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Hammersmith Hospitals Requires improvement

We are carrying out checks at Hammersmith Hospitals using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 February 2018

Our rating of Hammersmith Hospital stayed the same. We rated it as requires improvement because safe, responsive and well-led require improvement and effective and caring were good.

  • The ratings for each of the key questions remained the same since our last inspection.
  • We inspected Surgery during this inspection to check if improvements had been made. Our rating of the service improved. We rated it as good because effective, caring, responsive and well-led were good, and safe required improvement. The rating for responsive and 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 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 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. The ratings for responsive improved and the rating for well-led significantly improved; the rating for safe went down. We did not rate effective.
Inspection areas

Safe

Requires improvement

Updated 15 February 2018

Effective

Good

Updated 15 February 2018

Caring

Good

Updated 15 February 2018

Responsive

Requires improvement

Updated 15 February 2018

Well-led

Requires improvement

Updated 15 February 2018

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 19 October 2017

Surgery

Good

Updated 15 February 2018

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

  • Managers monitored staffing levels and patients’ needs daily.
  • Staff knew what incidents to report and how to report them. Staff told us they knew about serious incidents and never events which occurred on site but were not always aware of incidents on other sites in the trust.
  • .A critical care outreach team responded to emergencies five days a week. There were plans to extend this to a seven day service
  • Risk assessments were completed for patients on the surgical wards for falls, dehydration and pressure ulcers
  • Surgical site infection rates were monitored. The monitoring showed the infection rate was consistently below the England average.
  • Surgical services at Hammersmith Hospital held mortality and morbidity meetings to review adverse outcomes.
  • Readmission rates for hepato-biliary surgery were lower than the England average. Cardiac and cardio-thoracic readmission rates were higher than the England average.
  • Patients physical needs were assessed, and their care and treatment was delivered in line with evidence-based guidance.
  • There was participation in local and national audits. Findings were used to improve care and treatment and patients’ outcomes.
  • Nursing staff used national early warning scores (NEWS) to assess and monitor a patient’s condition and identify if they deteriorated. Staff provided care in line with the National Institute of Health and Care Excellence (NICE) Guideline (CG50) for deteriorating patients.
  • Staff were qualified and had the skills required to carry out their roles effectively. Staff’s training needs were identified and training was provided. Staff were supported to maintain and develop their professional skills and experience.
  • Hepatobiliary and pancreatic surgery patients at Hammersmith Hospital had a lower expected risk of readmission for elective admissions when compared to the England average.
  • There was good access to a specialist multi-disciplinary pain management team.
  • Patients’ needs were reviewed weekly by a multidisciplinary team to plan the care provided.
  • The average length of stay for Hepatobiliary and pancreatic surgery elective patients at Hammersmith Hospital was 4.5 days lower than the England average of 5.8 days.
  • The average length of stay for Cardiac Surgery elective patients at Hammersmith Hospital was 8.9 days, similar compared to the England average of 8.7 days.
  • The average length of stay for Cardiac Surgery for non-elective patients at Hammersmith Hospital was 10.7 days, which is lower than the England average of 12.0 days.
  • The cardiac preoperative assessment process was still being developed. High risk patients were assessed face to face two to three weeks prior to admission. Lower risk patients were assessed over the telephone.
  • The Friends and Family Test response rate for Surgery at Imperial College Healthcare NHS Trust was 35%, which was better than the England average of 29% between August 2016 and July 2017. Hammersmith Hospital had the highest response rate of any site in the trust.
  • Patients told us staff had involved relatives in discussions about their care and the support they would need after the procedure was completed.
  • Patients who had difficulty travelling to the hospital were admitted the evening before to ensured they were ready for surgery the next day.
  • Staff recognised how anxious and worried patients were and offered reassurance. Patients told us staff had been reassuring and recognised they were in pain and offered pain relief.
  • Patients with complex needs were highlighted on the trust’s clinical information system, which meant staff could consider any adjustments to their care, which might be required.
  • Care of the elderly medical staff assessed older patients, with dementia, undergoing a cardiac procedure.
  • Relatives were able to stay to support patients with special needs. Patients admitted via the heart attack centre were prioritised by the cardiac lab team in the morning. Patients with diabetes or other co-morbidities were prioritised .
  • Palliative patients were identified at the weekly multidisciplinary meeting. The palliative care team supported patients to make informed choices about their care.
  • Local leaders focused on quality and performance and developed plans for transforming the care provided on the Hammersmith site.
  • Clinical leaders provided clear, strategic goals and demonstrated commitment to achieving service improvement. Local leaders were visible, approachable and supportive to staff.
  • There was a strong governance framework to support the delivery of the strategy and good quality of care.
  • There was a programme of clinical and internal audit used to monitor performance and safety which identified where improvements could be made.
  • Processes for risk identification, recording and managing risks, issues and mitigating action were well managed. Recorded risks correlated with the risks highlighted by staff.
  • There was a positive culture which had resulted in improved recruitment and retention.
  • Staff understood the plan for developing services and described how they were motivated to play a role in developing the service.
  • Staff spoke positively about their managers in all the surgical specialities.

