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Queen's Hospital Requires improvement

Reports


Inspection carried out on 7 - 8 September and 11 - 12 October 2016

During an inspection to make sure that the improvements required had been made

Barking, Havering and Redbridge University Hospitals NHS Trust provides acute services across three local authorities: Barking & Dagenham, Havering and Redbridge, serving a population of around 750,000 and employing around 6,500 staff and volunteers.

Queens Hospital is the trust’s main acute hospital and opened as a private finance initiative (PFI) in 2006, bringing together the services previously run at Oldchurch and Harold Wood Hospitals. It is the main hospital for people living in Havering, Dagenham and Brentwood. The hospital has over 900 beds, including a hyper acute stroke unit (HASU). The Emergency Department (ED) treats over 150,000 walk-in and ambulance emergencies each year.

The trust was previously inspected in 2013, and due to concerns around the quality of patient care and the ability of the leadership team, the Trust Development Authority (TDA) recommended that the trust be placed in special measures.

We returned to inspect the trust in March 2015. A new executive team had been appointed, including a new Chair. Overall, we found that improvements had been made, however it was evident that more needed to be done to ensure that the trust could deliver safe, quality care across all core services.

The trust has continued its improvement plan, working closely with stakeholders and external organisations. On this occasion we returned to inspect the trust in September and October 2016, to review the progress of the improvements that had been implemented, to apply ratings, and also to make recommendation on the status of special measures. We carried out a focused, unannounced inspection at Queens Hospital of three core services that had previously been rated as inadequate in one or more domain – the Emergency Department (ED), Medical Care and Outpatients & Diagnostics (OPD). We also returned in October to carry out a more in-depth review of the trusts overall leadership and governance, where we also included an  announced inspection of Services for Children and Young People (CYP).

This inspection subsequently found that improvements had been made and ratings have been adjusted accordingly. Overall, we have found Queens Hospital as requires improvement.

Our key findings were as follows:

Are services safe?

  • Compliance with infection prevention and control (IPC) practices across the services we inspected were found to be inconsistent. IPC standards were observed within services for children and young people (CYP) to be good, including appropriate hand-washing, use of hand gel and personal protective equipment. However, we observed poor compliance in the emergency department (ED) and diagnostics and imaging department, including a lack of consistent hand washing or using sanitising gel between patients. Compliance with standards for infection prevention and control and hygiene including cleaning schedules, decontamination, record keeping and audits required improvement across all services inspected.
  • Safety thermometer data submitted nationally did not match the hospital’s divisional structure, making it hard to effectively benchmark performance against other trusts.
  • Fire safety standards in CYP services, including areas around the NICU were not always maintained. This included variable understanding from staff on emergency procedures, fire doors repeatedly wedged open and a lack of clear signposting for the location of fire extinguishers.
  • Medical staff were failing to meet trust targets for completion of mandatory training, across all topics.
  • Compliance with resuscitation training in ED was poor and medical staff completion rates in basic life support training were below the trust target.
  • Although nursing staffing levels had improved since the last inspection, some medical wards still had significant vacancy and turnover rates. On these wards, there was a reliance on bank and agency staff to fill vacant shifts. There was also reliance on locum doctors across the service.
  • The ED had done a lot of educational work around sepsis and the early identification of a septic patient. Staff understood how to use early warning scores and described how to escalate concerns appropriately.
  • Equipment and bedside safety checks were completed and there were procedures in place for staff to obtain technical support in the event of clinical equipment failure.
  • Systems were in place to respond to deteriorating CYP patients using the paediatric early warning scores system and availability of a paediatric intensive care transfer service.
  • There had been an improvement in the reporting of incidents and the sharing of lessons across the hospital.
  • Staff were aware of their responsibilities with regards to duty of candour requirements, confirming there was an expectation of openness when care and treatment did not go according to plan.
  • The dispensing and administration of medication on medical wards had improved, with prescription charts being used correctly and processes being correctly followed and audited.
  • Nursing staff demonstrated an awareness of safeguarding procedures and how to recognise if someone was at risk or had been exposed to abuse. They knew how to escalate concerns and were up-to-date with appropriate levels of training.
  • Patients on medical wards were assessed for a variety of risks on admission to the wards, using nationally recognised tools. Magnetic symbols were used on patient information boards to identify those patients at particularly high risk.
  • The trust had changed their electronic records system and introduced the electronic patient record (EPR),
  • There were appropriate protocols in place for safeguarding vulnerable adults and children, and staff were aware of the requirements of their roles and responsibilities in relation to safeguarding.
  • Extensive safeguarding systems and processes were in place within CYP services to help identify children and young people at risk of avoidable harm. This included regular multidisciplinary meetings, supervision sessions delivered by the safeguarding team and monthly strategic dashboards that enabled staff to monitor referrals and patient outcomes.
  • Staffing levels and skill mix were planned to ensure the delivery of outpatient, diagnostic and imaging services at all times.
  • All medicines were found to be in date and stored securely in locked cupboards.

Are services effective?

