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Inspection Summary


Overall summary & rating

Good

Updated 6 April 2018

Surgery

We rated safe and well-led as requires improvement, and effective, caring and responsive as good. The rating of responsive improved while outstanding for caring went down since our last inspection. Our overall rating of this service stayed the same. We rated it as requires improvement because:

  • Insufficient staffing in some clinical areas had led to delays in treatment and prescribing and the closure of some inpatient beds.
  • There was inconsistent management of risks related to medicines management.
  • Clinical governance, risk management and incident investigation systems did not follow a coherent or effective structure in which learning was shared between teams and specialties. Although there was local evidence of improvements in practice as a result of incidents and morbidity and mortality meetings, shared learning was not evident outside of the immediate specialty or service.
  • Between August 2016 and September 2017, the trust took an average of 59 calendar days to investigate and close complaints; which was significantly longer than the target of 25 days.
  • There was a disconnect between specialty and divisional teams and the senior trust and executive team. A cross-section of 14 clinical staff, including senior clinicians, said the senior team was difficult to communicate and engage with and they did not feel listened to. Although the executive team demonstrated efforts to engage with staff, very few of the individuals we spoke with had been able to participate. The senior team had a track record of high levels of staff turnover, which service-level staff told us meant there was little consistency.
  • There was limited evidence risks were regularly scrutinised or reviewed in a timely manner. We found the highest risk to clinical treatment related to the medical records system, which resulted in surgeons and anaesthetists sometimes carrying out treatment without access to the patients’ medical history.

However:

  • There were established safeguarding procedures appropriate to patient age groups. Although nurse and medical staff teams did not meet the trust’s 90% standard, at 75%, for completion of safeguarding children level 3, specialists across the hospital provided dedicated support and training opportunities.
  • The trust had significantly improved the use of the World Health Organisation surgical safety checklist in theatres. Quality and safety staff had audited the work to improve this safety tool, which resulted in a demonstrable trajectory of better practice.
  • Staff used a range of systems to monitor and care for patients whose condition was deteriorating. This included electronic calculation of early warning scores and automatic escalation to senior clinical staff.
  • An electronic monitoring system was in place across all clinical areas which enabled staff to monitor and track their patients throughout their care and treatment pathway.
  • Some teams and services, such as ear, nose and throat and clinical site practitioners, had implemented peer reviews or audits to assess their service and improve care for patients with complex needs.
  • Staff had access to extensive training and development opportunities and dedicated support from a practice education team. This team worked across the hospital and provided targeted, specialised training to staff. This was alongside simulation training and leadership development opportunities.
  • All surgical areas scored consistently well in the NHS Friends and Family Test, with all recommendation scores at 90% or above in 2017.
  • We saw an embedded culture of staff involving patients and parents when planning care and treatment. Staff took time to explain options and risks and patiently took time to answer questions.
  • Substantial work had been completed in relation to delivery of referral to treatment times (RTT) following a suspension prior to 2016. Dedicated data, clinical and quality teams worked together to improve data quality and reporting.
  • The trust had a target of full compliance with RTT national standards and no 52 weeks breaches by January 2018. Each specialty had a recovery trajectory aimed at achieving this. There was evidence of sustained improvements in the RTT with 29 of 49 recorded specialities achieving the RTT standard in December 2017 and 39 achieving it in January 2018.
  • There was evidence of effective, inclusive leadership at service level. Staff in all departments, wards and clinical services spoke positively of the support and leadership they received and said this contributed to a very welcoming culture.

