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Inspection Summary


Overall summary & rating

Good

Updated 10 April 2018

  • All core services previously rated as requires improvement improved to good. All core services were now good overall, except urgent and emergency care which was rated as required improvement. The domain of safe remained at requires improvement.
  • The Hospital ED had been refurbished including the provision of a full children’s ED , and new waiting area which had previously not been separate from the ED for adults. There were also new rooms for mental health patients
  • 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 and were complete.
  • Good medicines management processes were embedded in practice. There were measures in place to equalise pharmacy arrangements between the two sites.
  • 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.
  • Strong efforts had been made to ensure the merger ran smoothly and to adopt best practice from West Middlesex and to fully engage West Middlesex staff in the formulation of the trust’s PROUD values as well as ensuring senior trust leaders had offices there, were visible and conducted trust board meetings there on rotation with the Chelsea site.

Inspection areas

Safe

Requires improvement

Updated 10 April 2018

Effective

Good

Updated 10 April 2018

Caring

Good

Updated 10 April 2018

Responsive

Good

Updated 10 April 2018

Well-led

Good

Updated 10 April 2018

Checks on specific services

Medical care (including older people’s care)

Good

Updated 10 April 2018

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

  • The Hospital had made progress in all of the four areas listed above that we told them they must improve.
  • Medical services performed consistently well in the national patient-led assessment of the care environment (PLACE). In the previous 12 months, the service performed better than national and trust averages in all categories.
  • 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.
  • Safeguarding processes were embedded into clinical and administrative practice and we saw effective escalation of safeguarding concerns.
  • Ward managers and senior nurses were empowered to address nurse vacancies and improve retention with local initiatives. We saw this was effective in a number of wards and clinical areas.
  • Vacancy rates and turnover rates of doctors were generally low, with consultant vacancies covered by locum staff from within the trust.
  • Staff used effective, embedded medicines management processes and implemented learning and improvements when mistakes happened.
  • Staff learnt from incidents and implemented changes to practice and policy as a result.
  • There was consistent evidence staff used national and international best practice guidance and benchmarks in the delivery of care, audits and research.
  • From June 2016 to May 2017, patients had a similar to expected risk of readmission for elective admissions when compared to the England average.
  • Specialist teams had developed targeted training programmes to ensure staff had access to professional development and continued to advance their clinical competencies. Education programmes were also offered as a result of learning from incidents and complaints.
  • Multidisciplinary care was embedded into practice in all areas and a wide range of specialists coordinated care and treatment pathways.
  • The trust did not provide data on Mental Capacity Act (2005) training at site level, however we saw evidence of good practice in line with national guidance.
  • We observed consistent compassion and kindness from staff in all roles and significant effort to involve patients and their relatives in care planning and decision-making.
  • Staff were empowered to plan, pilot and implement services to meet the changing needs of the local population. All such projects were demonstrably focused on improving patient outcomes and reducing long-term morbidities.
  • The Gold Standards Framework was embedded into end of life care and staff delivered this in a person-centred way on each ward.
  • Staff worked to meet individual patient needs when they were at increased risk, such as those at risk of falls. This was demonstrative of an overall patient-centred approach to care planning and treatment.
  • Between September 2016 and August 2017 five of eight medical specialties performed better than the national average for referral to treatment within 18 weeks.
  • Leadership and governance processes were clearly structured and contributed to effective and stable ward teams in most areas.
  • Senior staff and ward teams placed value on engagement and this contributed to improvements in ward environments and work processes.

However:

  • There was variable compliance with the early warning scores system, which staff used to identify, monitor and escalate patients whose conditions were deteriorating. We saw limited evidence of sustained improvement as a result of audits and overall compliance was 92%, which did not meet the trust standard of 95%.
  • Senior ward staff did not always follow trust safety policies in relation to agency nurses.
  • Cleaning and housekeeping staff did not always ensure the safe storage of chemicals or hazardous substances in relation to national guidance.
  • Although audit results demonstrated consistently good standards of infection control practice and hand hygiene, there were localised exceptions to this.
  • There was variable completion of mandatory training and no clinical staff group in this division met the trust target for all training.
  • Patients in general medicine had a much higher than expected risk of readmission for elective admissions, with rates for respiratory medicine also higher.
  • Overall performance in national inpatient audits was variable and the Hospital did not meet minimum standards by significant margins (over 10% difference) in the national audit of inpatient falls or the lung cancer audit.
  • There was poor overall compliance with annual staff appraisals.

