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St Mary's Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 January 2015

St Mary’s Hospital is part of Imperial College Healthcare NHS Trust. It is an acute hospital and provides accident and emergency (A&E), medical care, surgery, critical care, maternity, children and young people’s services, end of life care and outpatient services, which are the eight core services always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection.

St Mary’s Hospital is a 484-bed general hospital based in London. The hospital provides a range of elective and non-elective inpatient surgical and medical services as well as a 24-hour A&38;E department and outpatient services.

The team included CQC inspectors and analysts, doctors, nurses, experts by experience and senior NHS managers. The inspection took place between 2 and 5 September 2014.

Overall, we rated this hospital as ‘requires improvement’. We rated effective and caring as ‘good’ but safety and responsive as ‘requires improvement’ and well led as ‘inadequate’.

We rated critical care, maternity and family planning, children and young people’s services and end of life as ‘good’ but ‘requires improvement’ for medical and surgery services, and inadequate for A&38;E and outpatients.

Our key findings were as follows:

Safe:

  • The principles of the ‘Five steps to safer surgery’ checklist were not embedded in theatre practice at St Mary’s Hospital.
  • Wards and departments were not always staffed in line with national guidance. Nurse staffing levels had been assessed using an acuity tool, and in some areas, were regularly reviewed. However, in some areas nurse staffing levels were below national standards. Action had been taken to mitigate the risk of inadequate staffing levels but was sometimes impacting on patient care. Services were consultant-led, although consultant cover was below national recommendations in some areas.
  • The standards of cleanliness of the premises and equipment were poor in some clinical areas. Most staff followed the trust’s infection control policy, but there was an inconsistent approach to being bare below the elbows and observing hand hygiene. Hand hygiene audits were undertaken by the ward staff but there was no peer review as these were undertaken by the ward’s own staff.
  • Staff had access to a range of mandatory training and attendance was monitored electronically and on paper. There was low compliance with mandatory training in some clinical areas.
  • The introduction of the new electronic record-keeping software at the trust had resulted in problems with booking outpatient appointments for patients. The trust was taking action to resolve these issues.
  • Medicines were not always stored securely to ensure that unauthorised personal did not have access to them.

Effective:

  • Staff were encouraged and supported with their continual professional development and there was a range of opportunities for staff to develop their skills, including completing degree and master’s level studies.
  • The majority of care was delivered in line with best practice guidance. Staff participated in a range of local and national audits. Outcomes for patients were similar or above the national average for a number of surgical specialties.
  • There was a high rate of patients who did not attend their outpatient appointment or surgical procedure. Action was not being taken to identify the reasons for this or to address the causes.

Caring:

  • Staff were caring and treated patients and their relatives with dignity and respect.
  • Patients commented positively about their care and treatment. The results from the NHS Friends and Family Test in many areas of the hospital were better than the England average, and a high number of patients would recommend this hospital to their family and friends.

Responsive:

  • The trust was not meeting some of its targets; these included sending out appointment letters to patients within 10 working days of receiving the GP’s referral letter, and not getting patient discharge summaries to GPs within target times.
  • Capacity in some areas did not meet demand; this had resulted in a backlog of more than 3,500 patients waiting for surgical intervention and a lack of level 2 high dependency beds. There were no plans to address this issue. There was a lack of bed capacity, particularly for level 2 patients stepping down from the intensive care unit (ICU) after brain and spinal injuries.

Well-led:

  • The trust had a vision and clinical strategy to improve health and to support innovation in healthcare that had been shared with all staff. The new chief executive of the trust was visible and had already made a positive impact on staff morale by listening to their concerns.
  • There was a lack of consistent governance arrangements – for example, the ICU and the rest of the level 2 beds in the hospital were not aligned.
  • The trust had a major incident procedure which most staff were aware of. Some staff had participated in training on how to respond to major incidents.

 

There were poor areas of practice where the trust needs to make improvements.

Importantly, the trust must:

  • Increase the number of cases submitted to the audit programme for the World Health Organization (WHO) surgical safety checklist to increase compliance with the ‘Five steps to safer surgery’.
  • Develop and implement systems and processes to reduce the rate of patients who do not attend their outpatient appointment or surgical procedure.
  • Review the level of anaesthetic consultant support and/or on-call availability to ensure it is in line with national recommended practice.
  • Review the arrangement for medicines storage and ensure medicine management protocols are adhered to.
  • Ensure all staff are up to date with their mandatory training.
  • Ensure all equipment is suitably maintained and checked by an appropriate person.
  • Ensure adequate isolation facilities are provided to minimise risk of cross-contamination.
  • Ensure consultant cover in critical care is sufficient and that existing consultant staff are supported while there are vacancies in the department.
  • Review the divisional risk register to ensure that historical risks are addressed and resolved in a timely manner.
  • Review the provision of the paediatric intensive care environment to ensure it meets national standards.
  • Review the provision of services on Grand Union Ward to ensure the environment is fit for purpose.

