You are here

University College Hospital & Elizabeth Garrett Anderson Wing Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 11 December 2018

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.

Inspection areas

Safe

Requires improvement

Updated 11 December 2018

Effective

Good

Updated 11 December 2018

Caring

Good

Updated 11 December 2018

Responsive

Requires improvement

Updated 11 December 2018

Well-led

Good

Updated 11 December 2018

Checks on specific services

Medical care (including older people’s care)

Good

Updated 11 December 2018

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

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff were aware of how to monitor and respond to patients’ deteriorating condition, including sepsis. The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. The service used information to improve the service.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • There was effective multidisciplinary working among staff. Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The trust planned and provided services in a way that met the needs of local people.
  • The service took account of patients’ individual needs. Carers were identified and appropriate support provided by staff.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. We were informed that visibility of trust leadership team had improved since the last inspection. At this inspection, we found that all staff we spoke with told us that the trust leadership team was visible.

However:

  • We observed a number of lapses in good infection prevention and control measures including four staff not bare below the elbow, and some staff not strictly adhering to appropriate use of personal protective equipment.
  • We observed not all staff disposed of infectious material correctly.
  • We observed two areas of dust in two departments: endoscopy and HASU.
  • The service had suitable premises and equipment and looked after them well. However, we found two ward areas where resuscitation equipment was not secure and could be accessed by unauthorised persons.
  • Mandatory and safeguarding training compliance rates for medical staff fell below the trust target.
  • Though the service had effective systems for identifying risks, planning to eliminate or reduce them, 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.
  • Senior leaders were clear of the business continuity plans for the service; however some charge nurse we spoke with were not aware of those plans.
  • We found a mixed picture with regard to the staff of the trust and identification with trust vision and values. In some wards the trust vision and its underpinning values were well embedded amongst staff in the service. In other areas, more emphasis was placed on the vision and values for an individual service which matched with the overall trust vision and values.

Services for children & young people

Good

Updated 15 August 2016

  • The service had a robust process for ensuring incidents were reported and investigated. All staff were aware of their responsibilities to report and lessons were learnt where incidents had taken place. Patient risks were appropriately identified and acted upon with clear systems to manage a deteriorating child or baby.

  • Care and treatment reflected current evidence-based guidelines, standards and best practice. The services participated in a number of national and local audits to measure their effectiveness and to drive improvements. Performance against the national neonatal audit programme and the national diabetes audit was better than the national average and there was evidence of local action plans to address any issues identified.
  • Pain was being effectively managed and regularly monitored. Nutrition and hydration was being monitored and dietician input was available when needed.
  • Children were cared for in a caring and compassionate manner. Their privacy and dignity was maintained throughout their hospital stay. Fully trained and registered children’s nurses and neonatal nurses throughout the service ensured that children and their families were informed about their care and were fully involved in any treatment decisions. Consent to care and treatment was obtained in line with legislation and guidance.

Critical care

Good

Updated 15 August 2016

  • There were effective systems in place to protect patients from harm and a good incident reporting culture.

  • Learning from incident investigations was disseminated to staff in a timely fashion and they were able to tell us about improvements in practice that had occurred as a result.

  • Safe numbers of staff cared for patients using evidence-based interventions. There was good access to seven-day services and the unit had input from a multidisciplinary team.

  • Staff at all levels had a good understanding of the need for consent and systems were in place to ensure compliance with the Deprivation of Liberty Safeguards.

  • There was good local leadership on the unit and staff reflected this in their conversation with us.

  • Staff and patients were engaged in decision making on the unit and provided feedback about the service.

  • The unit was engaged in research a large team of nurses and doctors dedicated to the research programme.

End of life care

Updated 14 January 2014

We found that the trust was improving support for people at the end of their lives.

The trust had recognised the need to increase the staffing levels in its palliative care team and was taking action to do this.

The trust was no longer using the Liverpool Care Pathway. It had been recently replaced by an interim “Excellent care in the last days of life – Individualised care plan.”

