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Chelsea and Westminster Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 10 April 2018

  • We rated caring at Chelsea and Westminster Hospital as outstanding. We rated safe, effective, responsive, and well-led as good.
  • All the departments we inspected had improved from requires improvement to good.
  • The Hospital environment was clean. Equipment was clean and maintained.
  • There were effective infection prevention and control measures in place.
  • Patient records included risk assessments and care plans were complete.
  • Good medicines management processes were embedded in practice.
  • Staff followed treatment protocols and national guidelines
  • Staff showed patients dignity, respect, care and emotional support and were helpful to patients and public in corridors.
  • Care was planned to meet patients’ needs.
  • The Hospital met national access standards for A&E 4 hour waits, most Referral to Treatment (RTT) and Cancer.
  • Divisional leadership which was across both sites was effective.
  • Staff were proud to work for the Hospital and were supported.

Inspection areas

Safe

Good

Updated 10 April 2018

Effective

Good

Updated 10 April 2018

Caring

Outstanding

Updated 10 April 2018

Responsive

Good

Updated 10 April 2018

Well-led

Good

Updated 10 April 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 28 October 2014

The department did not follow appropriate safety procedures for incident reporting and learning, equipment checks, safeguarding and mandatory training and local best practice guidelines were not up to date. Multidisciplinary working needed to improve. Staffing levels in the department had been assessed as appropriate.

National waiting times for appointments were being met but some clinics had short-notice cancellations. Patients were positive about their care but they were not always kept informed, for example, about delays in clinics. People with a learning or physical disability required better support to access services. The service had innovative plans for development but local and trust leadership needed to improve during its implementation. Governance and risk arrangements were fragmented and there was not always single responsibility for a programme or target. Staff and public engagement needed to improve.

Outpatients

Good

Updated 10 April 2018

We rated it as good because:

  • The department had improved how they managed incidents; there were clear processes in place for reporting and investigating incidents.
  • Staff had a good awareness of safeguarding and knew how to protect patients from abuse. Staff understood how to escalate safeguarding concerns and report incidents. Learning was shared effectively about safeguarding.
  • There was protection and support in place for women and children who had undergone female genital mutilation (FGM) or were considered to be at risk.
  • There were clear infection control procedures and an infection prevention and control lead. Staff were aware of their responsibilities around preventing infection.
  • There were clear protocols and procedures in place for assessing and responding to patients who became unwell in the department.
  • The department was visibly clean and there were cleaning schedules in use which were fully completed.
  • Medicines were managed safely and the Hospital audited their compliance with medicines procedures. Patients received the right medications at the right time.
  • Staff had a good understanding of mental capacity, deprivation of liberty safeguards and consent.
  • Patients we spoke with were universally positive about the care and treatment they received in the department.
  • The department met patients’ needs through a wide range of services; there were plans in place to improve patient access to the service.
  • Staff we spoke with were positive about the support they received from their managers and colleagues and there was good multidisciplinary team working.
  • There was a positive working culture in the department, staff we observed were friendly and helpful and proud to work at the Hospital.
  • We observed staff treating patients with kindness and compassion and there was emotional support in place.

However:

  • Managers in the department felt that incidents were underreported by staff. Incidents were not reported promptly and we were not assured that learning was shared.
  • There was limited auditing of the performance of the department.
  • Failure to mitigate staffing shortages in ophthalmology had resulted in poor patient outcomes for patients undergoing injections for wet macular degeneration.
  • The department was not compliant with all referral to treatment targets across the reporting period.
  • There was limited evidence that people’s views and experiences were gathered and used to shape improvements to the department.

Maternity and gynaecology

Good

Updated 28 October 2014

There were effective procedures that supported safe and effective care for women. Staff were caring and compassionate and treated women with dignity and respect. There were adequate numbers of staff to meet the needs of women. The shortage of midwives had been addressed and vacant posts had recently been recruited to. Staff had relevant training and a good awareness of safeguarding and child protection issues. National guidelines were being used but monitoring compliance needed to improve.  Overall, outcomes for women were good, although the caesarean section rate was higher than the England average. There was good multidisciplinary working between hospital and community midwives and GPs and across hospital departments.

