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The rating for ‘Maternity and gynaecology’ shown on this page does not reflect our latest judgement of services at Homerton University Hospital. We now inspect maternity and gynaecology services separately.

At our latest inspection, in April 2018, we rated the maternity services as good. We did not inspect the gynaecology services.

Inspection Summary


Overall summary & rating

Good

Updated 10 August 2018

Since our last inspection of acute services at Homerton University Hospital NHS Foundation Trust in 2014 and 2015, the trust had addressed or shown improvement for most of the previously reported concerns and requirement notices, for which we commend them. There were evident improvements in a number of areas, for example the introduction of maternal early warning scores and greater use of audit, and improved record keeping in surgery.

Across all services, the staff we spoke with knew how to report incidents and could give examples of learning from them. There was an open culture of incident reporting and a willingness to learn from incidents. Learning from incidents was shared with staff using a variety of different methods and was embedded in trust governance processes.

There were comprehensive, clearly defined and embedded processes to protect people from abuse. Staff were knowledgeable about safeguarding and were confident to escalate concerns. There were well-developed care pathways for ‘at risk’ patients, for example in maternity services and the emergency department.

There was good compliance with infection prevention and control across the hospital, although we saw inconsistent hand hygiene carried out by doctors and midwives in maternity services. All areas of the hospital we inspected were visibly clean, tidy, and clutter free. Patients, relatives, staff and managers we spoke with consistently told us they were satisfied with cleaning services in clinical areas. Equipment was well maintained.

The trust had improved the storage of medicines and Controlled Drugs in clinical areas and operating theatres. Staff were aware of policies and protocols in relation to the administration of medication and we observed adherence to these protocols. Staff recorded administration of medication and performance was maintained through audits.

The trust had introduced measures to better anticipate and manage patient risks. For example national early warning score (NEWS) in surgery and modified early warning score (MEWS) in maternity to assess and escalate deteriorating patients. Staff had good knowledge of what to do in the event of a patient deteriorating. There were good protocols in place for the recognition and management of sepsis in ED and the surgery service consistently met the 95% trust target for venous thromboembolism (VTE) risk assessments showing improvements from the last inspection.

Staffing was well managed in medical care and the emergency department. Although many services relied on bank and agency doctors and nurses to staff wards, local and divisional leadership mitigated the risks associated with temporary staff well.

Across services, patient care was delivered in line with good practice and evidence-based guidance from relevant bodies. Trust policies were reviewed regularly and new clinical guidelines were disseminated to staff appropriately.

There were good opportunities for education and development across services. Doctors in training were very positive about the support and teaching they received from senior clinicians.

Throughout our inspection, we saw consistent evidence of effective multidisciplinary team (MDT) working across all disciplines and wards. The delivery of patient care included all relevant healthcare professionals and their input was reflected in patient records. Ward staff worked closely with staff across acute and community services as well as practitioners in the local health economy.

Staff demonstrated compassion to patients and their relatives in all of the services we inspected. Staff included patients in decision making so they understood their care and treatment. Patients and their relatives spoke very highly of the kindness and compassion shown to them by staff.

People using the trust’s services were treated with dignity and respect. Patients told us they felt listened to by health professionals and felt informed and involved in their treatment and plans of care. Trust staff provided patient-centred support on wards, in clinics and in patients’ homes. For example, the surgical rehabilitation team visited patients in their homes for up to two weeks post discharge.

The trust’s services were responsive to the needs of people using them and adapted provision to meet the diverse and specific needs of the local community, including tailored clinics and support services for different populations. The integrated nature of the trust’s acute and community services facilitated the integrated delivery of care for patients between inpatient wards and community teams.

The trust had introduced a dementia identifier to support patients across the hospital. This was considered good practice by the Alzheimer’s Society and all staff received a dementia awareness training session.

