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St Helier Hospital and Queen Mary's Hospital for Children Requires improvement

We are carrying out checks at St Helier Hospital and Queen Mary's Hospital for Children using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 May 2018

Our rating of services stayed the same. We rated them as requires improvement because:

  • All mandatory training in key skills for medical staff and nursing staff and safeguarding training were below the trust target of 95%.
  • The use of rapid tranquilisation medication was not monitored.

  • The use of physical restraint on mental health patients was not monitored in the hospital.
  • There were significant staffing issues in some areas. In surgery, ward staff were expected to provide care for too many patients and did not always have enough time to provide the level of care they felt appropriate. Staffing on the neonatal unit (NNU) and on the children’s ward were also a challenge.
  • The emergency department (ED) was not meeting the Royal College of Emergency Medicine (RCEM) recommendations that consultants should provide 16 hours of emergency cover seven days per week. This was also the case at the last inspection in 2015.
  • In surgery, there was a lack of proactive leadership to address concerns identified within the risk register as well as lower level concerns escalated by operational staff.
  • In maternity, some black midwives reported being treated unfairly and lodged a collective, official grievance as a result. The trust carried out an internal investigation and recommendations have been made to improve to situation.
  • In maternity, the trust continued to focus more on trust wide outcomes rather than outcomes by unit, which obscured differences between the two units. The overall vision for the unit was not well defined. There was a lack of clarity on whether the maternity service was one service at two locations or two separate units.

However:

  • The trust met the A&E four hour waiting time target in eight out of 12 months from December 2016 to November 2017, and showed a trend of stability compared to the national standard and better than the England average.
  • Patients who are at risk as a result of their mental health received a mental health assessment within ED or the assessment unit by a qualified mental health professional.
  • In medicine, the hospital had improved the discharge process with the introduction of a new ward for patients who were medically fit and waiting to be discharged.
  • There was effective and positive multidisciplinary team (MDT) working. Allied health professionals (AHP) felt that they were valued team members.
  • Staff provided treatment and care in a kind and compassionate way and treated people with respect. Staff were very considerate and empathetic towards patients. Patients described staff as compassionate and caring and we observed positive caring interactions.
  • There was provision to meet the individual needs of children and young people using services at the hospital. There were efforts across the hospital to make the environment more child-friendly and welcoming for young people.

Inspection areas

Safe

Requires improvement

Updated 14 May 2018

Effective

Good

Updated 14 May 2018

Caring

Good

Updated 14 May 2018

Responsive

Good

Updated 14 May 2018

Well-led

Requires improvement

Updated 14 May 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 27 May 2016

Overall, we found that outpatients and diagnostic imaging were good. The service was rated as good for safety, caring, responsive and well-led. The effective domain was inspected but not rated. Some aspects of the delivery of safe patient care in relation to radiation safety were excellent.

Patients, visitors and staff were kept safe as systems were in place to monitor risk. Staff were encouraged to report incidents and we saw evidence of learning being shared with the staff to improve services. There was a robust process in place to report ionising radiation medical exposure (IR(ME)R) incidents and the correct procedures were followed. The pathology department had a comprehensive quality management system in place with compliance targets set at higher than the national average to improve safety and quality. There was evidence of excellent practice for the monitoring and administering of patient radiation doses to be as low as possible.

The environments we inspected were visibly clean and staff followed infection control procedures. Records were almost always available for clinics and if not, a temporary file was made using available electronic records of the patient. Staff were aware of their responsibilities within adult and children safeguarding practices and good support was available within the hospital.

Nurse staffing levels were appropriate and there were few vacancies. The diagnostic imaging vacancies were higher, particularly ultra sonographers. There was an ongoing recruitment and retention plan in place.

There was evidence of service planning to meet patient need such as the emergency eye service offered Monday to Friday 8.30am to 4.30pm for patients with sight threatening eye conditions, requiring urgent specialist ophthalmic treatment. National waiting times were met for outpatient appointments and access to diagnostic imaging. A higher percentage of patients were seen within two weeks for all cancers than the national average, but the cancer waiting times for people waiting less than 31 days from diagnosis to first definitive treatment and the proportion of people waiting less than 62 days from urgent GP referral to first definitive treatment were both below the national average.