Women had choices during birth and were involved in decisions about their care and treatment. Staff on the unit were polite and friendly. We observed women being treated with dignity and privacy. The environment was clean and spacious. The atmosphere in the maternity unit was calm and peaceful. The antenatal department offered a comprehensive screening programme and the maternity urgent care centre had a triage (assessment and prioritising) system for women.

A new governance structure had been implemented in January 2014 and this had improved assurance around quality and safety but there needed to be better monitoring of action plans, and lessons learned from incidents needed to be effectively disseminated to all staff. The monitoring of compliance with guidelines through audit but action plans to address identified issues were not always developed and implemented. The leadership and culture within the department needed to improve to ensure there was effective joint working between doctors and midwives to support women having a reduction in interventions, and so that staff felt supported and listened to. The department demonstrated public engagement, improvements and examples of innovative practice

Medical care (including older people’s care)

Good

Updated 10 April 2018

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

  • The Hospital made improvements in most of the areas above that we told them they must improve following the inspection in 2014.
  • There had been a review of staffing requirements for level two patients in AAU, the call bell system had been refurbished, there was evidence of sharing of learning from incidents, and there was regular review of the risk register with appropriate mitigating actions being indicated.
  • Overall, medicines were managed and stored appropriately across medical wards.
  • Staff demonstrated knowledge of safeguarding processes and were able to effectively escalate safeguarding concerns.
  • The senior divisional team used a ward accreditation scheme to monitor quality and safety performance in each inpatient ward. The results were used to identify areas of good practice and areas for improvement.
  • Although staff vacancies remained a challenge for the service, ward managers and senior nurses actively addressed recruitment and retention using various initiatives.
  • The work of the Hospital at night team mitigated the risk related to low junior doctor cover on medical wards at night.
  • Staff provided care and treatment in line with national guidance and good practice. The service monitored the effectiveness of care and treatment through continuous local and national audits.
  • Staff competencies were monitored by practice development nurses (PDNs) working within medical services who we found to be passionate and keen to improve the service.
  • There was effective multidisciplinary team (MDT) working, which was embedded into practice in all the areas we inspected.
  • Staff were knowledgeable about and demonstrated a good awareness of consent, mental capacity and the Mental Capacity Act (2005). This was evidenced in our conversations and from looking at patient records.
  • Staff treated patients and their relatives with kindness, compassion, respect and dignity.
  • Between September 2016 and August 2017, five of eight medical specialties performed better than the national average for referral to treatment within 18 weeks.
  • There was a clear vision and strategy for the service and senior staff understood their responsibilities in carrying out the strategy.
  • There had been an improvement in relation to staff engagement by senior teams. In 2014, we told the Hospital staff engagement needed to improve.
  • Leadership and governance processes had been simplified and were clearly structured and this encouraged effective governance from board level to ward level.
  • Risks identified on the risk register had appropriate actions to mitigate them and had been reviewed regularly. This meant the service had taken action in response to our 2014 recommendations.
  • There had also been an improvement in relation to service leading being aware of the risk faced by staff and patients on the wards.

However:

  • Similar to the findings in 2014, not all agency staff had access to the electronic patient records.
  • Due to staff shortages, ambulatory emergency care (AEC) staff were not always able to follow up patients requiring urgent investigation or ongoing support following discharge from AAU.
  • There was variable completion of mandatory training. For medical staff, the trust target of 90% was met in one out of eight training modules. For nursing staff the target was met in four out of nine modules.
  • There was poor overall compliance with annual staff appraisals with only 64% of staff having been appraised from August 2016 to July 2017.
  • From July 2016 to June 2017, the average length of stay for both medical elective and medical non-elective patients at Chelsea and Westminster Hospital was higher than the England average.
  • From August 2016 to August 2017, the Hospital had 91 complaints which took an average of 49 days to investigate and close. This was not in line with their complaints policy, which states complaints should be closed within 25 working days. Eighteen complaints remained open at the time of the trust’s submission.
  • Between September 2016 and August 2017 three of eight medical specialties performed worse than the national average for referral to treatment within 18 weeks.
  • On some medical areas, staff said they did not feel they were part of the service, for example the diagnostic centre.
  • Although the working culture was generally positive, some individuals said they did not feel supported by colleagues or senior staff on the wards.

