All inspections: University College Hospital & Elizabeth Garrett Anderson Wing

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at University College London Hospitals NHS Foundation Trust

We inspected the maternity service at University College London Hospitals as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our ratings of the maternity service stayed the same and the ratings for the hospital remained the same. We rated safe and well-led as good, and the hospital rating remained as requires improvement.

University College London Hospital is a large teaching hospital located in central London. Maternity services are located in the Elizabeth Garret Anderson Wing. The maternity service at University College London Hospital provides consultant-led and midwife-led care for both high and low risk women. The hospital is a tertiary referral centre for complex maternal and fetal indications.

How we carried out the inspection

During our inspection of maternity services at University College London Hospitals NHS Foundation Trust we spoke with 35 staff including senior leaders, obstetric staff, specialist midwives, matrons, midwives, student midwives, maternity support workers, nursery nurses, clinical governance leads and safety champions to better understand what it was like working for the service. We interviewed leaders to gain insight into the trust’s leadership model and the governance of the service. We reviewed 6 sets of maternity and 10 medicine records. We also looked at a wide range of documents including standard operating procedures, meeting minutes, risk assessments, recent reported incidents as well as audits and audit actions.

We ran a poster campaign during our inspection to encourage pregnant women and mothers who had used the service to give us feedback regarding care. We received 48 feedback forms from women. We analysed the results to identify themes and trends.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

University College Hospital and Elizabeth Garrett Anderson Wing is a large teaching hospital located in central London. It provides a range of acute and specialist services. The hospital includes the Macmillan Cancer Centre, which provides facilities for the diagnosis and treatment of a wide range of cancer and non-cancer conditions. The hospital has 679 general and acute inpatient beds, 12 theatres and one of the largest critical care departments in the NHS.

We last inspected the hospital in July 2018 and rated it as requires improvement.

Our rating of services went down. We rated the hospital as requires improvement because:

We rated safe and responsive at this hospital as requires improvement and we rated effective, caring, and well-led as good.
Although the trust had made many improvements to the hospital’s emergency department, we found a number of areas that still required improvement. Similar to the previous CQC inspection, we found that patient documentation was not consistently completed and that the department performed poorly against the Department of Health’s standard of 95% for time to treatment and decision to admit, transfer or discharge.
Patients with mental health needs often experienced delays within the ED and best practice guidelines for care and treatment of these patients were not consistently followed. At the time of this inspection, there was no parallel assessment of a patient’s physical and mental health needs. The trust was in process of reviewing its service level agreement with the third party provider of the psychiatric liaison service and was working with the provider to identify and address problems with service delivery.
Mandatory training compliance rates for medical staff fell below the trust target.
The trust performed worse than the 85% operational standard for patients receiving their first cancer treatment within 62 days of an urgent GP referral.
Midwifery staffing levels were low in relation to the acuity of women. Women did not always received one-to-one care in established labour. The trust recognised that this had a negative impact on staff morale and patient experience and we saw there were plans in place to address this. Staffing levels were regularly reviewed and staff were redeployed within the maternity unit when needed to keep patients safe.
We observed a number of lapses in good infection prevention and control measures including some staff not following trust procedures for bare below the elbow, use of personal protective equipment or disposal of infectious material. The cleanliness of the environment and equipment in some areas presented an infection control risk.
We found that actions from risk assessments were not always implemented. For example, concerns around use of surveillance cameras within the endoscopy unit were not addressed effectively and some of the divisional leaders were not aware of the use of these cameras within the unit. We were concerned that staff process flow was prioritised over patients’ privacy and dignity. After this had been pointed out to the trust they withdrew the use of the screen while they reviewed their practice in this area.
There was a backlog of GP and discharge letters in the IT system and there were delays for non-urgent letters being sent out via the new electronic systems. This was on the trust risk register, and an action plan was in place to resolve the issue.
Patients found it hard to contact the trust via telephone to discuss their appointment, with many calls going unanswered.
Emergency equipment was not always stored securely and checked daily. We found two ward areas where resuscitation equipment was not secure and could be accessed by unauthorised persons.
Whilst we saw many examples of good practice in relation to medicines management, the trust’s policies for safe storage and management of medicines were not always followed consistently.

