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University Hospital Lewisham Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 11 January 2019

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

  • We found some improvements had been made since the last planned inspection, in 2017, but, more work was needed to bring about the substantial improvements that were required.
  • However, some of the improvements were too recent to assess their effectiveness.
  • There were staffing shortages in most of the services we inspected and staffing levels were not always in line with national guidance. This was a problem at previous inspections but has worsened.
  • Shortages of nursing staff were impacting on the effectiveness of end of life care, availability of link nurses, and it was not a seven day service.
  • Medicines management remained a concern in surgery and at this inspection was also found to be a problem in the emergency department.
  • In surgery not all policies and procedures had been reviewed in line with agreed timescales and some policies were yet to be developed. In the emergency department staff were not aware of the all the policies related to the care of patients with mental health needs.
  • Tools to identify patients who may be deteriorating were not used consistently across the services inspected.
  • Not all medical staff were up to date with their mandatory training.
  • Patient records were not always fully complete. We found some incomplete care plans and nutritional assessments.
  • In end of life care, we found patients had not always received their pain relieving medicine on time.
  • The uptake of appraisals and completion of mandatory training was variable and did not always meet the trust target.
  • In day care morale was low and staff did not always feel supported by their immediate line managers.

However:

  • Some action had been taken following previous inspections with improvements maintained.
  • The profile and leadership of end of life care had improved and we found some action had been taken to improve patient care along with the systems for reviewing and improving the quality and safety of the service.
  • Maternity services had made improvements and was rated as good.
  • Staff were aware of the incident reporting system and there was a good culture of incident reporting.
  • We saw improvements in staff hand hygiene.
  • In most services we inspected there was good multidisciplinary working and we found good cross site working in maternity services.
  • In all services we inspected we found staff were caring and patients were treated with dignity and respect.
  • Services had systems to record and manage risk but, some risks were long standing and had yet to be resolved.
  • The majority of staff were positive about their immediate line managers and felt they were kept informed, listened to and their contribution was valued.
  • The divisions were undergoing a restructure at the time of the inspection with the aim of strengthening leadership and devolving decision making.
Inspection areas

Safe

Requires improvement

Updated 11 January 2019

Effective

Requires improvement

Updated 11 January 2019

Caring

Good

Updated 11 January 2019

Responsive

Requires improvement

Updated 11 January 2019

Well-led

Requires improvement

Updated 11 January 2019

Checks on specific services

Medical care (including older people’s care)

Updated 1 August 2018

We have not re-rated this service as we have only focussed on specific areas of concern.

Significant nursing vacancies meant staff had less time to spend with patients and provide relatives with up to date information.

Staffing shortages were also making it difficulty for permanent staff to attend mandatory training. It also impacted on learning from incidents and complaints.

Discharge planning was sometimes complicated due to the complex needs of patients and staff working under pressure.

Patients were positive about the care they received and we observed compassionate interactions between staff and patients.

We found good multidisciplinary working with allied health professionals supporting nurses where they could.

Staff were positive about their local managers who they felt supported them.

Services for children & young people

Good

Updated 17 August 2017

  • There was strong evidence of good learning from incidents including sharing of methods cross-site to reduce errors across both sites. All areas we saw were clean and regular audits supported this process.
  • Good hand hygiene was maintained rigorously including the introduction of specialist hand gel door dispensers in the neonatal unit to prevent infection. Patients and parents were positive about the compassionate care that they received and we observed kind and respectful care during the inspection.
  • Changes had been made to patient pathways, such as the introduction of ward reviews, and referrals to the hospital at home team which had decreased length of stay. There were a low number of formal complaints made about the service and response rates to complaints received were within the agreed timescales. Since the last inspection there had been clear progress in developing cross-site governance structures, risk management and learning.

