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King's College Hospital Requires improvement

We are carrying out a review of quality at King's College Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 12 June 2019

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

  • Not all staff had completed the required safety related mandatory training, which was as we found on our previous inspection.
  • The environment in which patients received treatment and care was not always suitable or risk assessed. Privacy was not always achieved in some areas, and equipment had not been checked in a consistent manner.
  • Medicines optimisation was not always achieved, and standards related to infection prevention and control were inconsistent.
  • Patient risk assessments were not always completed and updated.
  • Expected patient outcomes were not always met in some specialties.
  • Access to some services were not meeting some of the expected targets in outpatients and once referred for admission. Waiting times from referral to treatment, arrangements to admit, treat and discharge patients was not always in line with good practice.
  • Communication and engagement with staff by leaders was not always as strong as it could be, and some staff reported low morale.

However:

  • There were enough staff with the right skills and experiences and staff had access to professional development, were competent for their roles, and had opportunities for a review of their performance.
  • Care and treatment was delivered by a multidisciplinary team, in line with evidence based national guidance such as National Institute for Health and Care Excellence (NICE) and professional colleges.
  • The staff recognised the importance of reporting and learning from incidents. Investigations led to the sharing of information learned and improvements.
  • Patients were treated with respect and dignity, were involved in decisions about their care and were provided with information and choices.
  • The co-ordination and delivery of services took account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances.
  • Most clinical areas were led by staff who had the right experience, skills and knowledge. They understood the trusts values and strategic aims and fostered a culture where staff could do their best.

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

  • Not all staff had completed the required safety related mandatory training, which was as we found on our previous inspection.

  • The environment in which patients received treatment and care was not always suitable or risk assessed. Privacy was not always achieved in some areas, and equipment had not been checked in a consistent manner.

  • Medicines optimisation was not always achieved, and standards related to infection prevention and control were inconsistent.

  • Patient risk assessments were not always completed and updated.

  • Expected patient outcomes were not always met in some specialties.

  • Access to some services were not meeting some of the expected targets in outpatients and once referred for admission. Waiting times from referral to treatment, arrangements to admit, treat and discharge patients was not always in line with good practice.

  • Communication and engagement with staff by leaders was not always as strong as it could be, and some staff reported low morale.

However:

  • There were enough staff with the right skills and experiences and staff had access to professional development, were competent for their roles, and had opportunities for a review of their performance.

  • Care and treatment was delivered by a multidisciplinary team, in line with evidence based national guidance such as National Institute for Health and Care Excellence (NICE) and professional colleges.

  • The staff recognised the importance of reporting and learning from incidents. Investigations led to the sharing of information learned and improvements.

  • Patients were treated with respect and dignity, were involved in decisions about their care and were provided with information and choices.

  • The co-ordination and delivery of services took account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances.

  • Most clinical areas were led by staff who had the right experience, skills and knowledge. They understood the trusts values and strategic aims and fostered a culture where staff could do their best.
Inspection areas

Safe

Requires improvement

Updated 12 June 2019

Effective

Good

Updated 12 June 2019

Caring

Good

Updated 12 June 2019

Responsive

Requires improvement

Updated 12 June 2019

Well-led

Requires improvement

Updated 12 June 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 31 January 2018