However:

We rated all services inspected at this hospital as good, other than urgent and emergency services (ED).
The trust had made several improvements to the emergency department to provide a better and safer patient experience including improving consultant cover and how effectively the department managed sepsis.
Leadership within the ED and medical care services had improved.
The hospital had systematic and established systems in place for reporting, investigating and acting on incidents and serious adverse events. There was an open culture of reporting, and learning was shared with staff to make improvements.
There were effective arrangements in place to safeguard patients from abuse and mitigate the risk of it happening.
The service made sure staff were competent for their roles. Staff were encouraged to undertake continuous professional development, so the trust was ensured staff were competent for their roles and were able to provide an effective service.
Staff followed national professional standards and guidelines to achieve the best possible outcomes for patients receiving care and treatment. There was an effective process and system in place to ensure guidelines and policies were updated and reflected national guidance and improvement in practice. Audits and quality outcomes were conducted at departmental level to monitor the effectiveness of care and treatment.
Different groups of staff worked together as a team to benefit patients. Medical staff, nurses, midwives and allied health professionals supported each other and worked collaboratively to ensure patient centred and effective care.
Patients and their families were treated and cared for with compassion, patience and respect. Feedback from patients about their experience of care was consistently positive. We observed staff listening to patients and discussing aspects of their care.
Services were planned and provided in a way that met and supported the needs of local people, including those with complex or additional needs. The trust worked closely with the commissioners, clinical networks, patients and other stakeholders to plan the delivery of care and treatment.
There was a positive and friendly culture. We observed good team working amongst staff of all levels. Staff told us that they were proud to work for the hospital and were well supported by their colleagues.
Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Leaders were knowledgeable about service performance, priorities, as well as challenges and risks.
There was a strong culture of improvement, research and innovation. There was a commitment to improving services by learning both when things went well and when they went wrong. Safe innovation and team success was celebrated.

University College Hospital (UCH) is a teaching district general hospital situated in the London Borough of Camden in Central London. It includes the Elizabeth Garrett Anderson Maternity Wing and is part of the University College London Hospitals NHS Foundation Trust. It has close association with University College London (UCL).

The hospital has720 in-patient beds, 12 operating theatres and houses the largest critical care unit in the NHS. The Emergency and Urgent Care department sees approximately 171000 patients per year.

UCH is a major teaching hospital and is closely associated with the UCL Medical School. It is also a major centre for medical research.

In 2015 the urology department moved to the University College Hospital site in Westmoreland Street which had formerly been the Heart Hospital.

We carried out this inspection as part of our comprehensive acute hospital inspection programme for NHS acute hospital trusts. We had earlier inspected this hospital in November 2013 but we did not at that time formally give a rating for the hospital and its core services as we were at that time still in the pilot stage of our new and current methodology.

The announced part of the inspection took place between 8-11 March 2016, and there were further unannounced inspections which took place between 18 – 25 March 2016.

Our key findings were as follows:

Overall we rated University College Hospital as Good.
We rated surgery, critical care, maternity and gynaecology, services for children, and outpatients and diagnostic imaging as good. We rated urgent and emergency care, and medical care as requires improvement. Because specialist palliative care is provided through a service level agreement by a third party provider we have not reported on that service.
Overall we rated effective, caring, responsive and well- led as good and safe as requiring improvement.
The organisation had a long-standing model of tripartite management (nursing, medical and general management), reporting to a Medical Director. The organisation had a clear vision and ambition for specialist care and research. Local services, i.e. emergency care for the local population, also featured in the Trust strategy and it was noted that capital investment had been identified to the support the development of the Emergency Department.

We saw areas of good andoutstanding practice including:

There was outstanding local leadership in critical care with high levels of staff and patient engagement.
In maternity and gynaecology we saw examples of outstanding world class practice, notably the One Stop first trimester Down’s syndrome Screening clinic with immediate Fetal Medicine referral, the gynaecology Integrated ‘One Stop’ Diagnostic and Testing service, and the see and treat service in colposcopy.
We found all staff overwhelmingly to be dedicated, caring and supportive of each other within their ward and division.
We saw high levels of support given to staff in an innovative environment with good examples of innovation and best practice.
Improvements had been made to the environment inthe emergency department (ED)removing patients doubling up in cubicles which had been noted in the previous inspection.
We found patient feedback when treatment had been given to be overwhelmingly positive.
In surgery, staff demonstrated good knowledge of reporting, investigating and learning from incidents.
There were on-going improvements in the use of the World Health Organisation (WHO) five steps to safer surgery checklist.
We saw staff treating and caring for patients with compassion, dignity and respect.
There was good multi-disciplinary working in surgery and a strong focus on improvement at all levels.
In critical care there were effective systems in place to protect patients from harm.
Safe numbers of staff cared for patients using evidence based interventions.
Staff at all levels in critical care had a good understanding of the need for consent and systems were in place to ensure compliance with deprivation of liberty safeguards.
In maternity and gynaecology, staff were competent in their roles with good levels of collaborative working across the service.
In services for children, care and treatment reflected current evidence based guidelines.
In end of life care, the specialist palliative care team were knowledgeable, skilled and highly regarded.
In outpatients and diagnostic imaging, patients were treated with dignity and their privacy was respected.

However, there were also areas of poor practice where the trust needs to make improvements:

Despite improvements in the layout of the emergency department, the recent ED redesign to address the increasing demand for its services was failing to meet patient needs at the time of our inspection.
Patients in ED experienced significant delays in initial assessment.
Incidents in ED were going unreported due to staff pressure.
The ED did not meet Royal College of Emergency Medicine (RCEM) recommendations that an emergency department should provide consultant presence 16 hours per day 7 days per week.
In ED, early warning scores , sepsis screening and pain management were not being consistently recorded in patient records.
Mandatory training targets were not being met consistently.
Staff in ED complained that their concerns were not being listened to.
We were not assured that the leadership of the ED were providing sufficient or timely information to trust senior management on the concerns that staff had identified in relation to the service redesign.
In medical care, risks identified were not being recorded on risk registers.
Documentation and patient records across medical wards was inconsistent and sometimes of poor quality.
Patient outcomes on medical wards were variable.
In outpatients and diagnostic imaging the trust had performed mostly worse than the England average in 2014-15 for the percentage of people seen by a specialist within 2 weeks from an urgent referral made by a GP.
The trust also performed worse than the England average in relation to 31 and 62 day targets from referral to treatment.
The trust performed consistently worse than the England average for diagnostic waiting times in 2014-15.

Importantly, the trust needs to:

Examine its streaming process in ED and seek to engage ED staff in developing a system that meets the needs of patients in ED.
Significantly reduce average time spent per patient in ED.
Shorten the time to initial assessment of patients in ED.
Ensure full incident reporting, investigation and learning takes place
Examine emergency cover in ED to ensure it meets College of Emergency Medicine recommendations.
Ensure that any risks of alleged and potential bullying are understood and ensure that the trust takes action where that bullying is known or arises.
Ensure consistent and full recording or early warning scores, sepsis screening and pain management.
Ensure mandatory training targets are met consistently.
Ensure that all risks identified are noted on the risk register.
Examine recording of patient records and ensure improvements to meet consistent best standards across all wards.
Examine effectiveness of treatment across medical wards to comply with national guidelines to improve patient outcomes.
In medical care and all areas ensure that care of patients living with dementia or learning disability goes beyond mere identification and devise clear care pathways to meet the needs of these patients.
Review the policy on admitting paediatric patients in critical care including the management of paediatric patients on the adult critical care unit to assure delivery of safe and effective care.
Ensure all staff (including medical and nursing) working in paediatric outpatients receive and have regularly updated level 3 safeguarding training
Make necessary improvements on patient waiting times for treatment including referrals and emergency referrals from GPs.
Ensure improvements to diagnostic waiting times.
Review performance against the 31 day target from diagnosis to first definitive treatment, produce and improvement action plan and monitor performance against that action plan.

The above list is not exhaustive and the trust should examine the report in detail to identify all opportunities for improvement when determining its improvement action plan.

Professor Sir Mike Richards

Chief Inspector of Hospitals

University College London Hospital is an acute hospital run by the University College Hospitals NHS Foundation Trust. It is located in central London and provides acute and specialist services to the local populations of the London Boroughs of Camden, Islington, Barnet, Haringey and Westminster as well as patients from further afield. It has a total of 650 beds and serves a population of 1.3 million people. The hospital includes the Elizabeth Garrett Anderson (EGA) Maternity Wing, and Macmillan Cancer Centre.

