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Inspection carried out on 16 October to 22nd November 2018

During a routine inspection

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

  • The ratings of safe, responsive and well-led have improved, the ratings of effective and caring have stayed the same.
  • Our rating for surgery and critical care services improved to good and the rating for children services stayed the same as good overall.
  • The hospital had successfully implemented improvements highlighted during last inspection regarding the use of the safer surgery checklist, cleaning processes within theatres, safeguarding children training in recovery, theatre staffing and management and culture issues within theatres.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

  • The service had suitable premises and equipment and looked after them well.

  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.

  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time. However, we found that the surgical service did not always follow best practice when storing medicines.

  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.

  • The hospital had enough staff with the right qualifications, skills, experience and training to keep patients safe from avoidable harm and abuse, and to provide them with the care and treatment they needed. Ward managers matched staffing levels to patient need and could increase staffing when care demands rose. All staff understood their responsibilities to safeguard patients from abuse and neglect, and had appropriate training and support.

  • The hospital 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.

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.

  • 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.

  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.

  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.

  • The service made sure staff were competent for their roles. Except in surgery, managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

  • 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 understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. The unit had since introduced an animal therapy policy to enable dogs to be safely allowed on the unit for patients who wished to have them visit.

  • Staff provided emotional support to patients to minimise their distress.

  • 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.

  • People could access the service when they needed it. Waiting times from treatment were and arrangements to admit, treat and discharge patients were in line with good practice.

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

  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.

  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. However, staff survey results within surgery showed dissatisfaction in various areas.

  • The trust used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.

However,

  • We observed a few lapses in strict adherence to infection control procedures within critical care. Although the hospital controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

  • Although the service provided mandatory training in key skills to all staff. The trust target was set at a comparatively low 70% or 80% depending on the mandatory training module and the compliance rates for mandatory training for some staff groups were below these trust targets.

  • Although staff had training on safeguarding children and adults, the trust target was set at a comparatively low 75% and the compliance rates for mandatory training for some staff groups were below trust targets.

  • Managers did not always effectively appraise staff’s work performance.

  • There was no ratified strategy for critical care and children and young people services.

Inspection carried out on 14, 15, 16 and 26 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 adult congenital heart disease unit was the first of its kind in Europe and remains the largest.

The organisation houses approximately 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.

The organisation delivers care across two hospital sites: the Royal Brompton Hospital site, Chelsea and the Harefield Hospital site. 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 Royal Brompton site employs more than 2,200 staff. It has five dedicated operating theatres, one hybrid theatre and four catheter laboratories. The Royal Brompton hospital has 312 beds, including for:

  • surgery
  • intensive care
  • respiratory
  • cardiology
  • paediatric
  • paediatric intensive care patients.

Our key findings were as follows:

We rated the Royal Brompton hospital as requires improvement overall. This was because:

  • There were failures in infection control practices. This included variable hand hygiene audit results, inconsistent nurse practice and inadequate handling of intravenous fluids.

  • Systems, processes and standard operating procedures were not always reliable or appropriate to ensure cleanliness and safety of equipment and the environment in theatres.

  • Risks to people who used the services were not always assessed, monitored and managed. National Early Warning Score (NEWS) charts were not always used appropriately to guide escalation of deteriorating patients.

  • The World Health Organisation (WHO) five steps to safer surgery checklist was not fully embedded. 

  • Nurses on surgical wards did not understand the sepsis six pathway and were unclear of the triggers which would prompt initiation of the six steps.

  • Some areas of the hospital were dark and cramped, and some of the beds in the bays were close together due to limited capacity.

  • Space in the outpatients department was limited and insufficient to cope with the number of patients attending.

  • Patients were not consistently treated in a timely manner and within national indicators.

  • Staff satisfaction was mixed. A number of staff told us they felt bullied in their work place. Staff told us they did not always feel actively engaged in changes or empowered to speak up. Staff in surgery and theatres reported perceived bullying and harassment. A number of staff in the critical care service told us they felt unsupported.

However,

  • The hospital had a positive incident reporting culture There process for ensuring ensuring incidents were reported and investigated was embedded in practice. Staff were aware of their responsibilities to report incidents and staff knew about their responsibilities relating to duty of candour. Learning from incidents was shared among teams.

  • Staff had access to all the equipment they needed to keep patients safe. Resuscitation equipment was checked daily.

  • Medicines were largely stored and managed appropriately.

  • The majority of staff were aware of the safeguarding procedures including action to take to protect children and adults.

    However, staff caring for children and young people in the recovery area were not trained to the required safeguarding training standards.

  • There were high completion rates of mandatory training across the services.

  • There were sufficient nursing and medical staff to provide safe care for patients.

  • There were good processes to monitor patient outcomes and ensure that care was delivered in line with best practice.

  • The hospital participated in national and local research. The quality of care was monitored through a programme of audits.

  • The survival rate of patients who were treated with extracorporeal membrane oxygenation (ECMO) was higher than the international average measured by the Extracorporeal Life Support Organization.

  • Nutrition and hydration were well managed and individualised to each patient.

  • Patients had their pain regularly assessed and managed effectively.

  • Staff were competent and supported to provide a good quality service to patients. Staff were skilled in their specialist area and were supported in their roles by ongoing specialist training and development opportunities. However, ward staff expressed a current need for further training and support around the care of dying patients.

  • There was a strong culture of multidisciplinary team working involving a full range of health and social care professional and underpinned care and treatment.

  • Although MCA and DoLs training was not mandatory,

    capacity and consent issues were well understood by staff and correct procedures were followed in relation to these.

  • People using the services were treated with dignity and respect and felt involved in their care plans. Patients told us that they felt respected and cared for and had their choices and preferences listened and responded to in a timely manner.

