St Helier Hospital and Queen Mary's Hospital for Children

St Helier Hospital and Queen Mary's Hospital for Children is part of Epsom and St Helier University Hospitals NHS Trust. The trust provides local acute services for people living in the southwest London and northeast Surrey. St Helier Hospital provides acute hospital services to population of around 420,000.

St Helier Hospital and Queen Mary's Hospital for Children is home to the Southwest Thames Renal and Transplantation unit. There is also a Children's Hospital on this site (Queen’s Mary’s Hospital for Children). All emergency surgery is undertaken at St Helier Hospital and the majority of elective surgery is carried at the trust’s other location, Epsom General Hospital.

Epsom and St Helier University Hospitals NHS Trust employs around 5,024.8 whole time equivalent (WTE) members of staff. Many staff work across both sites, so it is not possible to assign an exact number of staff for each site.

We carried out an announced inspection of St Helier Hospital and Queen Mary's Hospital for Children between 10 and 13 November 2015. We also undertook unannounced visits to the hospital on 21, 23, 25 and 27 November 2015.

Overall, this hospital is rated as requires improvement. We found urgent and emergency care, medical care, critical care, maternity and gynaecology, services for children and young people required improvement. Outpatients and diagnostic services, end of life care and renal services were good, however surgery was inadequate.

Overall, we found the safety, effectiveness, caring, responsiveness and well-led all required improvement.

Our key findings were as follows:

Safe

• Staff were encouraged to report incidents, but there was inconsistent feedback and learning from incidents.
• Staff were not always carrying out daily checks of resuscitation equipment in all areas.
• Staff were aware of their responsibilities to protect vulnerable adults and children. They had access to the trusts safeguarding policy, understood safeguarding procedures and knew how to report concerns. However, the children’s ‘At Risk’ register in the ED had not been updated for three months.
• Inadequate nurse staffing levels on some surgical wards and inadequate numbers of midwives meant there was a risk to the quality of patient care. There was also a large number of vacant medical staff posts and high use of locums in paediatrics. However, the hospital had recently undergone a recruitment drive which had enabled it to fill some of its nursing and medical vacancies.
• The environments we inspected were visibly clean. However, the fabric of the St Helier building was reported as difficult to maintain due its age and the trust reported that this was likely to impact on the overall patient experience. This was due to the fact that staff reported difficulties in a range of areas including ensuring the building was hygienically clean; spacing between bed spaces was not in line with nationally recommended standards and a lack of appropriately equipped side rooms and isolation facilities for patients identified as being at risk of acquiring an infection, or whom had developed an healthcare acquired infection.
• The trust recognised that in relation to infection rates, they were performing worse when compared both nationally and to peer hospitals of a similar size. Again, reasons behind the poor infection rates were partly attributed to the fabric of the buildings. We were concerned that, in light of the fact the physical environment was not always fit for purpose, there had not been sufficient focus on staff consistently applying standard, evidence based practice such as decontaminating hands both before and after patient contact; staff not abiding by bare below the elbow policies; staff not applying isolation protocols in a timely way and staff wearing theatre clothing such as scrubs and theatre shoes in communal areas of the hospital such as the public coffee area located on the ground floor of St Helier hospital. Root cause analysis into incidents associated with patients acquiring healthcare-associated infections included a lack of isolation facilities (side rooms) as a contributing factor to the spread of MRSA in three additional patients during 2014/2015. The NHS estates and facilities dashboard placed the trust in the lower quartile for the percentage of side rooms available and in the lowest (worst) quartile for the amount of functional and suitable space available for the delivery of clinical care.
• The estates critical maintenance backlog was such that, when considering the negative financial performance of the trust for 2015/2016 and the projected budgeted deficit reported for 2016/2017, it was unlikely the trust was going to be able to deliver any significant impact to the backlog which was reported as a risk adjusted backlog of circa £37 million; this placed the trust as having the 16th highest estates backlog nationally and in 3rd position when compared to peer groups across London of a similar size and activity. The trust was in the highest quartile (worst when compared nationally) for the total reported backlog for maintenance.
• Following the inspection, the trust shared additional information of concern with us regarding the structural integrity of some parts of the St Helier campus. Concerns were identified regarding the external render of B and C block and the fact that large sections of render had become loose over time posing a potential risk of falling debris to people passing beneath. The trust had commissioned a range of structural assessments to determine the extent of the issue and to determine immediate remedial actions including the fencing off of certain areas of the estate. We have asked the trust to provide the commission with the necessary assurances and have shared the information with a range of partner regulatory bodies so as to ensure sufficient focus is given to the concerns identified. At the time of publication of this report, we are continuing to monitor the situation and will consider any appropriate regulatory action as we consider necessary. 
• The hospital had a mandatory training programme, however in most instances the completion rate was low. Staff spoke of pressures of work, particularly low staffing numbers that prevented them from attending training days.
• Staff accessed the service’s clinical guidelines on the Trust’s intranet but were not always reviewed and updated. The service contributed to national audits and undertook local audits.