Staff had good access to evidence based protocols and pathways. There was limited audit of patient waiting times for clinics, but patients received good communication and support during their time in the outpatients and diagnostics departments. Staff followed consent procedures and had a good understanding of the Mental Capacity Act 2005.

We observed and were told that the staff were caring and involved patients, their carers and family members in decisions about their care. There was good support for patients with a learning disability or living with dementia.

Staff were aware of the complaints policy and told us how most complaints and concerns were resolved locally.

The outpatients and diagnostic imaging departments had a local strategy plan in place to improve services and the estates facilities. From December 2015, the current outpatient services that are in Clinical Services Directorate will move to a new Outpatients and Medical Records Division. Staff expressed some concern over these changes.

Governance processes were embedded across outpatients and diagnostics. The directorate was commended on its risk register in a recent review of risk registers in the trust. Senior managers told us the newly appointed quality manager had made significant improvements in making sure priorities, challenges and risks were well understood. Good progress was evident for improving services for patients.

We found good evidence of strong, local leadership and a positive culture of support, teamwork and innovation.

Maternity

Good

Updated 14 May 2018

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

  • Following our inspection in 2015, there had been improvements to the maternity unit. Staff were adequately deployed and there were clear guidelines and escalation policies for addressing staff shortages. There had been improvements in sharing learning from incidents and range of audits took place in relation to risk areas.
  • Women received effective, evidence-based care from staff who were appropriately qualified to care for them. The unit had a significant number of specialist midwives, which ensured that women received specialist care suited to them.
  • There were effective systems in place to safeguard women and their babies from harm. Women identified as “high risk” were offered enhanced care by specialist midwives.
  • Feedback for the services inspected was mostly positive. Staff respected confidentiality, dignity and privacy of patients.
  • Women had a choice of where to give birth and almost all women now had one to one care in labour.
  • Community midwives covered specific geographical areas thereby ensuring women had access to midwives in their local area.
  • Admission process for women in labour had improved with a dedicated triage midwife on duty in line with national guidance.
  • The governance arrangements and their purpose were clear. Collection of data had improved to provide better oversight of the service.

However;

  • Some black midwives reported being treated unfairly and lodged a collective, official grievance as a result. The trust carried out an internal investigation and recommendations have been made to improve to situation.
  • The trust continued to focus more on trust wide outcomes rather than outcomes by unit, which obscured differences in the two units.
  • The overall vision for the unit was not well defined.

Maternity and gynaecology

Requires improvement

Updated 27 May 2016

We judged maternity as requiring improvement. Poor deployment of staff combined with inadequate numbers of midwives meant there was a risk to women's care. Processes for addressing staffing shortages were not well planned and did not take account of skill mix. There was inconsistent cascade of learning from incidents and complaints and the service was slow to implement change.

The hospital took part in national audits using trust wide and not unit-specific data.The use of merged data from both maternity units was unhelpful in terms of reflecting unit performance, because of the difference between the two units in terms of size,culture, activity, staffing and demographics. St Helier performed better on normal birth because it had a well-established birth centre, and had fewer instrumental births, but the hospital had much higher caesarean section rates and numbers of mothers smoking during pregnancy.

St Helier carried out a narrow range of audits and did not collect data on all standard indicators and some data was misleadingly reported, such as midwife to birth ratio which was reported on the basis of establishment rather than actual numbers of midwives to care for women.

The majority of patients told us staff were caring.Bereaved women were sensitively supported.

Flow through the maternity wards was poorly organised, and women were not always in the most appropriate wards.Little work had been done to find out what women wanted in their antenatal and postnatal care, and to design the service around their needs. There was no dedicated telephone line or triage for women in labour.

Not all high level risks were reflected on the risk register and action to manage risks was slow. There was little evidence of challenge in governance meetings. The culture was hierarchical and did not involve staff in developing the service.

There was a lack of strong leadership or vision. The communication route from ward to board was not effective.There was a lack of good quality data on many aspects of performance, and audits were not used to drive improvement or monitor change.

