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Inspection Summary


Overall summary & rating

Good

Updated 24 April 2014

Homerton Hospital became Homerton University Hospital NHS Foundation Trust on 1 April 2004 – one of the first 10 trusts in the country to achieve foundation status. The trust comprised a medium-sized hospital providing acute, specialist and community services to Hackney and the City of London. The trust also owned Mary Seacole Nursing Home and was responsible for Hackney and City community health services.

The trust served a diverse population: the London Borough of Hackney and the City of London. In 2010, the Indices of Deprivation showed that Hackney was the second most deprived local authority in the country, although there was evidence of less deprivation period 2007 to 2010. In contrast, the City of London (which is the country’s smallest county and holds city status in its own right) was judged as being the 262nd most deprived local authority (there were 326 local authorities with the first being the most deprived). Both Hackney and the City of London had increasing populations and higher than average numbers of patients from Black, Asian and minority ethnic communities. There was a consensus view from local stakeholders, patients and staff that The Homerton was part of the local community and met the needs of its local population well.

The trust provided specialist care in obstetrics and neonatology, foetal medicine, fertility, HIV, keyhole surgery, asthma and allergies, bariatric surgery and neuro-rehabilitation across east London and beyond. The trust had seen some changes in leadership in 2013 with three out of five executive directors having been appointed in 2013.  However, only one of these three executive directors, the Chief Nurse and Director of Governance, joined the trust from an external organisation.  The Chief Executive and the Chief Operating Officer were internal appointments and were working in other senior roles within the trust prior to taking up their new posts in 2013.

Staffing

The trust had over 500 beds and employed over 3,500 staff. A further 1,000 staff were either contracted to work or placed for training in the Homerton. Many of the senior staff at the trust had been working at the hospital for a number of years and students we spoke with said they were keen to come back to work at the trust when they qualified. However, in the medical wards we found there were nursing staff shortages, and that these were having an impact on patient care in being able to provide care in a timely manner. The trust spent 9.9% of total staffing costs on agency staff, nearly double the spend across London. Staff sickness rates overall at the trust were just below London and England averages, midwifery staffing sickness levels, were significantly lower and were 2% compared with an England average of 4.3%.

Cleanliness and infection control

All areas visited at the Homerton were clean and levels of cleanliness were the same on our unannounced inspection visits. In the NHS staff survey of 2012, 47% of staff said that hand washing facilities were always available which was worse than expected. However, when we visited, we saw there were adequate hand washing facilities and staff and visitors had access to liquid soap hand cleansing gel. During the 12 months from August 2012 to July 2013, the trust reported four cases of meticillin-resistant staphylococcus aureus (MRSA) infection; this was within a statistically acceptable range relative to the trust’s size and the national level of infection. During the same time period, there were 10 reported cases of Clostridium difficile, which was also within a statistically acceptable range given the size of the trust.

We rated the Homerton as a good hospital with an outstanding accident and emergency (A&E) department. Staff felt valued and enjoyed working in the hospital, and patients felt cared for and had faith in the staff looking after them.

Inspection areas

Safe

Good

Updated 24 April 2014

The Homerton was a safe hospital in which to receive treatment. We identified areas where staffing levels should be increased and this will improve safety for patients.

The rates of new pressure ulcers developing at the Homerton were lower than the average rate in English hospitals. The trust had two Never Events (events so serious they should never happen) between 1 December 2012 and 31 November 2013 – this figure was no more or less than trusts of a comparable size. We found that staff had learnt from the events to minimise the risk of them occurring again. All staff were aware of these events and could describe the processes that had been put in place to prevent them happening again.

The hospital was clean and well maintained. The roof required some repair work. However, the issues with the roof did not concern the clinical areas.

Effective

Good

Updated 24 April 2014

Patient care was effective. The staff worked well collaboratively to ensure patients got the best possible outcomes. National, evidence-based guidelines were followed and monitored; departments audited their work and shared their findings in departmental meetings. Before our inspection, we had some concerns about re-admission rates for patients who had been discharged from the Homerton – specifically, that patients may be being discharged earlier than appropriate. However, we found this was not the case and patients were overall discharged in a timely manner.

Overall, the multidisciplinary teams (MDTs) worked well together and this was particularly the case in the A&E department. 

Caring

Good

Updated 24 April 2014

Most patients we spoke with told us that staff were caring and respectful, and we saw staff treating patients with dignity and respect. During busy times in outpatients and A&E volunteers and staff gave patients food and drink while they waited to see a doctor. The one exception where this was not the case was in the maternity services; there were some negative comments about the attitudes of a few midwives at night from women on the maternity wards. 

Responsive

Good

Updated 24 April 2014

Services at the Homerton were responsive to patients’ needs. The trust was meeting A&E targets for 95% of patients being seen within four hours of arriving at the hospital. Although we initially had concerns that the number of unplanned re-admissions was higher than expected, the trust was able to explain why the figures were high.