Effective

• National audits that the trust took part in indicated that they adhered to best practice standards as well as or better than the England average, however there was a limited range of evidence for local audits.
• There was a lack of agreed guidelines specific to the critical care unit and multidisciplinary working was not well embedded.
• The hospital took part in national audits in the maternity service but we saw trust wide and not unit-specific data. The use of merged data from both maternity units was unhelpful in terms of monitoring unit performance, because of the difference between the two units in terms of size, culture, activity, staffing and demographics.
• Pain scores were not routinely recorded and patients were not always administered timely pain relief. There was inconsistency in the pain scoring tools staff used to assess patients whilst in the ED.
• Staff we spoke with were clear about their responsibilities in obtaining consent from people, however we saw no evidence of documentation of a ‘best interest’ decision making process for patients who did not have capacity to consent in some areas.
• We found staff appraisal completion rates were low.
• There was a lack of clarity amongst some staff with regard to how the Deprivation of Liberty Safeguards should be used.

Caring

• Staff treated patients with compassion, dignity and respect. Interactions between staff and patients were professional kind and friendly. Patients were positive about the care and treatment they received.
• Whilst Family and Friend Test feedback was positive, the response rate was notably low.
• In critical care, patients were not always given the opportunity to be involved in their care.
• In most cases, staff involved patients, their carers and family members in decisions about their care.
• Bereaved mothers were sensitively supported by staff in maternity.

Responsive

• The ED consistently performed at a rate better than the England average in meeting national standard of a doctor seeing 95% of patients within four hours of their arrival for the 12 month period November 2014 to October 2015.
• Patient information and advice leaflets were only available in English.
• Patients living with a learning disability were ‘flagged’ on the records system. However the department did not use a system for identifying patients living with dementia and there were no care arrangements for meeting their specific needs.
• In surgery, the trust had fallen below the standard for the referral to treatment times (RTT).
• Flow through the maternity wards was poorly organised, and women were not always in the most appropriate wards.
• In outpatients, there was limited audit of patient waiting times for clinics.
• Staff were aware of the complaints policy and told us how most complaints and concerns were resolved locally.
• There was inconsistent feedback and learning from and complaints.

Well-led

• Many staff had worked in the departments for many years. However, some were unaware of the trust’s vision of ‘Put the Patient First’.
• Governance arrangements in the medical directorate were adequate, and staff commented on very good multidisciplinary teamwork; collaborative care and line management support although a number of staff commented on the disjointed cross site working.
• Positive comments were received from many staff regarding the new senior management.
• The hospital had a number of innovative projects underway, including those relating to patients living with dementia.
• Risks for the service had been identified in various governance meetings and from a series of incidents but there lacked cohesiveness and a trust board understanding of how to address these issues in a timely manner.
• In critical care, the leadership team had struggled to achieve good team dynamics because of behavioural issues from certain staff members and have not been successful in their attempts to manage this. The service had been unable to agree a strategy and an external advisor had been appointed by the trust to assist the critical care workforce in achieving this. The culture on the unit was very hierarchical and challenges were not always welcome.
• In maternity, risks for the service were poorly identified and not managed in a timely way. There was little challenge in governance meetings. The culture was hierarchical and did not involve staff in developing systems. There was a lack of strong leadership or vision and there was not an effective communication route from ward to board.
• In renal, 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 addressed them. Staff spoke positively of the leaders and culture within the service.

