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St Mary's Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 28 February 2018

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

  • The hospital improved its rating of well-led since the last inspection, but the ratings for each of the other key questions remained the same.
  • We inspected Urgent and emergency care during this inspection to check if improvements had been made. Our rating of the service stayed the same. We rated it as requires improvement because safe, effective, caring, responsive and well-led required improvement. The rating for well-led improved but the ratings for each of the other key questions remained the same.
  • We inspected Surgery during this inspection to check if improvements had been made. Our rating of the service stayed the same. We rated it as requires improvement because safe and responsive required improvement and effective, caring and well-led were good. The rating for well-led improved but the ratings for each of the other key questions remained the same.
  • We inspected the Medical care (including older people’s care) service in October 2017 because we had concerns about the quality of the service. Our rating of the service stayed the same. We rated it as requires improvement because safe and responsive required improvement, and caring and well-led were good. The ratings for each of the key questions remained the same.
  • We inspected the Maternity service in October 2017 because we had concerns about the quality of the service. Our rating of the service went down. We rated it as requires improvement because safe, responsive and well-led required improvement, and effective and caring were good. The ratings for safe, responsive and well-led went down and the ratings for each of the other key questions remained the same.
  • We inspected the Outpatients and diagnostic imaging service in May 2017 to check if improvements had been made. Our rating of the service significantly improved. We rated it as good because safe, caring and well-led were good and responsive required improvement. We did not rate effective. The rating for responsive improved and the rating for well-led significantly improved. The ratings for each of the other key questions remained the same.
Inspection areas

Safe

Requires improvement

Updated 28 February 2018

Effective

Good

Updated 28 February 2018

Caring

Good

Updated 28 February 2018

Responsive

Requires improvement

Updated 28 February 2018

Well-led

Requires improvement

Updated 28 February 2018

Checks on specific services

Maternity and gynaecology

Good

Updated 7 January 2015

At the time of our inspection, the risk of unsafe care because of inadequate midwifery staffing had been mitigated by prioritising the needs of women in labour. However, the quality of care on postnatal wards was sometimes compromised. The business case for additional staff had been accepted and recruitment to these posts was underway.

Evidenced-based care was promoted and there was an audit programme to assess compliance with best practice. There was an embedded multidisciplinary approach to learning from incidents and complaints. Staff at all levels were able to raise concerns and these were addressed.

Specialist clinics assessed the needs of women with medical conditions. Specialist midwives and caseload midwives (midwives who deliver one-to-one care for an agreed number of women) supported women who were at risk. Women were encouraged to make a choice about the type of birth that was best for them and their babies. The community midwifery service provided local women with continuity of care.

There was training for midwifery staff and trainee doctors and opportunities for professional development. Staff were positive about their contribution to improving the quality of care and felt their contribution was recognised and valued.

Maternity (inpatient services)

Requires improvement

Updated 19 October 2017

Medical care (including older people’s care)

Requires improvement

Updated 19 October 2017

Urgent and emergency services (A&E)

Requires improvement

Updated 28 February 2018

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

  • The trust was not meeting national standards for median time from arrival to initial assessment or treatment, total time in the emergency department (ED), patients leaving the ED without being seen or four-hour performance. The initial triage of self-presenting patients was conducted by the urgent care centre (UCC), which was locally commissioned and provided by a primary care organisation registered with the CQC. The trust told us that they did not have control over this process or access to data relating to this part of the patient pathway, resulting in inaccurate data. However, the trust was unable to produce any data held locally relating to performance against these targets until a time after the inspection. The trust were therefore not able to demonstrate how they assured themselves of performance against these external targets.
  • The service did not always have enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. There was a high vacancy rate within the nursing team. High numbers of mental health patients meant that registered mental health nurses (RMNs) often struggled to provide the required enhanced levels of observation needed. The paediatric ED was failing to meet the London Quality Standards for paediatric consultant cover. The department was not meeting mandatory training levels for staff. Staff did not receive any formal training in caring for patients with mental health conditions. Staff appraisal rates did not meet the trust target of 95%, falling considerably short of this in some groups of staff.
  • Although record keeping standards had improved since the last inspection with the introduction of the electronic patient record (EPR), risk assessments were not always completed in the clinical decisions unit (CDU) and not all medication records we looked had a documented allergy status. Electronic systems used across the trust did not always ‘talk’ to one another.
  • The department were performing below the national average in many of the Royal College of Emergency Medicine (RCEM) audits.
  • The trust’s unplanned re-attendance rate to ED within seven days was generally worse than both the national standard of 5% and the England average. We noted low response rates in the NHS friends and family test (FFT), with the percentage of people who would recommend the ED as a place of treatment falling below the national average.
  • Capacity and lack of physical space within the department remained an issue, despite the refurbishment that had taken place. Space limitations affected the ability of staff to provide care, which maintained the privacy and dignity of patients. There was no waiting time information on display during our inspection and no patient information leaflets available in the adult ED department. Signage in the reception area and signs leading to the ED from the ground floor were confusing. Waiting areas were small and overcrowded at busy times. Not all portable equipment we checked had been recently serviced and labelled to indicate the next review date.

However:

  • Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. This had improved since our last inspection.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
  • 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.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. This had improved significantly since the previous inspection.
  • The service performed well in the Trauma Audit & Research Network (TARN) audit.
  • 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.
  • The dedicated paediatric ED was designed to meet the needs of children.
  • Since our previous inspection, the directorate level leadership, culture and overall governance structure had improved significantly.
  • 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.