In addition the trust should:

  • Improve the handover area for ambulances to preserve patient dignity and confidentiality.
  • Ensure that there is a single source of up-to-date guidelines for A&38;E staff.
  • Seek ways of improving patient flow, including analysing the rate of re-attendances within seven days.
  • Improve links with primary care services to help keep people out of A&E.
  • Ensure that all patients who undergo non-urgent emergency surgery are not left without food and fluids for excessively long periods.
  • Review the literature available to patients to ensure it is available in languages other than English in order to reflect diversity of the local community.
  • Ensure same-sex accommodation on Witherow Ward to ensure patients’ privacy and dignity are maintained.
  • Ensure learning from investigations of patient falls and pressure ulcers is proactively shared trust-wide.  
  • Develop a standardised approach to mortality review which includes reporting to the divisional boards and to the executive committee.
  • Review patients’ readmission and length of stay rates to identify issues which might lead to worse-than-average results.
  • Review the arrangements for monitoring compliance with statutory and mandatory training to ensure there is a consistency with local and trust-wide records.
  • Review the double-checking process for medication to ensure that staff are compliant with trust policies and procedures.
  • Monitor the availability of case notes/medical records for outpatients and act to resolve issues in a timely fashion.
  • Review the provision of adolescent services and facilities to ensure the current provision is able to meet the needs of patients.
  • Ensure that there is sufficient capacity to accommodate parents/carers while their child receives intensive care support.
  • Ensure that the children and young people’s service has representation at board level.

Follow up inspection November 2014

At the follow up inspection in November 2014, we found that significant improvements had been made in the accident and emergency department in response to the warning notice we served in September 2014.

Our key findings were as follows:

• The trust had undertaken a significant amount of work since our last inspection and addressed the issues outlined in the warning notice we served to resolve the breach of the regulation.

• There had been investment to improve the environment and plans implemented to minimise disruption to both patients and staff during this refurbishment.

• Staff followed the trust’s infection control policy, including being bare below the elbows and observing hand hygiene and using personal protective equipment as necessary.

• Daily cleanliness, infection control and hand hygiene audits were undertaken.

• The A/E department was visibly clean and clutter free.

• The hospital had implemented monitoring arrangements for the standards expected in the A/E department which included reporting arrangements to the executive committee.

• Cleaning schedules including the frequency and the time specific areas should be cleaned were displayed in the department and monitoring of cleaning in line with the schedule took place.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 7 January 2015

Effective

Good

Updated 7 January 2015

Caring

Good

Updated 7 January 2015

Responsive

Requires improvement

Updated 7 January 2015

Well-led

Inadequate

Updated 7 January 2015

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 7 January 2015

At inspection in September 2014 we found the standards of cleaning and maintenance of some equipment was inadequate. The department had some issues with patient flow because of the A&E department’s physical capacity in relation to the number of patients it could accommodate. There was a lack of bed capacity for those who needed admission. We also had some concerns about the leadership in the A&E department and the lack of drive to improve patient experience on this site for the next five years.

 

Care was generally satisfactory and there were sufficient staff. Staff worked well as a team. The department provided a prompt and safe service for trauma patients. Safeguarding arrangements, particularly for children, were effective.

 

At our follow up inspection in November 2014 we found the hospital had taken action to address the breach of the Health and Social Care Act 2008 in relation to infection control in the A/E department. The standards of cleaning and maintenance of equipment had improved. The refurbishment programme in the department was almost complete and had resulted in a positive impact on the environment and facilitated protecting patients against the risk of infection.

Surgery

Requires improvement

Updated 7 January 2015

The trust has a known backlog of patients waiting for elective surgery however, they did provide trust-wide plans to demonstrate how they planned to reduce the backlog and manage patients who had experienced long waits for their surgical interventions. There was evidence of good outcomes for patients who underwent surgery. Preoperative assessment for some surgical specialties was not managed effectively, which often led to cancellation of elective procedures. Data submitted by the trust showed that surgery cancellation rates were higher than the national average.

The trust had not taken sufficient steps to ensure that the ‘Five steps to safer surgery’ checklist was embedded in practice. Procedures and treatments within surgical services followed national clinical guidelines. Pain relief was effectively managed and most nutritional needs of patients were assessed and provided for. Nursing skills mix was regularly reviewed and there were low numbers of nursing vacancies with very few agency staff used. The majority of staff received mandatory training and further specialist training was available. Infection control procedures and practices were adhered to and regularly monitored.

Patients spoke positively about their care and treatment at the hospital. Results from the NHS Friends and Family Test were better than the England average, and a high number of patients would recommend this hospital to their family and friends.

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