The trust delivered a broad range of surgical services including a number of highly specialised services such as the Homerton Anal Neoplasia service (HANS), which was the only one of its kind in the UK and one of very few in the world. The hospital was also a regional centre for bariatric surgery. The service was actively involved in clinical research and in regional teaching of bariatric surgery doctors in training.

The emergency department used innovative standard operating procedures designed to be responsive to the needs of ‘at risk’ patients and patients with complex needs.

There was an effective system for bed management across the hospital, from the assessment unit and throughout the wards. Admissions and potential discharges were discussed daily in the consultant-led morning white board rounds, which informed the site managers and emergency department of bed availability throughout medical wards.

There were pockets of outstanding leadership within services at the trust, notably in the trust’s emergency department. The senior leadership of the emergency department was a dynamic and cohesive group with a high level of interaction and good communication across all staff groups. Each member of staff we spoke with told us the leadership team was supportive, visible and encouraging.

There was a clear governance structure within the division for Integrated Medicine and Rehabilitation Services (IMRS) and staff at all levels were clear about their roles and what they were accountable for. The divisional structures were well managed by the leadership triumvirate and communication from divisional leadership down to ward level was clear. The divisional leadership had oversight of clinical governance and operational governance through monthly divisional meetings. Departmental risks were widely understood and staff described the same risks as those identified by the leadership team. Measures were in place to mitigate identified risks.

Senior leaders and managers of services had, for the most part, a good understanding of risks to the service and these were appropriately documented in risk management documentation with named leads and actions.

During the inspection most staff we spoke with felt they were listened to by service and trust leadership and felt they could approach managers if they needed support.

The trust had responded to address whistleblowing incidences in both theatres and pre-operative assessment areas. At the time of our inspection, the trust’s interventions and development work were ongoing.

However,

There were some challenges with staffing in the maternity service. Consultant numbers were lower than expected for a unit this size and there had been a long running issue about whether to appoint a new consultant and how to attract more middle grade doctors. This meant there were not always consultant-led elective caesarean sections or consultant ward rounds. Midwifery skill mix arising from the high proportion of newly qualified midwives was a concern considering the high acuity of women using the service.

Despite many improvements in areas of weakness identified in the previous inspection, there remained a few areas where tighter control was needed, for example, ensuring emergency boxes on the delivery suite were immediately restocked after use, and that records of triage and baby observations were correctly maintained at all times.

Some women told us concerns about their experience of triage, and also said the level of activity on the postnatal ward meant they did not receive as much support from staff as they felt they needed.

In surgery and maternity services, mandatory training completion rates for medical staff was below the trust target of 90%. Nursing staff in the surgery service also did not meet trust targets for most mandatory training modules. However, senior leaders acknowledged this and were working to address this.

The trust did not provide specific training for staff in understanding their responsibilities under the Mental Capacity Act (MCA) or Deprivation of Liberty Safeguards (DoLS). The principles of MCA and DoLS were covered in the mandatory safeguarding training course, but staff understanding of the MCA and DoLS was variable across wards.

The capacity of the trust’s adult safeguarding team was limited due to vacancies and high workload. This meant that the safeguarding team was not always able to provide comprehensive support to all services. At the time of inspection the post for the trust lead nurse for safeguarding adults and learning disability acute liaison was unfilled and had been for the last six months. This created a current gap in the provision of services for patients with learning disabilities.

On medical wards recording of capacity assessments and decisions on DoLS was not consistently documented in patient records and patient notes used limited contextual information rather than using the specific MCA records sections. In some cases it was not sufficiently clear if patients had received a capacity or DoLS assessment.

There were frequent late starts in operating theatres. The service did not collect data for the number of ‘on the day’ list changes with reasons despite list changes contributing to late starts in theatres.

Governance processes in the Surgery, Women and Sexual Health division (SWSH) required improvement. Some of the maternity risks we identified were not recorded on the service risk register and there were inconsistent governance structures across surgical specialities. The divisional management team was aware of varied agendas and quality of reporting and there were plans to address this as part of the ongoing governance review.