Outpatients

We rated safe, responsive and well-led as good and caring as outstanding. The rating of responsive and well-led had improved since our last inspection. Our overall rating of this service improved. We rated it as good because:

  • We saw evidence of the use of national clinical guidelines and a culture of evidence based practice in the specialties we observed in outpatients.
  • The service made sure staff were competent for their roles. All nurses in the outpatients department had an appraisal within the last year. Staff told us they found it of benefit to take time out and reflect on their work and possible career development.
  • Staff cared for patients with compassion. We saw several examples of staff from all disciplines being supportive and kind to patients and their relatives. We saw staff comforting patients and carers and a high level of engagement with children and young people.
  • Patients and their relatives felt included in their plan of care. Patients told us nurses and clinicians spoke directly with them rather than just to their parents and carers. They felt included in discussions about their treatment and staff took time to ensure they understood what was discussed.
  • The service took account of patients’ individual needs. There were link nurses for patients with a learning disability, who staff and patients could contact for advice and support. Reasonable adjustments were made to provide a better patient experience for learning disabled patients.
  • The department supported people to be as engaged in their own health and wellbeing as possible. For example, speech and language therapists ran a group once a month for parents of children who recently had a cleft palate repair. Advice and information was shared about speech development, good oral hygiene and diet.
  • Staff we spoke with were very positive about the current leadership team and told us their biggest strength was their honesty and visibility. Staff told us there was good teamwork and they felt valued and got recognition for their work.
  • There was general consensus amongst managers and staff about what the departments’ top risks were. These included increasing demand on services and capacity in clinics, as well as the unplanned for arrival of inpatients from other hospitals to the outpatients department. Staff told us risks were discussed at staff meetings and managers shared information about what was being done to mitigate these risks.
  • Leaders developed a business strategy which was designed to increase the efficiency of the department and enhance patient experience. For example, providing extra space for clinics that had become too full.
  • The trust returned to reporting referral to treatment times in January 2017 in agreement with commissioners with noticeable improvements to the quality of the data. This showed that the trust’s referral to treatment time (RTT) for non-admitted pathways was similar to the England overall performance. Data on RTT for admitted pathways showed that 91% of patients were seen within 18 weeks with the between August and December 2017.

However:

  • We observed inconsistent adherence to infection prevention and control practice and recent hand hygiene results were poor. Hand hygiene audits from January to December 2017 demonstrated that the average compliance rate was 78%, with results varying between 50% and 96%. We observed doctors were not always ‘bare below the elbow’.
  • We noted there were no single use tourniquets in use which increased the possibility of infection.
  • We found inconsistencies in fridge temperature monitoring; we also saw that ambient temperature monitoring was not taking place in areas where medicines were being stored. There was no action plan in place to address this issue.
  • Patient identifiable information was left unattended in consulting rooms. This created the risk of private patient information being accessed inappropriately.
Inspection areas

Safe

Good

Updated 6 April 2018

Effective

Outstanding

Updated 6 April 2018

Caring

Outstanding

Updated 6 April 2018

Responsive

Good

Updated 6 April 2018

Well-led

Requires improvement

Updated 6 April 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 8 January 2016

There was a culture of high quality, child centred care delivered by competent staff. E

ffective systems were in place for reporting, investigating incidents using learning to change practice. The environment and clinical equipment were visibly clean and appropriately maintained. Medical records were available but they were not always transported using equipment that was suitably maintained.

There was participation in audits and care and treatment was provided in line with professional guidance. Staff had access to a range of mandatory training and professional development. While not all services operated seven days a week, services were flexible to meet patients’ needs. There was evidence of multidisciplinary team working and systems were in place to coordinate care with other departments in the trust.

Children, young people and their parents received compassionate care and were encouraged to be involved in decisions about their treatment. Feedback was proactively sought to improve the service. Cancellations were minimal and appropriate action taken. The trust was working to remedy the underlying issues which caused delays in clinics. Informal and formal complaints were listened to and action taken to resolve the issue.

There was a vision and strategy for the development of the service. There was identified leadership who were supportive and motivated staff. Governance and risk management processes were embedded into practice and fit for purpose.

However we were concerned in relation to the impact on outpatients following the discovery of unreliablereferral to treatment data and inconsistent application of the trust patient access policy.

