• Hospital
  • NHS hospital

Charing Cross Hospital

Overall: Requires improvement

Fulham Palace Road, Hammersmith, London, W6 8RF (020) 3311 3311

Provided and run by:
Imperial College Healthcare NHS Trust

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Background to this inspection

Updated 23 July 2019

Imperial College Healthcare NHS Trust was formed on October 1, 2007 by merging St Mary's NHS Trust and Hammersmith Hospitals NHS Trust and integrating with the faculty of medicine at Imperial College London.

The trust has 12 registered locations and employs almost, 11,000 staff. The registered locations are:

  • Queen Charlottes and Chelsea Hospital
  • Western Eye Hospital
  • Hammersmith Hospitals
  • Northwick Park Renal Centre
  • Ealing Renal Satellite Unit
  • St Charles and Hammersmith Renal Centres
  • West Middlesex Renal Centre
  • Brent Renal Centre
  • Charing Cross Hospital
  • St Mary's Hospital
  • Hayes Renal Centre
  • Watford Renal Centre

The trust has an estimated range of population served is between 1,500,000 and 2,000,000 people.

The trust has a total of 1,412 inpatient beds spread across various locations:

  •   733 Medical beds
  •  302 Surgical beds
  • 70 Children’s beds
  • 140 Maternity beds
  • 136 Critical Care beds

Overall inspection

Requires improvement

Updated 23 July 2019

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

  • The hospital ratings for safe, effective, caring, responsive and well-led remained the same.
  • We inspected Critical care this inspection in March 2019 to check if improvements had been made. Our rating of the service went up. We rated it as good because safe, effective, caring, responsive and well-led were good. The ratings for safe, effective, responsive and well-led all went up, and the rating for caring stayed the same.
  • We inspected Urgent and emergency care in November 2017 to check if improvements had been made. Our rating of the service went down. We rated it as requires improvement because safe, effective, responsive and well-led required improvement, and caring was good. The rating for safe, responsive and well-led went down, and the ratings for each of the other key questions remained the same.
  • We inspected Surgery during 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, and 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 improved. We rated it as good because safe and responsive required improvement; well-led was good, and caring and effective were outstanding. The ratings for effective, caring and well-led improved, 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 improved. We rated it as requires improvement because safe, responsive and well-led required improvement, and caring was good. The ratings for responsive and well-led improved; the rating for safe went down. We did not rate effective.