Critical care

Good

Updated 17 August 2017

  • There was a positive incident reporting culture, and learning from incident investigations was generally shared with staff in a timely manner.
  • The environment was clean, infection rates were low and staff complied with infection prevention and control practices. Nursing staffing levels met national standards.
  • Systems were in place to ensure the safe supply and administration of medicines.
  • Records were safely secured and contained documentation in accordance with national and local standards.
  • Care and treatment was delivered in line with national guidelines and best practice guidance.
  • There was an ongoing programme of clinical audit which included measurements of patient outcomes.
  • Interactions between staff and patients were individualised, caring and compassionate. Patients and their relatives felt they were treated with dignity and respect.

End of life care

Requires improvement

Updated 11 January 2019

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

  • At the last CQC inspection, we found there was poor completion of a patient’s end of life care plan in nursing notes. During this inspection, we found there were still inconsistencies.
  • The trust did not have a rapid discharge pathway in place and did not routinely record hospital patients preferred place of death which was reported at the last CQC inspection in March 2017.
  • There was no formal assessment in place to assess the efficacy of anticipatory drugs.
  • Shortages of ward staff meant there were low numbers of end of life care link nurses as well as occasional poor patient care.
  • Patients did not always receive their controlled drug analgesia as prescribed or on time.
  • There was just one fit for purpose concealment trolley which caused delays in transfer of bodies from wards to the mortuary.
  • Principles of Care for Dying Patients and use of the end of life care plans were not fully embedded in practice.
  • There was no succession planning for the current end of life care strategy 2016 - 2019.

However:

  • Consideration of the patient’s spiritual needs had considerably improved since the time of the last inspection.
  • Palliative and end of life care patients were no longer sent to the discharge lounge and there was a standard operating procedure which ensured this.
  • There was improved representation of end of life care at trust board level since the time of the last CQC inspection.
  • A separate end of life care risk register was introduced since the time of the last CQC inspection.
  • There were an increased number of clinical nurse specialists in the specialist palliative care team.
  • Patients and their relatives spoke positively about the care they received and commented on the sensitivity shown to them by all staff; including mortuary staff and members of the chaplaincy.

Maternity and gynaecology

Requires improvement

Updated 17 August 2017

  • We found the cleanliness of the environment and some equipment to be of a poor standard, even where green ‘I am clean’ stickers had been used to show that surface areas and equipment had been cleaned that day.
  • We observed that a number of key items of equipment were out of date for safety testing, such as CTG (cardiotocography) and BP (blood pressure) machines, incubators and resuscitaires.
  • We found that local leadership at the hospital had overlooked the basic issues of poor cleanliness and out of date equipment checks and the potential clinical, infection control and patient safety risks they posed.
  • While the service said it had enough Dopplers to assess babies’ health, these appeared to the inspection team to be not readily accessible.
  • IV (intravenous) fluids were unsecured in all ward areas, such as delivery rooms and emergency trolleys.
  • Mandatory training levels were below the trust’s benchmark of 85% compliance across a number of subject areas.

Outpatients and diagnostic imaging

Requires improvement

Updated 17 August 2017

  • Many patients complained about the waiting times in the outpatient clinics. They said they had not been given any update information about waiting times.
  • There was a lack of shared working across the trust within outpatients. Not all staff were aware of how to use the electronic reporting system.
  • The environment in general diagnostic imaging was not fit for purpose. Some equipment was in urgent need of replacement.
  • There was a shortage of radiographers and radiologists.