  • Although medical services performed better than trust and national averages in response rates for the NHS Friends and Family Test (FFT), recommendation rates were highly variable with little consistency in meeting the 90% target.

  • From July 2016 to June 2017 the average length of stay for medical elective patients was 10.3 days, which was higher than the national average of 4.2 days. The average length of stay for all individual specialities at the Hospital was also higher.

  • The Hospital achieved level C performance rating in the quarterly Sentinel Stroke National Audit programme.

Our findings reflect broad improvements in all of the areas we told the trust to take action on in 2015. However, our rating for safe has gone down. This reflects deterioration in standards relating to infection control and environmental management, poor compliance with basic life support training requirements and inconsistent use of some clinical risk assessments. We also found numerous examples of outstanding practice to improve person-centred care and staff engagement.

We spoke with 53 members of staff, seven patients and three relatives. Staff represented a range of roles and grades across all specialties and medical departments. We looked at 34 patient records and the overview of patient status for over 150 people. We reviewed over 100 additional pieces of evidence, including the minutes of meetings and audits. During our inspection we spent time on the acute medical unit, the acute assessment unit, the coronary care unit, the endoscopy unit and on every medical inpatient ward except for Crane ward, which was closed due to a norovirus outbreak.

Services for children & young people

Good

Updated 10 April 2018

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

  • Overall safety performance in the service had improved and there was 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 across children and young people’s services.
  • Clinical staffing was mostly well managed and there were processes in place to ensure safe staffing levels. There service had 24 hour consultant cover.
  • There were effective processes in place to assess and escalate deteriorating patients.
  • Overall compliance with infection prevention and control processes had improved. Equipment was checked regularly and medicines were stored appropriately.
  • Staff had a good understanding of safeguarding. Staff were aware of their responsibilities in relation to safeguarding children.
  • 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 in place to ensure that patients’ nutritional and pain management needs were met.
  • Overall, the trust had good performance in local and national patient outcome and performance audits. However, there were issues with data recording in the national neonatal audit programme (NNAP).
  • Staff were supported to develop and there was a culture of learning and teaching within the service.
  • MDT working had improved. There was effective multidisciplinary team (MDT) working both internally and externally, including SCBU, to support patients’ health and wellbeing.
  • The trust had invested in the recruitment of a public health consultant doctor to help address key public health outcomes in the local area.
  • There was a range of information and support available for children, young people, families and carers.
  • Staff understood their responsibilities for gaining children’s, young people’s and families consent.
  • Doctors, nurses and therapists worked in partnership with parents and families. Staff in children and young people’s services demonstrated a patient-centred approach which encouraged family members to take an active role in their child’s healthcare.
  • Staff were aware of the need to provide 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 for neonates and children and young people.
  • There was timely access to children and young people services and there was a good overall compliance of 95% for referral to treatment times.
  • There was provision to meet the individual needs of children and young people using services at the Hospital, including vulnerable patients and those with specific needs.
  • There was an established and stable leadership team in children and young people’s services. Staff told us senior leaders of the service were visible, approachable and supportive, and said the culture in children and young people’s services was nurturing.
  • The department used appropriate governance, risk management and quality measures to improve patient care, safety and outcomes. Staff awareness of the risk register had improved.
  • There was a clearly defined clinical strategy for children and young people services which detailed the vision 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 to engage young people in service planning.

However:

  • All staff were not achieving the trust’s 90% mandatory training target in December 2017.
  • Some agency staff did not have access to electronic patient information.
  • There remained some challenges with nursing staffing vacancies, for example, nurse staffing in Starlight Ward. There was a long-term plan in place to recruit staff and staff were working flexibly across the Chelsea and Westminster Hospital and West Middlesex University Hospital.
  • Staff could not access speech and language therapy in a timely way as the speech and language service was not based on the West Middlesex University Hospital site.
  • The fracture clinic did not have dedicated children’s plastering area.
  • Complaints were not always investigated in accordance with the trust’s complaints policy.
  • Senior staff with leadership and management responsibilities did not always have sufficient protected time and support to discharge their responsibilities.
  • Some staff did not feel fully engaged and involved in the merger of West Middlesex University Hospital with Chelsea and Westminster Hospital.
  • Staff told us the merger with Chelsea and Westminster Hospital had taken precedence since 2015 and this had an impact on the ability of children and young people’s services’ opportunities for research and innovation.