Critical care

Good

Updated 23 July 2019

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

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. All staff we spoke with demonstrated a good understanding of safeguarding vulnerable adults.
  • The service controlled infection risk well. All staff were observed to be ‘bare below the elbow’ and adhered to infection control procedures. All clinical areas we visited on the intensive care units (11 North and 11 West) and acute respiratory unit were visibly clean.
  • The service had made improvements in the storage and availability of equipment since our last inspection.
  • There was now a clear, formal pathway between level two and level three beds. Since the last inspection all level two beds were now co-located within the intensive care units on the 11th floor or were on the five-bedded acute respiratory unit where there were strict admission criteria.
  • Staff completed and updated risk assessments for each patient. Records we reviewed included comprehensive individual risk assessments. Where risk had been identified we also saw evidence that risk management plans were developed in line with national guidance and staff we spoke with could clearly articulate how to recognise sepsis.
  • The service followed best practice when prescribing, giving, recording and storing medicines. At our last inspection we found out of date medicines. At this inspection, medicines we checked were in date. Suitable arrangements were in place for the ordering, dispensing, prescribing, recording and handling of medicines.
  • The service now had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Medical staffing levels had improved since the last inspection. A consultant in intensive care medicine was also available 24 hours a day and could attend patients within 30 minutes.
  • The service managed patient safety incidents well and investigations were now being investigated in a timely manner by the lead nurse and consultant in the specialism the incident was related to. Staff recognised incidents and reported them appropriately. The lead nurse 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. Safety information was collected and shared with staff, patients and visitors on the units’ quality and safety boards.
  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. At our last inspection, the service was unable to demonstrate results from audit participation. At this inspection the service was able to demonstrate results from relevant national audits.
  • At our last inspection, the critical care outreach team were unable to provide us with activity data. At this inspection the team were able to demonstrate outreach activity data and audit results.
  • The service delivered care in line with national clinical guidance. Staff had access to policies, protocols and care bundles that were based on national guidance on the trust intranet.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.
  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate verbally using suitable assessment tools.
  • The service made sure staff were competent for their roles. Staff had regular appraisals and performance was monitored through mentorship from band 7 nurses. There was also good support from nurse educators, opportunities for learning and professional development and use of a simulation suite for teaching sessions.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals worked as a team to provide good care.
  • Staff understood their roles and responsibilities under the Mental Capacity Act 2005. Staff understood the relevant consent and decision-making requirements of current legislation and systems were in place to ensure compliance with deprivation of liberty safeguards.
  • 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. We found a high level of emotional support provided by staff on the intensive care unit and acute respiratory unit. Relatives spoke highly of the support they received from staff.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients and relatives were routinely involved in planning and making decisions about care options.
  • The trust planned and provided services in a way that met the needs of local people and patients who came from other regions. At our last inspection, we found that some level two patients were being cared for in non-critical care areas. At this inspection, we found that level two patients were being cared for in critical care areas. Level two and level three beds were now co-located within the intensive care unit and accommodated up to 14 level two and 10 level three patients.
  • There was also now an acute respiratory unit which provided non-invasive respiratory support for level two patients only.
  • At this inspection, we saw that the service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. At our last inspection we found that complaints were not always learned from and were not discussed during team meetings. The service received very few complaints, but we saw evidence that complaints were discussed at team meetings and directorate meetings. Staff also used patient and relative feedback to improve the service.
  • The service took account of patients’ individual needs. Nurses on the unit told us that they had strong links with the learning disability advice and support, inclusion and vulnerability officer. In the acute respiratory unit, patients were given hospital ‘passports’ which described a patient’s likes and dislikes and important information the nursing team needed to know about the patient’s care needs.
  • At our last inspection we found that complaints were not always learned from and were not discussed during team meetings. At this inspection we saw that the service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care. The service now had a site-based leadership team who had a good understanding of the risks and challenges to critical care services on the Charing Cross Hospital site. The site-based leadership team demonstrated good cross site working. They attended regular cross site directorate quality and safety meetings where performance and quality and safety issues were discussed. Critical care staff involved in the acute respiratory unit were also invited to respiratory governance meetings.
  • There was effective cross-unit working. The site leadership team attended regular cross site directorate quality and safety meetings where performance and quality and safety issues were discussed, and critical care staff involved in the acute respiratory unit were also invited to respiratory governance meetings.
  • At our last inspection, we found that the critical care outreach teams were not part of the critical care department’s governance arrangements and there were issues of parity between the teams across the three sites. At this inspection we found that the critical care outreach teams were now part of the critical care department’s governance arrangements and there was now parity between outreach teams across the three sites which was an improvement from the last inspection.
  • At our last inspection, senior management did not submit audit results to demonstrate the service’s effectiveness. At this inspection we received audit data which demonstrated that the service collected, analysed, managed and used information well to support all its activities. The service kept a monthly performance scorecard which contained information about the service’s performance such as staffing, infection prevention and control compliance and audit data.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The risk register was regularly reviewed and was now being updated in a timely manner with action plans in place. This was an improvement from the last inspection where we found that some risks had been on the risk register for a long time without a completion date. The issues and risks which managers identified were in line with what we found on inspection and there was alignment between these and the risks outlined on the risk register.
  • 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. Staff awareness of the vision of the service had improved since the last inspection.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff demonstrated an inclusive, open and honest culture and consistently spoke of good teamwork in a patient-centred environment.
  • The service was committed to improving services and promoted training, research and innovation. Nursing teams took ownership of various quality improvement projects such as hand hygiene, medications safety and assessments for delirium.

However:

  • The intensive care unit was in the process of moving fully to the use of electronic records but at the time of the inspection was still in transition and used a mixture of paper and electronic notes. This meant that there was a risk of errors due to the different systems being in use for documentation, however there was no evidence of impact on patient safety. This issue was logged as a risk on the risk register and a plan was in place for full transition to an electronic system.
  • Mandatory training compliance levels for doctors in training did not meet trust targets.
  • During our inspection, we saw some visitors tailgating into the intensive care unit and inspectors were also not challenged in the bed bay areas of the intensive care unit.
  • Bed occupancy rates remained high. The leadership team were aware of the high occupancy rates and told us this was due to a high number of patients awaiting discharge to ward beds. As a result, delayed discharges were on the risk register for critical care.
  • During our inspection we found a large two bedded bay which was shared by two patients of mixed sex due to delays discharging patients out of the intensive care unit. Curtains or screens were not used to separate the space which meant that the privacy and dignity of the patients could not be maintained.
  • 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.
  • Some trust wide policies that the critical care service used, lacked detail in signposting any practical guidance which staff used.

