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King's College Hospital Requires improvement

We are carrying out checks at King's College Hospital. We will publish a report when our check is complete.

Reports


Inspection carried out on 5th September 2017 and 5th and 6th October 2017

During a routine inspection

Our overall findings indicated improvements had been made in a number of areas we inspected, although there was work still to be done to bring some of the ratings to a level of good. In particular we noted the significant work already carried out and continuing as a means of developing a well-led service.

We found the medicine services at King’s College Hospital improved the previous rating of requires improvement up to good for safety. All other domains in medicine were rated as previously, which was good.

Surgical services at King’s Collage Hospital were rated as follows: Requires improvement for responsive, which was unchanged from previous ratings. Effective reduced its previous rating from good to requires improvement. Safe, caring and well-led were rated as good, with safe and well led being an improvement from the previous rating.

Critical care services improved its ratings up to good for responsive and well-led and remained as good for effective and caring. Safety was rated as requires improvement, unchanged from the previous inspection.

The diagnostic imaging department at King’s College Hospital was inspected as its own service for the first time but was not rated on this occasion.

Inspection carried out on 13 October 2016

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

King's College Hospital NHS Foundation Trust is a large provider of acute and specialist services that serves a population of over 1,000,000 in south east London and Kent. The trust operates from three acute sites; King's College Hospital Denmark Hill, Princess Royal University Hospital Bromley and Orpington Hospital.

The trust has over 1300 beds including 1050 acute, 125 maternity and 144 critical care beds. The trust receives over 250,000 emergency attendances, 115,000 inpatient spells and 960,000 outpatient attendances. All core services are provided from King's College Hospital Denmark Hill and Princess Royal University Hospital while inpatient, outpatient and surgical services are provided from Orpington Hospital.

We inspected the King’s College hospital Denmark Hill site and the Princess Royal University hospital on the 13 October 2016. The inspection was a focused inspection, carried out to review the progress made by the trust following our comprehensive inspection in April 2015. We had asked the trust to make improvements in a number of areas and issues requirement notices explaining how the regulations were not being met.

We did not visit the Orpington Hospital site but we spoke with staff and reviewed information provided to us by the trust.

Following this inspection we did not change the rating of the trust. Although there had been many improvements, there were areas still requiring further attention, as indicated below.

Princess Royal University Hospital

  • Continue to work with key stakeholders to improve patient flow throughout the hospital to reduce waiting times in the ED, cancellation of operations and delayed discharges.

  • Review and improve patient record documentation to ensure it is fully completed, and in line with national guidance. This includes the recoding of do not attempt cardio-pulmonary resuscitation (DNACPR) orders.

King’s College Hospital – Denmark Hill

  • Improve safeguarding training completion rates.

  • Ensure the documentation of the use of mechanical restraints mittens in CCU is recorded in patient care records.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 13-17 April 2015

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

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 carried out on 29 August 2012

During a themed inspection looking at Dignity and Nutrition

People told us what it was like to be a patient in King's College Hospital. They

described how they were treated by staff and their involvement in making choices

about their care. They also told us about the quality and choice of food and drink

available. This was because this inspection was part of a themed inspection

programme to assess whether older people in hospitals were treated with dignity

and respect and whether their nutritional needs were met.

The inspection team was led by a Care Quality Commission (CQC) inspector

joined by two compliance inspectors, a practising professional and an Expert by Experience. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We spoke with more than 40 patients as well a number of people who were visiting on the day. Patients felt that the hospital promoted the dignity of older people, and respected their choices. Patients had their treatment explained and were provided with a rough guide of the proposed length of their stay at the hospital.

A typical comment was, “staff are very knowledgeable about the care I am receiving, the consultants, nurses and junior doctors, discuss with me the treatment I am receiving and the possible outcomes”.

Patients spoke of their confidence in the service and felt safe when under the care of the hospital. They acknowledged that the hospital made appropriate provision for patients, with staffing levels that enabled a good patient experience. Staff interaction and engagement with patients promoted their wellbeing.