  • We found a number of clinical guidelines on the trust intranet were out of date. There was also issues with access to trust policies and guidelines for agency staff who had no computer access.
  • The ED performed worse than the national average in a number of Royal College of Emergency Medicine (RCEM) audits, including sepsis and septic shock, asthma in children, and paracetamol overdose.
  • Feedback from locum doctors was that training was limited and they felt training for them was not a priority.
  • Staff understanding of consent, capacity and Deprivation of Liberty Safeguards (DoLS) was varied.
  • Imaging Local Rules for the hospital had not been updated since 2012.
  • The standardised relative risk of readmission for all elective procedures was higher than expected in comparison to the England average.
  • Multidisciplinary team working was effective across disciplines. Most staff said they were supported effectively, and they felt valued and respected.
  • The pathways for patients with cancer were not always correctly managed. There was poor communication with tertiary centres, which caused delays with patients requiring tertiary treatment/diagnosis at other specialist hospitals.
  • The hospital performed worse than the previous year in both the Myocardial Ischaemia National Audit Project (MINAP) 2013/14 and the National Heart Failure Audit (2013/14). In the Lung Cancer Audit 2015, the trust was below expected standards for three key indicators relating to process, imaging and nursing measures.
  • The majority of patients in ED were assessed for pain and offered appropriate pain relief.
  • We observed good multidisciplinary (MDT) working between the emergency department (ED) and a number of other services, including psychiatric liaison and the nutritional team.
  • Nursing and medical staff completed a variety of local audits to monitor compliance and drive improvement. Staff told us that these led to meaningful change across the medical service.
  • In the National Diabetes Inpatient Audit (NaDIA) 2015, the hospital scored better than the England average for thirteen indicators out of twenty-one indicators.
  • The majority of staff received annual appraisals on their performance. Staff were satisfied with the quality of the appraisal process. The trust was supporting nurses with the revalidation process.
  • Patients attending the services we visited received care and treatment that was evidence based and in line with best practice.
  • The outpatients department and diagnostic and imaging services had introduced clinics Monday to Sunday to clear patient waiting list backlogs.
  • CYP services consistently met nine of the ten recommendations in the Royal College of Paediatrics and Child Health Facing the Future 2015 standards, which meant patients received timely and expert care from qualified staff.
  • Although there were gaps in the provision of some therapies, including occupational therapy, the hospital had made sustained progress in the increased provision of some services. For example, a paediatric epilepsy nurse had been recruited, a diabetes specialist team was in place and a dedicated paediatric dietician and pharmacist were in post.

Are services caring?

  • Patients and relatives across the services told us staff were predominantly kind, respectful and helpful. However, in ED we observed some negative interactions between staff and patients.
  • Staff overall provided psychological and emotional support to patients and relatives and could signpost them to other support services if required.
  • Bereavement services, were readily available to patients and their relatives. This included a multi-faith chaplaincy service and support from nurses.
  • The safeguarding children’s assurance group evaluated the feelings of children and young people with a learning disability and their parents and used the results to improve the service.
  • In the Friends and Family Test (FFT) the ED scored between 71% and 88% of patients recommending the department to others. This was below the England average.
  • 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.
  • The trust performed slightly below the national average in the National Cancer Experience Survey 2015.

Are services responsive?

  • The main waiting area and paediatric waiting area in ED were very busy during our second unannounced inspection, and some patients were unable to sit down.
  • There was no lead for dementia within the service at the time of our inspection.
  • The percentage of patients being seen and treated in ED within the recommended four hour timeframe and number of patients who left the department without being seen was worse than the national average.
  • The ED was not meeting its 15 minutes triage indicator for a high proportion of patients. The average time to triage was 28 minutes.
  • The trust’s performance for the 62 day cancer waiting time was consistently below the 85% England average from 1 March 2015 to 31 May 2016.
  • 14% of appointments were cancelled by the hospital. This was higher than the England average of 7.2%.
  • Patient information leaflets were not standardly available in languages other than English.
  • The Patient Advice and Liaison Service (PALS) did not always respond to complaints in a timely manner.
  • Paediatric phlebotomy services were in place to enable blood to be taken from children by staff trained to recognise needle phobia and to use distraction techniques. However, children and young people who needed a blood test were sometimes seen in adult outpatient phlebotomy.
  • The ED worked closely with local GPs to ensure they were meeting the needs of the local population.
  • There were a number of specialist teams available such as a frail and older people team, psychiatric support, domestic violence team, and alcohol liaison services.
  • There had been an 88% reduction in the overall backlog of patients waiting over 52 weeks since May 2016. This reflected an increased effort from the trust to reduce referral to treatment (RTT) times for patients using their services.
  • The hospital was using a range of private providers to assist in clearing the backlog of appointments where there were most demand services.
  • The outpatients department and diagnostic and imaging services had introduced clinics Monday to Sunday to clear patient waiting list backlogs.
  • People living with dementia received tailored care and treatment. Care of the elderly wards had been designed to be dementia friendly. A specialist dementia team and dementia link nurses were available for support and advice.
  • Support for people with learning disabilities was available. There was a lead nurse available for support and advice. There was a monthly safeguarding and learning disability operations group.
  • Catering menus offered many options to cater for those with different nutritional requirements.
  • Play specialists were available in CYP services and they provided children with a range of activities. There were three well-equipped play areas available, including a covered outdoor play area.
  • A sensory room and mobile sensory equipment was available to help support children and young people with sensory needs, learning disabilities or needs relating to autism.
  • A dedicated paediatric learning disabilities nurse had developed a hospital passport for children and visual communication aids. This helped staff to communicate with patients and to understand their likes, dislikes and worries.
  • Transition services were in place for children moving into adult services. This included support to gradually build their independence and one-to-one support as they were moved onto an adult pathway.

Are services well led?