The gynaecology service had weaknesses in incident reporting, and a high level of agency staffing leading to poor completion of patient observations and a past record of poor hygiene. Referral to treatment times were not always met.

Medical care (including older people’s care)

Updated 14 May 2018

  • The hospital had reviewed systems and processes to improve patient flow through the medical department.
  • The hospital had improved the discharge process with the introduction of a new ward for patients who were medically fit and waiting to be discharged.
  • The hospital had reviewed staffing levels in the department and had highlighted where extra staff are required and had made significant improvement in nurse recruitment from abroad.
  • The hospital had a system in place to respond to deteriorating patients and had a clear sepsis assessment tool and pathway.
  • Medical wards used a combination of best practice and national guidance to deliver care and treatment to patients, and staff were competent to provide this care.
  • Staff understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards was good. We saw examples of Deprivation of Liberty Safeguards in place for patients, and staff were aware of the importance of mental capacity assessments.

However:

  • Mandatory training figures were not in line with trust targets. Most staff had not completed the required mandatory training.
  • Controlled drugs were not always stored appropriately. The controlled drugs register did not always match the contents of the cupboard in ward B5.
  • Readmission rates were above the England average in clinical haematology services, general medicine, and geriatric medicine.

Urgent and emergency services (A&E)

Requires improvement

Updated 14 May 2018

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

  • All mandatory training in key skills for medical staff and nursing staff and safeguarding training were below the trust target of 95%.
  • The physical environment of the ED did not enhance patient safety.
  • The ED was not meeting the Royal College of Emergency Medicine (RCEM) recommendations that consultants should provide 16 hours of emergency cover seven days per week. This was also the case at the last inspection in 2015.
  • The use of restraint on mental health patients in the hospital was not monitored.
  • The ED failed to meet any standards in the RCEM for consultant sign-off audit and the severe sepsis and sepsis shock audit in 2016/2017.
  • The ED did not have specific arrangements to meet the needs of patients with dementia or means of identifying people with dementia by means of an identity band or special sticker
  • The senior management team acknowledged that the sharing of information was not robust and could be better in particular the sharing of learning from incidents.

However:

  • The trust met the A&E four hour waiting time target in eight out of 12 months from December 2016 to November 2017, and showed a trend of stability compared to the national standard and better than the England average.
  • From December 2016 to November 2017, the trust’s monthly percentage of patients waiting between four and 12 hours from the decision to admit until being admitted was better than the England average.
  • Patients who are at risk as a result of their mental health received a mental health assessment within ED or the assessment unit by a qualified mental health professional.
  • The paediatric ED, staffing levels complied with the Royal College of Paediatrics and Children’s Health (RCPCH) by having a minimum of two children’s nurses in the ED 24 hours a day seven days per week.
  • There was effective multidisciplinary working in the ED.
  • Staff provided treatment and care in a kind and compassionate way and treated people with respect. Staff were seen to be very considerate and empathetic towards patients.

Surgery

Requires improvement

Updated 14 May 2018

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

  • There were significant staffing issues, with staffing levels on all wards frequently falling below the hospitals own recommended levels for safe care.
  • Ward staff were expected to provide care for too many patients and did not always have enough time to provide the level of care they felt appropriate.
  • There were ongoing issues with equipment; in particular significant numbers of sterile surgery kits were missing necessary components. Despite the hospital having been aware of this issue for over a year, and the CQC having raised concerns regarding surgical equipment at the last inspection, this issue still had not been resolved.
  • Record keeping was inconsistent and they were not always completed accurately or stored securely.
  • Incident reporting and learning from incidents was not fully embedded with the department. Some staff did not have time to report incidents, and were disinclined to do so, given the lack of action taken and feedback provided when low-level incidents were reported.
  • Staff training in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) was much lower than the trust target and some staff did not feel confident in assessing a patient’s capacity. There was some evidence of capacity assessments not being completed where it would be appropriate to do so.
  • Appraisal completion was variable across departments and while a number of staff were positive about the process, ongoing support and supervision, particularly on the surgical wards, was inconsistent due to a number of management vacancies and cover arrangements in place. This impacted on both staff morale but also their ability to deliver consistently high quality care for patients.
  • At the time of our inspection there were some issues with patient flow through theatres, arising from the high demand on beds.
  • There were issues with the patient pathway in the surgical assessment unit (SAU); in particular, patients were being admitted from the unit following surgery, on some occasions, as a step down from critical care, which impacted on the demands placed on staff.
  • Ward staff described a “disconnect” between the senior leadership team and patient facing staff and a significant number of nursing ward staff described themselves as overworked and undervalued.
  • Due to the shortage in staff, there were cases of inappropriate delegation, with staff acting up to various roles or taking over different responsibility. A number of nursing staff were of the view, therefore that those staff acting up lacked the relevant authority to make decisions or impact within those roles.
  • There was a lack of proactive leadership to address concerns identified within the risk register as well as lower level concerns escalated by operational staff.