A patient told us, "it is my local hospital since I was a young child, I feel lucky, I would not change this for anywhere else, it is special and there are lovely doctors and nurses here".

Another person talked of the benefits of living near the hospital, they said, “the hospital is top class; I am of the opinion that I could not have been treated any better anywhere else; staff are professional and cheerful at the same time, which makes my disability easier to bear”.

A relative who visited daily told us they felt reassured by what they observed. They observed that staff were approachable and mindful of the needs of elderly people; they saw that patients received good support from staff especially at mealtimes, and had adequate nourishment and drinks.

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

We did not talk to people using the service at this review of compliance. We asked the registered provider to provide us with an action plan, and an update on their progress in response to the area of non compliance found by the Care Quality Commission on the inspection visit to the hospital on 21st March 2012.

The evidence we reviewed confirmed that King's College Hospital have acted on what they said, and was compliant.

Inspection carried out on 21 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 9 February 2012

During a routine inspection

We made an unannounced visit to King's College Hospital on 9th February 2012.

We spoke with people on the following wards, wards in the Health and Ageing Unit, (Marjorie Warren, Donne and Byron ), The Emergency department (ED), Oliver Ward, Christine Brown, Lonsdale, Annie Zunz, Katherine Monk, Mary Ray, Matthew Whiting, Davidson, Philip Isaacs Day Treatment Ward, Princess Elizabeth, Rays of Sunshine.

People receiving care and treatment at King's College Hospital told us that they were well looked after and that staff were generally sensitive and kind.

Elderly people said that nursing staff were gentle when carrying out personal care tasks. We saw that staff talked to patients in a kindly and respectful manner.

We heard from staff of the commitment within the hospital to providing good quality care for people with dementia. To further this there is a team who provide advice and training throughout the hospital. This helps to ensure that the needs of people with dementia are recognised and understood.

One of the wards has been redesigned to provide an environment which addresses the specialist needs of people with dementia. The ward is designed to provide a calming environment with features to help with people’s orientation and trigger memory.

Visitors told us that they liked the environment and feel that their relatives benefit from it.

Parents of child patients in the Emergency Department and on children’s’ wards told us that they were happy with the service. They found that staff were kind and caring, and that they were involved in decision making. One of the parents spoken to described the excellent service experienced in the Emergency Department for an injury sustained by their child.

Another parent said, “When I arrived at ED I was concerned about my child’s condition, we were seen promptly by the doctor, I am pleased that she was treated here in my local hospital, it is such an excellent service to have in our community”.

All of the parents spoken to on the wards were pleased with the way their children were cared for.

One parent said, ‘’The child’s voice is the most important thing they consider in the hospital and they are central to everything that happens’’.

Senior medical and nursing staff described the challenges faced when working at the busy emergency department as rewarding.

The following remarks were received from staff, “We provide an emergency service for people requiring urgent care, good teamwork is most important when responding and treating the people that come through our doors",

" the enthusiasm and inspiration of staff is fuelled by the desire to deliver the quality of care and treatment people need to treat their condition and make them well again.”

Inspection carried out on 9 December 2010

During an inspection in response to concerns

Feedback overall was very positive from people that use the service. We heard of the confidence people have in the services provided at the hospital. People using the stroke unit were pleased with the prompt response of the staff, and the subsequent treatment and care they received. Older people felt they were well cared for on the wards, and that staff listened and responded appropriately to their needs. The maternity service experiences for people were considered good, with suitable numbers of experienced staff personnel available. Mothers found that ante natal services were well coordinated, and that in-patient care and support were consistent and reliable.

People found that communication with staff was generally was good with procedures explained. People find that discharge arrangements are well organised but occasionally difficulties are experienced in keeping other care providers informed of last minute changes. Staff are trained and knowledgeable on policies and procedures that protect vulnerable people. They were enthusiastic and positive about their role and the support that they receive to work well. Staff receive both mandatory and specialist training. Support and guidance is available from senior staff within the ward and from a range of specialists.