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St Mary's Hospital Requires improvement

Reports


Inspection carried out on 26th February to 28th February 2019

During an inspection looking at part of the service

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 carried out on 7th November

During a routine inspection

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 carried out on 7th - 9th March 2017

During an inspection looking at part of the service

Imperial College Healthcare NHS Trust provides acute and specialist healthcare for a population of around two million people in north west London and the surrounding areas. The trust has five hospitals Charing Cross, Hammersmith, Queen Charlotte’s & Chelsea, St Mary’s and the Western Eye. Charing Cross Hospital is an acute general teaching hospital located in Hammersmith, London.

St Mary’s Hospital is one of the two locations of Imperial College Healthcare NHS Trust which provides maternity and gynaecological services along with Queen Charlotte’s & Chelsea Hospital. The maternity services comprised of the birthing centre. The postnatal and antenatal ward with 35 inpatients beds. The labour ward having eight delivery rooms, two theatres and two birthing pools. Maternity triage services are provided by way of three beds; this is a short stay area and is open 24 hours per day, seven days per week. A day assessment unit operating by an appointment system or low risk referrals from the emergency department. There is an antenatal outpatient service. The FMU services included fetal and perinatal scans and post termination of pregnancy and specialist pre-pregnancy fetal counselling. Two neonatal intensive care unit (NICU) with 22 cots including four intensive care beds, four high dependency beds and 14 special care cots. St Mary’s Hospital also provides independently funded maternity healthcare service at the Lindo wing.

Medicine and specialist medicine at St Mary’s Hospital sat under two directorates in the hospital. The majority of the medical wards were under the Medicine and Integrated Care Division while cardiac, haematology  and oncology were under the Surgery, Cardiovascular and Cancer Division. Medical wards include acute assessment unit (AAU) and other assessment wards, a clinical decisions unit (CDU), care of the elderly wards, general medical wards and specialist wards such as respiratory medicine, gastroenterology and endocrinology. The hospital also hosts an endoscopy suite and discharge lounge.

We plan our inspections based on our assessment of the risk to patients from care that is or appears to be less than good. We inspected the maternity and medicine (including elderly care) services because we had information giving us concerns about the quality of this service.

We last inspected the maternity and medicine (including elderly care) in September 2014 as part of our comprehensive inspection program and rated the services as good and requires improvement respectively. For maternity during that inspection we found the risk of unsafe care had been mitigated by prioritising the needs of women in labour. However, the quality of care on postnatal wards was sometimes compromised. 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. Specialist clinics assessed the needs of women with medical conditions. Specialist midwives and caseload midwives supported women who were at risk. 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. For medicine during that inspection we observed hospital discharges occurring after 10pm. We found that care plans for people living with dementia and diabetes were not used and we noted patients stayed in the hospital for longer than the national average. There were high vacancy rates among staff and it was not clear what the senior management was doing to address this.

During this inspection we found the over quality of the maternity service had changed from good to requires improvement. We rated safe, responsive and well-led as requires improvement and rated effective and caring as good.

During this inspection we found the overall quality of the medicine and elderly care services had stayed the same as at the previous inspection; although there had been some positive changes, the service continued to be rated overall as requires improvement

​. We rated safe and responsive as requires improvement and rated effective, caring, and well-led as good.

Our key findings were as follows:

In the maternity service:

  • There was one Never Event reported between January 2016 and December 2016.

  • Not all staff were able to give examples of learning from incidents or changes that had occurred as a result.

  • The maternity services did not always follow the trust’s medicine management policies so that medicines were safe for administration to patients. In particular, for date checking medicines and storing medicines in refrigerators.

  • Staff compliance with trust mandatory training was low and below trust target of 95%. For example, midwifery staff compliance with mental health/mental capacity training was 58% and consultant compliance with consent training was at 40%.

  • We found that 84% of relevant maternity staff had CTG training.

  • An audit of Intrapartum CTG “Fresh Eyes Buddy System” demonstrated that 87.5% of the notes were not meeting the standard.

  • The environment was challenging due to the nature of the building and in some need of repair.

  • The service did not monitor infant fall rates quality and the service’s safety dashboard information was not displayed for the public and patients. This meant that the public could not readily see information and statistics about the harms that had occurred in the maternity service.

  • Midwives were required to scrub as scrub nurses for second and emergency theatre lists. However, the department was currently reviewing the competency framework for this.

