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Great Ormond Street Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 22 January 2020

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

  • The service provided mandatory training in key skills in line with trust targets.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
  • Staff knew how to assess, monitor and manage patient risk. Staff identified and quickly acted upon children and young people at risk of deterioration.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
  • The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.
  • Staff assessed and monitored children and young people regularly to see if they were in pain and supported those unable to communicate using suitable assessment tools. Children and young people were given pain relief in a timely way.
  • Staff actively monitored the effectiveness of care and treatment. Opportunities to participate in benchmarking, peer review and research were proactively pursued. They used the findings to make improvements and achieved good outcomes for patients.
  • The continuing development of staff skills, competence and knowledge was recognised as integral to ensuring high quality care. Staff were proactively supported to acquire new skills and share best practice.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide high quality, effective care.
  • Staff treated all children, young people and their families with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
  • Staff took time to interact with children, young people and their families in a respectful and considerate way.
  • Staff provided emotional support to children, young people, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs. There was access to a range of services to support children and young people who were frightened, confused or phobic about aspects of their care and treatment.
  • Children and young people and parents were treated as important partners in the delivery of care.
  • The service planned and provided care in a way that met the needs of children, young people and their families served. They pro-actively liaised with services and with others in the wider system and local/national organisations to manage the discharge care pathway and plan future care.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • The culture of the services provided were centred on the needs and experiences of children, young people and their families who used services. The service had an open culture where children, young people, their families and staff could raise concerns without fear.
  • Staff felt respected, supported and valued. The services promoted equality and diversity in daily work and provided opportunities for career development.
  • Leaders operated effective governance processes, throughout the service. However, the planning and implementation of the electronic patient record did not meet the individual needs of all services. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.
  • Leaders and staff actively and openly engaged with children, young people and their families, staff, equality groups, the public and local and national organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.

However;

  • The service did not always use systems and processes to safely store, record or destroy medicines in line with legislation.
Inspection areas

Safe

Requires improvement

Updated 22 January 2020

Effective

Outstanding

Updated 22 January 2020

Caring

Outstanding

Updated 22 January 2020

Responsive

Good

Updated 22 January 2020

Well-led

Good

Updated 22 January 2020

Checks on specific services

Critical care

Good

Updated 22 January 2020

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

  • The service generally controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection.
  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
  • There were significant vacancies in the nursing workforce, but critical care wards were mitigating this risk to avoid any negative impact on patient care.
  • Patient records for the critical care wards were entered on an electronic records system. All ten sets of patient records we reviewed were fully completed and stored securely.
  • The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them using the trust’s systems and processes. Managers investigated incidents and shared lessons learnt with the whole team and the wider service.
  • During the inspection we saw staff treating patients with dignity, kindness, compassion, courtesy, and respect. Staff explained their roles and any care they deliver to patients and family members, including being considerate to patients who were not conscious, during any interactions.
  • Family members spoke very positively about the care their child received in critical care and how they were treated by the staff on the wards.
  • Family liaison sisters provided keyworker support for families experiencing a bereavement or those needing additional support.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to assist patients access services.
  • Families could access the family liaison service, a service staffed by senior nurses who worked across PICU and CICU. The family liaison service provided practical and emotional support to patients, parents, and other family members.
  • It was easy for people to give feedback and raise concerns about the care they received. The service treated concerns and complaints seriously, investigated them, involving family members and shared lessons learnt with all staff.
  • Staff we spoke with stated that the directorate leadership team were visible on the wards and approachable. We observed that critical care staff interacted well with the ward leadership team during the inspection and that they were approachable.
  • At the time of our last inspection it was identified that there were tensions between nurses and doctors on the critical care wards. During this inspection we found an improved relationship between doctors, nursing, and allied health professionals (AHP). Staff were very positive about their colleagues and we observed a collaborative working culture in place between the various disciplines.
  • Prior to the inspection we were informed that there had previously been some tensions within the nursing workforce. However, on inspection staff were positive about the nursing leadership. Staff stated that they felt there was now improved morale and that it felt like a different working atmosphere.
  • There was an effective corporate governance framework in place which oversaw service delivery and quality of care. The service had systems and processes to identify risks, plan to eliminate or reduce them, and cope with both the expected and unexpected.
  • The service was committed to improving services by learning from when things went well or wrong, promoting training, research and innovation. The critical care research team was embedded within the running of the service and was involved in numerous local, national, and international clinical and academic research projects.