Surgery

Requires improvement

Updated 28 February 2018

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

  • There were significant environmental challenges in main theatres that were not well managed. This included widespread damage to fixtures, fittings and equipment and an ineffective maintenance programme.
  • Infection control standards in theatres were inconsistent and as a result, risks to patients and staff were high.
  • Adherence to the World Health Organisation safer surgery checklists was variable during our observations and a task group had been set up to address on-going concerns.
  • Five specialties participated in the Department of Health ‘Getting it right first time’ project and used narrative feedback to drive improvements in evidence-based care and treatment.
  • Overall compliance with the monthly safer procedures audit was consistently high, with some areas for improvement in individual specialties.
  • The trust did not meet the tolerance of 1% of patients waiting more than six weeks for diagnostic assessment in any month between April 2017 and September 2017.
  • Patients regularly spent more than 24 hours in theatre recovery due to a lack of capacity elsewhere in the hospital.
  • The average length of stay for patients in each specialty was higher than the national average and in some cases significantly higher. However, this was partially reflective of the high levels of complexity the hospital saw and increasing demand on services.
  • The hospital continued to experience breaches in referral to treatment times against 18 week and 52 week pathways along with cancellations due to a lack of capacity. However, a multidisciplinary senior team of clinicians and non-clinical specialists were leading a waiting list improvement programme to address a large backlog of patients and improve data management.
  • Clinical governance systems did not always identify and address areas of risk to patient care and safety, particularly in relation to theatres.

However:

  • We found consistently good standards of record keeping in relation to patient notes and risk assessments.
  • Inpatient wards demonstrated sustained improvement through the ward accreditation programme and a number of teams had been awarded a gold standard as a result.
  • Care and treatment was benchmarked against the national standards and guidance of the Association for Perioperative Practice, the Association of Anaesthetists of Great Britain and Ireland and the Guidelines for the Provision of Anaesthetic Services. This included an audit programme across all specialties, network, and local peer reviews.
  • All staff had access to learning from audits and incidents through dedicated audit days.
  • Inpatient ward teams had improved nutrition and hydration through targeted work that was recognised with gold standard ratings by the ward accreditation team.
  • A dedicated team of clinical practice educators supported nurses to develop their clinical competencies and leadership skills. The team had developed specific competency frameworks to ensure nurses who provided high dependency care had specialist training.
  • Feedback from patients and relatives was consistently good and surgery services regularly achieved 100% recommendation scores in the NHS Friends and Family Test.
  • There was an embedded culture of dignity, respect, kindness and compassion in each clinical area and staff demonstrated persistence in achieving this.
  • In response to emergencies and major incidents in London, the senior team leading the major trauma service had implemented a number of service developments.
  • There was a continual drive to improve community services for patients, including those with high levels of vulnerability such as homelessness. This included community liaison teams, rehabilitation teams and social care specialists.
  • Quality improvement was evident in all clinical areas led by staff with appropriate experience. This was benchmarked or carried out in line with established frameworks including the US Institute for Health Care Improvement’s model for improvement.

Intensive/critical care

Good

Updated 7 January 2015

The critical care and high dependency areas were generally well-run. The main areas of risk were the lack of bed capacity and different governance arrangements over the level 2 beds outside of the ICU. However, the leadership team were aware of these concerns and had taken action to address these. Patient feedback was positive. There were some concerns relating to staffing levels as these were not always in line with national guidance. Mandatory training had not been completed by all staff.

Services for children & young people

Good

Updated 7 January 2015

While there were areas of innovative thinking, we found that children were being cared for in environments which were not fit for purpose and posed a potential risk to their safety and wellbeing. Areas including paediatric intensive care, children’s outpatients and the Grand Union Ward were not of sufficient size or design to effectively provide care to children in an era of ever-increasing reliance on technology. Bed spaces and cubicles were cramped; there was a lack of effective isolation facilities and a shortage of accommodation for parents/carers who wished to be near to their child or new-born infant while they receive intensive care therapies.

The division used a combination of National Institute for Health and Care Excellence (NICE), and Royal Colleges’ guidelines to determine the treatment they provided. Parents and children were complimentary about the care and treatment provided. Parents felt that staff across all disciplines were compassionate, understanding and caring. Where children and/or parents/carers had cause to complain, these complaints had been acknowledged, investigated and action plans generated to help improve services for the future. There was a strong and embedded approach to multidisciplinary working across the various specialities.

The senior management team was cohesive and all those working in this division were passionate about influencing the care and treatment for children and young people. There was a lack of progress made on risks which had been identified within the division. Some risks had existed for more than five years; there was little or no evidence to suggest that these risks were being addressed in an effective way. In addition, there was no representation of children and young people at board level.

End of life care

Good

Updated 7 January 2015

There was an inconsistent approach to the completion of ‘do not attempt cardiopulmonary resuscitation’ (DNA CPR) forms. In line with national recommendations, the Liverpool Care Pathway for end of life care had been replaced with a new end of life care pathway framework that had been implemented across the hospital. Action had been taken in response to the National Care of the Dying Audit for Hospitals 2013, which found the trust did not achieve the majority of the organisational indicators in this audit, but there was no formal action plan. However, the majority of the clinical indicators in this audit were met.

There was a recently developed end of life strategy and identified leadership for end of life care. The end of life steering group reported to executive committee. The specialist palliative care team (SPCT) were visible on the wards and supported the care of deteriorating patients and pain management. Services were provided in a way that promoted patient centred care and were responsive to the individual’s needs. Referrals for end of life care were responded to in a timely manner and the team provide appropriate levels of support dependent on the needs of the individual.

There was clear leadership for end of life care and a structure for end of life care to be represented at board level through the director of nursing.

Outpatients

Good

Updated 31 May 2017