However,

  • Patients described staff as compassionate and caring and we observed positive caring interactions.
  • There was positive multidisciplinary team (MDT) working. Allied health professionals (AHP) felt that they were valued team members and that their decisions and recommendations were accepted and valued by the medical team.
  • The service was planned and delivered to meet the needs of different people.
  • The average length of stay for surgical elective patients was better than the England average and met the England average for non-elective patients.
  • Only one percent of patients whose operations were cancelled were not treated within 28 days. This was better than the England average.
  • Staff spoke highly of the local leadership team.

Intensive/critical care

Updated 14 May 2018

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

  • There had been a lot of improvements since the last CQC visit.
  • Multidisciplinary (MDT) working was well embedded, the culture on the unit had changed and the leadership team had achieved good team dynamics. The ward had implemented MDT ward rounds, safety huddles, launched monthly newsletters, consultant meetings to agree guidelines and monthly governance meetings.
  • The risks identified on inspection reflected the risks on the risk register. The appointment of an external advisor helped in conducting a gap analysis, monitoring Guidelines for the Provision of Intensive Care Services (GPICS) and developing the strategy with the trust.
  • Relatives of patients were impressed with the care provided and felt involved in the decision making process.
  • The ICNARC standardised mortality ratio showed a trend of good outcomes on critical care.
  • Mortality rates were within the expected range and risk-adjusted acute hospital mortality data was better than expected in comparison with data submitted by similar units.
  • Staff including agency received a good induction and support prior to caring for patients independently.
  • There was an organ donation committee to ensure no missed organ donations and potential organ donations.
  • The governance structure had improved, there was a governance lead, a quality manager and more allied health professionals who attended the meetings.

However;

  • There were a high number of delayed discharges compared to similar units.
  • The unit did not meet the minimum environment standards.
  • Staff did not routinely receive feedback from incidents.

Services for children & young people

Good

Updated 14 May 2018

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

  • There was a good overall safety performance in the service and a culture of learning to ensure safety improvements. Staff were encouraged to report incidents and received timely feedback. There was evidence of learning from incidents, which was shared in a number of ways.
  • There were processes in place to ensure safe staffing levels. The service had 24 hour consultant cover.
  • There were effective processes in place to assess and escalate deteriorating patients.
  • There was good compliance with infection prevention and control processes. Equipment was checked regularly and medicines were stored appropriately.
  • Staff had a good understanding of safeguarding and were aware of their responsibilities in relation to safeguarding children. The service had good multi-agency partnerships to share relevant safeguarding information.
  • Patient records were completed to a good standard.
  • Staff provided care and treatment in line with national guidance and good practice. The service monitored the effectiveness of care and treatment through continuous local and national audits.
  • There were effective processes in place to ensure that patients’ nutritional and pain management needs were met.
  • Staff were supported to develop and there was a culture of learning and teaching within the service.
  • There was effective multidisciplinary team (MDT) working both internally and externally to support patients’ health and wellbeing.
  • There was a range of information and support available for patients and their families and carers. Staff helped patients manage their own health.
  • Staff understood their responsibilities as set out in the Mental Capacity Act (MCA).
  • Staff in children and young people’s services demonstrated a patient-centred approach which encouraged family members to take an active role in their child’s healthcare.
  • All staff interacted with patients and their family members and carers in in a caring, polite and friendly manner.
  • The service had a broad programme of emotional support services for children and young people and their families and carers. This included a variety of therapeutic support services.
  • There was timely access to a broad range of children and young people services including a number of highly specialist paediatric services. The flow of patients through children and young people services from admission, through theatres, wards and discharge was mostly managed effectively.
  • There was provision to meet the individual needs of children and young people using services at the hospital, including vulnerable patients and those with specific needs. There were efforts across the hospital to make the environment more child-friendly and welcoming for young people.
  • There was an established and stable leadership team in the CYP service. Staff told us senior leaders of the service were visible, approachable and supportive. There was an inclusive and constructive working culture within the services. We found dedicated staff that were knowledgeable about their work.
  • The department used appropriate governance, risk management and quality measures to improve patient care, safety and outcomes. Senior staff understood their local challenges and demonstrated a desire to improve CYP services for the benefit of patients.

