You are here

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.

Reports


Other CQC inspections of services

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

Inspection carried out on 10 April 2018

During a routine inspection

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 carried out on 28 October and 4 November 2015

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

Inspection carried out on 17, 23, 24 March 2015

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

The Homerton University Hospital provides maternity services for the local community of around 252,000 people in the London borough of Hackney.

The maternity unit delivered over 5,500 babies in 2014. There is a consultant led delivery suite as well as a midwifery led birth centre. The maternity unit is supported by a level 3 neonatal unit.

We inspected the hospital in February 2014 when we rated the maternity service as good for all fiveareas we look atand good overall. In response to concerns we undertook an unannounced focused inspection of the maternity unit on 17 March 2015 and an announced inspection on the 23 and 24 March 2015. Concerns had been raised by the Clinical Commissioning Group (CCG) and an external review into four of the maternal deaths between July 2013 and April 2014 which was shared with us on 24 February 2015.

Our key findings were as follows:

Safe:

  • There were systems and processes in place for reporting and investigating serious incidents and deaths but not all incidents inmaternity service were reported.
  • Therewere unacceptable levels of serious incidents and never events.
  • Reported incidents wereinvestigated but the response was slowresulting in continued potential risks to mothers and their babies.
  • Staff were not proactive in maintaining a safe environment and boththe environment andequipment werenot appropriately cleaned.
  • The wards had the required equipment. However resuscitation and emergency equipment had not been consistently checked to ensure it was ready for use.
  • Drugs were not administered or stored safely in the maternity service.
  • Midwifery staffing levels wereless than the recommendations of Birthrate Plus. Some shifts on the labour suite were staffed predominately withbank and agency staff.
  • The trust's safeguarding policy was out of date and did not reflect the latest national guidance.

Effective:

  • The unit's performance was outside the trust's internal and national targets for many of theoutcomes monitoredsuch as sepsis, post partum haemorrhageand the number of births by normal delivery.There was limited evidence of action being taken to address these areas.
  • There was limited evidence that audits undertaken had positively influenced practice.
  • Many of the clinical guidelines had been reviewed and were up to date.
  • Women and babies nutritional, hydration and pain relief needs were managed.
  • Maternity care assistants were responsible fortaking the observations of mothers and babies, however there was no processto ensure they were competent to undertake this task.
  • The majority of midwives did not understand the Mental Capacity Act (MCA) and their responsibilities in this area.

Caring:

  • Most women and their partners were positive about the care they received. They understood and felt involved in their care.
  • Most women and those close to them received the emotional support they needed.
  • There was a low response rate to the Friends and Family Test (FFT) andstaffwere unaware of the feedback from this survey.
  • Limited action had been taken in response to the national maternity survey (2013)and action plans developed to respond to the findings were notmonitored.

Responsive:

  • Staff were aware of the demographics of their local population and responsive to the needs of established ethnic minority groups but not to other groups.
  • Family members were often used to translate.
  • Complaints were not responded to in line with the trust's policy and response times.Staff were unaware of anylearning orchanges in practice in response to engagement with the people using the service.

Well-led:

  • The vision and strategy for maternity services was not well established.
  • Staff gave positive feedback about the leadership and culture of the service.
  • There were identified leadership roles in the maternity services, at ward level, staff felt supported by the matron and ward sisters.
  • Some performance data was unreliable and not used consistently to identify poor performance and areas for improvement.
  • Key risks were not recorded on the risk register and mitigating action had not been taken.

  • Poor standards and performance was not consistently challeneged by the patient safety committee.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure all incident investigations are completedin a timely manner, taking into account wider factorsand embedded into practice, sharing learning trust wide as appropriate.
  • Review the standards of cleaningand the maintenance of the environment and equipment taking action to ensure they are fit for purpose.
  • Ensure all staff adhere to the trust’s guidance on the use of MEOWS including routinely determine frequency of observations of women.
  • Review the outcomes for mothers and take appropriate action to address adverse outcomes.
  • Improve the quality and accuracy of performance data and increase its use in identifying poor performance and areas for improvement.
  • Ensure the risk register includes all key risks and mitigating actions to reduce these risks.
  • Identify common actions or issues in action plans to facilitate a more co-ordinated approach to learning and improvement.
  • Ensure interactions on the postnatal ward are not task specific.

The trust should:

  • Display information to demonstrate the service’s performance against safety measures or targets in all clinical areas.
  • Ensure the signage to maternity services is clear to avoid ambulance crews and mothers and their partners experiencing delays in accessing services.
  • Action should be taken to ensure all medicines are stored securely to avoid unauthorised access.
  • Improve the standard of record keeping, consistently recording mothers and babies observations, MEWOS and fluid balance.
  • Review the security arrangements in the service to prevent unauthorised access to wards and the removal of babies from the delivery suite or postnatal ward.
  • Review the training provided to maternity care assistants to ensure they have the necessary skills and competencies to deliver safe care to mothers and babies.
  • Use a neonatal early warning score to record baby’s observations including taking their temperatures within one hour of birth.
  • Ensure all policies reflect current national guidance and these are communicated to all staff. Including drafting and implementing a maternal collapse policy in line with professional guidance.
  • Ensure all staff are familiar with the structured communication tool method Situation, Background, Assessment, Recommendation (SBAR) and are able to use this tool effectively.
  • Review staffing and skill mix, including the percentage of non-permanent staff used to ensure they are appropriate to meet the needs of mothers and their babies.
  • Ensure all midwives understand the MCA, how this relates to their practice.
  • Explore ways to improve the response rate to the FFT and alternative ways to collect feedback from mothers and their partners.
  • Improve the provision of translation services and availability of written information in a range of languages other than English.
  • Improve the response times to complaints.
  • Explore ways to increase the level of enquiring and challenge among staff in relation to poor standards and performance.
  • Develop theleadership skills ofshift leaders to prepare them for this role and hold them accountable for their performance.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 5-7 February 2014