  • Feedback from patients and their relatives was consistently positive about the way staff treated them. There was a strong holistic, person-centred approach to providing care to patients.

  • Services were planned to meet the needs of the population served by the hospital.

  • Services were designed to meet the individual needs of patients including support for patients who had dementia or a learning disability.

  • Many of the clinical services were well led with good governance and risk management processes to monitor and evaluate care and report performance back to staff and to the trust board.

  • The hospital actively sought and responded to the views of the people using the service.

  • There was clear evidence of innovative and outstanding practice that had won many national awards. Policies developed within the trust were being used nationally and internationally.

We saw several areas of outstanding practice including:

  • The multidisciplinary working of the medicine services at the Royal Brompton Hospital offered both a clinical and holistic look at the patient’s needs.

  • All staff within the medical division at the Royal Brompton Hospital felt actively engaged by their leaders and spoke very highly of their managers.

  • In the service for children and young people, SPRinT training has won National awards Delegates attend the training from all over the world. The training has been taught and has commenced at other hospitals nationally.

  • There were continuous research programmes of note for cystic fibrosis which had international acclaim and use.

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

Importantly, the trust must:

  • The trust must ensure hand hygiene practices are rigidly followed by all staff at all times and that infection control practices are embedded in all clinical areas.

  • The trust must ensure operating procedures are in place are reliable to ensure the cleanliness and safety of equipment in theatres.

  • The trust must ensure patients at risk of deterioration are identified and escalated appropriately.

In addition the trust should:

In the medicine service:

  • All medical wards should ensure that patient medical records are locked away.

  • All medical wards should ensure corridors are free from clutter.

In the surgery service:

  • The hospital should ensure all staff who are involved in the care and treatment of children and young people are trained in level three safeguarding.

  • The hospital should ensure the use of the World Health Organisation (WHO) five steps to safer surgery checklist is fully embedded and utilised appropriately by all staff.

  • The hospital should ensure staff in theatres received adequate rest periods following on-call work.

  • The hospital should ensure the nursing management in theatres is appropriate and effective in the way in which change is managed throughout the department ensuring that all staff feel valued and involved.

In the critical care service:

  • The hospital should ensure conversations with patients and relatives that involve them in care are carried out consistently and routinely and are documented.

  • The hospital should ensure areas used to store medicines can be temperature-controlled and that this is monitored at least daily

  • The hospital should ensure junior doctors have robust, structured support in place that enables them to develop professional and clinical competencies.

  • The hospital should ensure new consultants receive an adequate induction.

  • The hospital should ensure quality monitoring and risk management processes are accessible by all.

In the end of life care service:

  • The hospital should introduce further formal training in End of life care (EOLC) for staff across the hospital, including training in the use of syringe drivers.

  • The hospital should train all porters annually in infection prevention and control and keep a formal record of this training.

  • The hospital should devise and introduce a validated assessment tool to document care of patients at the end of life.

  • The hospital should improve data collection methods surrounding issues relating to EOLC in order to enable benchmarking and audits.

  • The hospital should improve seven-day access to specialist palliative care provision.

  • The trust should consider introducing a lay member to the trust board with responsibility for EOLC.

In the outpatients and diagnostic imaging service:

  • The hospital should ensure all outpatients department clinics start at their published time, and consultants do not accept work commitments inside the hours specified in their job plans.

  • The hospital should reduce the time patients spend waiting in the outpatient’s waiting room.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 13 August 2013

During a routine inspection

We inspected The Royal Brompton Hospital over two days and visited 11 wards and departments, including the Paediatric and Adult Outpatients Departments. The specialist advisor accompanying us was a specialist in paediatric cardiology care. We followed the patient pathway from the intensive care departments through to the wards. We spoke with patients, families or carers and staff in every area we visited. We also spoke with senior management staff including the Chief Executive, Director of Nursing and Governance and the Director of Performance and Trust Secretary, as well as three non-executive members of the trust board.

Our overall impression was of good standards of cleanliness in the hospital. We found all grades of staff open and friendly and there was strong leadership provided in the wards and departments we visited. Staff told us that the management teams were supportive and provided on-going training. They described communication with management staff as good. They were proud to work for The Royal Brompton & Harefield Foundation Trust and wanted to tell us about their roles.

Patients’ we spoke with had had a positive experience of care and treatment at the hospital. They were treated with dignity and respect, were complimentary about staff, understood their care and treatment and said there were sufficient staff to meet their needs.

Inspection carried out on 30 January 2013

During a routine inspection

During the inspection we visited six inpatient wards at the Royal Brompton hospital. We also visited the adult and children’s outpatient departments. Patients who used the service told us that they were given information about their care and treatment before they underwent procedures. They said that staff was "very professional", "welcoming" and "very attentive”. The majority of patients told us that staff were “fantastic” and that the overall care at the Royal Brompton hospital had been “excellent”.

Patients told us they where knew the name of the staff member looking after them. Some people had regular visits to the Royal Brompton hospital for ongoing treatments, comments from patients included “the staff are so welcoming, home from home” and “I am provided with excellent care from staff”. The patients informed us that prior to discharge staff would discuss all relevant areas of ongoing care and support required, including medication that is discussed with the pharmacist.

Patients reported that they were aware of how to complain if they wanted to. The majority of people told us that they would initially discuss any issues with staff on duty. We observed that information on how to make a complaint was on display in all areas we visited. This included how to make a complaint through the Patient and Liaison Services (PALS) located at the Royal Brompton hospital.

Inspection carried out on 20 April 2011

During a routine inspection

Overall, patients were extremely positive about the healthcare provided at the Royal Brompton hospital. Comments from patients included ‘excellent care’, ‘Staff are wonderful’ ‘The best hospital I have stayed in’.

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.