.
  • The improved permanent staffing had not significantly improved flow through the department, partly because the number of patients had grown. The flow through the new EUCC in particular was slower than expected for a service of this kind. In the last 3 months of 2017 the UCC treated and discharged 85% of patients in four hours.
  • 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.
  • We had a number of concerns about the safety of patients and staff in the newly opened EUCC, particularly the small waiting area in which it was difficult for staff to observe patients and where there was not enough seating. Staff were aware some of these concerns but were not able to address them quickly.
  • At the last inspection that the lack of paediatric nursing capacity was rated as high on the recent corporate risk register. Paediatric nursing capacity had improved, although there were not always band 6 shift leaders, but shortage of paediatric nurses in ED remained on the risk register.

However:

  • We recognise that our inspection was at one of the busiest times of year and that staff were working under unusual pressure, and staff mainly remained calm.
  • At the last inspection, only 46% of consultants were permanent staff, but now 61% of consultants were permanent and the department was now able to provided 24 hour consultant cover at least five days a week. There was an almost full establishment of trainee doctors who were positive about the support and teaching they received from senior clinicians.
  • At the last inspection we had lacked of assurance that locum doctors and nursing staff had resuscitation training and CQC had required an improvement in performance. There were now robust arrangement for staff, including locum doctors had this training, and levels of resuscitation training had improved significantly among nurses too.
  • CQC had required an improvement in the response to sepsis identification and management at the previous inspection. On this inspection, there was prompt screening and management of sepsis. NHS England had commended the trust for being one of the trusts that had seen the greatest improvements in performance in assessing and treating sepsis within its emergency departments
  • At the last inspection, we received mixed feedback from staff regarding learning from incidents. The service had strengthened its arrangements for learning from incidents and complaints, and shared information about these effectively with staff.
  • There were reliable systems and training to protect people from abuse. Staff were knowledgeable about safeguarding.

Maternity

Good

Updated 22 June 2018

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

  • We rated effective, caring, responsive and well-led as good, and safe as requires improvement.
  • Staff were aware of their responsibilities in relation to protecting adults and children from abuse and harm. The maternity service had a named safeguarding midwife and designated specialist midwives for teenage pregnancy, perinatal mental health and substance misuse.
  • As we found during our last inspection, staff carried out regular assessments and responded well to patient risk. Modified early obstetric warning scores (MEOWS) were used consistently within notes. A system for monitoring and reviewing foetal heart rate by cardiotocography (CTG) was in place.
  • Women in established labour received one to one care in all cases between April and December 2017.
  • Consultant cover on the labour ward had increased and was an improvement from our last inspection.
  • Staff working within the maternity service were competent and had the skills to provide safe and effective care. A new model of supervision was being developed whereby midwives were offered restorative clinical supervision.
  • All women we spoke with said that midwives were courteous, treated them with respect and were sympathetic to their individual needs.
  • The service was developing a new personalised model whereby women would see the same midwife from antenatal, through delivery, to postnatal care in line with the Better Births report 2016.
  • We saw strong leadership throughout all areas of maternity who demonstrated an understanding of the performance of the service and its challenges. A determination for ongoing improvement was evident.
  • Staff engagement had improved since our last inspection. Staff told us that managers were visible on the wards, and had an open door policy.
  • Governance arrangements had improved since our last inspection, ensuring that all staff, including those that worked within foetal medicine and antenatal screening, received timely feedback for incidents.

However:

  • Medical staff were not meeting the trust target for many of the mandatory training modules. This included training for resuscitation level 2 (adult and newborn), and GROW training. We had found similar concerns at our last inspection.
  • Daily equipment checks were not always completed on the labour ward. Staff told us that equipment was not always readily available for them to care and treat women in a timely fashion.
  • The service were below the national average in standards set within the National Neonatal Audit Programme 2016.
  • Staff used curtains to protect women’s privacy when undertaking examinations and observation on the wards. However, on the antenatal ward and in triage we saw that the curtains were not always fully drawn. This meant women’s privacy and dignity was not being respected at all times.
  • The service were not meeting the national screening target of 50% for thalassaemia and sickle cell anaemia although staff were engaging with GPs and a new referral form had been implemented to support meeting the target.
  • Staff and patients told us that there were concerns about waiting times in the antenatal clinic. Waiting times in the antenatal clinic were not being monitored. We had found similar concerns during our last inspection.
  • The service were falling below their target waiting times for patients to be seen within triage.
  • Although community midwives felt integral to the maternity service as a whole, it was recognised that communication between the hospital and community could be improved.

Maternity and gynaecology

Requires improvement

Updated 2 July 2015

There had been significant improvements to the maternity services since our last inspections. Including improvements in the way women felt about the service, leadership and culture, staff engagement, medicines management and access and flow.  