Our findings reflect improvements in most of the areas we told the Hospital they must improve following the inspection in 2014. Although we found instances where staff had not managed or stored medicines safely or in line with the trust policy, overall there was appropriate medicines management across the medical service. Although we found that not all agency staff had access to electronic patient records, overall, our findings in relation to the safe domain were positive.

During our inspection, we spoke with 76 members of staff including health care assistants, doctors, nurses, allied health professionals and ancillary staff. Staff represented a range of roles and grades across all specialties and medical departments. We also spoke with the directorate leadership team, 34 patients and 15 relatives. We reviewed 23 electronic patient records, multiple paper records including bedside patient notes, 23 electronic prescription charts and various pieces of equipment. We also reviewed evidence sent to us before and after the inspection including minutes of meetings and audit results.

Urgent and emergency services (A&E)

Good

Updated 10 April 2018

  • The department had undergone a £12 million refurbishment since the last inspection. The environment was clean and spacious and supported a positive patient experience. Patients waited in appropriate areas and were seen in individual bays for assessments and treatment. There was no additional capacity in the department to accommodate increased attendances.

  • Staff monitored patients who were at risk of deteriorating appropriately. Early warning scores were in use in both adult and paediatric areas.

  • There were good protocols in place for the recognition and management of sepsis. The department had adopted a traffic light system for sepsis screening and patients were escalated according to risk.

  • The department had increased their standard grade four or above doctor provision since the last inspection. The middle grade doctor rota was sufficiently covered so there was no use of locum doctors.

  • There was consistent recording of information within the patient records reviewed. This included good completion of risk assessments and pain scores. The recording of pain assessments had improved since the last inspection.

  • Manager supported staff and provided new staff with an individual induction plan to make sure the skills they brought to the team were recognised along with any training needs.

  • Staff were professional and care for patients in a caring and compassionate manner. Feedback from patients and relatives was positive.

  • The department had good performance against the four-hour wait time for admission, treatment or discharge between October 2016 and October 2017.

  • When staff decided to admit a patient, the number waiting between four and 12 hours for a Hospital bed was generally below the England average between December 2016 and November 2017.

  • There was a positive culture within the department and staff generally felt supported by managers.

However:

  • Consultant cover did not meet the recommended 16 hours per day cover recommend for A&E departments by the Royal College of Emergency Medicine (RCEM). Consultant provision was on the services’ risk register. However, the existing consultants were providing cover out of their existing consultant resources to ensure the service remained safe.

  • There were still some delays in patients being triaged. Patients were not always triaged in line with the recommended 15 minute triage target. However, during the inspection all patents we reviewed were triaged within 15 minutes.

  • Staff had difficulty accessing approved mental health professionals (AMHPs) out of hours to conduct mental health act assessments. This created delays and increased waiting times to discharge or transfer to other services for patients with mental health concerns in the emergency department.