The maternity service did not proactively benchmark outcomes for women against national or pan-London standards and did not have plans for reducing rates of caesarean section. Consultant obstetricians’ engagement with the local maternity network was limited, although we were told this was likely to grow.

There were very few facilities for relatives in the surgical wards. Staff told us they used the staff room or office to communicate sensitive messages with families.

Inspection areas

Safe

Good

Updated 10 August 2018

Effective

Good

Updated 10 August 2018

Caring

Good

Updated 10 August 2018

Responsive

Good

Updated 10 August 2018

Well-led

Good

Updated 10 August 2018

Checks on specific services

Critical care

Good

Updated 24 April 2014

Patients’ needs were being met by the service, and patients were cared for in a supportive way. There were criteria for admission to the unit run by the intensive care staff and the critical care outreach team. Patients received safe care and were treated according to national guidelines and evidence-based practices. Patients and their families told us they felt the unit was safe and the care they received was “excellent”.

Staff used clinical governance methodologies such as audits to monitor the quality and outcomes of their patients. They reported incidents so they could improve on the quality of care patients received. There were processes to ensure patients received care and treatment that was as risk free as possible, and other processes to prevent the spread of infection and monitor risk.

Outpatients and diagnostic imaging

Good

Updated 24 April 2014

The outpatients department was a busy department and provided safe care. The department was clean and well maintained. When clinics were running late, patients were told how long the delays would be and given the reason for them. There were sufficient numbers of staff on duty.

The outpatients department generally met the Department of Health guidelines for ensuring patients received appointments within 18 weeks of referral. Patients told us staff were caring and explained their treatment to them. There were clear lines of leadership in the department and staff knew to whom to escalate concerns. 

Urgent and emergency services

Outstanding

Updated 10 August 2018

  • The service performed consistently better than the England average for patients admitted, transferred or discharged within four hours between February 2017 and March 2018.
  • Length of time for patient assessment from their arrival to the department was better than the overall England median.
  • No patients waited more than 12 hours from the decision to admit until being admitted.
  • The percentage of patients waiting between four and 12 hours from the decision to admit until being admitted was consistently better than the England average.
  • 95% of patients between March 2017 and February 2018 would recommend the service to friends and family if they needed similar care or treatment.
  • Staff demonstrated very good safeguarding awareness and were confident about how to escalate concerns.
  • The department was clean and equipment well maintained. Staff followed infection control policies and adhered to ’bare below the elbows’ policy.
  • There were good protocols in place for the recognition and management of sepsis.
  • The service made sure staff were competent for their roles. Appraisals were up to date for all nurses and doctors.
  • Staff knew how to report incidents and could give examples of learning from them.
  • Treatment was delivered in accordance with National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine (RCEM) guidelines.
  • There were many pathways in place which enhanced the patient experience in the department. Clinical pathways aim to promote organised and efficient patient care based on evidence-based medicine and aim to optimise outcomes.
  • There was an active quality improvement programme in place which was monitored by two consultants.
  • Doctors and nurses of all grades were given protected work time to participate in training.
  • We saw staff being compassionate to patients and their relatives. Patients and relatives spoke highly of the kindness and compassion shown to them by staff.
  • We saw staff communicated with and included people so that they understood their care and treatment.
  • There was a separate waiting area and assessment area for children.
  • There were innovative standard operating procedures designed to be responsive to the needs of ‘at risk’ patients or patients with complex needs.
  • The senior leadership of the service was a dynamic and cohesive group with a high level of interaction and good communication across all staff groups.
  • Each member of staff we spoke with told us the leadership team was supportive, visible and encouraging.
  • The department had a clear, achievable and sustainable five year strategy for medical and nursing staff.
  • There was a robust governance structure in place, organised in such a way as to provide full oversight of each area of the department and anticipate potential issues.
  • Patient safety, clinical effectiveness, patient experience, complaints and compliments were regularly discussed at all governance meetings.
  • The service risk register was reviewed and updated at every governance meeting. Departmental risks were widely understood and staff described the same risks as those identified by the leadership team. Measures were put in place to mitigate identified risks.