Outpatients

Good

Updated 6 April 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated safe, responsive and well-led as good. The rating of responsive and well-led had improved since our last inspection. Our overall rating of this service improved. We rated it as good because:

  • We saw evidence of the use of national clinical guidelines and a culture of evidence based practice in the specialties we observed in outpatients.
  • The service made sure staff were competent for their roles. All nurses in the outpatients department had an appraisal within the last year. Staff told us they found it of benefit to take time out and reflect on their work and possible career development.
  • Staff cared for patients with compassion. We saw several examples of staff from all disciplines being supportive and kind to patients and their relatives. We saw staff comforting patients and carers and a high level of engagement with children and young people.
  • Patients and their relatives felt included in their plan of care. Patients told us nurses and clinicians spoke directly with them rather than just to their parents and carers. They felt included in discussions about their treatment and staff took time to ensure they understood what was discussed.
  • The service took account of patients’ individual needs. There were link nurses for patients with a learning disability, who staff and patients could contact for advice and support. Reasonable adjustments were made to provide a better patient experience for learning disabled patients.
  • The department supported people to be as engaged in their own health and wellbeing as possible. For example, speech and language therapists ran a group once a month for parents of children who recently had a cleft palate repair. Advice and information was shared about speech development, good oral hygiene and diet.
  • Staff we spoke with were very positive about the current leadership team and told us their biggest strength was their honesty and visibility. Staff told us there was good teamwork and they felt valued and got recognition for their work.
  • There was general consensus amongst managers and staff about what the department’s top risks were. These included increasing demand on services and capacity in clinics, as well as the unplanned for arrival of inpatients from other hospitals to the outpatients department. Staff told us risks were discussed at meetings and managers shared information about what was being done to mitigate these risks.
  • Leaders developed a business strategy which was designed to increase the efficiency of the department and enhance patient experience. For example, providing extra space for clinics that had become too full.
  • The trust returned to reporting in January 2017 in agreement with commissioners with noticeable improvements to the quality of the data. This showed that the trust’s referral to treatment time (RTT) for non-admitted pathways was similar to the England overall performance. Data on RTT for admitted pathways showed that 91% of patients were seen within 18 weeks with the between August and December 2017.

However:

  • We observed inconsistent adherence to infection prevention and control practice and recent hand hygiene results were poor. Hand hygiene audits from January to December 2017 demonstrated that the average compliance rate was 78%, with results varying between 50% and 96%. We observed doctors were not always ‘bare below the elbow’.
  • We noted there were no single use tourniquets in use which increased the possibility of infection.
  • We found inconsistencies in fridge temperature monitoring; we also saw that ambient temperature monitoring was not taking place in areas where medicines were being stored. There was no action plan in place to address this issue.
  • Patient-identifiable information was left unattended in consulting rooms. This created the risk of confidential patient information being accessed inappropriately.

Medical care

Outstanding

Updated 8 January 2016

Patients in medical care services were protected from abuse and avoidable harm. There were enough trained and experienced doctors, nurses and other staff to react if patients deteriorated.

The service was treating many patients that could only be treated at very few other hospitals if any. Multi-disciplinary teams were well coordinated to ensure the best outcomes for patients.

The patients we spoke with were all very positive about the care they had received. One patient told us, “ It’s better than being in school, I come in three times a week. I love dancing with the staff”. Another patient told us, “ I have to come in for a check up every two years. It's a very good service, the doctors are brilliant and they’re good at listening and explaining things”.

Medical care services at the hospital were very responsive to the needs of patients. We found many examples where staff had made a special effort to meet the needs of patients.

The trust’s core vision of “The child first and always” was well recognised and owned by staff. The newer version of “always welcoming, always helpful, always expert and always one team” was less well recognised. Staff were focused on delivering high levels of care to patients.