  • The trust had developed a clinical vision and strategy and communicated this to staff of all levels across the hospital.
  • There was a system of governance and risk management meetings at both departmental and divisional levels across core services, however this had not yet developed effectively in some areas at the time of inspection. An external organisation had worked with the trust on ensuring their governance structures were more robust.
  • Managers and clinical leads were visible and approachable.
  • There was evidence staff could confidently provide feedback to the senior team and that changes were considered and implemented where possible.
  • Staff were encouraged to engage in research and pilot schemes to drive a culture of change to improve practice and the delivery of patient care
  • However, there was no clear vision and strategy for the ED service as we were told plans for the department were constantly changing. Some staff did not know about the departments plans to close King George Hospital accident and emergency department at night.
  • Although senior divisional staff had a good understanding of the risks to their respective services as recorded on the risk register; staff responsible for the immediate delivery of clinical care were not always aware of the recorded risks for their service.

We saw several areas of outstanding practice including:

  • The hospital provided tailored care to those patients living with dementia. The environment in which they were cared for was well considered and the staff were trained to deliver compassionate and thoughtful care to these individuals. Measures had been implemented to make their stay in hospital easier and reduce any emotional distress.

  • The trust had awarded the neonatal and community teams for their work in providing babies with oxygen home therapy, which significantly improved the quality of life for families.
  • 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. This had been positively evaluated and received a high standard of feedback from parents and patients.
  • Child to adult transition services were comprehensive and conducted with the full involvement of the patient and their parents. This included individualised stages of empowering the person to gradually increase their independence, the opportunity to spend time with paediatric and adult nurses together and facilities for parents to spend the night in adult wards when the young person first transitioned.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Take action to improve levels of resuscitation training.

  • Ensure there is oversight of the training done by locum doctors, particularly around advanced life support training

  • Take action to improve the response to patients with suspected sepsis

  • Take action to improve poor levels of hand hygiene compliance

  • Ensure fire safety is maintained by ensuring fire doors are not forced to remain open.

  • Ensure staff have a full understanding of local fire safety procedures, including the use of fire doors and location of emergency equipment

  • Ensure hazardous waste, including sharps bins, is stored according to related national guidance and EU directives. This includes the consistent use of locked storage facilities.

In addition the trust should:

  • Endeavour to recruit full time medical staff in an effort to reduce reliance on agency staff.

  • Ensure there is sufficient number of nurses and doctors with adult and paediatric life support training in line with RCEM guidance on duty.

  • Increase paediatric nursing capacity.

  • Ensure policies are up to date and reflect current evidence based guidance and improve access to guidelines and protocols for agency staff.

  • Take action to improve the completion of early warning scores

  • Improve appraisal rates for nursing and medical staff.

  • Regularise play specialist provision in the paediatric ED.

  • Consider how to improve ambulance turn around to meet the national standard of 15 minutes

  • Ensure staff and public are kept informed about future plans for the ED.

  • Restructure the submission of safety thermometer data to match the current divisional structure.

  • Continue to monitor hand hygiene across non-compliant wards and follow action plans detailed on the current corporate and divisional risk registers.

  • Monitor both nursing and medical staffing levels. Follow actions detailed on corporate and divisional risk registers relating to this.

  • Monitor and improve mandatory training compliance rates for medical staff. Improve completion rates for basic life support for nursing and medical staff.

  • Continue to work to improve endoscopy availability and service, as detailed on the corporate risk register.

  • Make patient information leaflets readily available to those whose first language is not English.

  • Ensure consent to care and treatment is always documented clearly.

  • Ensure each inpatient has an adequate and documented nutrition and hydration assessment.

  • Ensure there are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.

  • Ensure there are appropriate processes and monitoring arrangements in place to improve the 31 and 62 day cancer waiting time indicator in line with national standards.

  • Ensure the 18 week waiting time indicator is met in the outpatients department.

  • Ensure the 52 week waiting time indicator is consistently met in the outpatients department.

  • Ensure percentage of patients with an urgent cancer GP referral are seen by a specialist within two weeks consistently meets the England average.

  • Ensure the number of patients that ‘did not attend’ (DNA) appointments are consistent with the England average.

  • Ensure the number of hospital cancelled outpatient appointments reduce and are consistent with the England average.

  • There is improved access for beds to clinical areas in diagnostic imaging.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 2 to 6 March, 14 March and 20 March 2015

During a routine inspection

Barking, Havering and Redbridge University Hospitals NHS Trust is a large provider of acute services, serving a population of over 750,000 in outer North East London.  Queen’s Hospital is the trust's main acute hospital.

The private finance initiative (PFI), Queen’s Hospital opened in 2006 and brought together the services previously run at Oldchurch and Harold Wood Hospitals. It is the main hospital for people living in Havering, Dagenham and Brentwood. The Accident and emergency (A&E) department has one of the highest number of attendances in the country. The hospital has 786 beds, including a hyper acute stroke unit and delivers nearly 8,000 babies a year.

The hospital predominantly covers three local authorities; Barking & Dagenham which has very high levels of deprivation, Havering which is closer to the national average but has a relatively elderly population by London standards and Brentwood which is a less deprived area.

We inspected the trust in October 2013, and found there were serious failures in the quality of care and concerns that the management could not make the necessary improvements without support. I recommended to the Trust Development Agency (TDA) that the trust be placed in special measures in December 2013. 

Since the inspection a new executive team has been put into place including a new chair, new members of the board, a chief executive, medical director, deputy chief executive, chief operating officer and a director of planning and governance. The executive team has been supported by an improvement director from the TDA.

The trust developed an improvement plan ('unlocking our potential') that has been monitored and contributed by all stakeholders monthly and published. The purpose of this re-inspection was to check on improvements, apply ratings and to make a recommendation on the status of special measures.

Overall, this hospital requires improvement. The end of life care service was rated as good and all other services were rated as requires improvement. Of the five key questions that CQC asks, we rated the trust as good for caring; safe, effective, and well-led require improvement and responsive was inadequate.