However:

  • Whilst consultant cover was not in line with Royal College of Emergency Medicine (RCEM) recommendations, we were assured that processes were in place to mitigate this risk with the provision of senior doctor presence in the department 24 hours a day seven days per week in accordance with RCEM guidance.
  • There was a ‘toolkit’ of communication aids for to staff use with patients with learning disabilities, however some nurses we spoke with were not aware of this.

Maternity

Good

Updated 10 August 2018

Maternity and gynaecology

Requires improvement

Updated 11 February 2016

We inspected the trust's maternity services only.

We found improvements had been made to ensure the safety of the service and action had been taken to ensure the appropriate care and welfare of women. However we found robust observational checks of babies were not in place. The cleanliness and hygiene of the unit had improved significantly. The areas we inspected were visibly clean and there was a system of checking processes for ensuring high standards of cleanliness were adhered to. However we found a few isolated incidents where cleanliness could be improved. There was sufficient evidence that the warning notices for care and welfare of women and their babies and cleanliness and infection control had been met.


We found improvements had been made in assessing and monitoring the quality of the service. There were strengthened governance systems in operation and there was staff engagement in improving the quality of the service. However we found there was still a need to improve and strengthen governance structures and reporting systems. Governance information was reported adequately at appropriate meetings, however external challenge by the trust’s centralised governance team needed to be further embedded and supported by staff in the maternity unit to ensure appropriate support and challenge. A leadership programme was planned for senior staff within the service. There was evidence the warning notice had been met, however the governance structures in place needed further review and embedding to ensure they were consistently protecting women and their babies from unsafe care. We issued a requirement notice.

Medical care (including older people’s care)

Outstanding

Updated 10 August 2018

  • The environment on the medical wards and areas we visited was visibly clean and tidy and staff followed the trust’s infection control policy. We saw staff used personal protective equipment, washed their hands in between attending to patients adhered to the trust’s ‘bare below the elbow’ policy.
  • Although medical wards were reliant on bank and agency nurses to staff wards, local and divisional leadership had mitigated the risks associated with temporary staff well.
  • Identifying, screening and monitoring of patients at risk of deteriorating had improved significantly since the last inspection. The trust had improved access to the critical care outreach team which provided quicker response to deteriorating patients, while the sepsis nurse provided training for staff and advice for patients at risk of deteriorating.
  • There was consistent consultant presence on medical wards during normal hours and sufficient on-call support on nights and weekends. The use of locum doctors on medical wards was low, and there were speciality consultant roles on-site and on-call to manage specific patient emergencies.
  • Staff were aware of policies and protocols in relation to the administration of medication, and we observed adherence to these protocols. Staff recorded administration of medication, and performance was maintained through audits. Controlled drugs (CDs) were also managed safely and securely.
  • Medical ward staff investigated all incidents and used learning to improve the delivery of care. Incidents were reported on and discussed through the divisional governance structure, and from this actions were identified to minimise the risk of repeat occurrences. Staff told us they were encouraged to report incidents by managers and we found there was a positive attitude towards raising concerns.
  • Patient care was delivered in line with evidence-based guidance from the National Institute for Health and Care Excellence (NICE), the Royal Colleges and other relevant bodies. Policies we viewed were reviewed regularly, and new clinical guidelines were disseminated to staff by email and in divisional and team meetings.
  • Throughout our inspection we saw consistent evidence of effective multidisciplinary team (MDT) working across all disciplines and wards. The delivery of patient care included healthcare professionals from all the backgrounds necessary, and their input was reflected in patient records. Ward staff worked closely with staff in other divisions, as well as with community services.
  • Across medical wards we observed positive interaction between patients and staff. Staff were available to support patients when needed and treated them with dignity and respect. Interactions between staff and patients were friendly and staff took time to make sure patients were comfortable.
  • We found the service was responsive to the needs of patients and the local community. The division which included medical wards also included the delivery of local community services, which facilitated the integrated delivery of care for patients on their transfer from inpatient to community teams.
  • There was an effective system for bed management on the assessment unit and throughout the medical wards. Admissions and potential discharges were discussed daily in the consultant-led morning white board rounds, which informed the site managers and emergency department of bed availability throughout medical wards.
  • There was a clear governance structure within the division and staff at all levels were clear about their roles and what they were accountable for. The divisional structures were managed by the leadership triumvirate and communication from divisional leadership down to ward level was clear. The divisional leadership had oversight of clinical governance and operational governance through monthly divisional meetings.
  • During the inspection most staff we spoke with felt they were listened to by the divisional leadership and felt they could approach managers if they needed support. Staff stated managers had an open door policy and felt they would be listened to if they had any issues or raised any concerns.