Patients told us that staff attended to their needs promptly.

Well-led

Good

Updated 24 April 2014

The hospital was well led. Staff told us they felt supported and valued. The chief executive, medical director and chief nurse were well known at all levels of staffing; staff felt confident that not only would they be able to identify executive team members if they came onto the wards but that in many cases the executive team members would know them too. The non-executive board members we met were not as well known by the staff. We met with the council of governors and non-executive directors who clearly understood their role and were highly supportive of the leadership of the trust board.

A clear strategy for what the trust was achieving and aimed to achieve was evident and staff demonstrated the values of the trust – personal, safe, respectful, responsibility.

Checks on specific services

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)

Good

Updated 24 April 2014

The medical care wards we visited assessed and reviewed patients’ nursing and medical needs adequately and we found care was delivered in accordance with patients’ needs. However, some documentation, such as wound care management records, were not always adequately completed and there was a reliance on verbal nursing handover in place of appropriate recording of care planning and delivery. Some systems in place, including falls assessments and identifying deteriorating patients, did not meet nationally recognised guidelines.

The level of medical staff cover was good, as were the systems in place to ensure patients received multidisciplinary care. We found there were effective ward handover processes, but on some wards there were at times insufficient levels of trained nursing staff, which meant that patients did not always receive the care they needed in a timely fashion. There was a reliance on bank and agency staff to cover shifts, which was at times to the detriment of patients, including those who needed prompt pain relief and those with dementia.

Patients received compassionate care from well- trained staff who promoted their privacy and dignity. The majority of patients we spoke with were happy with the care they received, although some patients told us they had not been fully involved in their care, or informed about their progress. We found consultants did not always involve patients or their families in ‘do not attempt resuscitation’ (DNAR CPR) decisions.

The trust had appropriate arrangements in place to monitor the quality of the service, and we found that improvements had been made when there had been incidents or complaints relating to the medical wards. Staff were not always aware of the performance of their ward because they were not familiar with the  performance dashboard which had been implemented shortly before our inspection.

Urgent and emergency services (A&E)

Outstanding

Updated 24 April 2014

Since April 2013, the accident and emergency (A&E) department had consistently been meeting the government’s 95% target for admitting, transferring or discharging patients within four hours of their arrival in A&E. Initiatives were in place to respond to patient need and to ensure patients were seen in a timely manner.

Approximately a third of patients attending the department received services from the primary urgent care centre (PUCC). The role of a non-clinical navigator (NCN) was introduced to further support this patient group. The NCN supported patients to locate and register with their local GP practice. This meant patients were able to have their primary medical needs met in the local community rather than coming to the A&E department.

The team were was aware they had a high number of patients regularly re-attending the department. The first response duty team (FRDT) was established to address this. The FRDT worked with patients to identify their support needs and meet those needs in the community, reducing the number of patients requiring needing hospital admission.

We observed positive interactions between staff and patients. Staff took the time to listen to patients and explain to them what was wrong and any treatment needed. Patients told us they had all their questions answered and felt involved in making decisions about their care.

The staff we spoke with were proud to work for the A&E department and felt there was a ‘can do’ attitude within the team. There were processes in place to monitor the quality of the service and respond to areas highlighted as requiring improvement. We saw that learning was shared among the staff team regarding Never Events, incidents and complaints within the department and across the hospital. Staff were encouraged and enabled to attend training courses and further their skills and knowledge to improve the service provided to patients.

Surgery

Good

Updated 24 April 2014

Patients we spoke with during our inspection were positive about the care and treatment they had received. They were complimentary about the staff in the service and felt informed and involved. One patient told us they had chosen to be treated at the Homerton and another patient described it as “fantastic”. The two surgical wards had performed poorly in the Friends and Family test, but action had been taken to improve this. For example, staffing levels had been increased. Patients knew how to raise a concern and complaints were managed in line with the trust’s policy and procedure.

There were mechanisms to ensure that patients were kept safe. Patients were assessed before their surgery to ensure this was appropriately managed. They were also assessed when admitted to a ward area to determine the level of nursing required. We found some inconsistency and gaps in nursing documentation, such as repositioning charts, and patients’ preferences had not always been documented.

Patients received effective care that met their needs. Nationally recognised guidelines and pathways were followed and we found evidence of good multidisciplinary working. Theatres were responsive and had appropriate staffing coverage overnight and at weekends.

Staff were proud to work for the service and they had confidence in both service and trust leadership. There was an open, supportive culture where staff were encouraged to report concerns and were involved and empowered to make changes. There were clear clinical governance arrangements in place and managers were aware of the risks in their area and what action was being taken to reduce them

Intensive/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.

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.

Outpatients

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. 

Other CQC inspections of services

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