  • Between April 2016 and February 2017 90% of women had a named midwife, which was below target of 100% set by the clinical commissioning group as part of the clinical quality group acute quality metric.

  • There was limited information available on the wards for women and their relative about how to make a complaint and how to access the Patient Advice and Liaison Service (PALS).

  • We found two clinical guidelines that were out of date.

  • Only 84% of midwifery staff had bereavement training.

  • There was lack of visibility of executive team and senior leadership team on the floor.

  • Not all staff were aware of the directorate vision and strategy.

  • A recent serious incident identified weakness within the trust governance process and they had requested an external review of maternity clinical governance structure by Royal College of Obstetricians and Gynaecologists.

  • Maternity wards were in a dated building, which did not provide an optimum environment for women.

  • Throughout the maternity service, there was poor signage navigating to different parts of the maternity service.

  • Not all risks identified by us during the inspection were on the maternity service’s risk register and senior divisional leadership team did not had the oversight of all the problems at St. Mary’s site.

In the medicine service:

  • Staff on medical wards were not meeting the trust targets for almost all modules of mandatory training, including safeguarding, resuscitation, and infection prevention and control.

  • Medical wards were not meeting targets for MRSA screening set by the trust.

  • The vacancy rate for nursing staff across medical wards at St Mary’s Hospital was significantly higher than the England average.

  • We noted that a number of medications checked on the medical wards had passed their expiry date, and some wards were not following the trust policy on refrigerator temperatures.

  • Staff we spoke with stated that security could be slow to respond to incidents, and there were concerns this could result in staff being more exposed to aggressive or threatening patients.

  • We found some inconsistency amongst nursing staff and junior medical staff in their understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

  • Medical services at St Mary’s Hospital did not meet the NHS England national indicator for 18 weeks referral to treatment (RTT) times.

  • Discharge forms from the wards were inconsistent or incomplete, and this could result in delays to patients’ discharges from the discharge lounge.

  • Data provided by the trust show patients being discharged out of hours between 22:00 and 07:00, suggesting patients being moved out of the hospital at unsociable hours.

  • The hospital signage was not up to date and does not provide patients or visitors with information how to access the wards.

However,

In the maternity service:

  • Safeguarding vulnerable adults, children and young people was given sufficient priority and staff take proactive approach to safeguard and focus on early identification.

  • Staff had good understanding of the major incident and fire safety plans.

  • Information about people’s care and treatment and their outcomes was routinely collected and monitored. This information was used to improve care.

  • There was participation in relevant local and national audits and there were detailed follow up action plans to ensure improvement in patient care.

  • Consent to care and treatment was obtained in line with legislation and guidance.

  • All women we spoke with on antenatal, postnatal and labour ward were positive of their experiences, and the kindness, skill and supportiveness of staff.

  • Between April 2016 to February 2017, 0.7% of all births at St Mary’s Hospital (SMH) were home births and in January there were no home births, which was below the trust maximum target of 1%.

  • Staff were conscious of the need to protect the dignity and privacy of women in all areas of the service. Curtains were drawn around beds during examination all time and during ward round to ensure privacy.

  • Specialist staff offered sensitive bereavement support for women suffering miscarriages or stillbirth.

  • Services were planned and delivered in a way that met the needs of the local population.

  • Women were given a choice of times and dates for antenatal clinic appointments.

In the medicine service:

  • There were systems in place for staff to report incidents, and for incidents to be discussed in clinical governance meetings.

  • Staff we spoke with stated the electronic records system was accessible, and that they had received training in use of the system as part of their induction.

  • We reviewed trust policies on delivering clinical care throughout medical wards and found them to be in date and in line with best practice guidelines.

  • Local and national audits were used to benchmark care, treatment and practice against guidance established by a range of organisations that represented best practice.

  • Patients we spoke with were very positive about their experiences on the medical wards, particularly regarding their interactions with staff. We observed positive interactions between staff and patients throughout the medical wards we visited.

  • There were measures in place to manage patients being cared for on wards outside of the specialty for which they were admitted. The hospital also had systems in place to increase capacity to meet the needs of the local population during winter pressures.

  • The introduction of complaints investigators had much improved response times and the quality of investigations for complaints.