Our key findings were as follows:

  • Improvements had been made in a number of services since our last inspection.
  • The culture had significantly improved. It encouraged pride, responsibility candour, openness and honesty. 

Safe

  • There was a backlog of serious incidents and the quality of investigations into serious incidents lacked detail to ensure failings were understood and lessons were learned.
  • There were insufficient systems, processes and practices to keep patients safe. Lessons were not learned and improvements were not made when things went wrong.
  • Recruitment had been on-going however there was not always enough medical and nursing staff to meet the needs of patients.
  • The management of medicines needed improving to ensure safe administration and a reduction in medication errors.
  • The majority of clinical areas were visibly clean and staff adhered to good infection control practices.
  • Most staff groups achieved completing 85% of mandatory training.

Effective

  • Patients needs were assessed and care and treatment was delivered in line with evidenced-based guidance.
  • Patient outcomes were varied.
  • Some staff were not competent in carrying out their roles.
  • Pain relief and nutrition and hydration needs were assessed and met.
  • Consent, Mental Capacity Act 2005 and Deprivation of Liberty Safeguards were well understood by the majority of staff and part of a patients plan of care. 

Caring

  • Some national surveys have found that staff are not always compassionate. In response, staff had focussed on involving patients, keeping them informed and treating patients with dignity and respect.
  • During our inspection we saw and heard of compassionate, kind care and emotional support being provided.

Responsive

  • There was a focus on understanding the needs of local people and the community the trust served.
  • Urgent and emergency, children and young people and outpatients services were not always responsive to meet patients needs.
  • The emergency department was not meeting the national four-hour waiting time target introduced by the Department of Health.  
  • The hospital was persistently failing to meet the national waiting times target. Some patients were experiencing more than 18 weeks from referral to treatment time (RTT).
  • The access and flow of patients throughout the hospital had improved since our last inspection. The introduction of the Elders Receiving Unit (ERU) met patients needs.

Well-led

  • The new executive team was making improvements. The board was visible and engaging with patients and staff.
  • The leadership and culture were open, transparent and focussed on improving services.
  • At an executive level there was a vision and strategy in development to deliver good care and ensure sustainability. At a service level staff were less clear and many told us they were "fire-fighting".
  • The governance structures did not ensure that responsibilities were clear and that quality, performance and risks were understood or managed.

We saw several areas of outstanding practice including:

  • The values of the trust - passion, responsibility, innovative, drive and empowerment (PRIDE) were well known and embedded in the culture of the people working at the trust.
  • The new executive team were visible and engaged.
  • There was lots of involvement from the local community and voluntary organisations. The foyer had lots of people giving information for patients and visitors about services in the local area. For example dementia care, stop smoking and healthy eating.
  • Radiotherapy was one of the top five units in the country.
  • The genitourinary medicine (GUM) clinic had an excellent service with appropriate protocols and processes and support for patients.
  • There had been a number of initiatives to provide a responsive service for general surgery patients. The surgical assessment unit provided a timely service in emergencies and the 'hot clinic' reduced delays for patients.
  • The hospital was a regional centre for upper gastro-intestinal conditions. Outcomes for patients receiving o

    esophago-gastric cancer services were good.

  • There were good outcomes for stroke patients and the stroke service demonstrated good team work.
  • Play specialists had developed a way to distract children awaiting MRI scans which involved joining other children and families on a ‘train journey’ from the outpatient’s clinic down through the hospital corridors, using storytelling and positive reinforcement on the way. This had proved a good distraction for children and reduced their anxiety. We walked with one child and found them to be very engaged in the trail.
  • Consultant paediatricians undertook short notice or ‘HOT clinics’, whereby GPs could make a consultant to consultant referral reach a joint decision on action including if needed early assessment. GP’s reported positively to their commissioners on the success of this system.
  • The consultant led critical care outreach team’s seven day service had improved the outcome for patients through appropriate identification of deterioration and appropriate escalation.
  • The critical care outreach team provided a ‘critical care follow up outpatient clinic’ for patients who required support after leaving hospital. This ensured patients were making progress in the months following their discharge.
  • Neuro-intensive therapy unit encouraged diaries for patients who were staying for longer periods of time in the unit. Patient’s families kept a record of daily activities such as visits, progress and treatments, items of news and the weather. A free newspaper was offered to patients in general critical care to help orientate them.

  • The development of the Elders' Receiving Unit had improved frail, elderly patient care.
  • A dedicated team to support patients living with dementia . Wards could book a dementia trained health care assistant to support one or more patients in a bay on the ward. We were told this was, “A huge improvement” as they were dementia trained. Previously this role was done by a different bank nurse every day.
  • The nurse led oral chemotherapy service was the first in the country.
  • The hospital performed well in the National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme carried out in 2014.
  • The end of life care service was patient focussed and end of life care needs was well understood by the majority of staff from all staff groups.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • have clear governance with integrated systems and processes to support staff to provide care and treatment safely.
  • ensure serious incidents are understood, investigated and lessons are learned promptly.
  • review systems for sharing good practice across the divisions and trust wide.
  • ensure compliance with all national guidelines and trust policies for medicines management.
  • improve the service planning and capacity of outpatients by continuing to reduce the 18 week non-admitted backlog of patients as well as ensure no patients waiting for an appointment are coming to harm whilst they are delayed, reduce the did not attend, hospital cancellation and hospital changes rates and improve the 31 day cancer wait target.
  • improve the IT systems so they are up to date and the IT strategy is implemented and supports clinical staff to carry out their duties.
  • ensure all services for neonates, children and young people are responsive to their needs.
  • ensure the radiology is fit for purpose and fulfils its reporting timescales, particularly for CT scans.
  • continuously review staffing levels and act on them at all times of the day.
  • include a dietician as part of the critical care multidisciplinary team in line with the core standards for intensive care guidance.
  • comply with the Duty of Candour legislation.
  • comply with infection control code of practice in respect of hand hygiene audits, training and monitored improvement.
  • ensure locum and agency staff are competent and implement a formal induction process for all locum and agency staff in the relevant areas they care for patients.
  • ensure processes are in place for locum and agency staff in respect of accessing and using IT systems required for their role.
  • ensure patient risk assessments are acted upon.
  • Review the general medicine on-call rota to ensure it meets the needs of patients.
  • meet the Emergency Care standards in the Elder’s Receiving Unit.
  • audit and monitor the patient outcomes from the trust discharge strategies.
  • comply with the National Dementia Strategy.

