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Inspection carried out on 16 October to 22nd November 2018

During a routine inspection

Our rating of services stayed the same. We rated the hospital as good because:

We rated safe, effective, caring, responsive and well-led as good.

Our rating for surgical services improved to outstanding. We rated safe and responsive good and effective, caring and well-led as outstanding.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

  • The hospital controlled infection risk well and used innovative approaches to reduce the rate of surgical site infections. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. Key performance information reflected this.

  • The hospital managed patient safety incidents well. Services were committed to an open safety culture where all safety issues raised by staff and patients were highly valued. Staff recognised incidents and near misses and reported them appropriately.

  • The hospital continued to provide care and treatment that was planned and delivered in line with current evidence-based guidance, standards, best practice, legislation and technologies. There continued to be a truly holistic approach to assessing, planning and delivering care and treatment to people who use the service.

  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.

  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. We saw that staff were supported to maintain and further develop their professional skills and experience. We saw that practice educators were available in each ward and department to support staff.

  • Staff of different kinds continued to work together as a team to benefit patients. Staff, teams and services were committed to working collaboratively and found innovative and efficient ways to deliver joined-up care to people who used services. For example, we saw the surgical service were split into care groups which were structures to involve MDT working. All relevant staff, were regularly involved in assessing, planning and delivering patients care and treatment. Staff worked well together to understand the range and complexity of people’s needs. There was a holistic approach to planning patients discharge, transfer or transition to other services which was started at the earliest possible stage.

  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

  • Staff continued to involve patients and those close to them in decisions about their care and treatment.

  • The trust planned and provided services

    , amenities and care

    in a way that met the needs of all people

    using the service locally and nationally including patients and their families.

  • The service took account of patients’ individual needs in a holistic manner including mental, emotional and social care needs.

  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.

However,

  • The hospital provided mandatory training in key skills to all staff. Compliance for nursing staff within surgical service was generally good and met the trust target, however, medical staff completion was below the trust target and there was a low completion rate of basic life support training.

  • There was no standardised procedure within surgical services to ensure medicines and equipment used for organ retrieval were checked and re stocked within surgical service. Although staff told us this was a task completed at the beginning of every shift there was no assurance and no way of knowing if the bag had been tampered with.

Written patient information was not available in other languages and formats suitable for patients with sensory disabilities such as blindness

Inspection carried out on 14 - 16 June 2016

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

The Royal Brompton and Harefield NHS Foundation Trust is the only specialist heart and lung unit in the country that treats both children and adults. The trust is home to Europe's largest centre for the treatment and management of cystic fibrosis.

The organisation provides 512 inpatient beds, of which 360 are general acute beds, 59 paediatric beds and 93 critical care beds. They deliver in the region of 38,619 inpatient admissions and 178,495 outpatient attendances (2014/15).

The organisation delivers care across two hospital sites: the Royal Brompton Hospital site in Chelsea and the Harefield Hospital site to the north of London. They employ in the region of 3,298 staff and have a financial revenue of £367.5 million, generating a financial deficit of £3.3 million during 2015/16.

The organisation has a stable executive and non-executive leadership team, led by Chair Neil Lerner and Robert Bell, CEO of eleven years. Two members of the Executive team took up post within 12 months prior to inspection, including the Director of Nursing and the Interim Medical Director.

The trust's vision and mission is to be the UK’s leading specialist centre for heart and lung disease, developing services through research and clinical practice to improve the health of people across the world.

We inspected The Royal Brompton and Harefield NHS Foundation Trust, including the six core services: Medicine, Surgery, Critical Care, Services for Children and Young People (the Royal Brompton site only), Outpatients and Diagnostic services and End of Life Care services. We inspected the two acute sites - the Royal Brompton Hospital and the Harefield Hospital.

Harefield Hospital is situated in the countryside to the north of London.

The hospital has more than 1,300 staff, five operating theatres and four catheter laboratories. Harefield Hospital has 168 beds, including beds for:

  • Cardiac and thoracic surgery

  • Cardiology

  • Day case unit

  • Adult intensive care

  • Transplant surgery

    The hospital is one of the largest centres in the world for heart and lung transplants. It has jointly pioneered work in the development of ‘artificial hearts’ (also known as left ventricular assist devices or LVADs).

    The hospital has a dedicated heart attack centre which deals with heart attack emergencies from outer north-west London, providing primary angioplasty in the specialist catheter laboratories.