We saw several areas of outstanding practice including:

  • The trust had introduced Side by Side for Alzheimer’s patients, an initiative by the Alzheimer's Society service which helps people with dementia to access recreational activities. This included arts and crafts, harmony singing and Friday afternoon tea parties.

  • The trust developed a nutrition pathway called the Nutrition Support in Hospital (NoSH) which was designed to ensure patients particularly people with dementia, received the food and drink they need while in hospital without losing the independence they had before admitted to the hospital.

  • The Medicine and Integrated Care Division introduced a nurse-led cirrhosis clinic offering improved screening to patients at high risk of developing of severe complications from substance misuse, such as liver cancer. The clinic recently won the “Innovative Project of the Year” award from St Mungo’s homelessness charity.

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

Importantly, the trust must:

  • The maternity and medical service must ensure that they always follow the trust’s medicine management policies so that medicines are safe for administration to patients. In particular for date checking medicines and storing medicines in refrigerators.

  • The service must improve compliance with its mandatory training for all staff groups.

  • The maternity service must ensure to ensure there is comprehensive oversight of problems and that the risk register is reflective of all risks within the directorate.

  • The service must improve the management of CTG monitoring. This should include improving CTG training rates for relevant maternity staff and improvements in the "Fresh Eyes Buddy System" to ensure standards are met

  • The trust must take action to ensure medical wards are meeting resuscitation training requirements for their staff.

  • The trust must ensure they implement the recommendations made in the Royal College of Obstetricians and Gynaecologists (RCOG) report from April 2017, 'Review of Maternity Services at Imperial College Healthcare NHS Trust, St Mary's Hospital site'.

In addition the trust should:

In the maternity service:

  • Ensure that up to date safety thermometer and key relevant information are displayed on the quality improvement boards.

  • The service should ensure that second theatre and emergency theatre lists are appropriately staffed.

  • The service should ensure that all clinical guidelines are up-to-date.

  • The trust should ensure that there is more visibility of executive and senior leadership team.

  • The service should ensure a consistent approach and more user friendly patient information available and displayed in wards including information about PALS.

  • The service should urgently review and improve the signage for the various maternity wards and department, particularly for fetal medicine unit.

  • The service should address the estates issues related to kitchen and patient shower areas.

In the medicine service:

  • The trust should improve performance of the number of staff on medical wards completing mandatory training in relation to trust targets.

  • The trust should ensure medical wards are meeting targets for MRSA screening set by the trust.

  • The trust should ensure that medications are not retained past their expiry date, and medication refrigerators are within the temperature range identified in the associated trust policy.

  • The trust should ensure there is a clear process for a timely response from hospital security to incidents or staff being expose to violence and aggression.

  • The trust should ensure staff have a clear understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

  • The trust should improve the consistency and completeness of discharge information for patients transferred to the discharge lounge.

  • The trust should improve hospital signage, ensure it is up to date and provides clear information for visitors on how to access the wards.

  • The trust should ensure that patients are not discharged out of hours (between 10pm and 7am), without a clear reason for doing so, a robust discharge plan in place, and a safe place to discharge patients.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 22-24 November 2016

During a routine inspection

St Mary's Hospital  is an acute general teaching hospital located in hospital in Paddington, London. The hospital was founded in 1845 and has been operated by Imperial College Healthcare NHS Trust since 2008. The trust's central outpatient departments were located at St Mary's Hospital, Charing Cross Hospital and Hammersmith Hospital which were overseen by a single leadership team (Lead Nurse, Clinical Director and General Manager), with dedicated clinical and administrative leadership teams based on each site.

Our last comprehensive inspection of the trust was undertaken in September 2014 when we rated the outpatients and diagnostic imaging service at St Mary's Hospital as inadequate. The purpose of this focused follow-up inspection was to inspect core services that had previously been rated as inadequate.

During this inspection we found the service had improved. 

We rated the 

outpatients and diagnostic imaging service at St Mary's Hospital

as good overall.

Our key findings were as follows:

  • Staff felt there was a positive incident reporting culture that promoted honesty within a ‘no blame’ culture. Staff at all levels told us they felt supported when they submitted incident reports and felt the level of feedback was appropriate.

  • All areas met or exceeded the trust’s 90% compliance target with hand hygiene and ‘bare below the elbow’ policies.