The trust also provides specialist services at the Hospital for Tropical Diseases, the Royal National Throat, Nose and Ear Hospital, the National Hospital for Neurology and Neurosurgery, the Royal London Hospital for Integrated Medicine, the Heart Hospital and the Eastman Dental Hospital. It was one of the first to gain foundation trust status.

Our focus on this inspection was on University College London Hospital as part of our acute hospital inspection programme. We did not inspect the specialist services.

We chose to inspect University College London Hospital as one of the Chief Inspector of Hospital’s first new inspections because we were keen to visit a range of different types of hospital varying from those considered to be high risk of poor care to those where the risk of poor care was judged to be lower. University College Hospital was considered to be a low risk provider. It has been visited by CQC five times since it was registered in October 2010 and has always been assessed as meeting the standards of care set out in legislation.

Our inspection team included CQC managers, inspectors and analysts as well as doctors, nurses, allied health professionals, a pharmacist, senior midwife, patient representatives and people who have used services (Experts by Experience) as well as senior NHS managers. The team spent three days visiting the hospital and conducted further unannounced visits six and seven days afterwards. We held a public listening event in Camden and heard directly from 30 people about their experiences of care.

Our analysis of data from CQC’s ‘Intelligent Monitoring’ system before the visit indicated that the trust was operating safely and effectively across all services. The trust’s mortality rates were as expected or better than expected for a trust of its type and size.

We found that, generally, services were safe, effective, caring, responsive to patients’ needs and well-led. When we inspected we saw many examples of good care. We were impressed by the dedication of the doctors and nurses we saw and the level of support that they were given as well as the mutual respect shown within teams, leading to high levels of care. We were also impressed with the emphasis placed at all levels from the trust’s board and governors down to ward level on putting the needs of patients first.

The vast majority of patients we spoke to at University College Hospital were very positive about the care they received. Many members of staff told us that they felt well supported by senior clinical staff who responded quickly to requests for help. Staff told us they were proud to work at the trust and proud of the level of care they were able to deliver.

It has a stable and experienced board and the trust’s Governors act very much as patient champions, providing challenge. There is a clear governance structure based in clinical divisions but with a corporate overlay and this has resulted in high levels of care being developed and maintained.

We wish to emphasise here some of the many good aspects of care we saw being delivered at this hospital,including:

The commitment of staff in A&E to delivering good care
In Medical Care, examples of excellent caring staff, well supported, with good care and positive interaction with patients.
In Surgery examples of excellent care, support for patients’ needs and a strong consultant presence.
In Intensive/Critical care, examples of caring efficient staff showing good multi-disciplinary working with good clinical outcomes.
Maternity services that overall were safe, caring, effective, responsive and well –led.
In Children’s care a strong collaborative style of working for the benefit of children, young people and their families.

We did however note areas of the hospital where staff were delivering care under pressure and where the environment was less good:

In A&E we found that staff, to their credit, were delivering safe care but in very difficult circumstances. The physical environment was inadequate. Due to shortage of space, facilities and equipment and patients’ privacy and dignity was severely compromised. We also found that the emphasis on receiving large numbers of patients through A&E instead of direct to an appropriate receiving clinical area was making the situation worse.In failing to address these issues we found trust leadership in A&E needed to be strengthened and improved. We believe the trust should take action to alleviate those pressures.
We found a risk of unsafe surgery as the World Health Organisation (WHO) surgical safety checklist was not always fully completed.
On medical wards, we were concerned about written nursing assessments, care plans and care delivery records being insufficiently completed. Although we saw no evidence of unsafe care being delivered, insufficient recording meant there was an increased risk of inappropriate or unsafe care or treatment.
The management of outpatient clinic was not adequate resulting in overcrowding and patients being left without seating in busy periods.
During our visit we became aware that the trust may not be recording its cases of hospital acquired infection in accordance with national guidelines. We raised this with the trust at our inspection. It is currently in discussion with Public Health England on this issue.
The trust was not ensuring that the paperwork for patients who had been assessed as not requiring resuscitation was always fully completed.