In addition the trust should:

  • consider increasing the target rates for mandatory training.
  • review the effectiveness of the rota co-ordination for junior doctors
  • review the accessibility of the radiology services and consider a duty radiographer structure.
  • review the service level agreement for accessing therapies to ensure it meets patients needs promptly.
  • continue to improve patient record availability at outpatient clinics.
  • the culture of staff within radiology and the anti-coagulation to ensure they feel part of the organisation.
  • review the environment in outpatients to improve the waiting and reception areas.
  • review the environment and the staffing levels of the day-care surgery unit.
  • review nurse staffing levels and skill mix on surgical wards, particularly out-of-hours.
  • review the availability and presence of consultant obstetricians and speciality registrar level doctors so that labour ward cover is in line with local and national recommendations.
  • consider an increase in establishment in the dementia team and the pain team.
  • review the audit programme in surgery so that internal audits are completed and implemented.
  • review the theatre electronic recording system to ensure accurate data is available.
  • consider ways to increase multidisciplinary team working within critical care.
  • consider ways to make the overnight accommodation for visitor to patients in general intensive care less austere.
  • consider ways to engage patients in providing feedback specifically related to critical care services.
  • continue to increase the availability of medical records.
  • monitor the impact on patients from the reduction in Coronary Care Unit beds.
  • review the processes for medicines to take away on discharge.
  • consider undertaking a needs analysis in respect of those whose first language is not English.
  • improve engagement between junior doctors and management.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 14-17 October 2013

During a routine inspection

Barking, Havering and Redbridge University Hospitals NHS Trust is a large provider of acute services, serving a population of over 750,000 in outer North East London.  Queen’s Hospital is the trust's main acute hospital.

The private finance initiative (PFI), Queen’s Hospital opened in 2006 and brought together the services previously run at Oldchurch and Harold Wood Hospitals. It is the main hospital for people living in Havering, Dagenham and Brentwood. The Accident and emergency (A&E) department has one of the highest number of attendances in the country. The hospital has 786 beds, including a hyper acute stroke unit and delivers nearly 8,000 babies a year.

The hospital predominantly covers three local authorities; Barking & Dagenham which has very high levels of deprivation, Havering which is closer to the national average but has a relatively elderly population by London standards and Brentwood which is a less deprived area.

We inspected the trust in October 2013, and found there were serious failures in the quality of care and concerns that the management could not make the necessary improvements without support. I recommended to the Trust Development Agency (TDA) that the trust be placed in special measures in December 2013. 

Since the inspection a new executive team has been put into place including a new chair, new members of the board, a chief executive, medical director, deputy chief executive, chief operating officer and a director of planning and governance. The executive team has been supported by an improvement director from the TDA.

The trust developed an improvement plan ('unlocking our potential') that has been monitored and contributed by all stakeholders monthly and published. The purpose of this re-inspection was to check on improvements, apply ratings and to make a recommendation on the status of special measures.

Overall, this hospital requires improvement. The end of life care service was rated as good and all other services were rated as requires improvement. Of the five key questions that CQC asks, we rated the trust as good for caring; safe, effective, and well-led require improvement and responsive was inadequate.

Our key findings were as follows:

  • Improvements had been made in a number of services since our last inspection.
  • The culture had significantly improved. It encouraged pride, responsibility candour, openness and honesty. 

Safe

  • There was a backlog of serious incidents and the quality of investigations into serious incidents lacked detail to ensure failings were understood and lessons were learned.
  • There were insufficient systems, processes and practices to keep patients safe. Lessons were not learned and improvements were not made when things went wrong.
  • Recruitment had been on-going however there was not always enough medical and nursing staff to meet the needs of patients.
  • The management of medicines needed improving to ensure safe administration and a reduction in medication errors.
  • The majority of clinical areas were visibly clean and staff adhered to good infection control practices.
  • Most staff groups achieved completing 85% of mandatory training.

Effective

  • Patients needs were assessed and care and treatment was delivered in line with evidenced-based guidance.
  • Patient outcomes were varied.
  • Some staff were not competent in carrying out their roles.
  • Pain relief and nutrition and hydration needs were assessed and met.
  • Consent, Mental Capacity Act 2005 and Deprivation of Liberty Safeguards were well understood by the majority of staff and part of a patients plan of care. 

Caring

  • Some national surveys have found that staff are not always compassionate. In response, staff had focussed on involving patients, keeping them informed and treating patients with dignity and respect.
  • During our inspection we saw and heard of compassionate, kind care and emotional support being provided.

