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St Mary's Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 23 July 2019

Our rating of hospital stayed the same. We rated it 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 Critical Care as part of this inspection in March 2019 to check if improvements had been made. The rating of the service had remained the same. We rated it as good because safe, effective, caring, responsive and well-led were good. The rating for responsive went up, and the ratings for safe, effective, caring and well-led remained the same.
  • We inspected the Maternity service as part of this inspection in March 2019 to follow-up on concerns we had from the previous inspection in October 2017. We found that the service had improved, and the rating of the service went up. We rated it as outstanding, because caring and responsiveness were outstanding, and safe, effective and well-led were good. The rating for safe, caring, responsive and well-led went up, and the rating for effective remained the same.
  • We inspected Children’s and young people’s services as part of this inspection in March 2019 to check if improvements had been made. The rating of the service had remained the same. We rated it as good because effective, caring, responsive and well-led were good. However, safe required improvement. The ratings for safe, effective, caring, responsive and well-led all remained the same.
  • We inspected Urgent and emergency care in November 2017 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 in November 2017 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 23 July 2019

Effective

Good

Updated 23 July 2019

Caring

Good

Updated 23 July 2019

Responsive

Requires improvement

Updated 23 July 2019

Well-led

Good

Updated 23 July 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 19 October 2017

Services for children & young people

Good

Updated 23 July 2019

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

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

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

  • The service usually had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. However, staff told us there were sometimes shortages.

  • The service had enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.

  • Staff kept detailed records of patient care and treatment. Records were clear, up-to-date and easily available to all staff providing care.

  • The service followed best practice when prescribing, giving, recording and storing medicines.

  • 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 used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.

  • 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.

  • 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.

  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. 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 the local people.

  • The service took account of patients’ individual needs.

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

  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.

  • Managers at all levels in the trust had 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 and staff including nurses and doctors promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

  • There were arrangements in place for governance and risk management.

  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. We saw that risks found on inspection were included on the risk register.

  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

  • The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However:

  • The premises and environment were not always suitable for the services being provided, with one of the risks being legionella and pseudomonas in the water.
  • Whilst improvements had been made since the last inspection, the ongoing renovation work meant there was a lack of isolation facilities in the PICU.
  • Staff on the wards told us play specialists were only available three days a week due to lack of resourcing.
  • The service faced challenges in mental health care provision.
  • Staff survey results showed signs of disconnection with senior management. The NHS staff survey 2017 results showed only 35% of staff thought that senior managers tried to involve staff in important decisions. Only 25% of participants thought that communication between senior management and staff was effective and only 13% felt that senior managers acted on staff feedback.
  • There was no central log for child safeguarding cases.

Critical care

Good

Updated 23 July 2019

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

  • Patients were treated and cared for with compassion, respect, and dignity. Staff understood the impact of patients care, treatment or condition to their wellbeing and those close to them. Patients’ needs and preferences were considered and acted on to ensure services were delivered to meet those needs.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

  • The service controlled infection risk well.

  • There were enough nursing staff on duty to meet the needs of the patients. Staff had the right qualifications, skills, training, and experience to keep people safe from avoidable harm and to provide the right care and treatment.

  • 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.

  • Staff worked together as a team to benefit patients. Doctors, nurses, and other healthcare professionals supported each other to provide good care.

  • Records were clear, up to date, and easily available to all staff providing care.

  • Staff recognised incidents and reported them appropriately. There were processes to ensure complaints were dealt with effectively. When things went wrong, staff apologised and gave patients honest information and suitable support.

  • 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.

  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.

  • Patients and those close to them were treated as active partners in the planning and delivering of their care and treatment. Patients were giving appropriate information and encouraged to make decisions about their care and treatment.

  • Managers had the right skills and abilities to run a service providing high-quality sustainable care.

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

  • Managers across the department promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.

  • The department had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

  • The department collected, analysed, managed, and used information well to support all its activities, using secure electronic systems with security safeguards.