Surgery

Good

Updated 10 April 2018

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

  • The overall completion rate for mandatory training for nursing staff at the Hospital had improved since the last inspection from 72% to 87%. Work was ongoing to raise this to the trust target of 90%. Electronic (E) learning was used for the majority of mandatory training.
  • Staff in the operating theatres and Treatment Centre followed the World Health Organisation (WHO) surgical safety checklist and five steps to safer surgery, and monitored this to make sure this was completed accurately.
  • Observations and a review of documents confirmed a minimum of four hourly national early warning scores (NEWS) were carried out and recorded recording for all patients.
  • Vacancy rates for nursing staff had improved. The Hospital reported an overall vacancy rate among nursing staff in surgery of 7% from August 2016 to July 2017. This was an improvement from the last inspection where the vacancy rate was 15%.
  • Junior surgical doctors reported no current gaps in the on-call rota and they said that they were supported well by their senior colleagues.
  • We saw improvements which showed that medicines were being stored securely. We also saw that tamper evident seals were in use for emergency medicines to ensure that they were readily available when needed and fit for use.
  • Patients and staff now had access to safety thermometer information, as it was presented on the patient safety and staffing boards in each ward.
  • The Practice Development Nurse (PDN) was heavily involved and engaged in developing new staff, and was particularly keen to impart high standards of documentation and care delivery. We saw that newly qualified staff were well supported by this process.
  • Multi-disciplinary (MDT) working was evident, such as collaboration between occupational therapists, physiotherapists and pharmacists. Staff working in Decontamination Services showed outstanding MDT working with the surgical teams.
  • We observed patients were looked after in a caring and professional manner. Most patients that we spoke with during this inspection were very complimentary about the level of care they had received.
  • Psychological support was provided to patients where needed. For example the Burns Unit had five psychologists who were able to provide support to patients who had experienced a burns injury. This service also included their relatives.
  • Patients scheduled for surgery had all been through pre-assessment and assessed by the anaesthetists to be fit for surgery.
  • From July 2016 to June 2017 the average length of stay for all elective patients at Chelsea and Westminster Hospital was 3.1 days, which is better than the England average of 3.3 days.
  • There were quiet facilities in the Hospital, which patients, relatives and staff could use in their personal time and space for reflection.
  • Staff at ward level were able to corroborate senior management’s accounts of being regularly present and involved at ward level and we were told by a senior manager that the Chief Operating Officer was very visible both on and off the rota for working clinically.
  • There were no individual strategies for each of the surgical specialities. However, we saw that the strategy for the surgical division was broadly linked to the trust’s three corporate strategies.
  • There were ongoing plans to increase private patient working within the NHS framework, with a potential increase in the operating capacity.
  • There was a transparent and open culture where staff escalated concerns, reported incidents and sought support from peers and seniors.

However,

  • Access to mandatory training for nursing staff varied across wards and clinical areas with some staff having dedicated time to complete training whilst others having to undertake their training in their own time.
  • We looked at a total of 11 patient records. There were a number of different ways in which staff were recording medical data at the time of our inspection. This had the potential to cause confusion, given the combination of written notes and online notes.
  • We found issues with the monitoring of fridge and room temperature readings where medicines were being stored. Staff took minimum, current and maximum temperature readings each day however, we did not find evidence of action taken by staff when temperatures were found to be outside of the recommended range.
  • The service did not meet national standards for care and treatment in key areas, such as length of Hospital stay and perioperative assessments.
  • There remained some overlap in understanding of differences between mental capacity and mental health and this was mainly amongst junior nurses, though they were clearly aware of when and how to escalate to senior nurses.
  • The service had not achieved its referral to treatment (RTT) target for general surgery, oral surgery, trauma and orthopaedics and urology. However, it was meeting the target for: ENT, ophthalmology, plastic surgery and cardiothoracic surgery.
  • From August 2016 to August 2017 there were 160 complaints about surgery. The trust took an average of 57 working days to investigate and close complaints. This was not in line with the trust’s complaints policy, which states complaints should be completed within 25 working days. As of August 2017, there were 22 complaints still open and yet to be completed.

Intensive/critical care

Good

Updated 28 October 2014

The unit had sufficient numbers of nursing and medical staff on duty and there were effective procedures for safe care. The patient Safety Thermometer was not embedded but there were plans to develop this. Medicines were safely and securely stored. Patients received care and treatment according to national guidelines and there was good multidisciplinary team working to support patients. Patient and performance outcomes were compared across North West London but the trust had re-evaluated this and intended to participate in the Intensive Care National Audit & Research Centre (ICNARC) from July 2014.

Staff cared for patients in a compassionate manner with dignity and respect. They involved patients and, where appropriate, their relatives in the care of the patient. Patients and their relatives were happy with the care provided. Emotional and spiritual support were provided. The leadership on the unit was visible and staff were passionate about providing excellent quality care. Governance arrangements supported assurance around quality, risk and safety. There was a culture that supported staff to develop innovative ways of working. Patients’ engagement was well developed through a range of feedback approaches.