Responsive

  • There was a focus on understanding the needs of local people and the community the trust served.
  • Urgent and emergency, children and young people and outpatients services were not always responsive to meet patients needs.
  • The emergency department was not meeting the national four-hour waiting time target introduced by the Department of Health.  
  • The hospital was persistently failing to meet the national waiting times target. Some patients were experiencing more than 18 weeks from referral to treatment time (RTT).
  • The access and flow of patients throughout the hospital had improved since our last inspection. The introduction of the Elders Receiving Unit (ERU) met patients needs.

Well-led

  • The new executive team was making improvements. The board was visible and engaging with patients and staff.
  • The leadership and culture were open, transparent and focussed on improving services.
  • At an executive level there was a vision and strategy in development to deliver good care and ensure sustainability. At a service level staff were less clear and many told us they were "fire-fighting".
  • The governance structures did not ensure that responsibilities were clear and that quality, performance and risks were understood or managed.

We saw several areas of outstanding practice including:

  • The values of the trust - passion, responsibility, innovative, drive and empowerment (PRIDE) were well known and embedded in the culture of the people working at the trust.
  • The new executive team were visible and engaged.
  • There was lots of involvement from the local community and voluntary organisations. The foyer had lots of people giving information for patients and visitors about services in the local area. For example dementia care, stop smoking and healthy eating.
  • Radiotherapy was one of the top five units in the country.
  • The genitourinary medicine (GUM) clinic had an excellent service with appropriate protocols and processes and support for patients.
  • There had been a number of initiatives to provide a responsive service for general surgery patients. The surgical assessment unit provided a timely service in emergencies and the 'hot clinic' reduced delays for patients.
  • The hospital was a regional centre for upper gastro-intestinal conditions. Outcomes for patients receiving o

    esophago-gastric cancer services were good.

  • There were good outcomes for stroke patients and the stroke service demonstrated good team work.
  • Play specialists had developed a way to distract children awaiting MRI scans which involved joining other children and families on a ‘train journey’ from the outpatient’s clinic down through the hospital corridors, using storytelling and positive reinforcement on the way. This had proved a good distraction for children and reduced their anxiety. We walked with one child and found them to be very engaged in the trail.
  • Consultant paediatricians undertook short notice or ‘HOT clinics’, whereby GPs could make a consultant to consultant referral reach a joint decision on action including if needed early assessment. GP’s reported positively to their commissioners on the success of this system.
  • The consultant led critical care outreach team’s seven day service had improved the outcome for patients through appropriate identification of deterioration and appropriate escalation.
  • The critical care outreach team provided a ‘critical care follow up outpatient clinic’ for patients who required support after leaving hospital. This ensured patients were making progress in the months following their discharge.
  • Neuro-intensive therapy unit encouraged diaries for patients who were staying for longer periods of time in the unit. Patient’s families kept a record of daily activities such as visits, progress and treatments, items of news and the weather. A free newspaper was offered to patients in general critical care to help orientate them.

  • The development of the Elders' Receiving Unit had improved frail, elderly patient care.
  • A dedicated team to support patients living with dementia . Wards could book a dementia trained health care assistant to support one or more patients in a bay on the ward. We were told this was, “A huge improvement” as they were dementia trained. Previously this role was done by a different bank nurse every day.
  • The nurse led oral chemotherapy service was the first in the country.
  • The hospital performed well in the National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme carried out in 2014.
  • The end of life care service was patient focussed and end of life care needs was well understood by the majority of staff from all staff groups.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • have clear governance with integrated systems and processes to support staff to provide care and treatment safely.
  • ensure serious incidents are understood, investigated and lessons are learned promptly.
  • review systems for sharing good practice across the divisions and trust wide.
  • ensure compliance with all national guidelines and trust policies for medicines management.
  • improve the service planning and capacity of outpatients by continuing to reduce the 18 week non-admitted backlog of patients as well as ensure no patients waiting for an appointment are coming to harm whilst they are delayed, reduce the did not attend, hospital cancellation and hospital changes rates and improve the 31 day cancer wait target.
  • improve the IT systems so they are up to date and the IT strategy is implemented and supports clinical staff to carry out their duties.
  • ensure all services for neonates, children and young people are responsive to their needs.
  • ensure the radiology is fit for purpose and fulfils its reporting timescales, particularly for CT scans.
  • continuously review staffing levels and act on them at all times of the day.
  • include a dietician as part of the critical care multidisciplinary team in line with the core standards for intensive care guidance.
  • comply with the Duty of Candour legislation.
  • comply with infection control code of practice in respect of hand hygiene audits, training and monitored improvement.
  • ensure locum and agency staff are competent and implement a formal induction process for all locum and agency staff in the relevant areas they care for patients.
  • ensure processes are in place for locum and agency staff in respect of accessing and using IT systems required for their role.
  • ensure patient risk assessments are acted upon.
  • Review the general medicine on-call rota to ensure it meets the needs of patients.
  • meet the Emergency Care standards in the Elder’s Receiving Unit.
  • audit and monitor the patient outcomes from the trust discharge strategies.
  • comply with the National Dementia Strategy.