  • Staff followed appropriate medicine management procedures that reduced the risk of incorrect doses and administration. Medicines were stored according to manufacturer instructions and mistakes were acted upon to reduce the risk they could happen again.

  • The number of patients seen in outpatients with temporary notes as a result of their case records being unavailable was better than the national benchmark maximum of 4% of patients.

  • Safeguarding processes were well established and staff demonstrated appropriate knowledge of them. All staff had access to trust safeguarding policies. Clinical staff in sexual health and HIV services had a higher level of safeguarding training that enabled them to safely care for vulnerable and at-risk patients, including those complex needs and challenging social circumstances.

  • Processes were in place to ensure children and young people seen outside of paediatric services were cared for using appropriate safeguarding policies. Staff used monthly multidisciplinary safeguarding meetings to review such instances.

  • Staff in diagnostic imaging used the World Health Organisation (WHO) surgical safety checklist for radiological interventions and the Society of Radiographer’s ‘pause and check’ process as part of a robust risk management process.

  • Consultant and nursing cover was generally adequate to meet demand. Where staff sickness might impact the ability to run a clinic, specialist registrars were able to provide some cover. Staffing levels were determined by the length of clinics and number of patients and according to consultant job plans.

  • Staff in each service provided care and treatment that was benchmarked against the guidance of national bodies of practice, including the Medicines and Healthcare Products Regulatory Agency, National Institute of Health and Care Excellence, the Faculty of Sexual and Reproductive Health and the British HIV Association.

  • Between January 2016 and December 2016, the hospital met the two week wait target for cancer referrals in every month.

  • Waiting times in diagnostic imaging were better than the national target of six weeks for the five core diagnostic services between April 2016 and December 2016.

  • Dedicated radiation protection advisers and radiation protection supervisors were in post and provided oversight for diagnostic imaging services to comply with Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2006 and the IR(ME) Amendment Regulations 2011 safety guidance.

  • Staff spoke positively about the annual appraisal and professional development record process and said they had been able to secure training and development activities as a result.

  • There was evidence of multidisciplinary working, including with safeguarding and infection control teams and between specialties. Weekly and fortnightly cross-site multidisciplinary meetings took place in diagnostic imaging that enabled clinicians to support each other and strategise complex cases.

  • Staff treated patients with kindness and a friendly manner during all of our observations, including in clinical and non-clinical settings.

  • Reception staff demonstrated understanding and patience when dealing with anxious or flustered patients and we saw reception staff in the Jefferiss Wing treat people who were waiting outside with particular compassion while they waited.

  • Patients consistently told us they felt welcomed and valued in the service and they found staff attitudes to be memorable because of their warmth and positivity.

  • When clinics were delayed or disrupted staff maintained communication with patients every 30 minutes and offered them water and advice about the delay and options for rebooking. .

  • The volunteer service had started a pilot programme in main outpatients to scope the potential benefits and impact on patient experience of having a team based there permanently.

  • An outpatient improvement programme was in place to reduce waiting times and delays to clinics. A new standard operating procedure enabled senior staff in main outpatients to escalate to the management team if a doctor was late for a clinic that resulted in delays to patients. We saw this worked well during our observations.

  • In November 2016, main outpatients had achieved a turnaround time of 10 days for 95% of referrals, which was the trust target.

  • A new complaints and concerns policy enabled complaints to be recorded, investigated and resolved within the trust’s 40 day maximum target. The new system also enabled services to identify trends in complaints to drive improvements.

  • A new general manager and seniornursein main outpatients had conducted a significant nursing and leadership review of the service and restructured it to deliver results in the outpatient improvement programme.

  • All of the staff we spoke with were positive about the overall vision and future strategy for the trust. Most staff also felt empowered to promote positive change and provide suggestions for improvement in their own local services.

  • Clinical governance structures helped staff to manage risks to services and involved an appropriate range of staff in most cases. Risk registers were updated regularly and staff with appropriate experience and knowledge managed these.

  • The majority of staff we spoke with felt positively about the leadership in their service and described a work culture that facilitated development and innovation. This was particularly the case in cardiac, sexual health and HIV services.

  • Feedback from patient engagement was used to improve services, particularly with regards to staff communication in main outpatients and the role of trust volunteers.

  • Individual services engaged with their staff teams to improve working conditions and deliver better patient services. This included through consultation on working patterns and the implementation of a working group in diagnostic imaging to identify solutions to some of the challenges the team faced.

