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Queen Elizabeth Hospital 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 improvement had been made since the planned March 2017 inspection but more work was needed to bring about the substantial improvement that was required.
  • However, some of the improvements were too recent to assess their effectiveness and in critical care we found improvements made following the March 2017 inspection had not been sustained.
  • The emergency department (ED) was, at times, overcrowded and patients were cared for in corridors with screens used to try and maintain privacy and dignity for patients. Managing demand and capacity had been a long standing problem for the hospital.
  • In critical care privacy and dignity was sometimes compromised as the beds were very close to each other.
  • There were staffing shortages, medical, nursing and allied health professionals, in most of the services we inspected. Consultant cover in the ED and critical care was not in line with national guidance.
  • The uptake of appraisals and completion of mandatory training was variable and did not always meet the trust target. This was a particular problem for medical staff.
  • Shortages of nursing staff were impacting on the effectiveness of end of life care and it was not a seven day service.
  • We found problems with the management of medicines in surgery, ED and critical care.
  • In the emergency department staff were not aware of the all the policies related to the care of patients with mental health needs and the hospital did not have a clear pathway for patients attending the ED with known or suspected mental health issues
  • Some policies in surgery and critical care were past their review date and/or not dated.
  • The hospital had not always met the 62-day referral to treatment target for patients with cancer.
  • In most services we inspected we found delays in responding to complaints.
  • Services we inspected had systems to monitor the quality and safety of care provided but in surgery medical staff were not fully engaged in improvement projects or the quality agenda.

However:

  • Some action had been taken following previous inspections with some 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 systems for reviewing and improving the quality and safety of the service.
  • Maternity services had maintained its rating of good and we found good cross site working.
  • Systems to ensure patient safety in the emergency department had been established and there were plans to reduce the overcrowding with the establishment of the clinical decision unit.
  • The day care unit was no longer used to care for patients when beds on the appropriate ward were not available and there was improved compliance with the spinal trauma pathway.
  • In critical care patients who had previously been transferred to another hospital for some procedures were now able to be treated at QEH.
  • We found staff were caring and compassionate and we observed positive interactions between patients and staff.
  • In most services we inspected staff were positive about their immediate line manager and felt they were supportive and approachable.
  • 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.

We found vacancies in both nursing and medical staff was impacting on staff being able to consistently deliver quality and safe care.

Staff were not always aware of learning from incidents and complaints.

There were some problems with discharge planning but, work was in progress to improve the process.

Staff were working very hard to meet the needs of patients and there was good multidisciplinary working.  

Staff spoke positively about their local managers and were optimistic about the recent appointments of the chief executive and chief nurse.

Services for children & young people

Requires improvement

Updated 17 August 2017

Services for children and young people were rated requires improvement because of concerns about the number of nursing and medical staff in the neonatal unit (NNU). The service also did not meet national guidance for paediatric consultant cover. The number of play specialists had also been reduced which impacted on their availability to support children.

Children and young people who attended the Hippo unit, and had first attended the urgent care centre, sometimes experienced delays in having their observations carried out. Due to the times the service operated they sometimes had to attend the Emergency Department when it closed which prolonged their time in the hospital.

Since the last inspection in February 2014, there had been some improvement in cross site working and governance processes. However, some of the risks, increased number of cots in the NNU, identified during the inspection were not recorded on the risk register or little or no progress had been made. Medical cover was an example of this and discussions had been taking place for three year little progress had been made.

However, children and young people received effective care and staff were caring and competent to perform their roles and responsive to the individual needs of children.

Critical care

Requires improvement

Updated 11 January 2019

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

  • We observed some gaps in the consultant rota due to the number of consultant vacancies; this meant that the service was not consistently meeting FICM and ICS guidance for consultant cover.
  • We found some aspect of medicines storage concerning as some medication were stored in cupboards with a label for a different medication.
  • Staff were not using local Safety Standards for Invasive Procedures, as recommended by national patient safety alert, for all invasive procedures carried out on the unit.
  • We found a number of policies kept at the patient bedside were past their review date or were not dated.
  • ICNARC data showed that unplanned readmission to critical care within 48 hours of discharge was worse when compared with results for similar units.
  • Flow and delayed discharges were still a significant issue for the unit. We saw that the percentage of delayed discharged was worse than the England average.
  • Occupancy rates were consistently greater than the Royal College of Anaesthetists recommendation of 70% critical care occupancy.
  • Concerns previously highlighted about the medical leadership of the unit remained unchanged, Staff described the medical leadership as ‘disengaged’.
  • We were not assured the leadership team had a robust plan to address the issue of consultant recruitment.
  • There was no clear vision and strategy for the critical care unit.

