You are here

King's College Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 30 September 2015

King's College Hospital Denmark Hill Site is part of King's College Hospital NHS Foundation Trust. The trust provides local services primarily for people living in the London boroughs of Lambeth, Southwark, Bromley and Lewisham. King's College Hospital Denmark Hill Site provides acute services to an inner city population of 700,000 in the London boroughs of Southwark and Lambeth, but also serves as a tertiary referral centre in certain specialties to millions of people in southern England.

King's College Hospital NHS Foundation Trust employs around 11,723 whole time equivalent (WTE) members of staff with approximately 8,785 staff working at King's College Hospital Denmark Hill Site.

We carried out an announced inspection of King's College Hospital Denmark Hill Site between 13 and 17 April 2015. We also undertook unannounced visits to the hospital on 25 and 28 April 2015.

Overall, this hospital requires improvement. We found that urgent and emergency care, medical care, services for children and young people and outpatients and diagnostic services were good. However surgery, critical care, maternity and gynaecology services and end of life care required improvement. 

The effectiveness of care, care of patients and the leadership at this hospital were good overall. However, the hospital required improvement in order to provide a safe and responsive service towards patients and their carers.

Our key findings were as follows:

Safe

  • There was an open and transparent approach to the investigation of incidents. Staff were encouraged to report incidents when they occurred.
  • There were largely adequate medical and nursing staff on duty to provide safe care to patients apart from medical care, maternity and neonatal intensive care services.
  • There were effective arrangements in place to minimise risks of infection to patients and staff.
  • Medicines were stored, recorded and administered safely to protect patients.
  • The support provided by the iMobile team for deteriorating patients was excellent.
  • The critical care service did not meet basic safety standards in some areas, particularly on the high dependency units.

Effective

  • Staff followed accepted national and local guidelines for clinical practice.
  • There was a multidisciplinary, collaborative approach to care and treatment that involved a range of health and social care professionals.
  • Some newly qualified midwifery staff had not received appropriate training to enable them to carry out their roles effectively.
  • Patients were given timely pain relief and pain scoring tools were consistently used.
  • The nutritional needs of patients had been assessed and patients were supported to eat and drink according to their needs.
  • Understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards was variable and some groups of staff needed to improve their knowledge in these areas.

Caring

  • Patients were cared for by staff who were kind, caring and compassionate in their approach. Patients were supported, treated with dignity and respect and were involved as partners in their care.
  • Patients felt that they were listened to by health professionals, and were involved in their treatment and care.
  • Staff respected patients’ choices and preferences and were supportive of their cultures, faith and background.

Responsive

  • Services were planned to meet the needs of the local population.
  • The emergency department (ED) was often overcrowded. Patient flow required improvement and waiting times were above the national average, due to capacity constraints and the trust’s arrangements for making decisions to admit patients.
  • Referral-to-treatment times were not being met in a number of surgical and outpatient specialties. Surgical procedures were cancelled and not always rescheduled and undertaken within 28 days.
  • There was a lack of critical care beds, which affected patients’ length of stay and delayed discharges.
  • Outpatient services were not organised in a manner that responded promptly to ensure that patients’ needs were met.

Well-led

  • The leadership, governance and culture of the hospital promoted the delivery of high quality, person-centred care.
  • Robust governance arrangements were in place to monitor, evaluate and report back to staff and upwards to the trust board.
  • Most staff were proud of working for the department and staff worked well together as a team.

We saw several areas of outstanding practice, including:

  • Trauma nurse coordinators tracked pathways and the progress of trauma patients by visiting them daily on the wards. This role also included networking with other trusts and coordinating repatriation in advance.
  • The ED had an established youth worker drop in scheme operated by a London-based organisation, which was effective in supporting vulnerable young people. Staff could refer young people to the service, although engagement was voluntary. The service also supported young people to access specialist services, such as housing support and access to social workers.
  • The iMobile outreach service was innovative and there was evidence that it was producing positive outcomes both for patients and the critical care service as a whole.
  • The pioneering work being done by neurosciences, liver and haematology specialist services.
  • The surgical directorate had set up the first national training for a trauma skills course in the country.
  • There were well-established pathways for pregnant women, which provided appropriate antenatal care, including access to specialist clinics for women with medical needs.
  • The foetal medicine unit provided interventions, such as foetal blood transfusions, fetoscopic insertions of endotracheal balloons and laser separation procedures of placental circulations for complicated monochorionic twin pregnancies.
  • The enhanced scanning programme included combined screening for chromosomal abnormalities at 12 weeks, with women being given the results on the same day.
  • The gynaecology and urogynaecology services offered a one-stop service with diagnostics carried out by a specialist doctor. The hospital was a regional training unit for this service and the unit was recognised as a gold standard unit by The British Society of Urogynaecologists.
  • For children with complex liver conditions and those who required surgery as neonates, staff developed and advocated the use of innovative and pioneering approaches to care.