In addition the trust should:

  • consider increasing the target rates for mandatory training.
  • review the effectiveness of the rota co-ordination for junior doctors
  • review the accessibility of the radiology services and consider a duty radiographer structure.
  • review the service level agreement for accessing therapies to ensure it meets patients needs promptly.
  • continue to improve patient record availability at outpatient clinics.
  • the culture of staff within radiology and the anti-coagulation to ensure they feel part of the organisation.
  • review the environment in outpatients to improve the waiting and reception areas.
  • review the environment and the staffing levels of the day-care surgery unit.
  • review nurse staffing levels and skill mix on surgical wards, particularly out-of-hours.
  • review the availability and presence of consultant obstetricians and speciality registrar level doctors so that labour ward cover is in line with local and national recommendations.
  • consider an increase in establishment in the dementia team and the pain team.
  • review the audit programme in surgery so that internal audits are completed and implemented.
  • review the theatre electronic recording system to ensure accurate data is available.
  • consider ways to increase multidisciplinary team working within critical care.
  • consider ways to make the overnight accommodation for visitor to patients in general intensive care less austere.
  • consider ways to engage patients in providing feedback specifically related to critical care services.
  • continue to increase the availability of medical records.
  • monitor the impact on patients from the reduction in Coronary Care Unit beds.
  • review the processes for medicines to take away on discharge.
  • consider undertaking a needs analysis in respect of those whose first language is not English.
  • improve engagement between junior doctors and management.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21, 22 May 2013

During a routine inspection

Patients are spending too long in the ED at Queen’s. The accident and emergency department (known as the Emergency Department) has not met key national quality indicators as a result of extensive delays in the care of patients. On some occasions patients who needed to be admitted to the hospital had waited for more than 14 hours in the department. Ninety five percent of patients should be seen within four hours and no patient should be in the department for more than 12 hours. These delays increase the risk of poor outcomes for patients.

Patients are waiting too long to be assessed when they arrive by ambulance. In March and April 2013 95% of patients arriving at Queen’s by emergency ambulance were assessed within 43 minutes and 45 minutes respectively. The quality indicator for this measure is 15 minutes, and the maximum time any patient should wait is 20 minutes.

Patients are waiting too long see a specialist doctor when referred. On the first day of our inspection we found that the average waiting time was 3 hours 15 minutes and one patient had waited up to 7 hours 27 minutes. This means that specialist diagnosis and treatment are potentially being delayed which puts patients at risk of having a poor outcome.

We found that some improvements had been made for patients in the “Majors” area since our last inspection. They included better provision of food and drink including hot meals. Patients are accommodated on beds instead of trolleys. The Trust has recently funded two agency health care assistants (HCAs) to provide cover twenty four hours seven days per week. In addition there is an extra housekeeper on duty for every shift.

There are not enough full time consultant or junior doctors to provide medical care for the number of people who attend Queen’s ED.

Inspection carried out on 28, 29 November and 5 December 2012

During an inspection to make sure that the improvements required had been made

The accident and emergency department (known as the Emergency Department) has not met most of the national quality indicators as a result of extensive delays in the care of patients. Five percent of patients who need to be admitted to the hospital are waiting for more than 11 hours in the department. The Trust should be aiming to transfer 95% of patients who are being admitted to wards within four hours of their arrival.

This has led to poor care for patients in the ‘Majors’ area where seriously ill patients are cared for. The ‘Majors’ environment is unsuitable for patients to be nursed in for long periods of time for a variety of reasons such as, lack of privacy/dignity, no washing facilities, no storage space for personal belongings and no bedside tables. There is a limited range of food and drink available.

We found that many patients, who were there for a long period of time, including over-night, were nursed on trolleys when they should have been moved onto a bed. This increases the risk of them developing pressure damage, dehydration, and an increase in falls.

There are not enough consultant or junior doctors to provide medical care for the number of people who attend Queen’s ED. In the ‘Majors’ area there are not enough nurses to provide adequate care for patients.

The Emergency Department Medical Unit (EDMU) had the names, dates of birth and diagnosis of patients on ‘white boards’ which were visible to both the public and other patients.

Inspection carried out on 5, 6 December 2012

During an inspection to make sure that the improvements required had been made

Since our last inspection the maternity services at Queen’s Hospital has made a range of improvements and the care of women has improved. Women we spoke with were unanimous in saying that the care they had received was of a high standard. One woman said “they have been really helpful, I think it’s fine”, and another commented “I wanted a water birth which I got, the midwife was spot on, when she needed a break another one covered so I was never on my own”.

Women are seen more quickly in the triage area when they arrive at the hospital and more quickly when they need to be seen by an obstetrician. They are performing less caesareans sections than most other hospitals in London, but need to improve the time for carrying out emergency caesarean sections.

As part of our inspection we looked in a number of treatment rooms in the antenatal and labour wards to check that equipment was available, and that maintenance records had been kept up to date. Our inspection covered, cardiotocography monitors (CTGs - which are used by staff to monitor the condition of the baby before it is born), infusion pumps, adult resuscitation equipment and infant resuscitaries. We found that the maternity services had all the equipment it needs and that it is properly maintained.

There was sufficient experienced midwifery and medical staff to ensure women received care that met their needs. All women in labour had a midwife with them all of the time.

Inspection carried out on 28 March 2012

During an inspection to make sure that the improvements required had been made

Patients we spoke with told us that they were generally pleased with the treatment they received but others told us of delays in being seen. One patient told us “everyone is nice and I have received very good care”.

Patients told us that “it is always busy but staff are very good”.

During an inspection to make sure that the improvements required had been made

We undertook this review because we were following up on compliance actions which the trust had declared compliance with. The review focused on pressure sores, pneumonia care pathway, management of medicines incidents as well as training for temporary staff.

We asked the trust to provide evidence to support their compliance.