Surgery

Requires improvement

Updated 11 January 2019

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

  • The management of medicines had not improved and there remained issues with the management and record keeping for controlled drugs, as well as the storage of other medicines. These matters had been highlighted to the trust at our comprehensive inspection in March 2017 and had been the subject of a requirement notice at that time.
  • Whilst the environment was generally clean and clutter free, the corridor leading to the Vanguard theatre suite was being used to store equipment including sterile surgical kits. This presented both an infection risk to patients and a fire safety risk to patients and staff. This was addressed following our first visit, after we raised the concern to staff.
  • A number of policies and procedures had not been reviewed in line with their review date and there were a number of vital policies yet to be developed.
  • Records in respect of patients' nutrition were incomplete.
  • Whilst there were examples of positive multidisciplinary team (MDT) working throughout the division, the relationship between staff in the day surgery unit and the endoscopy staff was dysfunctional. The local leadership had failed to address the working relationships of staff. This impacted not only on the effectiveness of patient care, but had the potential to affect patients’ confidence in those caring for them.
  • Recruitment and retention of staff continued to be a critical issue for the trust, which the leadership had failed to fully address. At our inspection in March 2017, the issue had related solely to middle grade doctors, however, there were now recruitment and retention issues for medical staff of all grades, including consultants and junior doctors.
  • Risks remained on the risk register for a prolonged period and, whilst efforts were made at mitigation, the risks were not resolved.
  • Staff in the day surgery unit were highly critical of leadership at all levels. A significant number of staff we spoke with reported low morale.

However:

  • Adherence to hand hygiene best practice had improved significantly since March 2017 inspection.
  • Clinical nurse specialists (CNS) provided support to patients with particular conditions from pre-admission through to discharge.

Urgent and emergency services

Good

Updated 11 January 2019

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

  • There was a clear leadership structure. The emergency departments came under different directorates. The adult emergency department was part of the acute and emergency medicine (AEM) division and the paediatric emergency department part of the children and young persons (CYP) division. At a local level the adult emergency department (ED) was led by the clinical director. There was a clear clinical leadership presence in the department.
  • The operating plan set out a clear vison for the ED at University Hospital Lewisham (UHL) which included service improvements.
  • There was an emergency department education strategy for all nursing grades which set out the opportunities for further learning and development. Nursing staff told us there were opportunities for them to progress.
  • There was a culture of honesty, openness and transparency and staff told us there was learning from mistakes. Staff felt valued, supported and spoke highly of their job; there was good team work and peer support.
  • Risks for the ED were incorporated on their divisional risk registers with details of the actions to mitigate them and regular review.
  • In the paediatric ED, staffing levels complied with the Royal College of Paediatrics and Children’s Health (RCPCH) by having a minimum of two children’s nurses in the ED 24 hours a day seven days per week. All nursing staff were registered children’s nurses.
  • The records reviewed showed the ED used the National Early Warning Score (NEWS) system to detect deterioration in adult patients. As part of the quality assurance in the ED the nurse in charge of majors checked all patients every four hours.
  • Mental health liaison nurses were available to assess patients 24 hours a day seven days per week.
  • Staff we spoke with were aware of how to report incidents. Staff told us that learning from incidents was shared.
  • The ED participated in national audits to improve the care and treatment provided to patients. They also acted in response to the audit findings.
  • The trust was participating in the national commissioning for quality and innovation (CQUIN); improving services for people with mental health needs who present to A&E to reduce attendances by frequent attenders.
  • The trust had a comprehensive emergency department education strategy which set out the additional training requirements for nurses, emergency nurse practitioners (ENP) and advances clinical practitioners (ACP).
  • The trust had a service level agreement with a neighbouring mental health trust detailing the service provision and staffing availability of the mental health liaison team.
  • Consultants were available seven days a week in the both departments and on-call if required.
  • Staff provided treatment and care in a kind and compassionate way and treated people with respect.
  • People told us the staff were very friendly and helpful. All the patients we spoke with were happy with their care and raised no concerns. In the paediatric ED one parent told us the treatment of their child is ‘always very impressive’.
  • The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was consistently better than the England average from May 2017 to April 2018.
  • The emergency department had a relative’s room where families could go to discuss issues with medical staff or amongst themselves relating to loved ones care or emotional support.
  • Staff took time to ensure patients and their families understood treatment. We observed doctors speaking respectfully and professionally about next steps for patients.
  • The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment is no more than one hour. The trust met the standard over the 12 month period from June 2017 to May 2018, and was consistently better than the England average over the same time period.
  • The ED had taken steps to address flow through the department. Patients attending the ED were streamed to GP services which were available seven days per week or the Urgent Care Centre that was available 24 hours per day 365 days per year.
  • The ED could refer patients directly to the acute admissions unit AMU and the frailty unit which meant patients did not need to be assessed by a medicine consultant prior to admission.
  • Four recently reconfigured cubicles enabled the department to accommodate mental health patients awaiting admission. The department also has a psychiatric assessment room for patients requiring a Mental Health assessment.
  • Complaints were investigated and closed in line with the trust policy complaints being responded to within 25 working days of receipt. The ED took an average of 15 working days to investigate and close the complaints.