However:

  • We saw that the patients requiring surgical tracheostomies or magnetic resonance imaging (MRI) were no longer being transferred to another unit as the hospital was now equipped to carry these procedures.
  • There was a good reporting culture and staff received feedback and were able to tell us about lessons learned from recent incidents.
  • We found that multidisciplinary working had improved considerably since our last inspection, with weekly MDT meetings taking place on the unit.
  • The training and development programme in place for supported nurses through each step of the National Competency Framework for Adult Critical Care Nurses. We saw evidence all nursing staff were suitable trained and assessed prior to working independently.
  • The number of non-clinical transfers had significantly improved since the last inspection and was now comparable to a similar unit.
  • Staff cared for patients with compassion and Friends and Family Test responses showed that over 90% of respondents reported they would recommend the service.
  • All staff, including medical and AHPs, described the nursing leadership as excellent and inspiring. The matron and senior nurses created a culture of openness which enabled staff of all discipline to interact well with each other.

End of life care

Requires improvement

Updated 11 January 2019

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

  • There was still not a seven-day SPCT service.
  • The often-large paper patient medical records were not always fully bound or in the correct order.
  • We noted inconsistent completion of mental capacity assessments, the recording of pain scores and eating and fluid intake charts.
  • There was no succession planning for when the current end of life care strategy comes to an end in March 2019.
  • Minutes from the end of life steering group showed that attendance was variable.

However:

  • Awareness of end of life care at staff and trust level had improved since our previous inspection.
  • There was evidence of good multidisciplinary team working between ward staff, the specialist palliative care team (SPCT) and other allied healthcare professionals (AHP).
  • A dedicated end of life risk register had been introduced since our last inspection.
  • With the help of the SPCT rapid discharge of patients to their homes or other preferred place of care could be arranged.

Maternity and gynaecology

Good

Updated 17 August 2017

Maternity and gynaecology were rated good because there were systems to monitor and improve the quality and safety of care provided. We saw evidence of reporting and learning from incidents and there were sufficient staff to care for women and their babies. Care was informed by national guidance and outcomes for women using maternity services were monitored.

Staff were caring and responsive to the needs of women and had developed a range of services to meet the varied and complex needs of women who used the service. Women told us that staff answered their questions and were ‘kind’ and ‘patient’.

Women were able to choose where they gave birth.

There was a good cohesive leadership team and which had established

effective links with local and regional commissioners of services, local authorities, GPs and patients to coordinate care for women.

However, the environment for women using gynaecology services was not always appropriate or sensitive to their needs and some women experienced long waiting times.

Outpatients and diagnostic imaging

Good

Updated 17 August 2017

Outpatients and diagnostic imaging were rated as good because patients were receiving safe, effective care and the service was well-led. The service needed to improve how it responded to patients.

We found a good culture of reporting incidents and the environment was safe and clean. Equipment had been cleaned and checked. Care and treatment was provided in line with national guidance and regulations. Patients told us staff were kind and said they felt involved in their care with staff providing explanations as needed.

Staff were positive were about their immediate managers and said they supported them and they felt valued. Outpatients and diagnostic imaging had developed a five year strategy for improving the service

However, the service was not always meeting national referral to treatment times and the ‘Did not attend’ (DNA) rate was higher than the England average. Many of the clinics were observed were running late and there was no evidence that this was being monitored.

Surgery

Requires improvement

Updated 11 January 2019

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

  • Medicines were not managed safely and effectively. Poor practices were observed and this had not improved since our last inspection. We have issued the trust with a requirement notice under regulation 12: Safe care and treatment.
  • There was a lack of strong oversight for ensuring staff completed mandatory training. Compliance rates were variable and we found no improvement since our last inspection.
  • We were not assured patient risk assessments were fully completed. We reviewed records where risk assessments had not been fully recorded and risk assessment tools had not been used properly. We found escalation pathways were not always followed correctly.
  • Incidents of a low level were not always reported or captured, which meant there were missed opportunities for identifying common themes and trends.
  • There was a shortage of medical staff and allied health professionals (AHPs)and this was a high risk on the surgical divisions risk register. The risk register identified there was no funding to action this further in relation to the AHPs.
  • More work was needed to ensure referral to treatment times (RTT) and the 62-day target for patients with cancer were being met.
  • Acute medical patients were placed on ward 15AB as outliers, resulting in a need for ward transfer as staff were not trained to provide the medical care required.
  • Governance processes were not robust. Risks were not addressed quickly and vital policies had not been developed or updated. We still found patient records were loose and not in chronological order. This had not improved since our last inspection.
  • Morale amongst medical staff was low and as a result they were not fully engaged in the governance agenda and quality improvement projects.
  • Staff were not fully engaged with the trusts visions, values and mission.