We saw areas of outstanding practice including:

• The leadership of the outpatients and diagnostic imaging teams was very good with staff inspired to provide an excellent service, with the patient at the centre.
• The diagnostic imaging department worked hard to reduce the patient radiation doses and had presented this work at national and international conferences.
• The OPAL team had clearly had a positive impact in increasing the quality care of the elderly, particularly those living with dementia.

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

Importantly, the trust must:

• Ensure child protection notifications are always up to date.
• Ensure there are adequate numbers of nurses and midwives to deliver safe and quality care.
• Implement agreed guidelines specific to the critical care units.
• Ensure the management, governance and culture in the critical care units, supports the delivery of high quality care.
• Obtain feedback from patients/relatives in the critical care units, so as to improve the quality of the service.
• Make sure the 'Five steps to safer surgery' checklist is always fully completed for each surgical patient.
• Identify, analyse and manage all risks of harm to women in maternity services
• Ensure identified risks in maternity services are always reflected on the risk register and timely action is taken to manage these risks.
• Improve the care and compassion shown to patients in the medicine, surgical and critical care areas.

In addition the trust should:

• Ensure that the consultant hours in the emergency department meet the RCEM recommendation.
• Ensure staff were not always carry out daily checks of resuscitation equipment in all areas.
• Ensure the children’s ‘At Risk’ register in the ED is kept up to date.
• Ensure that the trust's infection control procedures are complied and theatre staff do not wear theatre gear such a gowns and head covers in public areas.
• Improve staff attendance at mandatory training
• Ensure clinical guidelines on the trust’s intranet are always reviewed and updated.
• Ensure there are agreed guidelines specific to the critical care unit and that multidisciplinary working is well embedded.
• In maternity, ensure monitoring data is separated by location.
• Ensure ‘best interest’ decisions are documented for patients who did not have capacity to consent.
• Ensure staff appraisals are completed as required.
• Ensure all relevant staff are clear about how the Deprivation of Liberty Safeguards should be used.
• In critical care, ensure patients are always given the opportunity to be involved in their care, where appropriate.
• Improve the referral to treatment times in surgery.
• Improve the 31 day cancer waiting times for people waiting from diagnosis to first definitive treatment and the 62 day waiting time for people waiting from urgent GP referral to first definitive treatment.
• Improve the flow of women through the maternity wards and ensure women are cared for in the most appropriate wards.
• Ensure there are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments, the auditing of patient waiting times and the timely and appropriate follow up appointments.
• Improve the cohesiveness of risk management and address them in a timely manner.
• In critical care, ensure good team dynamics and better working relationships amongst staff; an agreed strategy for the unit that includes the critical care workforce across the two sites and that all risks are identified and on the risk register.
• In maternity, ensure risks are properly identified and managed in a timely way, leadership
• Review arrangements for admission of women to maternity wards so that a member of staff can greet women and prevent unauthorised access.
• Ensure policies reflecting national evidence-based guidance are communicated to all staff.
• Ensure staff were able to use the structured communication tool, SBAR (Situation, Background, Assessment, Recommendation), effectively.
• Review the skill mix on the maternity wards.
• Increase the number of sonographers in radiology.
• Ensure that the paediatric emergency department comply with Royal College of Paediatric and Child Health guidelines.
• Ensure the servicing of equipment is undertaken on a regular basis and that broken equipment is removed from clinical areas.
• Ensure pain scores are routinely recorded in the emergency department.
• Improve the response times to complaints in the medical directorate.

Professor Sir Mike Richards

Chief Inspector of Hospitals