Governance arrangements were, in the main considered to be sufficiently robust. Dashboards were utilised and offered staff a snap-shot of a range of quality indicators and outcomes to ensure that clinical performance could be assessed. Audits programmes were utilised to underpin the existing governance arrangements.

However, the existing governance arrangements did not always encompass the totality of clinical and maternity services provided to women; those working in foetal medicine and the ante-natal screening service were not always included in, nor received timely feedback from incidents which may have impacted on the management of the woman and her unborn baby and so there was the potential for delays in lessons learnt and service improvements being implemented as a result of clinical incidents.

The service did not employ sufficient numbers of consultant obstetricians to ensure that the labour ward was appropriately supported; the existing establishment was not in-line with national and London based recommendations. A business plan had been submitted to the executive team to increase the number of substantively appointed consultant obstetricians.

Evidenced-based care and treatment was delivered. Outcomes for women were similar to other services when compared. Midwives were competent and kept up to date with their mandatory training. Women received their choice of pain relief and were supported to feed their babies in their preferred method.

Women's needs were met through the way services were organised and delivered. The configuration of maternity services at the hospital meant the service was more responsive. However the gynaecology services were not always responsive.

Medical care (including older people’s care)

Good

Updated 22 June 2018

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

  • Compliance with mandatory training completion exceeded the trust’s standard of 90% in all courses for nursing staff, including in safeguarding.
  • We found consistently good standards of adherence with infection control processes, which reflected improvements made since our last inspection.
  • There was a consistent drive from staff at all levels to improve patient safety through effective risk management systems including audit and practice development.
  • Staff demonstrated substantial knowledge in safeguarding principles and adapted trust and national guidance to meet the needs of their patient groups.
  • Auditing was part of the trust’s strategy to ensure services were evidence-based, contributed to ongoing accreditation and benchmarked the service. This included on a local and national level.
  • Several teams were research active and demonstrated how this resulted in improved patient outcomes. This included a reduced average length of stay in the respiratory wards and significantly improved community rehabilitation access for patients.
  • The endoscopy service was accredited by the Joint Advisory Group (JAG) on GI Endoscopy, which meant care and treatment was benchmarked and audited against national and international best practice.
  • Staff demonstrated kindness and compassion and the ability to communicate openly with patients. This was reflected in the results of the NHS Friends and Family Test and from our observations.
  • Specialist teams were in place for learning disabilities and dementia care. The teams were readily available and ward teams had access to tools and training to aid communication and care.
  • Significant work from allied health professionals had been focused on improving discharge planning and processes and improving access to community rehabilitation and reablement services.
  • There was significant evidence of wide-reaching improvements in staff engagement from senior trust teams and ward leadership teams.

However:

  • Mandatory training compliance amongst doctors was variable and did not meet the overall 90% standard.
  • Results from monthly clinical records audits indicated highly variable practice, with significant and persistent poor performance in the completion of nurse-led transfer checklists.
  • Although divisional risk and governance teams used risk registers, risks were not always reviewed in a timely manner and risks of up to 11 months had occurred with no effective control measures in place.
  • Between November 2016 and October 2017 RTTs, as a percentage within 18 weeks, varied from 73% to 88%. This was worse than the national average.

Surgery

Good

Updated 22 June 2018

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

  • In 2017, an extra 5000 operations and 95000 outpatient appointments had been undertaken as part of the trust’s recovery and improvement plan.
  • The trust had achieved the target 5% reduction in falls per 1000 bed days.
  • There had been some improvement on monitoring adherence to national guidelines and some improvement in completion of national and internal audits.
  • Patients were protected from the risks of surgery by improved engagement in the ‘fiver steps to safer surgery’ checks in the operating theatre department.
  • From November 2016 to October 2017 the trust’s referral to treatment time (RTT) for admitted pathways for surgery remained similar to the average for England.
  • Risks to people were assessed, monitored and managed on a day-to day basis. Staff understood their responsibilities and actions required in identifying patients at risk from deterioration, harm and abuse.
  • Staff were qualified and had the skills to carry out their roles effectively and in line with best practice.
  • Patients’ individual needs were taken into account and the service was planned around the demands of the local people.
  • Arrangements were in place to ensure patients with additional needs were supported and could access care.
  • Staff understood and adhered to relevant legislation when obtaining consent for surgical interventions.
  • Clinical governance systems had become more integrated since our previous inspection. This was enabled by the appointment of designated quality and risk advisors, and a nursing audit schedule.

