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Inspection carried out on 9 January 2018

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

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 carried out on 15,16,17 April 2015 and 1 - 3 May 2015

During a routine inspection

Great Ormond Street Hospital for Children NHS Foundation Trust is one of four dedicated children's hospital trusts in the UK. The trust operates from a single site in central London. It is the largest paediatric centre in the UK for intensive care, cardiac surgery, neurosurgery, cancer services. nephrology and renal transplants. Children are also treated from overseas in their International and Private Patients’ (IPP) wing. There are more than 50 different clinical specialties at Great Ormond Street Hospital (GOSH). Together with the UCL Institute of Child Health, it forms the UK’s only academic biomedical research centre specialising in paediatrics. Its status as a Specialist Children’s Hospital means that most of the children treated are referred from other hospitals or overseas.

We carried out this inspection as part of our comprehensive acute hospital inspection programme adapted for dedicated children's hospitals. The trust was rated as low risk in the CQC intelligent monitoring system. The inspection took place between 14 and 17 April and unannounced inspections took place between 1 and 3 May 2015. We also inspected the Children and Adolescent Mental Health Services ( CAMHS) provided by this trust as part of our inspection.

Overall this trust was rated as Good. We rated it outstanding for being effective and caring. We rated it good in providing safe care. We rated it requires improvement for being responsive to patients needs and in being well-led.

We rated medical care and end of life care as outstanding. We rated critical care, child and adolescent mental health services and transitional services as good. We rated surgery, and outpatients and diagnostic imaging as requires improvement.

Since our inspection, the trust alerted us to long-standing problems with the reliability of their patient information systems, which affected the validity of the trust’s reporting of referral to treatment (RTT) times. This had the potential to delay the admission of patients waiting for non-emergency treatment. We have reflected these problems in our assessment of services in this report.

Our key findings were as follows:

  • All staff working at the hospital were extremely dedicated, caring and proud to work for the hospital.
  • We saw high levels of care, professionalism and innovative treatment of patients who had been referred for care by other hospitals.
  • The culture was very open and transparent. Parents and children were kept fully involved in their treatment. There was an evident commitment to continually improve the quality of care provided. Children and young people were involved in decision making as far as possible.
  • We saw good examples of duty of candour in practice. Staff were very open when things had gone wrong, expressed full apology and offered full support to parents, children and carers.
  • The new Chief Executive was very visible, had shared his vision for the trust and had gained the early respect of staff members.
  • The executive team were well known to members of staff and patients and did regular walkabouts on the wards.
  • There was outstanding care demonstrated in all departments where there was a tangible level of staff working together in pursuit of excellence of care. All supported the mission statement of the trust which was " the child first and always".
  • When decisions were made to stop treatment, this was done thoroughly and with good governance via the ethics committee and always with maximum consultation with parents or carers.
  • The reporting of incidents was fully embraced by all members of staff we spoke with. Incidents were thoroughly investigated and learning obtained and shared with all staff across the hospital.
  • End of life care was embedded in all clinical areas of the hospital and not seen as the sole responsibility of the palliative care team.
  • Where the trust had completed a refurbishment or rebuild, the facilities were modern, extremely child friendly and conducive to excellent patient care and dignity. There remained some wards, not yet refurbished, rebuilt or relocated where the environment was less good. The hospital recognised this and was in the middle of a total refurbishment/rebuild project.

We saw several areas of outstanding practice including:

  • Clinicians from other hospital services delivered specialist training on physical health issues for CAMHS staff. In return CAMHS staff provided training and expertise to other departments across the hospital, for example on learning disabilities and autism.
  • Because the hospital is treating many patients that could be treated at very few hospitals in the UK it is developing ground breaking clinical guidance which it is sharing with clinical colleagues in the wider medical community.
  • The hospital has developed a pocket-sized guide to help staff working with children with learning disabilities.
  • The Feeding and Eating Disorders Service (FEDS) received 100 % approval in the latest Friends and Family test with 93% saying they were extremely likely and 7% saying they were likely to recommend the service.
  • The Psychological Medicine team provided an outreach service across the country where necessary.
  • Staff in CAMHS were actively involved in research in their specialist areas including Autism and Feeding and Eating disorders.
  • CAMHS introduced a screening tool for mental health problems and the psychological medicine team conducted a study to improve the understanding of the patient experience, diagnosis, treatment and outcomes regarding non-epileptic seizures in children.
  • The FEDS and MCU (Mildred Creak Unit)teams developed a policy around re-feeding syndrome to increase understanding of the issue.
  • In critical care there were excellent mortality and morbidity meetings, and robust safety monitoring of all patients.
  • The Intensive Care Outreach Network(ICON) and Clinical Site Practitioners (CSP) are part of the hospital at night service and hold responsibility for any deteriorating child 24 hours a day, seven days per week.
  • In pharmacy services the chief executive receives monthly reports of prescribing errors; a daily check ensures all electronic prescriptions are screened before the end of each weekday (Monday to Friday)and patients are informed by text message when prescriptions are ready.
  • In transitional care young people feel empowered by the Young Persons' Forum.
  • Joint transitional care clinics are held with on-going hospital providers.
  • In outpatients weekly education sessions were protected to ensure staff maintained currency in mandatory areas and had the opportunity to take part in further specialist training from a clinical educator

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

Importantly the hospital must:

  • Resume WHO checklist audits in surgery
  • Ensure that there are clear arrangements for reporting transitional care service performance to the board.
  • Ensure that its referral to treatment (RTT) data and processes are robust and ensure that staff comply with the trust's patient access policy in all cases.
  • Ensure greater uptake of mandatory training relevant to each division to reach the trust's own target of 95% of staff completing their mandatory training.
  • Ensure that, particularly in critical care, communication between senior nurses and senior medical staff is enhanced and that the contribution of nursing is fully reflected in the hospital's vision.

In addition the hospital should:

  • Ensure early improvements in the environments of wards which have not been refurbished, rebuilt or relocated.
  • Standardise radiation protection training for junior radiologists to overcome inconsistencies caused by short rotations.
  • Develop a dedicated advocacy service for its Child and Adolescent Mental Health service ( CAMHS).

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 25 September 2012

During a routine inspection

As part of the inspection an unannounced visit was carried out by six compliance inspectors, one pharmacy specialist and one paediatric specialist on 25 September 2012. We visited various inpatient wards including private patient wards, outpatient areas, diagnostic and testing areas and administrative offices. Overall, we spoke with 24 children or their parents/families and to 35 members of various staff.

In general, the children and parents/families we spoke to were very positive about the experiences they had had at the hospital. Most of the children and parents we spoke with told us that they felt supported, respected and very happy with their involvement in the care provided. They spoke highly of the medical and nursing staff. The majority of children and parents we spoke with told us that they disliked the taste of the food and the choice of food was poor. All the parents we spoke with felt that their children were safe in the hospital, it was a clean environment and were happy with the way their medicines were managed. All of the parents we asked knew how to make a complaint if they needed to.

Some comments included:

“We are very happy with all the care and support we have received here”.

“The staff are respectful".

“The nurses and the doctors are very, very good.”

“Food is bland and plain, it's the same thing everyday.”

“I feel safe”.

“The ward has always been clean”.

“Any issues I have raised have been sorted out immediately”.

Inspection carried out on 9 June 2011

During a routine inspection

All the parents we spoke to during our visit were happy with the care provided for their children. They were kept involved in the plans for treatment. We observed positive interactions between staff, parents and their children on the wards we visited. The last patient and family satisfaction survey, published in March 2011, shows a high level of overall satisfaction at 96%.