We found that staff were caring and responsive to patients’ needs. There was a good working relationship between the different support services that were available. We received positive feedback from relatives of patients.

However, the trust was not ensuring that the paperwork for patients who had been assessed as not requiring resuscitation (do not attempt resuscitation or DNAR) was always fully completed. We found examples where there was no evidence recorded of discussions with the person or their family members and there was no consultant signature to indicate they had reviewed the order.

We found that the trust was seeking to develop and improve its End of Life service. It had an End of Life Board to provide senior leadership in developing the service at the trust. A five-year strategy for End of Life is currently at draft stage.

Surgery

Good

Updated 15 August 2016

  • Staff demonstrated good knowledge of the process of reporting; investigating and learning from incidents. We saw good evidence of local and trust wide learning from incidents that had occurred. There were on-going improvements in the use of the World Health Organisation (WHO) Safer Surgery checklist. Staff demonstrated that this was embedded in their practice and audit data demonstrated this was carried out to a high standard.
  • We saw staff treating and caring for patients with compassion, dignity and respect. Patient feedback was positive. Patient outcomes were monitored through internal and external audits and benchmarked against other services.
  • There was a strong focus on improvement from all levels of staff when results were less them optimum.There was good multidisciplinary team (MDT) working between doctors, nurses and other allied health professionals throughout patient pathways.

Urgent and emergency services

Requires improvement

Updated 11 December 2018

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

  • The department did not meet the Department of Health’s standard of 95% for time to treatment and decision to admit, transfer or discharge.
  • Similar to the previous CQC inspection, we found that patient documentation was not consistently completed.
  • There was inconsistent documentation of pain scores in both adult and paediatric patient records.
  • Nursing and medical staff training compliance rates were below the trust target for both paediatric basic life support and safeguarding children level 3.
  • At the time of this inspection, there was no parallel assessment of a patient’s physical and mental health needs. Patients with mental health needs could leave the emergency department before their mental health assessment.
  • There was a backlog of GP discharge summaries not sent out to surgeries.

However:

  • Consultant cover improved and now met the Royal College of Emergency Medicine recommendation of at least 16 hours cover seven days a week.
  • Incident reporting and shared learning was significantly improved.
  • There was an improved culture in the department. Staff told us the more recently established leadership team was very visible and consulted with them about proposed changes and improvements. They said they were proud to work for the hospital and felt well supported by their colleagues. We observed good team working amongst staff of all levels.
  • Staff followed national professional standards and guidelines to achieve the best possible outcomes for patients receiving care and treatment.
  • We observed staff listening to patients and discussing aspects of their care. We saw several examples of kindness showed to patients.
  • Leaders were realistic about the challenges they faced in order to continue to improve the delivery of service and make it more sustainable. There was a three year improvement plan which most staff were aware of and were optimistic would improve the quality of the service.

Gynaecology

Good

Updated 11 December 2018

We previously inspected gynaecology jointly with maternity so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

  • Incident reporting systems were in place and there was a good culture of reporting, investigating and learning from incidents.
  • There were effective arrangements in place to safeguard patients from abuse and mitigate the risk of it happening.
  • Infection prevention and control processes were carried out in accordance with local and national policy, and infection rates were lower than the national average.
  • Staffing levels were planned, implemented and reviewed to keep people safe. Medical cover was available 24 hours a day, seven days a week.
  • Emergency equipment was easily located, accessible, and ready for use.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Audits and quality outcomes were conducted at departmental level, to monitor the effectiveness of care and treatment.
  • Medical staff, nurses, midwives and other allied health professionals supported each other and worked collaboratively to ensure patient-centred and effective care.
  • Emotional support was provided by people with appropriate skills and experience.
  • Feedback from patients about their experience of care was consistently positive. Patients were treated with respect and dignity.
  • Patients received same day diagnosis and treatment, via walk-in clinics in gynaecology outpatient and gynae-oncology outpatient services.
  • Referrals for treatment and consultations for additional services were arranged in a timely manner.
  • It was clear to patients how to complain or raise a concern.
  • There was a clear statement of vision and values driven by quality and safety, which was understood by staff at all levels.
  • The leadership team was knowledgeable about the service’s performance, priorities, and the challenges it faced and were taking some action to address them.