Neonatal services

Good

Updated 8 January 2016

The NICU at GOSH had very good systems and processes in place to protect babies from harm and these included reporting and learning from incidents. Nurse staffing levels were in line with national guidance and staff had access to a range of training both internally via the GOSH education department and at local universities. The needs of the babies and theirmothers or carerswere met by skilled and experienced staff including breast-feeding experts. The staff members were accustomed to caring for babies with co- morbidities. Policies were based on NICE and other relevant national guidelines. NICU shares data with the British Association of Perinatal Medicine. There was a formal escalation process in place for managing deteriorating babies and outwith NICU in the high dependency unit care staff have been trained in its use and knew how to effectively use theclinical site practitioner service and the hospital at night team.

The capacity and flow of babies through the NICU was managed by collaborative working with other providers across London and further afield. The team of senior medical team co-ordinated the Intensive Care Outreach Network (ICON) which worked closely with the site practitioner team. Nursing staff felt supported by the senior nursing team and were able to raise concerns without fearof retribution. The staff members we spoke with were fully aware of the new chief executive and his plans for the future direction of the Trust. Interprofessional working was fully embedded within NICU.

Transitional services

Good

Updated 8 January 2016

Young people were being treated with dignity, respect and compassion. Clinical teams supporting care were committed to supporting young people requiring transitional services. We found examples of excellent care pathways for young people with specific long-term health needs transitioning to adult services.

We saw evidence of trust wide “Transition to Adult Health Services Integrated Care Pathway” (ICP) audit and re-audit of “transition arrangements for young people”.However, we found that there was no overall responsibility or leadership for transitional services in the trust at board level.

Surgery

Requires improvement

Updated 6 April 2018

  • Short staffing in some clinical areas had led to delays in treatment and prescribing and the closure of some inpatient beds.
  • There was inconsistent management of risks in medicines management.
  • Clinical governance, risk management and incident investigation systems did not follow a coherent or effective structure in which learning was shared between teams and specialties. Although there was local evidence of improvements in practice as a result of incidents and morbidity and mortality meetings, shared learning was not evident outside of the immediate specialty or service.
  • Between August 2016 and September 2017, the trust took an average of 59 calendar days to investigate and close complaints; which was significantly longer than the target of 25 days.
  • There was a disconnect between specialty and divisional teams and the senior trust and executive team. A cross-section of 14 clinical staff, including senior clinicians, said the senior team was difficult to communicate and engage with and they did not feel listened to. Although the executive team demonstrated efforts to engage with staff, very few of the individuals we spoke with had been able to participate. The senior team had a track record of high levels of staff turnover, which service-level staff told us meant there was little consistency.
  • There was limited evidence risks were regularly scrutinised or reviewed in a timely manner. We found the highest risk to clinical treatment related to the medical records system, which resulted in surgeons and anaesthetists sometimes carrying out treatment without access to the patients’ medical history.

However:

  • There were established safeguarding procedures appropriate to patient age groups. Although nurse and medical staff teams did not meet the trust’s 90% standard, at 75%, for completion of safeguarding children level 3, specialists across the hospital provided dedicated support and training opportunities.
  • The trust had significantly improved the use of the World Health Organisation surgical safety checklist in theatres. Quality and safety staff had audited the work to improve this safety tool, which resulted in a demonstrable trajectory of better practice.
  • Staff used a range of systems to monitor and care for patients whose condition was deteriorating. This included electronic calculation of early warning scores and automatic escalation to senior clinical staff.
  • An electronic monitoring system was in place across all clinical areas which enabled staff to monitor and track their patients
  • Staff had access to extensive training and development opportunities and dedicated support from a practice education team. This team worked across the hospital and provided targeted, specialised training to staff. This was alongside throughout their care and treatment pathway.
  • Some teams and services, such as ear, nose and throat and clinical site practitioners, had implemented peer reviews or audits to assess their service and improve care for patients with complex needs.
  • simulation training and leadership development opportunities.
  • All surgical areas scored consistently well in the NHS Friends and Family Test, with all recommendation scores at 90% or above in 2017.
  • We saw an embedded culture of staff involving patients and parents when planning care and treatment. Staff took time to explain options and risks and patiently took time to answer questions.
  • Substantial work had been completed related to the delivery of the referral to treatment times (RTT) following a suspension prior to 2016. Dedicated data, clinical and quality teams worked together to improve data quality and reporting.
  • The trust had a target of full compliance with RTT national standards and no 52 weeks breaches by January 2018. Each specialty had a recovery trajectory aimed at achieving this. There was evidence of sustained improvements in the RTT with 29 of 49 recorded specialities achieving the RTT standard in December 2017 and 39 achieving it in January 2018.
  • There was evidence of effective, inclusive leadership at service level. Staff in all departments, wards and clinical services spoke positively of the support and leadership they received and said this contributed to a very welcoming culture.

