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University Hospital Lewisham Requires improvement

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

Reports


Inspection carried out on 25th September 2018 to 26th September 2018

During a routine inspection

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 carried out on 22-23 May 2018

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

We undertook an unannounced focussed inspection at University Hospital Lewisham in response to concerns from patients, their relatives and staff about discharge arrangements for patients, staffing levels and poor care of patients. We inspected medicine (including older people's care) on 22 and 23 May 2018.

As this inspection is focused on specific areas of concern, we have not re-rated this service.

University Hospital Lewisham (UHL) is part of Lewisham and Greenwich NHS Trust. The trust was formed in October 2013 by the merger of Lewisham Healthcare Trust and the Queen Elizabeth Hospital Greenwich (following the dissolution of the South London Healthcare Trust by the Trust Special Administrator). The trust provides acute and community services.

Prior to this inspection the hospital has had two planned comprehensive inspections in February 2014 and March 2017 and was rated requires improvement at both of these inspections.

Our key findings were as follows:

  • We found a significant shortage of nursing staff which was impacting on the continuity of patient care. Nursing staff told us they often felt they did not have sufficient time to spend with patients. 
  • Discharge arrangements were working reasonably well but, the complexity of the requirements of some patients had increased and staff were having to manage more complex discharge plans while working under pressure.    
  • The reliance on agency staff meant it was difficult to share learning from complaints and incidents with staff. It also impacted on permanent nursing staff being able to attend mandatory training.
  • Information about the quality and safety of care displayed on wards was not always up to date.
  • Patients told us staff kept them involved in decisions about their care but, relatives felt nurses were too busy to talk to them.  
  • Staff had a good understanding of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.
  • We observed nurses and allied health professionals treating patients with kindness and patients were positive about the care they received.
  • There was good multidisciplinary working with senior nursing staff recognising and appreciating the support they had received from allied health professionals.
  • Staff spoke highly of their local managers who were aware of the challenges and were working hard to address the shortages while providing support to staff. 

Areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Take action to ensure that sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed.

In addition the trust should:

  • The hospital should ensure that all staff adhere to advanced PPE protocols when treating patients in isolation.

  • Display latest infection control and safety thermometer information.

  • The hospital should ensure that learning from incidents is shared appropriately with all staff, including agency staff.

  • The hospital should work to ensure that discharge plans are effectively communicated to patients’ relatives, in advance of their discharge.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 7 – 9 March 2017

During a routine inspection

University Hospital Lewisham is a district general hospital providing a full range of services including emergency department, medical, surgery, critical care, maternity and gynaecology, services for children and young people, outpatients and diagnostic imaging and end of life care. It serves the population of the London Borough of Lewisham and the wider area of south east London. Community health services for adults and children and young people are also provided for Lewisham.

We carried out a comprehensive announced inspection at the hospital between 7- 10 March 2017 as part of our planned acute hospital inspection programme. We carried out further unannounced inspections during March 2017.

We rated critical care, and services for children and young people as good. We rated urgent and emergency services (A&E), medical wards, surgery, maternity and gynaecology, outpatients and diagnostic imaging, and end of life care as requires improvement.

In addition we rated community services for adults as good and community services for children and young people as outstanding.

We rated effective care and caring as good and safe care, responsive care and leadership as requires improvement.

We rated University Hospital Lewisham as requires improvement overall.

Our key findings were as follows:

  • In some areas, safeguarding training rates and mandatory training rates fell well below the trust’s target.
  • There were significant shortages of medical, nursing and allied health professional staff in most departments which were having an impact on delivery of care and patient safety. Although the trust was actively trying to recruit into vacant posts there was limited evidence of success.
  • In some areas, principally surgery, medicines management processes were not in line with hospital policy or national guidance.
  • In medical care, infection control processes, including waste management and adherence to the control of substances hazardous to health guidance, was variable.
  • In surgery, we observed numerous breaches of Infection Prevention and Control (IPC) policy, potentially placing patients at significant risk of infection.
  • In maternity and gynaecology 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.
  • In outpatients the environment in general diagnostic imaging was not fit for purpose.
  • Whilst care was in line with relevant National Institute for Health and Care Excellence (NICE) and other national and best practice guidelines, there was a risk to clinical outcomes and patient safety due to maternity guidelines not being merged across the Lewisham and Greenwich sites and some guidelines also being out of date.
  • The hospital was not providing responsive care in all areas.
  • Emergency and urgent services (ED) did not meet the wait to treatment time of one hour during the 12 months from October 2015 to September 2016.
  • The hospital breached the admit or discharge within four hours of arrival each month between December 2015 and November 2016
  • Waiting times for treatment were well above the England average.
  • There were insufficient systems in place to manage the fundamental issues of capacity and flow within the ED. ED performance was below the objectives set out in the delivery plan.
  • In medical care, referral to treatment (RTT) times was not met in rheumatology where 80% of patients were seen within the target of 18 weeks.
  • Cancer treatment times did not meet the national two-week standard in relation to lung cancer. In November 2016, 61% of patients were seen within two weeks.
  • There were higher than national average numbers of delayed discharges due to problems with access and flow within the hospital. Bed occupancy was also higher than the national average which could limit the service’s ability to provide a bed in the event of an emergency.
  • In critical care there were higher than national average numbers of delayed discharges due to problems with access and flow within the hospital. Bed occupancy was also higher than the national average which could limit the service’s ability to provide a bed in the event of an emergency.
  • In outpatients and diagnostic imaging, many patients complained about the waiting times in the outpatient clinics.
  • The hospital took significantly longer than their target to investigate and respond to complaints which were not responded to in a timely manner.
  • There was limited cross site working with Queen Elizabeth Hospital (QED) For example ED staff did not support each other across sites when there was capacity to do so
  • There was a lack of shared working across the trust within outpatients and diagnostic imaging.
  • There were issues around local leadership at the hospital. For example on some of medical wards, staff said they were demoralised which they attributed to high vacancy rates, increased workloads, being constantly moved around to cover other wards, and a lack of support from matrons who staff thought should have been doing more to support them.
  • Staff across medical wards reported a culture where they were not valued, or respected by matrons.
  • There was no documented strategy for the critical care service, and there were concerns around the medical leadership and governance arrangements.
  • There was no clinical ownership of the risk register within the surgical directorate.
  • In services for children and young people, there were low levels of attendance at governance and safety boards which reduced opportunities for sharing of information to the appropriate people.
  • In surgery, the leadership team were unaware of the issues with medication within theatres.
  • The leadership team in maternity had overlooked basic issues of cleanliness and infection control.
  • Some BME members of staff that we spoke with felt opportunities for staff development, promotion, training and support wasn’t always afforded to them in the same way that it was given to their Caucasian counterparts.

However:

  • Staff were caring and compassionate and patients were treated with dignity and respect.
  • Emotional support was provided by the chaplaincy or multi-faith services.
  • Patients expressed a positive view of the care and treatment they received.
  • Interactions between staff and patients were individualised, caring and compassionate. Patients and their relatives felt they were treated with dignity and respect. However there were aspects of caring in medical care wards that required improvement.
  • There were good examples showing that the needs of people living with mental health issues were being addressed. For example, in ED the child and adolescent mental health services (CAMHS) transformation had improved care with the majority of referrals being seen on the same day (Monday to Friday).
  • In medical care, there were various initiatives to increase awareness of dementia through the hospital’s dementia strategy.
  • In maternity and gynaecology there was good support from The Kaleidoscope Team which worked with vulnerable women and those with mental health needs.
  • There was a positive incident reporting culture, and learning from incident investigations was generally shared with staff in a timely manner in ED, critical care and services for children and young people.

Importantly, the hospital must:

  • Ensure effective systems to assess and monitor the quality and safety of the care and treatment in all services across the hospital.
  • Address and improve issues of medicines management in surgery and services for children and young people.
  • Address and improve issues of cleanliness and infection control in medical care, surgery and maternity and gynaecology.