End of life care

Good

Updated 10 April 2018

  • Following our inspection in 2014, there had been improvements to End of Life Care (EoLC). The trust had implemented a clear strategy for end of life care and the service was now represented at the trust board level. End of life care was fully embedded throughout the trust and had a high profile in the trust.

  • The trust had addressed areas of concern from the last CQC inspection. Investment in EoLC meant there were now sufficient numbers of staff to provide safe care. Staff were appropriately qualified to provide care and treatment based on national guidance.

  • Staff knew how to report incidents and there were effective systems in place to safeguard vulnerable adults. Managers investigated incidents and shared lessons learned.

  • Patient feedback was mostly positive. Staff treated patients with compassion, dignity and respect. Patients and their relatives were involved in their care.
  • Services were developed to meet the needs of patients. Staff arranged rapid discharge in line with patients’ preferences. Staff had access to translators when needed giving patients the opportunity to make decisions about their care, and day-to-day tasks. Patients had individualised care plans tailored to their needs.

  • Patients and relatives had access to the Hospital’s chaplaincy, which was open to people of all faiths and none. The bereavement and mortuary services took into account people’s religious and cultural needs and were flexible around people’s needs.

  • There was good local leadership in place. Staff felt valued, were supported in their role and had opportunities for learning and development. Staff were positive about working in EoLC.

  • The service had implemented a number of innovative practices to improve patient care. These included improvements made to the fast track discharge process as well as comprehensive training program across the trust.

However:

  • We found inconsistencies in the way “do not attempt cardiopulmonary resuscitation” (DNA CPR) records were completed. A recent audit of DNACPR records showed there were certain areas which fell below the 100% target for certain standards.

  • 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.

Outpatients

Good

Updated 10 April 2018

We rated it it as good because:

  • Staff understood how to protect patients from abuse and were aware of their roles and responsibilities for escalating safeguarding concerns. Staff had training on how to recognise and report abuse.
  • Records were held securely with in lockable note trolleys which had a keypad. Records used by reception staff were kept out of sight to ensure patient’s confidentiality was maintained. We observed nursing checking records in separate rooms in clinical rooms out of sight of patients.
  • The OPD looked visibly clean. Cleaning schedules and daily checklists were completed and in place in the OPD departments. Checklists from November 2017 were held and where available. This had improved since the last inspection.
  • Medicines were stored in locked cupboards and treatment rooms. The trust audited prescriptions against with the trust medicines policy in July 2017. The audit included OPD prescriptions and assessed compliance with 20 standards which covered various aspects of the Medicines policy. Of these, 18 (90%) scored 80% compliance or greater.
  • The OPD was part of the planned care division which had an audit programme. For the year April 2017 to March 2018 six audits which had been registered. This demonstrates the Hospital was engaged in auditing the effectiveness of the care they provided.
  • Staff were able access appropriate pain relief for patients within outpatient’s clinics. Patient’s pain was assessed and monitored. Staff in outpatients could give patients paracetamol if they experienced pain, but if patients needed other analgesia these would be prescribed by a medical practitioner.
  • There were systems in place to obtain consent from patients before carrying out most procedures or providing treatment, which we saw evidenced in patients’ notes. Records reviewed showed evidence that consent was gained for care and treatment. Staff told us they had access to guidance for obtaining consent from a patient with a learning disability.
  • Staff provided treatment and care in a kind and compassionate way and treated people with respect. Staff were seen to be very considerate and empathetic patients. Patients we spoke with were positive about the staff that provided their care and treatment. They told us they had confidence in the staff they saw and the advice they received.
  • Patients told us they were given written information on their aftercare and leaflets on a healthy lifestyle.
  • Patients told us staff helped them to understand their care and treatment, and that medical staff took time to ensure they answered their questions. Several patients told us they the doctors explained their conditions and treatment options, and answered there questions.
  • The OPD took account of people’s needs. The OPD offered a range of services for patients, this included audiology, ENT, dermatology, breast surgery, podiatry, respiratory, trial without catheter and fracture clinics.
  • West Middlesex Hospital was meeting its cancer referral targets between September 2016 and September 2017. The operational target of 93% for patients to be seen within 2 weeks of an urgent referral from a GP had been met (93%). The operational target of 85% for patients for patients receiving their first treatment within 62 days of an urgent GP referral had been exceeded (91%). This was higher than the England average.
  • Outpatient clinics were clearly signed and colour coded on the floor to OPD areas so that people could find their way to respective clinics. The hospital also used volunteers to guide patients to the right departments however volunteers were only on site one day of the inspection.
  • There was a clear management structure across the Planned Care Division which operated across both Hospital sites, the West Middlesex University Hospital and Chelsea and Westminster Hospital. Staff were positive about the skills, knowledge and experience of their immediate managers. They felt supported by their managers and the trust.
  • Staff described good team and peer support; they felt they worked well as a team. We saw multidisciplinary working which involved patients, relatives, and nursing staff working together to achieve good outcomes for patients. Most patients acknowledged a positive and caring ethos and were happy with the care they received.