During a routine inspection

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 carried out on 3, 4 December 2013 and 10 January 2014

During a routine inspection

This inspection took place over three days and focused on community health services for young people, adults and children living in Hackney and adjoining neighbourhoods in the City of London. The inspection team visited two health centres, a pulmonary rehabilitation group and CHYPS (City and Hackney Young People's Service Plus), which was a one stop shop for health information, health services and free advice for young people aged 11-19 years old. We spoke with a wide range of community based health professionals including midwives, therapists, community nurses and health visitors.

We met with people who use the service and their representatives throughout the inspection. We spoke with 41 people and 19 people completed our comment cards, which were available at the health centre and clinic on the days we visited these services.

Most people told us they were pleased with the quality of the service. Comments from people using the service included, "the leg ulcer clinic is very good. They look after me and I'm very very happy with the service", "the health visitors always answer questions, they do listen to you and respond. The information has been good" and "I am treated with respect and they listen to me, but sometimes I can wait half an hour to an hour to be seen."

We found that people who use the services we inspected were treated in a respectful manner. They were provided with information about their care and treatment, and were supported to make choices. People told us they received individualised care and they felt safe with staff. Most people using the service told us that staffing levels were satisfactory, although three people said their district nurses were sometimes late. Records showed that staff had regular training. The trust had appropriate systems in place for monitoring the quality of the service.

Inspection carried out on 6 February 2013

During a routine inspection

We visited the Maternity and the Elderly Care Units and spoke with patients, relatives and staff from medical, nursing and other backgrounds. Patients and relatives were predominantly positive about their experiences.

One patient on the Maternity Unit told us, “I’ve never had any problem. That is why I keep coming here. The midwives know exactly what they are doing but there should be more midwives on the delivery ward.” Another patient said, “the midwives are very nice. They offered to show me and help me with breastfeeding. There was more than enough staff and I felt really supported.”

A patient on the Elderly Care Unit said, “the nurses are looking after me nicely, and encourage me to eat and get strong. They come and make sure that I am comfortable. The food is good, mostly. Another patient told us, “sometimes it’s good, sometimes it’s bad. It depends on the staff. They always talk to me with dignity and respect. They do their cleaning good, its always clean."

We found patients received care that met their needs and was delivered in a respectful manner.

Patients told us they felt safe and knew how to make a complaint.

There were adequate staffing levels to meet patients’ needs and staff received training, support and supervision.

Systems were in place to monitor the quality of the service and respond to issues that needed improvement.

Inspection carried out on 20, 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 22 November 2011

During a routine inspection

We carried out this inspection on 15 November and 22 November 2011, visiting the following wards and departments:

Aske Ward (elderly care), Edith Cavell Ward (gastroenterology/rheumatology), Lamb Ward (respiratory/general medicine) and Lloyd Ward (endocrinology/haematology/general medicine); the Delivery Suite and Birthing Centre, Templar Ward (postnatal care) and Turpin Ward (antenatal care); Starlight Ward (paediatrics); the Accident and Emergency Department and the children's Accident and Emergency Department; the Regional Neurological Rehabilitation Unit and a range of outpatient clinics. We also talked to the hospital-based social work team and visited the Patient Advice and Liaison Services office.

This inspection focused on the acute services provided by the trust at Homerton University Hospital. In the course of the inspection we spoke to around 40 patients and relatives, 30 members of staff, reviewed 15 patient records and observed the environment in all the areas we visited.

Most patients and their relatives said they received a very good level of care, treatment and support. Patients described Homerton as a 'good hospital'. People generally praised the staff and said that they explained and answered questions about their care and treatment. Very few people we spoke to had complaints about the service they had received.

Our observations of care and discussions with patients and staff identified some specific issues around patient experience in the Regional Neurological Rehabilitation Unit. We recognised that this service was achieving positive outcomes and helping people's recovery and rehabilitation but felt that at times the trust did not do enough to protect people's dignity on this unit.

Inspection carried out on 16 March 2011

During a themed inspection looking at Dignity and Nutrition

People were positive about the Homerton University Hospital and praised the staff as caring and hard working. Patients told us that staff treated people with kindness, for example when helping people to eat. People had generally been given enough information but medication was sometimes an area where people wanted to know more. People said that they and their families had been involved in decisions and they had received helpful support from professionals. People felt able to raise any issues and said that staff had always listened even if the problems were not fully resolved.

Most of the people we spoke to said there was a choice of meals and the food was good. One person did not find the hot meals appetising but could find things they liked from the cold options. At the time of our visit, patients reported a lack of choice of kosher meals. One patient said they had to wait too long for lunch and we also observed this. Patients said that staff checked they had enough to eat. Two people mentioned that they were weighed regularly and their fluid intake was being checked. One of the patients we spoke to had initially been admitted to the ward after tea time. The nurses had brought them some food so they did not go hungry. None of the other patients we interviewed had missed a meal.