Our key findings were as follows:

We rated Harefield Hospital as good overall because:

  • There was a positive culture of incident reporting and there were established processes for investigating incidents. ‘Grand Rounds’ took place every week and learning from incidents was one of the topics often talked about. We saw that incidents and mortality was reviewed at the monthly Harefield Quality and Safety Group meetings for the heart division and that action points were identified. Incident management was in line with the duty of candour.
  • There was an open and transparent culture across the hospital, where staff felt comfortable to express their views and approach managers with their concerns. Learning from incidents and complaints was shared across the specialist team and the trust, now that data had been coded in such a way to allow this.
  • Patients attending outpatients and diagnostic imaging departments received care and treatment that was evidence based and followed national guidance and staff worked together in a multidisciplinary environment to meet patients’ needs.
  • We observed good infection prevention and control (IPC) practices by staff and noted compliance audits completed in this area. Clinical equipment was serviced, clean and functioning. Daily monitoring of resuscitation equipment had taken place in most surgical areas.
  • Consent processes were robust and documentation associated with these processes was adapted to the individual patient’s needs and understanding.
  • Patients and their families were continually positive about the care and treatment they received at the Harefield Hospital. They told us they felt involved in their care and built strong, caring and supportive relationships with staff.
  • Feedback from patients and their relatives was complimentary about the care they received on the wards; they told us staff were kind and tried to make them feel comfortable. Patients told us staff came quickly when they used the call bell.
  • Staff had a good understanding of safeguarding principles and knew what to do to keep people safe. Staff had access to specialist support if they needed help with safeguarding or child protection.
  • Although the wards had vacancy rates of 18.5% whole time equivalents, we observed staffing levels were in line with planned staffing levels. Staffing levels were tracked throughout the day and nursing staff would be moved across the division as needed.
  • Multidisciplinary working underpinned the care provided to patients. Consultant-led multidisciplinary board rounds were held on a daily basis.
  • A pain scoring system was used with patients across the wards. Staff had access to the pain management team which was led by a consultant anaesthetist and was available for patients for both chronic and acute pain.
  • Nursing staff had access to practice educators and ward-based mentors. New staff were supernumerary on the wards for the first three weeks and received clinical supervision. Nurses told us there were opportunities for learning and development and they could access training online. The practice educators held study days to assist nursing staff with their Nursing & Midwifery Council (NMC) revalidation.
  • Staff had access to allied health professionals such as speech and language therapists, dietitians, tissue viability specialists, physiotherapists and clinical nurse specialists.
  • Patients admitted over the age of 75 years were screened for dementia within 72 hours of admission.
  • The service was led by experienced clinicians with autonomy in decision making and a clear strategy for the service in place.
  • There were suitable governance arrangements in place. Clinical directors felt they were supported and described being supported top down and bottom up in shaping their services.
  • There was evidence of engagement with the public and staff members. Staff were encouraged to develop ideas which could improve the quality and/or efficiency of the trust’s services.
  • The trust was consistently above the England average for the 31 day cancer waiting times from April 2015 to April 2016.
  • Diagnostic waiting times were consistently below the England average from January 2015 to January 2016.
  • The ‘did not attend’ (DNA) rate was below the England average from September 2014 to August 2015.

However:

  • Compliance with mandatory training was below the trust's target of 75% for medical staff and allied health professionals.
  • There was no on site pharmacy service available from 1pm on Saturdays and all day Sunday, this was covered by an on call service.
  • Systems were in place to ensure incidents were reported, investigated and lessons learnt. However, follow up of incidents within the trusts 10-day period was poor.
  • Senior medical staff did not fully complete the World Health Organisation (WHO) checklist despite several discussions about the risk to patient safety. The WHO checklist is a simple tool designed to improve the safety of surgical procedures by bringing together the whole operating team to perform key safety checks during vital phases of surgical procedures.
  • The referral to treatment (RTT) national indicator trust performance fell below both the England average and referral to treatment standard of 92%. The 18-week RTT times for elective cardiac surgery were an issue due to an increased demand in the service. The trust explained they aimed to be back to standard by 2017.
  • The performance for the 62 day cancer waiting time was consistently worse than the England average from April 2015 to April 2016.
  • Staff and patients told us some clinics regularly started late and led to longer waits for patients.
  • Cancellation rates of elective patients trust-wide had a marked increase in the first three quarters of 2015 to 2016 and this did not show signs of improvement. Many patients were rebooked for treatment within 28 days of cancellation.

We saw several areas of outstanding practice including:

Outpatients and Diagnostic Imaging

  • Diagnostic and imaging services provided a number of examples of outstanding practice, including the imaging department's expertise in a range of inflammatory respiratory diseases including amongst others asthma, allergy, COPD, cystic fibrosis, idiopathic pulmonary fibrosis, and acute lung injury.
  • The imaging department's research included exhaled inflammatory biomarkers, skeletal muscle biopsies, imaging, extensive lung physiology techniques, nasal and bronchoscopic sampling,, bronchial challenges, as well as a large range of preclinical techniques including models of asthma and COPD.