However:

  • Mandatory training completion for medical staff on wards was 73%, below the trust target of 90%.
  • We found staff understanding of the responsibilities for Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLS) was variable across wards.
  • Recording of capacity assessments and decisions on deprivation of liberty were not consistently or appropriately documented in patient records. The safeguarding team had introduced a new electronic MCA form in June 2017 to improve recording of capacity assessments, however this was not being used consistently on medical wards.
  • We found a variable degree of knowledge and promotion of the trust values across medical wards. Some staff were able to identify the four trust values, while others were unclear.

Surgery

Good

Updated 10 August 2018

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

  • Following our last inspection in February 2014 we issued one requirement notice requiring the service to take action to remedy breaches to Regulation 20 (1) (a), in relation to records and issued seven actions the provider should take to improve. During this inspection, the service had dealt with or shown improvement for most of the previously reported concerns.
  • The trust had addressed the previous inspection’s requirement notice in relation to records through the implementation of electronic patient records (EPR) throughout the hospital. We reviewed 28 patient records and found all records were completed in a logical and comprehensive way with no gaps or inconsistencies.
  • Staff were encouraged to raise concerns and to report incidents and near misses. The division effectively shared learning from incidents and good practice with staff through regular meetings.
  • All of the areas we inspected were clean, tidy, and clutter free. Patients, relatives, staff and managers we spoke with consistently told us they were satisfied with the cleaning services in the ward and operating theatre areas.
  • During our last inspection we identified concerns around the storage of medicines and controlled drugs. During this inspection we found this had improved and medicines and controlled drugs were stored securely in the clinical areas and operating theatres. A remote electronic system monitored fridge temperatures and if temperatures were out of range, the pharmacy team received an alert.
  • The trust had clearly defined and embedded processes to keep people safe from abuse and staff demonstrated understanding of safeguarding processes and awareness on how to escalate and report safeguarding concerns.
  • During our last inspection we found the trust did not use the nationally recommended early warning score for monitoring changes in a patient’s condition. During this inspection, we found this had improved as the trust had implemented the national early warning score (NEWS) to effectively assess and escalate deteriorating patients. Staff had good knowledge of what to do in the event of a patient deteriorating.
  • During our last inspection we identified concerns around the consistent completion of venous thromboembolism (VTE) assessments. During this inspection, we found this had improved as the surgical service consistently met the 95% trust target for VTE risk assessments.
  • The service demonstrated effective internal and external multidisciplinary (MDT) working, for example the service had links with the trust social worker and the homeless liaison officer as part of discharge planning.
  • During our last inspection, we were told there was no orthopaedic medical cover based on site out of hours. During this inspection, we found the service had improved the onsite orthopaedic medical cover for out of hours with eight consultants who provided orthopaedic medical cover on call and remote support (off-site) from an orthopaedic senior doctor in training.
  • People using the trust’s surgical services were treated with dignity and respect.
  • Patients told us they felt listened to by health professionals, and felt informed and involved in their treatment and plans of care.
  • Staff provided patient-centred support in clinics and in homes. For example, the surgical rehabilitation team visited patients in their homes for up to two weeks post discharge.
  • The service was responsive to the needs of people using it and had adapted to meet the diverse needs of the community it served.
  • During the last inspection we found the trust did not have a dementia identifier which was considered good practice by the Alzheimer’s Society. During this inspection, we found this had improved as the trust had introduced a dementia identifier and all staff received a dementia awareness training session.