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

  • There was a good incident reporting culture and senior leaders had a good oversight of the common incidents within medical services and understood what changes needed to be made to improve. We saw evidence to suggest learning from incidents was communicated to staff.
  • The management of a deteriorating patient had improved. Staff’s understanding of sepsis identification and management and when and how to escalate a deteriorating patient was good.
  • Nursing staffing levels was still one of the main risks all staff identified in medical services. However, staff said nursing staffing was improving and senior leaders provided regular updates regarding recruitment and retention.
  • We saw practice was in line with national recommendations and evidenced based guidance. Use of NICE guidelines was in place across a range of conditions and staff were able to access guidance if required.
  • Staff were well supported and reported good access to training and development.
  • Multidisciplinary (MDT) working across medical services was still good and there was a team approach when discussing patients’ care and treatment. All staff said the MDT working in the trust was excellent.
  • There was an improvement in the number of staff who understood the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff understood the principles of the Act and how these applied in practice.
  • Patient and relative feedback was mostly positive and we saw patients were cared for in kind and compassionate ways that maintained dignity. We saw numerous thank you cards expressing gratitude to staff for their input and help.
  • We found services had been developed to meet the needs of patients who used it. For example, Marjory Warren Ward had a sensory room and sensory wall for patients with dementia. They had also painted patient bays different colours so patients could identify their bays easier. Oliver Polkey Ward was in the process of getting a roof top garden for longer term neurology patients to access.
  • The trust had recognised the cultural diversity of their local area and ensured staff had access to translators when needed, giving patients the opportunity to make decisions about their care. Food menus were also available in Braille for patients who had sight impairments.
  • There has been a transformation of the leadership of medical services and the new leadership had been in place since March 2017. Feedback from staff was that there were positive changes as a result of the new leadership. Leaders were present and supportive and there was a positive culture across services.
  • Clear governance structures were in place and we saw effective management of risks.

However:

  • We were not assured all medical wards were managing equipment in a way that was in line with hospital protocol and kept people safe. For example, we found two resuscitation trolleys that were not checked on a daily basis. We also found two medicine fridges in which temperatures had exceeded the recommended level on a regular basis.
  • The majority of the time we saw records were stored securely and kept people safe. However, on some occasion we saw staff had left confidential information displayed and computers were logged in and unattended. Agency staff did not have access to the online system and we had some concerns this meant they were unable to access patient information in a timely and accessible way.
  • The trust’s performance in the sentinel stroke audit had got worse and previous performances indicated the unit was capable of much higher performance.
  • Medical services still had a higher than expected risk of readmissions for some of their services, which was above the England average. This included haematology and general medicine services.
  • There were still some challenges with flow through the hospital and patients’ average length of stay for both elective and non-elective care was above the England average. Senior leaders identified patient flow as one of their risks and were taking a number of steps to mitigate this including the opening of a new medical ward in preparation for winter pressures.

Critical care

Good

Updated 31 January 2018

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

  • The service had improved since our last inspection in 2015. Patient records were now comprehensive, with all appropriate risk assessments completed. Staff were aware of their responsibilities under the MCA and we saw appropriate records were in place in patients’ notes. Management staff had sight of risks on the units and mitigating plans were in place to address those risks.
  • There were effective systems to protect patients from harm and a good incident reporting culture was in evidence. Patient records were comprehensive with appropriate risk assessments completed. The iMobile (critical care outreach) team provided rapid response and stabilisation to patients who needed immediate attention and transfer.
  • Staff provided evidence based care and treatment in line with national guidelines and local policies. Patient outcomes were better than the national average.
  • Patient feedback for the services we inspected was mostly positive. Staff respected confidentiality, dignity and privacy of patients. Patients were engaged through surveys and feedback forms and the response showed high satisfaction with the service.
  • Services were developed to meet the needs of patients. Feedback from patients was taken into consideration in designing a new critical care unit. Overnight stay near the hospital was arranged for relatives, and patients had access to a follow up clinic after they were discharged from the units.
  • The CCU had implemented a number of innovative services and developed these to meet patients’ needs. The CCU was engaged in research activities and had supported a significant amount of National Institute for Health Research (NIHR) portfolio studies.
  • There was good local leadership on the CCU. Staff felt valued, they were supported in their roles and had opportunities for learning and development. Staff were positive about working in the CCU.

However:

  • Medical staffing was stretched and did not comply with recommended guidelines. Pharmacy and therapy staffing levels were below the recommended guidelines.
  • Although plans were in place to open a new critical care unit, current bed spaces did not comply with the Department of Health’s building note HBN 04-02 which sets out a minimum standard of space for effective infection control.
  • The average bed occupancy on the CCU was consistently above 100% and there were delayed discharges from critical care units.