However:

  • Medical staff did not meet compliance targets for completion of mandatory training.
  • There were delays in the overall pathway from referral to treatment for some patients and the overall 62-day cancer waiting time target was only met in 77.2% of cases in 2017/18 against the national target of 85%. The trust informed us this was associated with a high rate of late referrals from other organisations, and that 87.5% of patients referred directly to UCLH were treated within 62 days of GP referral, meeting the national target of 85%.
  • Staff we spoke with were unclear about the arrangements for the governance of the termination of pregnancy services and there was no formalised audit programme to allow outcomes to be compared with other benchmarks, and enable improvements in practice.
  • There was no system to ensure effective oversight and review of staff objection to being involved in termination of pregnancy.

Maternity

Good

Updated 11 December 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

  • The service 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.
  • The service had a comprehensive system in place to investigate perinatal mortality and morbidity cases and ensuring learning was shared, and actions were taken to improve the safety and quality of patient care.
  • Staff were up to date with their mandatory, safeguarding and maternity specific training. The overall compliance for all maternity and medical staff was better than trust target.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • All termination of pregnancy documentation was completed in accordance with the Abortion Act.
  • There was an effective system in place to assess, respond and manage risks to women who used the service. Staff could recognise and respond to signs of deterioration health and emergencies.
  • The service used current evidence-based guidance and quality standards to inform the delivery of care and treatment to women. There was an effective process and system in place to ensure guidelines and policies were updated and reflected national guidance and improvement in practice.
  • The maternity service monitored patient outcomes continuously through the use of a rolling maternity dashboard and national and local audits, thereby having a clear assurance of quality against identified goals.
  • The maternity audit schedule was comprehensive and included local and national audit. The local and national audits were completed and actions were taken to improve care and treatment when indicated. The service performed better than national average in the National Neonatal Audit programme and perinatal mortality rate (MBRRACE audit).
  • The multidisciplinary team worked together and supported each other to provide good care.
  • Women and their families were treated and cared for with compassion, patience and respect. Feedback from patients confirmed that staff treated them well and with kindness. Partners were made to feel welcome and involved in their partner’s pregnancy, labour and birth.
  • Staff provided emotional support to patients and their relatives to minimise any distress. Women had access to specialist staff such as perinatal mental health team, psychologist, psychiatrist, chaplaincy and a bereavement midwife. Staff also provided support to women who had experienced miscarriage or stillbirth.
  • The Friends and Family Test (FFT) is a measure of patient satisfaction. Findings were similar to national average and showed women and their families had a good experience from the antenatal period to the postnatal period in the community.
  • The maternity service was 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, women and other stakeholders to plan the delivery of care and treatment for the local population.
  • There was access to services through a one stop shop first trimester Down’s syndrome screening clinic which offered same day diagnosis and treatment in the fetal medicine unit. This met patient needs by reducing the number of hospital visits as well as possibly leading to cost savings.
  • The service introduced an online antenatal class for women and a weekly skype for women over forty years to meet their needs following their feedback. There was plan to extend this service to the birth reflection clinic and fear of birth clinic.
  • The service ran a tocophobia (fear of giving birth) clinic for women and developed an anxiety tool to support women.
  • There were arrangements in place to support people with complex or additional needs and those who were in vulnerable circumstances such as substance misuse and people with learning disabilities with good access to specialist midwives.
  • The maternity service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Staff told us the triumvirate and local leaders were visible and approachable.
  • The leadership were knowledgeable about quality issues and priorities, understands what the challenges were and took action to address them. We saw that leaders had plans in place to address staffing, low morale and access and flow of the service.
  • Staff told us they felt listened to and well supported by managers and colleagues and were confident to raise any concerns they had.
  • The maternity service used a systematic approach to continually improve the quality of its services and standards of care. Staff understood their roles and accountabilities and felt the governance processes were now clear.
  • Managers across the service promoted a positive culture that supported and valued staff.
  • The service was committed to improving services by learning both when things went well and when they went wrong.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • There was a strong culture for improvement, training, research and innovation. We saw various examples that the service worked collaboratively with other hospitals in the region and carried out various innovation and improvement work to improve maternity care provision for the local population. The leadership promoted continuous improvement and staff were accountable for delivering change. Safe innovation and team success was celebrated.