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

Importantly, the trust must:

  • Review its facilities within critical care so that it meets both patient needs, and complies with building regulations. This includes bed spacing and storage facilities, particularly for IV fluids and blood gas machines.
  • Ensure that the 'Five steps to safer surgery' checklist was always fully completed for each surgical patient.
  • Re-configure the Liver outpatient clinic in order to avoid overcrowding.
  • Ensure patients referral to treatment times do not exceed national targets.
  • Improve patient waiting times in all outpatients’ clinics.
  • Review the capacity of the maternity unit so that women and their babies are receiving appropriate care at the right place at the right time.
  • Implement a permanent solution to the periodic flooding following heavy rain of the renal dialysis unit and endoscopy suite areas.
  • Ensure that current trust policy around syringe drivers affords optimum protection for patients against the risk of adverse incidents.
  • Ensure the cover for the concealment trolley for deceased patients is in good repair and not an infection control risk.

In addition, the trust should:

  • Fully complete controlled drug registers in the ED.
  • Complete safeguarding flowcharts for children attending the ED.
  • Improve the number of senior ED medical staff trained in safeguarding children training at level 3 to meet Intercollegiate Committee for Standards for Children and Young People in Emergency Care Settings recommendations.
  • Identify and mitigate risks to patients attending the ED, such as the development of pressure sores, falls and poor nutrition.
  • Improve the uptake of training on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards for staff working in the ED, medical care, surgery and services for children and young people.
  • Review staff understanding of the Mental Capacity Act 2005 in critical care and end of life care, to ensure their practice and documentation reflects the legislation.
  • Develop guidelines for admission to the children’s clinical decision unit (CDU).
  • Review the area used for the children’s CDU to ensure the environment fulfils the criteria for a ward area.
  • Review the practice of undertaking adult consultations in the children’s ED.
  • Improve patient flow and waiting times in the ED, including their arrangements for making decisions to admit patients.
  • Take action to improve the percentage of ED patients seen, treated and discharged within four hours.
  • Consider ways of improving the documentation of patient safety checks.
  • Improve attendance at mandatory training.
  • Improve theatre utilisation and a reduction in cancellations.
  • Improve the referral to treatment times.
  • Improve patient flow through the surgical pathway.
  • Consider ways of improving the discharge process by engaging with external agencies.
  • Consider how staff can be made aware of the broader strategy for the surgical division.
  • Review the systems for checking equipment to ensure that they are in date, in working order and stock is effectively rotated.
  • Ensure it continues to review its critical care bed capacity so that it can meet its expected admissions.
  • Review its patient record documentation to ensure it is fully completed and information between wards is seamless.
  • Review its use of the Waterlow assessment to ensure those patients that need pressure-relieving support, receive it.
  • Review the nursing, consultant and junior doctor levels on the neonatal intensive care unit.
  • Review the space between cot spaces on the neonatal intensive care unit as they were sometimes restricted or limited.
  • Provide clear and up-to-date information on outpatient clinic waiting times.
  • Monitor the availability of case notes/medical records for outpatients and act to resolve issues in a timely fashion.
  • Review medical cover for gynaecology and obstetrics.
  • Stop overbooking outpatient clinics including the liver outpatients department clinic.
  • Share outpatients and diagnostic imaging performance data with clinical staff.
  • Make sure the preferred place of care/preferred place of death, or the wishes and preferences of patients and their families is documented.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 30 September 2015

Effective

Good

Updated 30 September 2015

Caring

Good

Updated 30 September 2015

Responsive

Requires improvement

Updated 30 September 2015

Well-led

Requires improvement

Updated 30 September 2015

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 30 September 2015

Maternity inpatient care and treatment was not always received in the right place and/or at the right time at times of peak demand. These issues were long standing, and had not been resolved at the time of our inspection, in spite of action to deal with the flow of women through inpatient areas. Midwifery, support and medical staff worked hard to keep women safe, but sickness levels among midwives had risen. Consultant leave was not covered, and this caused additional pressures on medical staff.

It was recognised that medical cover at night, which was provided across gynaecology and maternity inpatient services, was insufficient to guarantee prompt review and treatment of patients.

There were a number of innovative and ground-breaking services in maternity and gynaecology. Care and treatment was evidenced-based and the audit programme monitored adherence to guidelines and good practice standards. Actions were identified following audits and these were re-audited.