However:

  • The trust had acted upon some concerns raised at our last inspection. The day care unit had been reopened solely as a day surgery service and was used more appropriately. Beds were ring fenced and the environment provided more privacy and was no longer used as an escalation area.
  • The trust had stopped extra beds being placed in rooms five and six on ward 12, and there was improvement in adherence to the spinal trauma pathway.
  • An extra support staff member had been recruited in ward 15AB, which had reduced incidents of patient falls. This was an improvement since our last inspection.
  • The surgical division were in the process of restructuring and redefining their vision and values for the service. Under the guidance of new leadership, staff felt more positive of future improvements, although it was too early to meaningfully assess the level and positivity of their impact on the service.

Urgent and emergency services

Requires improvement

Updated 11 January 2019

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

  • We found there had been some improvements in the access and flow in the emergency department (ED) since our last inspection. However, demand and capacity still posed problems in regards to the number of patients waiting in the department and length of time patients waited for admission.

  • During our previous inspection we found patients were not always cared for in areas that were appropriate, met all of their needs and had sufficient space to accommodate the potential number of people using the service at any one time. We found that this was still the case during this inspection.

  • During our previous inspection in March 2017 we found the ED environment was sometimes overcrowded. We found there was still overcrowding in the ED. We found patients on trolleys along the ED ‘majors’ corridor. This constituted a barrier to evacuation in the event of an emergency.

  • There was no clear pathway for patients attending the ED with known or suspected mental health issues that reflected national and best practice guidance. Staff we spoke with raised concerns about the lack of a mental health strategy for the ED.

  • The joint protocol between the ED staff and mental health liaison staff for observing patients at high risk of suicide and self-harm was not always followed. Staff were unaware of the procedures for caring for a patient that had received sedation by injectable medicine (rapid tranquilisation). There was no policy staff were aware of in regards to rapid tranquilisation.

  • The ED was not meeting the College of Emergency Medicine recommendations for 16 hours consultant cover seven days a week.
  • The department did not have a policy in regards to the care of bariatric patients. Staff also told us there were issues with the availability of equipment for bariatric patients.
  • We found mitigating actions on the risk register did not fully address identified risks. Risks on the risk register had not always been addressed in a timely way.
  • The culture in ED was positive and inclusive at local level, but some staff felt this did not extend to the wider organisation. Some staff told us there was a culture at the trust that urgent and emergency care patients were the responsibility of the service and not the wider organisation.

However:

  • There was a new 52 bed clinical facility which was scheduled for opening in December 2018. This would provide increased capacity in urgent and emergency care services.

  • ED staff were committed to providing a safe, compassionate and caring service. Patients we spoke with were mostly positive about the staff in the ED.

  • During our previous inspection we reported that patients were often waiting with ambulance crews by the main public corridor to the ED. There had been improvements in the London Ambulance Service (LAS) handover times, with the department meeting the 15 minute target for ambulance handovers. There was also improved performance in regards to patients receiving treatment within one hour of arrival.

  • The ED had introduced quality rounds as part of the department’s daily routine. There was quality round log books to record these. Quality rounds were completed four hourly across ED areas including the waiting area.

  • The ED had a comprehensive education strategy as an aspect of the divisional clinical strategy. An aspect of the strategy was linking junior clinical fellows (JCF) and middle grade posts with education fellowships to attract and retain medical staff.

  • Hand hygiene compliance audits had been above the trust’s 95% target in the 12 months prior to August 2018.

Maternity

Good

Updated 11 January 2019

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

  • Staff had the right skills and experience and were clear about which guidelines and legislation they were working too. These ensured women were provided with the best level of care based on best practices.
  • There had been improvements in staffing with new consultant posts filled and newly qualified midwives ready to join the service. Rota gaps were often filled with regular staff undertaking overtime to ensure a safe service.
  • The environment in which women received care was managed safely and staff followed infection prevention and control practices.
  • The services were arranged to meet the individual needs of women and their families. Women had their physical, mental and social care needs regularly assessed throughout all stages of their pregnancy. Feedback from women was overwhelmingly positive about their personal choices, and the level of care and support received.
  • The culture was supportive, open, and honest and promoted good working practices. Managers promoted innovation and supported staff to come up with ideas on how the service could be improved.
  • Incidents, risks and near misses were regularly reported and acted upon. There were arrangements for monitoring the quality of service, performance outcomes and risk register together with action plans enabled continuous oversight.

However:

  • Mandatory training skills did not always meet the trusts own targets.
  • Improvements were required to ensure complaints were responded too in a timely manner and in line with the trusts policy.