Services for children & young people

Good

Updated 10 April 2018

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

  • There was a good overall safety performance in the service and a culture of learning to ensure safety improvements. Staff were encouraged to report incidents and received timely feedback. There was evidence of learning from incidents, which was shared in a number of ways.
  • Clinical staffing was mostly well managed and there were processes in place to ensure safe staffing levels based on patient acuity. Their service had 24 hour consultant cover.
  • There were effective processes in place to assess and escalate deteriorating patients.
  • There was good compliance with infection prevention and control processes. Equipment was checked regularly and medicines were stored appropriately.
  • Staff had a good understanding of safeguarding and were aware of their responsibilities. The service had good multi-agency partnerships to share relevant safeguarding information.
  • Patient records were completed to a good standard.
  • Staff provided care and treatment in line with national guidance and good practice. The service monitored the effectiveness of care and treatment through continuous local and national audits.
  • There were effective processes to ensure that patients’ nutritional and pain management needs were met.
  • The trust had good performance in local and national patient outcome and performance audits. For example the Hospital NICU had the lowest perinatal mortality rate in the UK and the Hospital demonstrated the highest rates of breastfeeding at the time of discharge.
  • Staff were supported to develop and there was a culture of learning and teaching within the service.
  • There was effective multidisciplinary team (MDT) working both internally and externally to support patients’ health and wellbeing.
  • There was a clear research ethos within children and young people services.
  • There was a comprehensive range of information and support available for patients and their families and carers. Staff helped patients manage their own health.
  • Staff understood their responsibilities as set out in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).
  • Staff worked in partnership with parents and families. They demonstrated a patient-centred approach which encouraged family members to take an active role in their child’s healthcare. All staff interacted with patients and their relatives and carers in in a caring, polite and friendly manner. All of the people we spoke with were very happy with their care and treatment.
  • Staff spent time with children to help make their experience more comfortable, relaxed and home-like. They supported them after discharge with teaching and community support.
  • The service had a broad programme of emotional support services for children and young people and their families and carers. This included a variety of therapeutic support services. There were appropriate and sensitive processes for end of life care.
  • Young people were supported by a dedicated youth worker, who was trained in counselling and talking therapies. There was a dedicated play therapy team which incorporated play into clinical interventions and therapies.
  • The Hospital delivered a broad range of services for children and young people, including a number of highly specialist paediatric services. There was timely access to services and good overall compliance of 95% for referral to treatment times. Flow within the service from admission, through theatres, wards and discharge was mostly managed effectively.
  • There was very comprehensive provision to meet the individual needs of children and young people, including vulnerable patients and those with specific needs. There were efforts across the Hospital to make the environment more child-friendly and welcoming for young people.
  • The Hospital school was rated as ‘outstanding’ by Ofsted and teachers at the school provided educational and learning support to children and young people across the Hospital.
  • There was an established and stable leadership team in the CYP service. Staff told us senior leaders were visible, approachable and supportive. There was an inclusive and constructive culture within the services. We found highly dedicated staff who were very positive, knowledgeable and passionate about caring for children and young people.
  • The service used appropriate governance, risk management and quality measures to improve patient care, safety and outcomes. Senior staff understood their local challenges and demonstrated a desire to improve CYP services for the benefit of patients.
  • There was a clearly defined clinical strategy for the service up to 2020.
  • The service engaged with young people and parents and carers in the design of services. The trust had established a Hospital Youth Forum. There were examples of service co-design, for example parental involvement in the redevelopment of the NICU.
  • There was a very strong record of innovation in the Hospital’s children and young people services and the trust was internationally recognised as an innovator and leader in paediatrics and neonatology research.

However:

  • During our inspection we found isolated instances where trust policies were not adhered to, for example in the safe management of controlled drugs and consent recording, and mandatory training completion.
  • There remained some challenges with clinical staffing vacancies, for example nurse staffing in the neonatal unit and on the paediatric burns unit. Managers were aware of these challenges and there were interim measures in place to ensure safety.
  • Some trust computer systems did not always work as effectively as they should, which impacted staff efficiency, for example the policy database and online learning platform. There was limited Wi-Fi network access in some areas of the Hospital.
  • Some staff felt the trust could do more to support them, for example staff with leadership and management responsibilities and healthcare assistants.
  • Some clinical areas were suboptimal, for example the paediatric high dependency unit (HDU) was not always used for its intended purpose and the paediatric ambulatory care unit did not provide a high quality experience for patients.