There were robust care pathways for pregnant women to access appropriate services.

Gynaecology services were responsive to women’s needs.

The safety of maternity and gynaecology services was enhanced because reporting of, and learning from, incidents was promoted. There was systematic, multidisciplinary review of incidents. Risks were recorded and plans put in place to address, or mitigate these risks. The risk register was used to respond reactively to issues that had been recorded, and not to anticipate risks that might arise.

Senior management in women’s services had succeeded in establishing integrated clinical governance structures, including risk management, across the newly merged trust, which now included Princess Royal University Hospital.

There were clear reporting routes to the trust-wide committees and the board. There had been changes to the delivery of gynaecology services at the Denmark Hill site as a result of the merger, and senior management in maternity services had spent time supporting and developing maternity services at Princess Royal University Hospital. Following the structural reorganisation, the aim of the women’s service was to achieve stability and the delivery of high quality care.

Medical care

Good

Updated 30 September 2015

Medical care (including older people’s care)

Updated 30 September 2015

Patients received care based on the best available evidence and national guidance. The hospital scored highly in most of the patient outcome measures which indicated good adherence to evidence-based measures, which improved outcomes for patients. Patients gave their consent for care and treatment and were involved in decision making. There was an effective multidisciplinary approach to care and good team working.

Patients were cared for by staff, who were kind, caring and compassionate in their approach. Patients praised the staff, for their attitude and approach, using adjectives, such as “wonderful,” and “absolutely fabulous”. Patients were involved in decisions about their care and treatment. The service was planned to meet the needs of the people it served and care was responsive to people’s individual needs and wishes. Systems were in place to manage and learn from complaints. There was strong and passionate leadership and a culture of openness, with an enthusiasm to further develop and improve services for the future.

Regarding safety, there were many aspects of good practice, including the reporting and management of incidents and infection prevention and control. The iMobile critical care outreach service provided excellent support to wards, but, in some areas, the identification and escalation of deteriorating patients was inconsistent. In addition, nurse staffing in some wards and the environment within the renal dialysis unit needed improvement.

There was no formal approach to identifying the possibility of sepsis or implementation of Sepsis Six in the medical assessment centre or acute medical unit. 

Urgent and emergency services (A&E)

Good

Updated 30 September 2015

Staff demonstrated an open and transparent culture about incident reporting and patient safety. Staff understood their roles and responsibilities and were empowered to raise concerns and to report incidents and near misses actively to promote learning and improvement.

There were adequate medical and nursing staff on duty to provide safe care to patients. Medicines were stored, recorded administered safely to protect patients from the risk of medicine misuse. Patients were safeguarded from abuse. Staff were aware of their responsibilities to protect vulnerable adults and children, although some improvements were required in documentation relating to safeguarding and staff training.

Staff followed accepted national and local guidelines for clinical practice. The department had developed a number of pathways to ensure that patients received treatment focused on their medical needs. The trust participated in national College of Emergency Medicine audits so that they could benchmark their practice and performance against best practice and other emergency departments.

There was a multidisciplinary, collaborative approach to care and treatment that involved a range of health and social care professionals. Patients were given timely pain relief and pain scoring tools were consistently used.

Patients in the ED were supported, treated with dignity and respect and were involved as partners in their care. Patients felt that they were listened to by health professionals, and were involved in their treatment and care. Staff treated patients with respect. Patients and their relatives and carers told us that they felt well-informed and involved in the decisions and plans of care. Staff respected patients’ choices and preferences and were supportive of their cultures, faith and background.

The emergency department was often overcrowded. Patient flow required improvement and waiting times were above the national average due to capacity constraints and the trust’s arrangements for making decisions to admit patients (DTA). This meant patients were not transferred to areas treating their speciality, but were accommodated in the ED for longer than necessary. There were no trust guidelines for admission to the children’s CDU, which did not fulfil the criteria for a ward area. It was not clear why children were admitted to the CDU rather than the short stay paediatric unit. Admission to the CDU avoided breaches relating to length of stay in the department.

The leadership, governance and culture of the ED promoted the delivery of high quality person-centred care. Clear governance structures were in place and were designed to enhance patient outcomes. Staff were proud of working for the department and staff worked well together as a team. There was an effective and comprehensive process in place to manage risks.

Surgery

Requires improvement

Updated 30 September 2015

Referral-to-treatment times were not being met in a number of surgical specialties. Surgical procedures were cancelled and not always rescheduled and undertaken within 28 days. Theatre utilisation was not always maximised and there were cancelled procedures and delays in arranging surgery within expected timeframes. Patient flow through the surgical services was limited by availability of beds linked, at times, to delayed discharges.