Surgery

Good

Updated 10 April 2018

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

  • The trust had improved on their own performance in completing mandatory training for nursing staff.

  • The trust had improved on the number of hand hygiene audits performed and displayed these results on the “proud to care boards” outside their wards.

  • Medication was stored correctly.

  • The Hospital had improved their training in safeguarding from 45% compliance to 96% compliance in nursing staff.

  • There were improvements in theatre utilisation since the time of the last CQC inspection.

  • There was evidence of good multidisciplinary working across the surgical services.

  • The most recent figures for average length of stay for surgical elective patients were better than the England average.

  • ENT, ophthalmology, plastic surgery and cardiothoracic surgery were above England average for referral to treatment times.

  • Discharge rates had improved slightly, with the introduction of a ‘2 b4 12’ initiative. This scheme encouraged the discharge of two patients before midday from each ward.

  • Patients had spoken to their surgeon and knew who had performed their surgery.

  • In 2016/207 only 3% of cancelled operations were not treated within 28 days.

  • Staff reported a positive culture within the Hospital and staff were happy to work for this trust.

However:

  • Some fridge temperatures that were out of range were not acted upon.

  • Only 50% of patients had pre-operative assessments prior to surgery. The trust had taken action to remedy this.

  • Referral-to-treatment time (RTT) performance remained below the England average for urology, trauma and orthopaedics, oral surgery and general surgery.

  • Storage space was still limited in theatres.

  • There was still a low response rate to Family and Friends Tests (FFT).

  • Risk registers did not include the risks we found on inspection.

Urgent and emergency services

Good

Updated 10 April 2018

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

  • The Hospital had undergone refurbishment since the last inspection to improve the environment for staff and for patients, including providing a children’s ED with a children’s waiting area with audio and visual separation from the main waiting area. Our previous concerns about the privacy of patients during registration and streaming had been overcome in the new design.
  • There had been clear improvements in flow through the department into the Hospital. This had reduced ambulance handover times and increased the percentage of patients being seen, treated, discharged or admitted within four hours.
  • The number of nurses had been increased since the previous inspection and appeared sufficient for the level of activity.
  • We saw effective team working across the department and with other areas in the Hospital.
  • At the last inspection we had noted that learning from incidents and issues was limited. There had been improvements in recording and learning from incidents. An electronic incident recording system had been introduced. Staff told us that they discussed incidents in team meetings, at handover and had feedback in emails.
  • There were reliable systems and training to protect people from abuse. Staff were knowledgeable about safeguarding, although numbers of staff with up to date training in high-level child safeguarding needed to increase.
  • Junior doctors were positive about the support and teaching they received from senior clinicians. Longer serving nurses reported improvements in training opportunities.
  • Staff cared for patients with compassion and professionalism and we received mainly positive feedback from patients and their friends and relatives.
  • Leaders and senior managers were visible to staff.
  • The service had a clear vision and strategy that all staff understood and put into practice.
  • The department had governance, risk management and quality measures to improve patient care, safety and outcomes.
  • Staff and managers were clear about the challenges the department faced and had plans to deal with them.

However, although many of the concerns identified at the last inspection had been rectified:

  • 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 service’s risk register.
  • Not all patient records and risk assessments were fully completed, including assessment of capacity and dementia , although risk assessments of patients with mental health problems had improved.
  • There were few standardised pathways to ensure consistent, evidence based care and treatment.
  • We found inconsistent recording of information within patient records. We saw no capacity assessments or assessments of dementia for elderly adults. There was little information for patients about the emergency department and its processes or information to support patients to help them lead healthier lives.