However, we also found:

  • The critical care outreach team were not providing a 24-hour service. They were not meeting critical care staffing standards for an outreach service.
  • The hospital did not have a formalised approach to reviewing patients after they were discharged from critical care.
  • There was no designated psychological service to meet needs of all critical care patients.
  • Venous thromboembolism (VTE) assessments were not completed for all patients on the acute respiratory unit.
  • Learning from incidents was not always shared promptly between all staff working in critical care areas.
  • The clinical audit data was only collected from the intensive care unit. The level 2 acute respiratory beds were not included in data collection.

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 and diagnostic imaging

Good

Updated 31 May 2017

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.

Urgent and emergency services

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.

Maternity

Outstanding

Updated 23 July 2019

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

  • Our rating of the service had improved. We rated it as outstanding because the ratings for both caring and responsive. The trust had taken note of concerns raised about the maternity service at the previous inspection and made improvements in the areas of maternity training, cardiotocography (CTG) training, fresh eye buddy system, oversight on the risk register, emergency theatre staffing, signage, estate, visibility of leadership and governance of serious incidents.
  • The service provided mandatory and maternity specific training in key skills to all staff. Most staff received up-to-date mandatory training. The overall compliance for all midwifery and medical staff was 91% which was better than the trust target (85%).

  • Compliance with core maternity specific mandatory training and skills, such as cardiotocography interpretation, was 92% and above the trust target.
  • The trust had clear systems, processes and practices in place to safeguard adults and children from avoidable harm, abuse and neglect that reflected relevant legislation and local requirements. Staff understood how to protect patients from abuse and the service worked collaboratively with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.

  • There was an effective system in place to assess, respond to and manage risks to patients. Staff could recognise and respond to signs of deterioration and emergencies. Staff completed and updated risk assessments for each patient.

  • The midwife to birth ratio was 1:24, which was in line with national recommendations.
  • 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. This was an improvement from the last inspection.

  • Although the clinical rooms where medicines were stored were sometimes hot, the service had mitigated the risk to ensure medicines were safe to use. Therefore, we were assured effective governance arrangements were in place to ensure safe storage of medicines, fridge temperatures were checked daily, and that out-of-date medicines were replaced, when indicated.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques to support women’s feeding when necessary. The service made adjustments to patients’ diets for religious, cultural and other preferences.

  • Staff assessed and monitored patients regularly to see if they were in pain. The service performed better than the national recommendations and standards on the waiting time for epidurals and the average on women receiving obstetric anaesthesia during caesarean sections.

  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. The service performed better than average on all outcomes in the 2017 National Neonatal Audit.

  • 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.

  • The midwifery and medical staff supported women that accessed the maternity service to live healthier lives and manage their own health, care and wellbeing.
  • Staff treated and cared for women with compassion, patience, dignity and respect. Feedback from people who used the service and their relatives was continually positive about the care they received, and the way staff treated them.

  • There was a strong, visible person-centred culture in the service and relationship between staff and patients was strong and supportive.
  • The maternity service was planned and delivered care in a way that met the diverse needs of the local and surrounding population.

  • The maternity service was flexible, provided choice to women and ensured continuity of care.
  • Women repeatedly told us that they had good access to the hospital and did not experienced prolonged delays to be seen.
  • There was a high level of staff satisfaction across all disciplines and equality groups. Staff were proud of working in the service, spoke highly of the culture and the improvement they had made to the service since the last inspection.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action, which it developed with staff, patients, and local community groups.

However:

  • There were inconsistencies in the monitoring of emergency equipment to ensure it was safe and effective for patient use.

  • From October 2017 to October 2018, the trust’s maternity Friends and Family Test (postnatal ward) performance (% recommended) was slightly worse than the England average.

  • We found some printed clinical guidelines and protocols that were out of date in the maternity areas.
  • Overall the service controlled infection risk well. There were systems and processes to control and prevent the spread of infection. The majority of the department was visibly clean, tidy and free of any odours, however the standards of cleanliness were not always maintained on the antenatal and postnatal ward at night.

Maternity (inpatient services)

Requires improvement

Updated 19 October 2017