Staff had not been able to complete all the required mandatory training, which supported the delivery of safe patient treatment and care. There was a lack of understanding regarding Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The recording of required safety checks for surgical patients was not always completed to a consistent standard.

There were good arrangements in place for reporting adverse events and for learning from these. Staffing arrangements in surgical areas were managed to ensure sufficient numbers of skilled and knowledgeable staff were on duty during day and night hours.

Consent was sought from patients prior to treatment and care delivery. Consultants led on patient care and there was access to specialist staff for advice and guidance. Procedures were in place to continuously monitor patient safety and surgical practices and patient care reflected professional guidance.

Surgical outcomes were generally good and results were communicated through the governance arrangements to the trust board. Patient experiences were positive with regard to the treatment and care by doctors, nurses and other staff.

Surgical staff spoke positively about their departmental leadership and felt respected and valued. Staff were generally aware of the trust’s values, but had not been made aware of the strategic plans. Staff reported the surgical directorate as being a good place to develop their skills and expertise.

The governance arrangements supported effective communication between staff and the trust board. Risks were continuously reviewed and discussed. The trust board was informed and updated with regard to service delivery and performance. The views of the patients and staff were sought in respect to improving and developing services.

Intensive/critical care

Requires improvement

Updated 30 September 2015

Although the critical care service at the hospital had positive patient feedback, produced better than average outcomes for patients, were involved in innovative practice and treated highly complex patients, due to its transplant and trauma services, there were fundamental areas of the service that required improvement.

Although there was work in place to build a new set of critical care units, current facilities were not adequate, with a lack of bed and storage space. There was a lack of bed capacity and a lack of infection control facilities. The HDU did not always meet patient to nurse ratio standards.

Medicines management was not appropriate in a number of areas, particularly storage. There was a high, but improving rate of pressure ulcers. Patient records were haphazard, although there were also plans to improve this via a new electronic system. Mental Capacity Act 2005 awareness and recording was not always in place. There was multidisciplinary working, but it was not taking place across all the staff groups. Governance arrangements were fragmented.

There was an innovative iMobile service (who provided the outreach service), patient outcomes were better than peer services, incident reporting and learning was in place, patient harms (other than pressure ulcers), were well managed, public engagement was proactive, and staff development was positive.

Services for children & young people

Good

Updated 30 September 2015

Nursing staff levels were seen to be in line with national standards in the majority of clinical areas, except for the neonatal intensive care unit where nursing levels were such that one-to-one care could not always be provided in line with national standards.

Continued increased capacity within the neonatal intensive care unit meant that the number of consultants and junior doctors employed was not sufficient to meet the needs of the unit. The existing model of medical cover was not sustainable in the long term, as there was a reliance on the good will of a small number of doctors to work additional hours.

The environment in which children and neonates were cared for was, in the main, appropriate. However, the increased capacity of the neonatal intensive care unit meant that space between cot spaces was sometimes cramped, which meant that access to cots was sometimes restricted or limited.

The uptake of mandatory training in some professions was far below the trust standard. Staff demonstrated an open and transparent culture about incident reporting. A culture of optimising patient safety was apparent amongst nursing and medical staff alike. Staff understood their roles and responsibilities in reporting incidents and described how they learnt from incidents.

Patients were safeguarded from the risk of abuse. Staff were well versed in the trust’s local safeguarding policies and could describe national best practice guidance. Staff adopted a truly holistic approach to assessing, planning and delivering care. Staff developed and advocated the use of innovative and pioneering approaches to care, especially for those children with complex liver conditions and those who required surgery as neonates. Additionally, the service hosted national specialist multidisciplinary bariatric services for children with obesity issues.

Clinical teams were committed to working collaboratively to enhance the provision of care to children. The service led on a range of national medical and surgical initiatives and worked in conjunction with a range of third party peers to drive forward advancements in paediatric surgery and medicine. Paediatric mortality rates were seen to be in line, or better than peer averages across a range of specialties. The service participated in a range of local and national audits, including clinical audits and other monitoring activities, such as reviews of services, benchmarking, peer review and service accreditation. Accurate and up-to-date information about effectiveness was shared internally and externally and was understood by staff. Information from local and national audit programmes was used to improve care and treatment and people’s outcomes, but some work was required regarding the management of patients with asthma and diabetes. When people were due to move between services their needs were assessed early, with the involvement of all necessary staff, teams and services. People’s discharges or transition plans took account of their individual needs, circumstances, ongoing care arrangements and expected outcomes.