In addition the hospital should:

  • Ensure mandatory training targets are met in all services at the hospital.
  • Improve its recruitment processes to mitigate vacancy levels in medical, nursing and allied health professional staff.
  • Merge maternity guidelines across both major hospital sites and within community midwifery.
  • Address performance targets currently not being met as detailed above.
  • Ensure complaints are dealt with in accordance with trust timeline targets.
  • Ensure that service and department leaders are aware of issues and concerns within their departments and act to rectify them.
  • Identify ways to empower and support staff to make improvements and take the lead in decisions and improvements in their services.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 26-28 February 2014

During a routine inspection

The hospital provides services to the residents of Lewisham, an approximate population of 275,000 people. it is part of the recently formed Lewisham and Greenwich NHS Trust, and as a whole the trust provided healthcare to a wider population of over 550,000 people of Lewisham, Greenwich and Bexley.

During the inspection, the team looked at many areas. The detail of their findings is within the main body of the report. However in summary we found that:

Elements of the acute medical pathway (which is based on a different model on each site) are not providing optimal flow of patients through the hospital. This includes difficulties in accessing critical elements of some patient pathways provided externally to the Trust; as part of forming the new merged trust, some of these external pathways are needing to be reset and agreed.

Particularly on the Lewisham site issues around waste management were identified. The inspection team identified a number of areas where clinical waste was stored (including bins containing used hypodermic needles) that were not securely locked. We saw this in a number of places at various times. We considered this to be a risk to safety of patients and public.

The approach taken by the executive team to the formation of a single, inclusive organisation is appreciated by staff on both sites. .

The review team felt that the Executive Team should plan to re-evaluate their management capacity to address the issues described at regular intervals to ensure that this remains adequate.

The staff on both sites are committed to high quality care and this is a focus of their work

Inspection carried out on 26 February 2014

During Reference: not found

Inspection carried out on 2 August 2013

During a routine inspection

This inspection looked at maternity services at University Hospital Lewisham. The inspection included the hospital’s antenatal clinics, the day assessment unit, antenatal ward, the labour ward, birth centre and postnatal ward.

Most women we spoke with were happy with the maternity care they received. They said the staff were caring and explained what was happening. Women said they had enough information about their care and were able to make choices. We saw very positive feedback from women attending the birth centre.

Most staff said that communication and team working was good on the labour ward with effective consultant cover. We were told the unit ethos was to provide the best service possible. However we saw some examples of care on the antenatal and postnatal wards which was insensitive and unsafe. We also saw that confidential notes were not always stored securely.

Midwives had mixed views about supervision with some saying they had not received enough support. Staff spoken with praised the training for their job roles provided by the trust.

The trust had systems to monitor the quality of care. However we found that managers were not making active use of available information or staff engagement to monitor and improve the service.

Inspection carried out on 8, 11 February 2013

During a routine inspection

The main focus of our inspection was on the care and treatment provided to more vulnerable patients, for example older people, people receiving end of life care and people with dementia or learning disabilities.

The trust worked in co-operation with other partners, and was part of an innovative “developing integrated pathways across health and social care” project.

There were clear pathways and tools which were aimed at meeting the needs of vulnerable patients; however, some of the measures and tools within the pathways were not yet fully implemented or had not been audited to assess whether they were meeting patients' needs.

Some of the care records and assessments we saw did not reflect people’s needs, or were incomplete or inaccurate, which meant there was a risk that not all patients experienced care, treatment and support that met their needs.

Overall, patients’ views and experiences were taken into account and staff respected and promoted their privacy. However, patients' personal dignity was not always taken into account. Some patients were complimentary about the service they had received, and told us, “staff are busy but they do have time to talk to me and they listen to me. They do a great service”, “the nurses work really hard, they have lots to do” and “staff have been marvellous”. However, during our inspection we saw examples of poor communication, and some patients told us that staff did not listen to them or their views.

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 24 May 2011

During a routine inspection

We spoke to staff and people during our visit at the hospital. People told us they were happy with the care they received and praised the nursing staff. People we spoke with also told us that they felt safe on the ward and also felt that their concerns and comments would be listened to and acted upon.

Inspection carried out on 16 March 2011

During a themed inspection looking at Dignity and Nutrition

Patients we spoke with were mostly very positive about their experiences of care and treatment and said that staff listened to them. Patients told us they were happy with the care they received and praised the nursing staff. ‘I call them and they come, I couldn’t want better’, was a typical comment.

Patients we spoke to were happy with the food which was served. They were satisfied with the support provided during meal times, and the presentation and amount of the food served. “It’s always served hot”, “portion size is quite good” were some of the comments patients made about the food.