End of life care

Good

Updated 10 April 2018

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

  • Security measures had been improved in the mortuary since the last inspection in July 2014. Closed circuit television had been installed, free access was restricted to certain groups of staff and there was a signing in book to be completed.
  • Medical staffing had increased since the time of the last inspection.
  • In July 2014, we found there was not an effective system to identify patients who should have access to palliative care. During this inspection, staff told us they had training from the SPCT which meant they were more confident and better able to identify patients in their last year of life.
  • End of life care was embedded in practice throughout the Hospital. The specialist palliative care team provided training in a variety of forums and reinforced the message that end of life care was everybody’s responsibility.
  • There was early recognition of when a patient was in their last days or hours of life, at which point a compassionate care agreement would be completed and if they had complex symptoms, be escalated to the specialist palliative care team. This was an individualised care plan based on the five priorities of care of the dying patient. It was agreed with the patient and/or their next of kin. It supported staff to provide good quality of care for people who are dying. Each care plan was led and regularly reviewed by a named consultant and named nurse, supported by the specialist palliative care teams as required.
  • Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders we viewed were completed properly and reflected the information included in the patient’s mental capacity assessment.
  • There was adherence to national clinical guidelines and a culture of evidence based practice. There were local audits carried out which informed and improved practice.
  • 22 wards were working towards Gold Standard Framework accreditation. The Gold Standards Framework (GSF) is a model that enables good practice to be available to all people nearing the end of their lives, irrespective of diagnosis. It enables frontline staff to provide a gold standard of care for people nearing the end of their life.
  • There was a comprehensive programme of training across the trust in relation to end of life care. This was delivered by members of the specialist palliative care team and included ‘pop up’ training on wards in areas of weakness identified in local audits.
  • There was strong evidence of good multidisciplinary working. This was in keeping with the message as put forward by the SPCT which was that ‘end of life care was everybody’s responsibility’. Training sessions were planned for clinical and non-clinical staff. Governance meetings were attended by a range of staff from different specialisms.
  • The chaplaincy team was an integrated part of the overall delivery of care to the dying patient.
  • Patients and their relatives told us they were fully included in discussions around their plan of care.
  • There were established governance systems in place which identified risk and monitored quality against national standards. Local audit outcomes informed actions as required to continuously improve end of life care standards.
  • There was good representation of end of life care at trust board level which was a public demonstration of the importance the trust place in good end of life care.
  • Staff had a clear vision for the direction in which the service should go and told us the leadership team was approachable and supportive.

However:

  • The current information technology system did not fully support all aspects of record keeping. It did not allow for certain data to be collected and could not support coordinated care plans between the Hospital and GP.
  • A recent audit of DNACPR records showed there were certain areas which fell below the 100% target for certain standards.
  • There was inconsistency in how compassionate care agreements were completed.

HIV and sexual health services

Outstanding

Updated 28 October 2014

There were effective procedures to support a safe and effective service for patients. Clinical standards were adhered to and patients were appropriately involved in research and drug trials. The environment at clinics was clean and uncluttered. The clinics at 56 Dean Street and Dean Street Express were trendy, modern and bright. One patient representative told us the team had brought “sexual health and HIV services into the 21 century”. Patients described the service offered at each of the clinics as “exceptional”, “caring”, “confidential” and “quick”. Staff were highly trained and were compassionate and caring. They treated patients with dignity and respect and “normalised” conversations about sexual health. Staff worked in a multidisciplinary way to centre care around the patient.

Each location had identified the demographic of the people using their service and provided speciality clinics, outreach, community engagement and counsellors suited to the people using the service. The team constantly explored new and innovative ways to deliver the service. National guidelines were being used and most patients could access services at one of the locations within 48 hours. The service reviewed its performance through patient surveys and the patient champions. There was clear governance and strong leadership and staff at all levels felt involved in decisions and ideas that could help the division and individual locations run well. The service was well-recognised at local and national levels.