Inspection carried out on 19 March and 4 April 2012

During an inspection to make sure that the improvements required had been made

We undertook two separate visits, both of which were unannounced. The first visit was undertaken in March 2012, it spanned a three day period and was undertaken to follow up concerns from the previous visit in September 2011. The second visit was undertaken in early April 2012, approximately two weeks later. This visit was in response to concerns raised to us by a member of staff. Some of the concerns were issues we had already looked at but we checked them again, for example staffing, others were new. Where we found concerns during either of the visits we have included these in the main body of our report.

We spoke to staff and new mothers during our visits. In general the new mothers were happy with the care they received, one mother told us, “All staff are very friendly, I didn’t want to come here before but I’ve been very impressed” another told us, “Care in antenatal was good, last time I was here it was awful. I was apprehensive to come here but I’m pleased I did”. One new mother was generally satisfied with the care provided although felt she had to wait a long time to be transferred from the labour ward to the postnatal ward.

We talked to staff about patient care, staffing levels and equipment. Staff told us that patient care has improved; they told us about some changes which had been made and plans for additional changes to further improve the service. They also told us that in general staffing levels were much better than they were 12 months ago but that the issue with skill mix remained. Staff told us that there were concerns around maintaining a full staffing compliment, this was of particular concern for the midwifery care assistants. Staff informed us that they generally had enough equipment but that time could be wasted looking for things and that some equipment items, specifically 'pumps' were in short supply.

Inspection carried out on 28 March and 3 April 2012

During an inspection to make sure that the improvements required had been made

We did not speak to people who use radiology services on this occasion.

This review was carried out in order to follow up on issues regarding radiology services that were reported on in the CQC investigation report of October 2011.

Inspection carried out on 20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 15 September 2011

During an inspection in response to concerns

As part of this review additional visits were also carried out on 16th, 19th and 20th of September.

We spoke to mothers on the postnatal ward and asked them about the staffing levels and care they received. In general new mothers were happy with their experience although when speaking to a mother in the discharge lounge she was unhappy with the delay. One mother told us, “I have a history of fast labour but was assessed quickly when I arrived and was taken to the ward straight away, there were no delays. The midwives were all very attentive”. Another waiting in the discharge lounge told us, “I’ve been in the discharge lounge since 10am and told my partner to collect me, we’re still waiting four and a half hours later”.

When talking about staffing one mother told us, “staff had quite a lot of time for me actually”. She felt there were enough staff the previous night and a lot of staff came running to help when she experienced her complications. Another said, “I was not left alone during labour and had not been worried or anxious. Most of the staff attitudes were good, sometimes there are cultural differences and the staff are not aware how they come across, but I never feel it is deliberately towards me.”

Although mothers were happy with their care and we found improvements had been made since our previous visit we still found evidence of poor patient care and the skill mix of the midwives working the shifts was not satisfactory.

Based on these concerns an emergency action plan was agreed between the commissioners, the trust and NHS London. We subsequently made eight visits on a weekly basis from 12 October 2011 to 30 November 2011 to monitor progress with the action plan. We found that some improvements have been made but the trust continue to struggle to meet some of the targets. Whilst we are satisfied that the trust are making progress concerns remain and we will continue to follow these up.

Inspection carried out on 12 October 2011

During an inspection to make sure that the improvements required had been made

Overall, people we spoke with told us that staff were helpful and worked hard. People told us that most of the staff were friendly and were responsive to their needs.

"Some staff are very good, some are not. I realise they have got an unthankful job but some of them could be more pleasant. Staff are obviously busy. You sometimes wait quite a while when you press the buzzer. Don’t know if they are busy elsewhere".

"I can’t say anything bad about it. I press the buzzer and they come quick. I think they do a great job".

"Mum has been here a day. No problems, staff are nice. They give good care. She is hearing voices and had a fall. All her needs seem to be taken care of".

Inspection carried out on 10 October 2011

During an inspection to make sure that the improvements required had been made

Patients using the service had mixed views about the A&E department, some patients were generally pleased with the treatment they received but others told us of delays in being seen. One patient told us “everyone is nice”. Although patients were generally positive about their experience the evidence we reviewed demonstrated the A&E department continue to struggle with the volume of patients which sometimes impacts on the care received.

Inspection carried out on 1, 29 March 2011

During an inspection in response to concerns

In general patients told us that staff were very busy and that sometimes it took a long time for staff to attend to their needs! Patients could see that staff were working very hard and felt that they were very pleasant and helpful when they did tend to them. Staff were also of the opinion that they were short staffed and at times very 'stretched' which impacted on the level of care they were able to provide to individual patients.

Staff working in the Accident and Emergency department commented how busy the department is and that patients arrive in the department but the patient flow is not right so there is nowhere for the patients to go, which on occasions leads to paramedics queuing in corridors with patients.

Inspection carried out on 17 January 2011

During an inspection in response to concerns

We spoke to staff and patients during our visit at the hospital. Patients were generally happy with the care they received whilst in hospital but concerns were raised about Summary of our findings for the essential standards of quality and safety Page 3 of 28 how busy the service was by patients and staff. One patient told us, ‘‘Staff kept saying it’s very busy, very busy and staff were not helpful. There were less staff on labour, I asked if there were enough staff, they said, ‘no’’. Another patient told us, ‘The service was excellent; the staff did what they said they would do. We were not left alone, and staff reacted quickly to our needs’.

Staff were very concerned that the service was, ‘stretched’ and this was supported by other evidence we reviewed including incidents which had occurred in the maternity unit, staffing rotas as well as other documentation.

Inspection carried out on 22 September 2010 and 29 March 2011

During an inspection in response to concerns

We spoke to people who use the services and found that in general they were happy with the care provided by the hospital.

Inspection carried out on 26 June 2010

During an inspection to make sure that the improvements required had been made

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.