However:

  • There remained some challenges with staffing vacancies, for example, nurse staffing in the neonatal unit (NNU) and on the children’s ward. Managers were aware of these challenges and there were interim measures in place to ensure safety.
  • The hospital had one lift to serve all floors. The lift was taken out of service when routine maintenance was required. However, a business plan was in place to build a new external lift.
  • There was no formal clinical supervision for nursing staff.

End of life care

Good

Updated 27 May 2016

The Specialist Palliative Care (SPCT) team provided end of life care and support six days a week, with on call rota covering out-of-hours. There was visible clinical leadership resulting in a well-developed, motivated team.

Patients told us the ward based staff and the palliative care clinical nurse specialists were caring and compassionate and we saw the service was responsive to patients’ needs. The SPCT responded promptly to referrals. There was fast track discharge for patients at the end of life wishing to be at home or their preferred place of death.

Staff throughout the hospital knew how to make referrals to the SPCT and referred people appropriately. The team assessed patients promptly, to meet patient needs. The chaplaincy and bereavement service supported patients’ and families’ emotional and spiritual needs when people were at the end of life.

Most hospital staff were complimentary about the support they received from the SPCT. Junior doctors particularly appreciated their support and advice, and said they could access the SPCT at any time during the day. They recognised that the SPCT worked hard to ensure that end of life care was well embedded in the trust.

The director of nursing had taken the executive lead role for end of life care, along with a non-executive director (NED), to ensure issues and concerns were raised and highlighted at board level. The trust's board received EOLC reports, outlining progress against key priorities within the EOLC strategy, including audit findings, themes from complaints and incidents, evidence of learning and compliance with end of life training requirements.

The SPCT provided a rapid response to referrals, assessed most patients within one working day. Their services included symptom control and support for patients and families, advise on spiritual and religious needs and fast-track discharge for patients wanting to die at home.

The National Care of the Dying Audit 2013/2014 (NCDAH) demonstrated that the trust had not achieved three out of seven organisational key performance indicators. At the time of the inspection, the trust had not fully rolled out the replacement of the LCP, and this delay meant that staff were not fully supported to deliver best practice care to patients who were dying. The leadership failed to apply enough urgency to have an individual plan of care in place.

Renal

Good

Updated 27 May 2016

Overall, we found renal services were good. Reviews of care through incident investigation and morbidity and mortality were completed throughout the service and opportunities for learning were shared with staff. Infection control practices were robust in all areas. Staffing levels and skill mix were appropriate in all areas across the service with low agency staff usage.

Patient outcomes were in line or exceeded with national standards and effectiveness was regularly assessed and benchmarked. There was effective multidisciplinary working, with specialist nurses and allied health professionals and joint clinics were held with relevant specialties including diabetes. However we noted that standards for vascular access for haemodialysis were not met.

Most patients’ spoke positively of the care they received within the hospital, and individual patient needs were met. Delays in transport were noted as a particular concern by patients’ and their carers.

The environments in the dialysis units were cramped and in some areas, including at St Helier, facilities for patients were limited.

The service was well led with a clear vision and strategy and effective governance and risk management processes. Managers in the service were aware of shortfalls and took steps to address them. Staff spoke positively of the leaders and culture within the service