However

  • Whilst the ED was meeting the Royal College of Emergency Medicine (RCEM) recommendations that consultants should provide 24 hour 7 days a week cover. The service did not have a minimum of 16 hours of consultant presence 7 days per week. This was similar to what we found at the last inspection.
  • Mandatory training was below the trust target of 85% for medical staff in all 10 mandatory training courses and nursing staff in seven of the 14 mandatory training courses made available to them.
  • Whilst nursing staff reported that rapid tranquilisation was rarely administered to mental health patients in the ED department. Staff did not know if the trust had a rapid tranquilisation policy.
  • Some aspects of medicines management was safe. In the adult ED we found there were no records of the FP10s in stock and that no action was taken when fridge temperatures were out of range.
  • On the inspection we saw evidence of good practice in relation to hand hygiene and compliance to the trust policy of bare below elbows. However, the trust’s own internal audit data compliance varied from between 100% and 73%.
  • Appraisal rates of nursing staff for the period April 2017 to March 2018 was below the trust target of 90%.
  • There was little information for patients attending the emergency department about quality and performance.
  • Whilst privacy and dignity was maintained; curtains and screens were used in majors and resus areas. We observed that patients queuing to be streamed at the entrance of the ED could be overheard when discussing their health issues with the streaming nurse which compromised patients’ dignity and respect.
  • The ED did not have specific arrangements to meet the needs of patients with dementia or means of identifying people with dementia by means of an identity band or special sticker.

Maternity

Good

Updated 11 January 2019

We rated it as good because:

  • Staff had the appropriate skills and knowledge to assess and respond to patient risks. They reported incidents and safeguarding concerns when appropriate as well as keeping informative and up to date records of women’s care and treatment.
  • All clinical equipment and environments were clean, tidy and met the criterions set out in the Health and Social Care Act 2008: code of practice on the prevention and control of infections. Medicines were stored and checked appropriately.
  • At the time of inspection, both medical and nursing staffing levels were safe and met the Royal College of obstetrics and gynaecology (RCOG) recommendations and the ‘safe midwifery staffing for maternity settings’ (NICE NG4) guidance.
  • Care and treatment provided by the maternity service was in line with and met national evidence-based guidance. Patient outcome information was routinely collected and assessed by the trust.
  • The maternity service had strong multi-disciplinary team (MDT) working relationships between different types and levels of staff.
  • Staff treated women and their partners with care and compassion within all areas of the maternity service. Women, their partners and families were emotionally supported whilst under the care of the maternity service.
  • Staff ensured that people’s individual needs were identified and met. Midwives were appropriately trained to deliver care to women with additional support needs.
  • Staff spoke highly of both trust wide and local leadership. There was an open and honest culture within the maternity service.
  • There were effective structures, systems and processes to ensure safe and high quality care was delivered to service users. Information systems collated service information which was used to identify risks and patient outcomes.

However:

  • The dirty utility room within the labour ward was not always securely locked which meant that anyone could gain access to a potentially infectious area.
  • Some of the service’s foetal monitoring systems had signalling issues which meant they could sometimes stop working.
  • Daily equipment checks were not always documented. This included medical fridges resets and glucagon hydrochloride injection kit checks.
  • The trust did meet the mandatory training, appraisal or complaint response rate targets they had set for themselves.