  • Staff felt recognised and rewarded for their work through trust and local initiatives and spoke positively of opportunities to work with colleagues in other areas to gain a better understanding of how they worked.

We saw several areas of outstanding practice including:

  • The senior team in the Jefferiss Wing, including sexual health and HIV services, demonstrated a sustained track record of building staff skill mix and service sustainability through promoting specialist training, practice education and rewarding performance.This resulted in positive impact on the local population because it meant people who were vulnerable or at-risk received timely support and treatment.
  • The outpatient improvement programme had begun to deliver results in a relatively short space of time and the process, involving staff consultation and a restructured leadership and governance team, meant clinic delays had been reduced and communication with patients improved.

However, there were also some areas of practice where the trust needs to make improvements: 

  • The hospital should ensure all staff working in clinical areas have appropriate fire safety training and an understanding of local evacuation procedures.

  • The hospital should ensure incidents are fully investigated within a reasonable timescale in such a way that allows trends to be identified so as to ensure the service remains safe.

  • The hospital should ensure contractors providing services are able to respond within a reasonable time to complaints made by patients against the trust in cases that involved both providers.

  • The hospital should ensure doctors in training have up to date mandatory training in all required areas.

  • The hospital should ensure pre-qualification allied health professionals have up to date mandatory training in all areas.

  • The hospital should ensure each radiology practitioner has a documented local induction for checked competency in working under IR(ME)R guidelines.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 2-5 September 2014 25 November 2014 Follow up inspection 25 November 2014

During an inspection looking at part of the service

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 carried out on 2-5 September 2014

During a routine inspection

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:

  • Improve the standards of cleanliness of premises and equipment.
  • 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&38;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.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 30, 31 July and 1 August 2013

During a routine inspection

We inspected St Mary�s Hospital over three days and visited 15 wards and departments, including the Emergency Department, which consists of Accident and Emergency (A&E) and the urgent care centre. The specialist advisor accompanying us was a specialist in emergency medicine. We also visited a ward for older people, adult surgical and medical wards, imaging, outpatient departments and the records department. We followed the patient pathway from the A&E through to the wards. We spoke with patients, families or carers and staff in every area we visited. We also spoke with senior management staff including the Chief Executive, Director of Nursing and Deputy Medical Director as well as a non-executive member of the trust board. We did not inspect paediatric or maternity departments.

Our overall impression was of the good standards of cleanliness of the hospital and the openness and friendliness of all grades of staff and of the leadership provided in the wards and departments we visited. Most patients had had a positive experience of care and treatment at the hospital. They had been treated with dignity and respect, were complimentary about staff, understood their care and treatment and said there were sufficient staff to meet their needs. Care and treatment was planned and delivered in a way that ensured patients' safety and welfare. Risk assessments were completed for all patients as part of their admission procedures.

Staff told us that management had improved in the last 12 months. This included support and training, communication and management�s expectations of staff. They were proud to work for Imperial College Healthcare NHS Trust and wanted to tell us about their work and their plans for improving patients� experiences.

Medical records were managed securely and were accessible when needed. There were processes for managing safeguarding incidents in conjunction with local authority safeguarding teams.

Inspection carried out on 21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 10 May 2012

During an inspection in response to concerns

We did not speak with people using the service during our visit. This was because the focus of our visit was the "Never Events" reported by the trust. In the areas we visited people were undergoing surgery and it would have been inappropriate to talk with them.

During a check to make sure that the improvements required had been made

On this occasion we did not speak to people that used the service. We reviewed the action plan and evidence that the provider had submitted to provide assurance that the relevant improvements had been completed.

Inspection carried out on 23 March 2011

During a themed inspection looking at Dignity and Nutrition

The majority of patients and relatives we spoke to said their experience had been positive; staff were polite, sensitive to their needs and treated them with respect. They were satisfied with their overall care. Patients said that staff encouraged them to be as independent as possible but were available to help as needed.

Patients were nursed in single sex bays and had access to single sex bathroom facilities. They felt their privacy was protected. Patients told us they had never felt embarrassed or uncomfortable during their hospital admission.

The majority of patients and relatives we spoke to said they had a good choice of food in sufficient quantities, regular hot drinks provided and cold water was always available. Patients told us that staff offer them hand wipes prior to meals and that staff were available to help them with eating if needed.