Surgery

  • The Harefield transplant team pioneered the Organ Care System in cardiothoracic transplantation. This is a method for transporting and optimising potential donor hearts. Most other cardiothoracic transplant services have adopted this system. A lung transplant version has also been utilised.
  • VAD (ventricular assist device) team members were some of the most highly skilled in the UK. They could care for patients undergoing surgery for the insertion of an artificial heart without the need for the company who make the heart being present. No other service in the UK can provide this without the company being present.
  • Patients undergoing surgery at the Harefield Hospital had excellent outcomes for cardiac, thoracic and cardiothoracic transplant (heart, lung and heart-lung transplant).

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

The trust should:

End of Life Care

  • Ensure ward nurses should undergo regular syringe driver update training to maintain their competence.
  • Audit the use of opioids within palliative care as per NICE Quality Standard CG140.
  • Provide formal training to staff so that they feel confident in recognising patients in the last stages of life and they are able to provide the care that they require.
  • Ensure nursing staff within the specialist team are up to date with their mandatory training.
  • Ensure PALs officers are given full role specific training rather than relying on previous work experience.
  • Provide consultant cover seven days a week, face to face for palliative care patients as per national professional guidance.
  • Use a valid assessment tool to document patients' care at the end of their life to ensure compliance and consistency.
  • Improve their data collection process so that relevant data is easily accessible to improve patient care.
  • Flag patients with learning difficulties or dementia within their electronic records systems so that staff are immediately aware of a patient's extra needs.
  • Record the number of people that died at their preferred place of death for audit and improvement purposes.
  • Record end of life care complaints separately to enable learning and changes to take place.
  • Meet all national KPIs as set out in the national audit for end of life care so that it can compare and improve itself and encourage development and change.

Outpatients and Diagnostic Imaging

  • Ensure all clinics start at their published time, and consultants do not accept work commitments inside the hours specified in their job plans.
  • Reduce the time patients spend waiting in the outpatients waiting room.

Critical Care

  • Follow up on concerns around inconsistencies in patient observation scoring including the visual infusion phlebitis (VIP) score and scores relating to confusion and delirium.
  • Ensure that staff are appropriately and consistently managing risks associated with venous thromboembolism (VTE) in all critical care wards.
  • Ensure there is consultant intensivist cover in all critical care wards including HDU at weekends in line with the Faculty of Intensive Care Medicine (FICM) guidance on medical staffing.

Surgery

  • Ensure staff complete the WHO checklist in its entirety and that staff are present for the 'five steps to safer surgery' process.
  • Ensure surgical staff are completing patients observational NEWS charts fully and escalating unwell patients as a matter of urgency.
  • Follow up on concerns around the culture in relationships between senior surgical staff and their colleagues.
  • Ensure staff are trained in understanding the sepsis six pathway and responding to septic patients.
  • Ensure that it is meeting the national indicator for cardiac surgery referral to treatment time.

Medicine

  • Ensure that hand gel is clearly indicated at the entrance to the wards/clinical areas.

  • Ensure that hand hygiene in the cath labs meets the trust's target of 90% for medical staff and allied health professionals.

  • Ensure that mandatory training meets the trust's target of 75% for medical staff and allied health professionals.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 3 February 2014

During a routine inspection

During this inspection we visited outpatients, pre assessment, operating theatres, the intensive care and high dependency units, the day case unit and inpatient wards. Patients we spoke with said their care was “excellent”, that they were "happy with the information they’d been given pre operatively" and that care was “second to none”.

We looked at patient records in the areas we visited and saw that these were comprehensive and fully completed.

Most patients we spoke to were happy with the food provided at the hospital. They told us they had been given an appropriate choice over what they could eat and drink.

All parts of the hospital we saw during our visit were clean and we observed staff complying with good practice for the prevention and control of infection.

Both patients and visitors considered there were enough staff to meet the needs of patients and we saw that staffing was planned according to patients’ needs. Staff considered they had good quality training and felt confident in their roles and tasks.

The Trust had a number of systems in place to gather record and evaluate the quality of services provided. These included systems to help staff identify risks to patients and develop strategies to manage risks and areas of concern. Patient feedback was collected and analysed to seek ways of improving the experience of patients. Clinical audits were carried out regularly on the units.

Inspection carried out on 20 June 2012

During a routine inspection

The majority of patients and relatives we spent time with said that their experience had been very positive, staff were always polite, treated them with respect and all were satisfied with their overall care. Some comments were, "I have been treated with dignity and respect by all staff" and "The medical care and attention given to me has been excellent".

Inspection carried out on 15 September 2010

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

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.