Diagnostic imaging

Updated 31 January 2018

We did not rate the service. Our finding are detailed as follows:

  • The department had taken a proactive approach following the removal of some of their radiology registrars in April 2017. The potential negative impact on the service was greatly minimised by a robust action plan, reviewing of processes and development of staff.
  • Staff knew how to use the incident reporting system, received feedback about incidents and there was evidence of learning from these where relevant.
  • Staff were very patient focused and patients and carers spoke positively about the care and compassion shown by the diagnostic imaging staff.
  • Managers were visible to their staff and provided opportunity for regular appraisals, support and professional development.
  • New equipment had been and was in the process of being installed. Staff could see the progress being made to improve the quality of the service offered.
  • We found evidence of strong local leadership and a positive culture of support, teamwork and focus on patient care.

Surgery

Requires improvement

Updated 12 June 2019

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

  • The service provided mandatory training in key skills to all staff but did not make sure everybody had completed it. Compliance rates for medical staff were poor and we issued the trust with a requirement notice for them to address this matter.
  • The service did not always control infection risks well. Staff did not always keep premises and equipment clean. They did not always use control measures to prevent the spread of infection.
  • Staff did not always complete an updated risk assessment for each patient. The completion of malnutrition universal screening tool (MUST) scores did still not reach the trust target of 100% and this had not improved since our last inspection.
  • Patient outcome targets did not meet the national benchmark and the trust were not performing well in key areas.
  • People could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with good practice.
  • Most managers at all levels in the surgical division had the right skills and abilities to run a service providing high-quality sustainable care. However, there was a distinct lack of communication and strategic level engagement with clinical staff from the senior executive team.

However:

  • The trust had enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff cared for patients with compassion and took account of their individual needs. Feedback from patients confirmed that staff treated them well and with kindness.
  • There were systems and processes for effective learning, continuous improvement and innovation.

End of life care

Good

Updated 12 June 2019

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

  • The trust provided mandatory training in key end of life skills to all new staff at induction and at regular updates.
  • There were enough staff with the right skills and experiences to ensure the delivery of care. Staff had access to professional development, were competent for their roles, and had opportunities for a review of their performance.
  • Risk assessment of equipment and its availability had improved since the last inspection. There was greater oversight of competence for the use of specialised equipment.
  • There was good multidisciplinary working. The specialist palliative care team worked closely with the local hospice and there was access to clinical expertise within the hospital.
  • Care and treatment was delivered in line with evidence based national guidance such as National Institute for Health and Care Excellence (NICE) guidance.
  • Patient outcomes were monitored and improved through participation in the national care of the dying audit and subsequent internal audits relating to the end of life care for the dying patient.
  • There were a range of training initiatives available for a variety of staff groups involved in end of life care so that staff had the skills, knowledge and experience to deliver effective end of life care.
  • Patients at the end of life and those close to them were treated with kindness, respect and compassion. They were involved in making decisions about their care.
  • There was a clear vision and strategy in place with identified priorities and monitoring of action taken by the end of life care team.
  • Governance structures around end of life care were in place to ensure continuous improvement.
  • There was a strong culture of quality end of life care across the trust, with active engagement, involvement, commitment and representation from a range of staff groups.

Maternity

Good

Updated 12 June 2019

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

  • There had been an improvement in the visibility of senior management since the director of midwifery and women’s health had taken up their post six months earlier. Maternity had a clearly defined accountability structure.

  • Medicines optimisation was managed well. The pharmacist visited daily and checked drugs and administration charts.

  • Staff kept detailed records of women and babies care and treatment. There had been action to improve assessment of risks to women and their babies since our previous inspection. Staff completed and updated women and babies risk assessments and care records.

  • All staff we spoke to were aware of their responsibilities relating to duty of candour under the Health and Social Care Act (Regulated Activities Regulations) 2014.

  • Care was being provided in accordance with the National Institute for Health and Care Excellence (NICE) quality standards. All guidance and policies within maternity services had been reviewed and were based upon current guidance.

  • The antenatal unit was midwife led. We found staff were committed to providing and promoting normal birth.

  • The trust was working towardsUnited Nations (UN) Children's Fund Baby Friendly accreditation. The Baby Friendly Initiative is based on a global accreditation programme ofUnited Nations Children's Fund and the World Health Organisation.