Staff acknowledged that the demands on the service were increasing year-on-year and that capacity had proven to be difficult to manage during peak times. This was especially pertinent to the neonatal intensive care unit (NICU), whose activity had been seen to be increasing annually. The organisation recognised the need to extend children's services over the coming years to ensure that it could continue to meet the needs of the population it served. Plans had commenced to build a new children's hospital on the Denmark Hill site and local initiatives had commenced, including the opening of a paediatric short stay unit to help alleviate capacity problems in the short term.

Staff were aware of the trust vision and values. Staff had been provided with information on trust developments that had been cascaded down from their line managers. The service had a child health specific strategy, which was aligned to the trust-wide strategy. The strategy was driven by quality and safety and took into account the requirement for the service to be fiscally responsible. There were governance arrangements in place, for which a range of healthcare professionals assumed ownership. Further work was being undertaken to strengthen the governance relating to children who received care or treatment outside the auspices of child health services. There was evidence that risks were managed and escalated accordingly.

Nursing staff reported good management support from their line managers. Changes to the management team within the NICU was said to have a had a positive impact on the service. Innovation and long-term sustainability were seen as key priorities for the leaders of the service. Participation in national and international research was a driving motivation for clinical staff in order that the wellbeing and clinical outcomes of children could be enhanced.

End of life care

Requires improvement

Updated 30 September 2015

Current trust policy around syringe drivers was inconsistent across the sites and did not protect patients from adverse incidents. The cover for the concealment trolley was in poor repair and was an infection control risk. We saw little evidence of the documentation of preferred place of care/preferred place of death or the wishes and preferences of patients and their families. Although there was a unified do not attempt cardio-pulmonary resuscitation (DNA CPR) policy, orders were not consistently completed in accordance with the policy. There were also no standardised processes for completing mental capacity assessments.

Staff at King's College Hospital (the Denmark Hill site) provided compassionate end of life care to patients. The specialist palliative care team (SPCT) provided face-to-face support, seven days a week, with a palliative care consultant providing out-of-hours cover. There was strong clinical leadership of the SPCT and chaplaincy team resulting in well-developed, strong and motivated teams.

Bereavement support was available from the social workers, chaplaincy and bereavement office staff, who were able to provide support for carers and their families following the death of their relative. The teams worked well together to ensure that end of life policies were based on individual need and that all people were fully involved in every part of the end of life pathway. However, we did not see any evidence of a long-term vision around end of life care across the trust.

Relatives of patients receiving end of life care were provided with open visiting hours and were also offered ‘keepsakes’ from the deceased patient. There was excellent spiritual/religious awareness by staff across the hospital and facilities were in place to support the different cultures and religions of the local population.

End of life care was embedded in all the clinical areas and staff we spoke with were passionate about end of life care and the need to ensure that the wishes and preferences of their patients and families were met as they entered the last stage of their life.

There was a multidisciplinary team approach to facilitate the rapid discharge of patients to their preferred place of care or preferred place of death. Patients were cared for with dignity and respect and received compassionate care. Medicines were provided in line with guidelines for end of life care.

Outpatients

Good

Updated 30 September 2015

Patients received a caring service, as staff treated them with compassion, kindness and respect. Positive feedback had been received by the trust from patients using the outpatients and diagnostic and imaging departments. The service was delivered by trained and competent staff who had been provided with an induction as well as mandatory and additional training specific for their roles.

The leadership, governance and culture with the outpatient and diagnostic imaging services promoted the delivery of person-centred care. Staff were supported by their local and divisional managers. Risks were identified and addressed at local level or escalated to divisional or board-level if necessary. The trust promoted a good working culture. However, some clinical staff we spoke with did not feel supported by their line managers.

Many patients complained about the waiting times in the outpatient clinics. They said they had little information about the waiting times and staff were not always open with them about it. There was no systematic template of clinic schedules for the hospital. Different clinics used different templates and some templates allowed for the over booking of clinics and multiple bookings of appointments under one time slot.

Outpatient services were not organised in a manner that responded promptly to ensure patients’ needs were met. Some patients experienced long delays in waiting times to their first outpatient appointment. The booking team were taking action to address waiting times and monitored patients who did not attend for appointments.

The liver clinic environment presented challenges for staff and patients, particularly in relation to the space required for patients to sit comfortably while waiting for their appointments. Seating areas were cramped and, throughout our inspection, we saw patients standing in areas of the clinic, who were unable to find a seat. Access for patients and visitors with mobility issues was challenging, due to tight spaces in corridors and seating areas in some areas of the clinic.