However:

  • The surgical division did not meet its targets for patients to be seen within 18 weeks.
  • Staff and managers were unable to confirm the number of clinically significant wound infections on the surgical wards in the past year and unable to identify trends in infection in the hospital. We were told that the infection prevention and control team did not have a system to identify trends in infection.
  • Seven-day services were not provided by therapy staff which could cause delays in rehabilitation and discharge planning.
  • The service had been unable to deliver an increase in discharge rates between 8am and 12 noon.
  • Compliance with mandatory training for medical and dental staff was below the trust’s target.
  • Compliance with appraisal for therapy staff was below the trust’s target.
  • There was limited access to counselling and psychology services for patients.
  • There was some evidence of multidisciplinary working between medical staff, nursing staff and allied healthcare professionals. However, multidisciplinary team meetings and ward rounds did not always include all necessary staff.
  • Recording and reporting of local audits across the division was inconsistent. An electronic reporting system introduced in 2017 for this purpose was not being used.
  • The temperature of medicines storage was not monitored in all areas.
  • General Surgery and ENT patients at Queen's Hospital had a higher expected risk of readmission for non-elective admissions than the average for England.

Services for children & young people

Good

Updated 7 March 2017

There was clear and sustained improvement from our previous inspection. This included the implementation of an audit programme that led to benchmarking of care standards and improvements in practice.

There was improvement in learning from incidents and how these were communicated with staff, including examples of changes in practice and policy as a result of learning.

Improvements had been made in nurse staffing levels, with an increase in recruitment and a reduction of turnover. Although there was still a vacancy rate of 11% in the nurse team, 15 new staff nurses were due to start and an overseas recruitment programme had been successful in attracting qualified nurses to the hospital.

Medical staffing levels were consistently good and medical care was consultant-led, with support provided by other clinicians with appropriate training and specialist knowledge.

Safeguarding procedures were robust and embedded in clinical practice and a system of meetings, staff training, supervision and audits acted as checks and balances to ensure children were protected from avoidable harm.

Services were benchmarked against the guidance and standards of national health organisations as a measure of good practice. This included audits of the care received by patients with diabetes and epilepsy. The outcomes of audits resulted in improvements to the service.

Practice development nurses provided support in staff development including competency assessments, training sessions and one-to-one support. In addition, staff were provided with the opportunity to develop specialist link roles. This represented part of a broader programme to encourage staff training and development.

A weekly multidisciplinary psychosocial meeting ensured patients with complex needs or those who needed community social support were reviewed by a specialist team. Staff used this meeting to plan complex discharges, review safeguarding alerts and ensure care and treatment met individual needs.

Feedback from patients and their parents was consistently good in the trust’s in-house ‘I want great care’ survey. Staff demonstrated kind, compassionate and friendly care in all of our observations and all of the parents we spoke with told us they were happy with the service.

Services were planned to meet the needs of the local population. This included Saturday outpatient clinics, a daily phlebotomy service and a weekly visit from a peripatetic local authority school teacher.

Two dedicated play specialists and two play workers were available in Tropical Bay and Tropical Lagoon wards and children had access to a range of activities, equipment and toys. This included two indoor play areas and a secure outdoor play area attached to Tropical Lagoon. A sensory room and mobile sensory equipment were also provided.

A dedicated paediatric learning disability nurse had introduced support resources for patients, including a children’s hospital passport and visual communication tools. This helped staff to build a relationship with patients who found it challenging to make themselves understood.

Transition services were in place for when a child moved into adult services. This was a structured approach that provided patients with gradually increasing levels of independence followed by the support of both children’s and adult’s nurses as they moved.

Clinical governance structures enabled staff to monitor risks to the service and involve patients and staff in improvements. This was achieved through various means including a patient safety summit, clinical safety and quality meetings, whole unit team meetings and the use of a risk register to track changes in risk status.

Changes to leadership in children’s services had been well received by staff and as part of the trust’s ongoing improvement programme, a new lead nurse was due to join the hospital in January 2017 with a remit of improving communication between hospital services and the care of young people.

Staff were encouraged to provide feedback on their work and hospital policies and this was acted upon. In addition, staff with an interest in research were supported to participate to help inform innovative practice.

However, environmental safety and waste management standards were not always consistent. This was because access to areas used to store sharps bins and waste was sometimes uncontrolled and there was a lack of compliance with fire safety guidance in some areas.

Multidisciplinary staff did not attend nurse and medical handovers or ward rounds and short staffing in therapies teams meant there was inconsistent input from physiotherapy and dietetics and no occupational therapy service. This was evident in the inconsistent standards of nutrition risk assessments in patient records.

Local audits identified documentation of consent to treatment as an area for improvement. Nursing staff were aware of this and handovers included a discussion of which patients had consent forms completed.

End of life care

Good

Updated 2 July 2015

Patient’s do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms were accurately completed in all cases. Patients had a clear care plan which specified their wishes regarding end of life care, staff were aware of their wishes in regards to the preferred place of death. There was good coordination across all divisions to ensure consistency of approach in end of life care. Staff knew how to report concerns. Staff were respectful and maintained patients’ dignity, there was a person centred culture. Patients told us staff were caring and compassionate. They also said they had appropriate access to pain relief and were happy with the food and drink offered. Specialist palliative care team members were competent and knowledgeable. There were examples of good multidisciplinary team working.