End of life care

Good

Updated 16 December 2014

There was an inconsistent approach to the completion of ‘do not attempt cardiopulmonary resuscitation’ (DNA CPR) forms. 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 organisational majority of the indicators in this audit, but there was no formal action plan. However, the majority of the clinical indicators in this audit were met. 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.

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 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.

Surgery

Requires improvement

Updated 16 December 2014

The hospital had not taken sufficient steps to ensure the ‘Five steps to safer surgery’ checklist was embedded in practice, despite two ‘Never Events’ occurring elsewhere in the trust in the preceding 18 months.

While there was evidence of good outcomes for patients who underwent surgery, the hospital was not sufficiently responsive to patients’ needs. The trust did not provide us with evidence of a plan to reduce the backlog of patients waiting for elective surgery nor to deal with patients who had experienced long waits for their surgical interventions.

Surgical wards had low numbers of nursing vacancies; they regularly reviewed the skills mix and used a low volume of agency staff. Patients spoke positively about their care and treatment at the hospital. They told us staff were caring, compassionate and professional.

Urgent and emergency services

Requires improvement

Updated 28 February 2018

Our overall rating of this service went down. We rated it as requires improvement because:

  • We observed that not all staff adhered to the infection control policy and did not consistently comply with hand hygiene practice and ‘bare below the elbows’ policy.
  • The air-way trolleys were not checked regularly and we found out of date and loose single use items in one air way trolley.
  • We were not assured of effective systems in place to check emergency medications and it was unclear how the department could ensure that checks were carried out daily at each shift.
  • We found that in the clinical decision unit, CD cupboard keys were not held by a registered nurse and were kept in an open tray by the nursing station, which was against the medicine regulations.
  • Junior clinical staff were inconsistent in sepsis six management. We observed two suspected cases of sepsis and in both cases, not all six initial indicators were assessed. None of the staff we spoke with had any specific sepsis training.
  • Clinical staff in ED were inconsistent in their practice in recording falls risk assessment.
  • We found that paper records were not stored securely in clinical decision unit and major’s area.
  • The department were performing below the national average in many of the Royal College of Emergency Medicine (RCEM) audits.
  • Staff appraisal rates did not meet the trust target of 95%, falling considerably short of this in some groups of staff.
  • General observations confirmed staff considered the privacy and dignity of patients. However, during busy period, capacity issues and space limitations affected the ability of staff to provide care which maintained the privacy and dignity of patients. Sensitive conversations were easily overheard when patients were nursed on trolleys in the corridor.
  • The department’s capacity issue along with its physical layout provided a challenging environment to staff. Five resuscitation bays were frequently used for seven to eight patients.
  • The department was not meeting the needs of people with learning disability (LD) and no specific actions were taken by the department to address the needs of people with LD. Staff showed limited understanding of caring and meeting the needs of LD patients.
  • The department was not proactive in their risk assessments and not all risks identified by us during the inspection were reflected on the risk register.
  • During periods when the service was very busy we found that the leadership did not had the full understanding of the problems faced as staff were too busy looking after patients to inform leadership. We were not assured that the directorate level leaders had the full oversight of the problems faced by staff.

However:

  • The urgent and emergency department at Charing Cross Hospital had a stable medical workforce. Between July 2016 and June 2017, the department reported, turnover rate of 0% and only 0.07% sickness rate.
  • Staff were aware of the incident reporting procedures and how to raise any concerns, staff said they were encouraged to report incidents and received direct feedback from their line manager, clinical leads and in teaching sessions.
  • We were assured that patient were receiving timely pain relief. We reviewed 16 sets of patient’s notes, which showed pain relief was offered in all applicable cases and was followed up appropriately.
  • We observed good multidisciplinary team working and positive interactions across all staff levels.
  • During quieter periods, we observed compassionate care delivered by nurses and doctors. Staff engaged in an open and positive way with patients and their relatives.
  • Most patients told us they felt informed about the treatment they would receive and the processes in the department.
  • We found the needs of people living with dementia were being met.
  • There was clear leadership structure for both medical and nursing staff. Local leadership team was described as visible and proactive by all clinical staff.