 

However:

  • We observed inconsistent staff compliance with IPC best practice guidance in relation to hand hygiene.
  • Resuscitation equipment on critical care wards was not consistently checked, which was not in line with guidance from the Resuscitation Council.
  • Critical care wards had a significant turnover of its nursing workforce, which meant that since our last inspection many experienced staff had left the service.
  • The availability of pharmacy cover on critical care wards fell below the levels recommended by the Society of Critical Care Medicine. Staffing for pharmacy, a known risk, was on the directorate risk register.
  • On PICU we saw medicines cupboards and fridges within the medicine’s room were unlocked. We also found some expired medicines which had not been segregated from medicines still in use.
  • We were told by staff that medicine related incidents had increased since the implementation of electronic prescribing, which was also on the board assurance framework (BAF).
  • At the time of our inspection all critical care wards had beds closed which was impacting on their ability to admit children requiring intensive care. Staff on the critical care wards and the directorate leadership team stated that this was due to the wards not having sufficient staff to meet the critical care staffing level standards. Data provided by the trust demonstrated that between the 02 and 30 of September 2019, of the 19 PICU beds, 13 to 15 beds were open. Similarly, 15 to 17 of the 21 cardiac intensive care beds (split across Flamingo and Alligator), were open.
  • Availability of beds was a significant factor in the number of refused admissions to critical care wards. Staff we spoke with stated that the number of refused admissions was higher than the national average.
  • Delayed discharges for clinically fit patients from PICU to the wards was a recognised issue and on the directorate risk register. It was acknowledged that these delayed transfers were having a negative impact on flow and capacity. To mitigate this risk there were daily bed management reviews in critical care. In September 2019, the trust had commenced a project focusing on internal trust discharges which involved clinical leads. This continued to be an issue and update notes on the directorate risk register stated that step down capacity on the wards was limited due to the lack of available nursing staff.
  • Although staff were positive about their colleagues across all disciplines and the change in morale, staff were frustrated about some of the decisions taken by the trust. Particularly in relation to a change in the specialist nurse bank rates. All members of the multi-disciplinary team were aware of the impact this had had on the morale of the nursing staff. Many staff felt that this could have been a contributing factor in staff turnover in the past 12 months.

Surgery

Good

Updated 22 January 2020

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

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills and understood how to protect patients from abuse. Staff kept detailed, up to date records of children and young people's care and treatment. The service-controlled infection risk well. Staff knew how to assess, monitor and manage patient risk. The service managed patient safety incidents well. Staff recognised and reported incidents and near misses.
  • All staff were actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking, peer review and research were proactively pursued. The continuing development of staff skills, competence and knowledge was recognised as integral to ensuring high quality care. Staff worked well together for the benefit of patients. Staff advised patients on how to lead healthier lives and supported them to make decisions about their care. Key services were available seven days a week.
  • Staff respected patient’s privacy and dignity. They provided emotional support to patients, families and carers and helped them understand their conditions. Patient and parent feedback was consistently positive. Children and young people told us staff treated them well and with kindness. Parents told us that staff went the extra mile and that the care their child received exceeded expectations.
  • The service planned and delivered care, in collaboration with other organisations, to meet the needs of patients. Staff took account of children, young people and their parents' individual needs and preferences. The trust made it easy for children, young people and parents to give feedback and used this information to improve care and services provided.
  • Leaders had the skills and knowledge to deliver effective services. They supported and encouraged staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued and were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • In theatres, systems to ensure equipment was maintained and safe to use were not effective.
  • Not all medicines were stored safely or destroyed in line with legislation.
  • Discharge summaries and clinic letters were not always sent to the patient’s GP in a timely manner.
  • Staff were unclear whether information leaflets were available in different languages and formats.
  • The service was looking at ways to improve access, as referral to treatment times were below the England average.
Other CQC inspections of services

Community & mental health inspection reports for Great Ormond Street Hospital can be found at Great Ormond Street Hospital for Children NHS Foundation Trust.