  • During the last inspection, we found lack of information on display for patients who wanted to raise a concern. During this inspection, we saw some improvement in signposting for patients in some surgical areas but not all.
  • The trust had responded appropriately to address whistleblowing incidences in both theatres and pre-operative assessment areas. At the time of our inspection, the trust’s interventions and development work were ongoing.
  • Senior leaders and managers of the surgical service had a good understanding of risks to the service and these were appropriately documented in risk management documentation with named leads and actions.
  • The trust delivered a broad range of surgical services including a number of highly specialist services such as the Homerton Anal Neoplasia service (HANS). It was the only one of its kind in the UK and one of very few in the world.
  • The hospital was a regional centre for bariatric surgery. The service was actively involved in clinical research and in regional teaching of bariatric surgery doctors in training.

However:

  • Medical and nursing staff in the service did not meet trust targets for most mandatory training modules. However, senior leaders acknowledged that the current method of monitoring compliance rates was not robust enough and they were currently addressing this.
  • The NHS Friends and Family Test (FFT) response rate for surgery was 19% between December 2016 and November 2017, which was worse than the England average of 29%.
  • During this inspection, staff and managers told us about frequent late starts in theatres. We requested trust data in order to investigate this further but found the trust did not collect the requested data. For example, the trust did not collect data for the number of ‘on the day’ list changes with reasons despite list changes contributing to late starts in theatres.
  • There were very few facilities for relatives in the surgical wards. Staff told us they used the staff room or office to communicate sensitive messages with families.
  • The trust had inconsistent governance structures across surgical specialities. The divisional management team was aware of varied agendas and quality of reporting and there were plans to address this as part of the ongoing governance review.
  • The NHS Staff Survey 2017 survey results showed the trust scored below the national average (86%) for this indicator with 76%.
  • During our last inspection the trust was asked to consider introducing ‘patient safety at a glance’ boards across all wards to improve communication and safety. During this inspection we found the surgical wards did not display the NHS safety thermometer information for staff or patients to view.

Services for children & young people

Good

Updated 24 April 2014

We spoke with 12 children, 15 parents, nine nurses, three managers, four doctors and received 11 comment cards. We found that children’s services were safe. Whenever possible, children were protected from avoidable harm.

There were effective systems in place to ensure the care delivered met children’s individual needs. Staff had appropriate training and followed standard operating procedures as well as relevant guidance to deliver care. Staff were caring and described as “loving”, “easy to talk to”, “very supportive, through a difficult time” and “willing to go the extra mile”.

The trust served a diverse population, was responsive to children’s needs, including services such as City and Hackney Young People's Services Plus (CHYPSPlus), which provides holistic health services for young people aged 11-19 years. Staff were aware of the trust’s values and vision, and felt supported by senior management. They told us they could report incidents without the fear of being blamed. 

End of life care

Good

Updated 24 April 2014

Patients received safe end of life care. There were systems in place to ensure patients were kept safe. They were given information and support to make decisions about their care as inpatients, and they were involved in the planning of their discharges. Patients’ individual care needs were being met within the hospital and effective discharge planning took place that used established links with local community services including St. Joseph’s Hospice in Hackney. Staff received appropriate training and support, and understood the good practice guidelines and pathways in place. The service was well led by an experienced palliative care team that was respected and valued by medical, nursing and other colleagues in the hospital.

Other CQC inspections of services

Community & mental health inspection reports for Homerton University Hospital can be found at Homerton University Hospital NHS Foundation Trust.