Intensive/critical care

Good

Updated 8 January 2016

There were systems and process in place to promote safe and effective care. There was a formal escalation process in place for managing deteriorating children and young people. Incidents were reported, investigated and learning took place. Nurse staffing levels were in line with national guidance. Staff had access to a range of training and professional development, ensuring they were competent for their role.

Policies and guidelines were based on NICE and other relevant national guidelines. The service participated in local and national audit including PICANET. The unit’s capacity and flow was managed effectively. There was a vision for the development of the service and identified nursing and medical leadership

Services for children & young people

Good

Updated 8 January 2016

Young people accessing specialist mental health services within the hospital were treated with genuine kindness and respect by highly skilled and experienced staff. Parents told us that the treatment and support their children received for their complex mental health issues was ‘lifesaving’ and offered hope for their future.

All children had personalised and holistic treatment plans with input from a dedicated multi-disciplinary team. Children and parents were involved in the development of care plans and risk assessments. Family therapy, support and psycho-education groups were available for parents and carers.

The environment was clean and safe with a notable calm and contained atmosphere and children had access to a range of therapies and activities. Restraint was minimal and issues of consent and capacity thoughtfully addressed with the involvement of children and their carers. Patient records were thorough and regularly reviewed.

Effective systems were in place for reporting and managing incidents, the learning from these investigations was used to embed positive changes. Feedback was proactively sought to improve the service.

The service was involved in innovative research and the MCU was accredited as Excellent by the Royal Society of Psychiatrists Quality Network for Inpatients CAMHS. The service shared expertise and delivered training to other trust departments.

Staff had access to a range of mandatory training and professional development opportunities.

Governance and risk management processes were embedded into the service. There was effective, supportive leadership across the service. However some staff felt concerned that the current reconfiguration of the service could potentially impact on the quality of specialist treatment delivered. Staff turnover was low, and staff told us they were proud to work in the service.

End of life care

Outstanding

Updated 8 January 2016

Parents we spoke with could not praise the quality of the care and support given by GOSH any higher. One parent wrote in an email, “GOSH and the healthcare professionals involved in our child’s care are leading the world in paediatric care.” All staff across the hospital were found to be compassionate, caring and considerate and wanted to do the best they could for children and their families.

We found that care and treatment was safe, evidenced based and followed accepted standards and professional guidance. There were clear care pathways for children being cared for in the hospital and community and all parties involved in the child’s care were included in these plans.

There was excellent multidisciplinary team working in palliative and end of life care services which included chaplaincy and dedicated psychological and social support teams. An ethics committee safeguarded C&YP interests in the event of a conflict in care and treatment.

Children and their families were given the choice as to whether they wished to receive end of life care at the hospital, at home or in a hospice. The service took into account individual circumstances and needs and supported them in their decisions without judgement.

End of life and palliative care was well-led. The team were thought of highly by colleagues within the hospital and by other professionals from around the world.

The team were passionate about continually improving the service, which included training programmes for nurses and GPs from hospitals