However:

  • Midwifery staffing levels were low in relation to the acuity of women. However, staffing levels were regularly reviewed and staff were redeployed within the maternity unit when needed, to keep patients safe from avoidable harm and to provide the right care and treatment. Women did not always receive one-to-one care in established labour in line with national guidance.
  • We were not assured effective governance arrangements were in place to ensure safe storage of medicine, fridge temperatures were checked daily, and that out-of-date medicines were replaced, when indicated.
  • Emergency equipment was not always stored securely and checked daily. Clinical equipment was not regularly serviced and calibrated, and we saw that out-of-date equipment was not always replaced.
  • We had concerns on the cleanliness of the environment and equipment and we were not assured there were effective controls in place to prevent the spread of infection.
  • There was low staff morale due to staffing and capacity issues.
  • The service was not following best practice on the bereavement bed room provision and facilities. The bereavement rooms were not ensuite and did not have catering facilities.
  • There was no signage inside the lifts to inform patients or families which floor the different units, wards and clinic were situated on.
  • Women could generally access the right care at the right time but experienced delays in transfer or admission unto the labour ward or delivery suite when there were capacity issues. Access to care was managed by staff to take account of women’s needs, including those with urgent needs.
  • Staff we spoke with were unclear about the arrangements for the governance of the termination of pregnancy services and there was no formalised audit programme to allow outcomes to be compared with other benchmarks, and enable improvements in practice.
  • There was no system to ensure effective oversight and review of staff objection to being involved in termination of pregnancy.

Outpatients

Good

Updated 11 December 2018

We previously inspected outpatients services jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

  • The service provided mandatory training in key skills to all staff and made sure overall staff compliance rates met the trust target.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe and to provide the right care and treatment. Where a gap in skill was identified, staff were encouraged to broaden their skill set to ensure continuity of care for all patients.
  • 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.
  • Different groups of staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them with kindness and respect.
  • The trust planned and provided services in a way that met the needs of local people. The trust ran out-of-hours clinics for certain specialities in order to meet patient needs.
  • The service took account of patients’ individual needs. Volunteers were available within the department, to guide patients to clinics and appointments as required.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The CEO worked within a specialist clinic on a regular basis, and was available to staff of all grades to answer any questions.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. The trust conducted friends and family test (FFT) surveys, participated in the NHS staff survey, as well as including both staff and patients in the development of innovations.

However:

  • The trust performed worse than the 85% operational standard for patients receiving their first cancer treatment within 62 days of an urgent GP referral. Performance was also worse than the England average for all four quarters of 2017-2018.
  • The did not attend (DNA) rate for the hospital’s outpatient department was worse than the national average.
  • The trust did not take part in the national patient choices scheme which enables patients to select the time, date and location of their initial appointment.
  • Patients found it difficult to contact the department via telephone to discuss their appointment.
  • There was a lack of confidentiality at the checking-in desk for patients.
  • The fracture clinic waiting area was overcrowded and had a lack of available seating for patients waiting for their appointments. However, to address this and reduce patient wait times, the fracture clinic was running virtual appointments.
  • Signage in the department was not always clear. Patients found it confusing and difficult to locate clinics.
  • Patient records were not always stored securely. Paper records were stored in cabinets that were unattended and unlocked.
  • There was a backlog of GP discharge letters in the IT system and there were delays for non-urgent letters being sent out via the new electronic system.