  • There were good training and education opportunities available to staff. The trust employed a dedicated maternity education team. New midwives joining the trust completed a preceptorship programme.

  • Most women we spoke with told us they felt involved in planning and making decisions about their care.

  • The maternity service had completed actions to meet the requirements of the ‘saving babies lives’ care bundle, with the aim of reducing stillbirths, neonatal deaths, and intrapartum brain injuries.

However:

  • There were a range of outcome indicators that were not meeting the trust’s standards and actions in response were not always timely. The trust’s key performance indicator (KPI) for all caesarean sections (CS) was above the trust’s KPI standard.

  • Rates of Hypoxic Ischemic Encephalopathy (HIE), this is a type of brain damage that occurs when an infant’s brain doesn’t receive enough oxygen and blood, from January to December 2018 were worse that the trust’s target of zero.

  • The service provided mandatory training in key skills to all staff. However, mandatory training targets were not being met.

  • Some staff had not had not updated training in safeguarding vulnerable adults and children in accordance with the trust’s training schedule.

  • The maternity department had been closed on eight occasions between January and December 2018 due to labour ward capacity.
  • Although some staff understood how and when to assess whether women had the capacity to make decisions about their care. Training rates for the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards were low.

  • Staff recognised incidents, reported them appropriately, and managers investigated them. However, lessons learnt were not always shared with the whole team and the wider service.

  • The service took concerns and complaints seriously, investigated them and learnt lessons from the results. However, the time taken to respond to complaints was not always achieved in accordance with the trust’s complaints policy.

  • The service did not have a defined vision and strategy for what it wanted to achieve and workable plans to turn it into action.

Outpatients

Requires improvement

Updated 12 June 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated outpatients as requires improvement because:

  • The service did not take steps to ensure all staff completed the required mandatory training. Compliance rates for required safety related training amongst medical staff was poor.
  • The service did not always have suitable premises or equipment and did not always look after them well.
  • Patient’s privacy and dignity was not always maintained due to the environments staff were working in, although staff tried their best to maintain standards where possible.
  • Outpatient services showed generally poor performance in referral to treatment (RTT) and cancer waiting times. The trust was performing worse than the England average and national standard for both the RTT incomplete pathway, where patients should be seen within 18 weeks, and for urgent cancer referrals, where patients should be seen within two weeks. This meant the service was not always responsive and could not always meet patient urgent clinical needs in a timely manner.
  • Services did not always provide the right information to service users prior to their appointments. Incorrect telephone numbers were often printed on appointment letters.
  • Morale amongst administrative staff across most services was low.
  • Not all risks on the risk register for OPD had not been reviewed recently, and it was not clear if all risks were being addressed.
  • There were some additional plans for the long-term future of the OPD, but these were not an immediate priority due to the current challenges faced by the department. Plans did not always have clear timescales, and staff could not give examples of being involved in such plans.

However:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.

  • Services were delivered and co-ordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances.

  • The trust used a mostly systematic approach to continually improving the quality of its service, with clear escalation and reporting structures.

Urgent and emergency services

Requires improvement

Updated 12 June 2019

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

  • The service did not ensure staff had completed mandatory training, and expected targets were not always being achieved. Staff we spoke with felt mandatory training was ineffective and did not help them in their role.

  • The service did not have suitable premises and equipment was not looked after well. The design and layout of the emergency department (ED) did not always protect patient’s privacy and dignity. There was no dedicated paediatric mental health assessment room available and there was a lack of consideration given to ligature points. Safety checks on equipment were not carried out consistently across all areas and we found several items within resuscitation trolleys which were out of date.

  • The service did not always follow best practice when prescribing, giving, recording and storing medicines. We could not be assured patients received the right medicines at the right dose at the right time. Patient records were inconsistent in their recording of administered medicines and dosage amounts.

  • Patients could not access care and treatment in a timely way.Waiting times for treatment and arrangements to admit, treat and discharge patients were worse than the England average and national standard.

  • The trust did not have effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

  • Staff we spoke with felt leadership within the ED was not always effective and staff did not always feel their ideas were listened too.