However:

  • We were not assured there was a clear pathway for identifying patients at risk of sepsis.
  • Although compliance with World Health Organisation safer surgery checklists had improved since the last inspection, audits showed inconsistent performance for all five steps.
  • The service was using the five steps to safer surgery surgical checklist but had not developed more detailed local safety protocols – local safety standards for invasive procedures (LocSSIPs.)
  • Controlled drugs brought into the hospital on admission were not always checked until the patient was being discharged which meant there was a risk that any missing medicines were only identified at the end of their stay.
  • All patients at Hammersmith Hospital had a slightly higher expected risk of readmission for elective admissions when compared to the England average.
  • Mandatory training rates did not meet the trust’s target of 90% but they were higher at the Hammersmith than Charing Cross and St Marys.
  • Medical and dental staff did not achieve the trust target of 90% for any of the mandatory training modules
  • The surgical debrief was not documented.
  • One patient told us they were not impressed with the catering service. They said staff were embarrassed offering food they knew was culturally unacceptable. Following our inspection the trust provided further evidence, which showed they provided menus that met patients’ different cultural needs.
  • Referral to treatment time for cardiothoracic surgery had improved but 78.8% of patients were referred for cardiothoracic treatment within 18 weeks compared to the England average of 84.4%.
  • The operating department did not have a theatre reserved for emergencies

Intensive/critical care

Requires improvement

Updated 16 December 2014

Critical care services at Hammersmith Hospital required improvement. We were concerned with bed capacity and staffing arrangements. Capacity was stretched and staffing levels were either not appropriate or not taking into account other arrangements in the hospital. Some aspects of safety requirements were not always adhered to. However, there was good patient feedback and good outcomes for patients.

Services for children & young people

Requires improvement

Updated 16 December 2014

Both the children’s outpatient department and the David Harvey Ambulatory unit were clean and tidy and there were processes in place to regularly monitor the standards of cleaning. There were procedures in place to manage the deteriorating neonate, child or young person. Whilst medical records were kept safely, there was an emerging theme that clinicians did not always have access to full sets of clinical notes or referrals in-time for clinics.

Children’s services followed national evidence-based care and treatment and carried out a small selection of local audits to ensure compliance. However, there was no auditing of care in which the service could be benchmarked either locally or nationally.

Children and those close to them, such as their parents or carers, were involved in the planning of care and treatment and were able to make individual choices on the care they wished to receive. People spoke positively about their experience of using the David Harvey Unit, which during 2013/2014 received a very low number of complaints.

Whilst the department had embraced the wider “Connecting Care 4 Children” initiative, there was little vision or future strategy for the department. There was no evidence to demonstrate that there had been consideration to alleviating the pressures of the over-subscribed outpatient department located at St Mary’s Hospital.

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. 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