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Hammersmith Hospitals Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 23 July 2019

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 Children and Young People’s services 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 and responsive were good, and well-led required improvement.
  • 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 and responsive were good, and well-led required improvement. The rating for safe, effective and responsive went up and the rating for caring and well-led remained the same. The rating for effective had improved, and the ratings for safe, caring, responsive and well-led remained the same.
  • We inspected Surgery in November 2017 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 23 July 2019

Effective

Good

Updated 23 July 2019

Caring

Good

Updated 23 July 2019

Responsive

Requires improvement

Updated 23 July 2019

Well-led

Requires improvement

Updated 23 July 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 19 October 2017

Services for children & young people

Good

Updated 23 July 2019

We rated well-led as requires improvement and safe, effective, caring and responsive as good. Our rating of this service stayed the same. 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. Staff had training on how to recognise and report abuse and they knew how to apply it.

  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

  • The service had suitable premises and equipment and looked after them well.

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

  • There were processes in place to care for deteriorating patients.

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

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

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

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

  • At the time of our last inspection, we found that the service carried out a very limited range of audits to ensure the service was compliant with national guidance and best practice. Since our last inspection, we found some improvements had been made in this area. The service provided care and treatment based on national guidance and evidence of its effectiveness.

  • Staff gave patients enough food and drink to meet their needs and improve their health. 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 using suitable assessment tools and gave additional pain relief to ease pain

  • Managers monitored the effectiveness of care and treatment and used the findings to improve them.

  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

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

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

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

  • Staff involved patients and those close to them in decisions about their care and treatment.

  • Staff provided emotional support to patients to minimise their distress.

  • The trust planned and provided services in a way that met the needs of the local people.

  • The service took account of patients’ individual needs.

  • People could access the service when they needed it.

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

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

  • The unit used secure electronic systems with security safeguards.

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

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

However:

  • The service provided mandatory training in key skills to all staff but did not make sure everyone completed it.

  • At the time of inspection, there was no formal process in place to clinically assess patients waiting to be triaged in the ambulatory care unit.
  • There was no band 7 unit manager or dedicated nurse for the outpatient department, with no formal interim arrangements in place at the time of inspection.
  • At the time of our last inspection, we found there were no robust processes in place for monitoring the overall quality of the service. This remained the case. The David Harvey Unit was not routinely collating data such as the time taken to triage and initially assess patients as an example. Waiting times were not routinely collected, nor was the time it took for patients to be treated and discharged.
  • Senior staff from the unit were not always able to attend all cross-site meetings because of staffing concerns and the band 7 vacancy. Staff told us there were plans to enable video conferencing in the unit to improve attendance, but this was not in place at the time of inspection.
  • Staff survey results for the division showed signs of disconnection with senior management. The NHS staff survey 2017 results showed only 35% of staff thought that senior managers tried to involve staff in important decisions. Only 25% of participants thought that communication between senior management and staff was effective and only 13% felt that senior managers acted on staff feedback.
  • The service did not have good local systems to identify risks, or plan to eliminate or reduce them, in order to cope with both the expected and unexpected. We were not able to corroborate whether risks related to us on inspection, regarding the capacity of the unit and maintenance of estates, were formally recorded.

Critical care

Good

Updated 23 July 2019

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

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. At the previous inspection in 2014, we found mandatory training was not up to date. At this inspection, mandatory training compliance rates met trust targets.

  • Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse, and they knew how to apply it.

  • The service controlled infection risk well. At the previous inspection in 2014, we found items were not always clean and checks for cleanliness were not always carried out. At this inspection, all areas we visited and all equipment we saw was clean and hygienic.

  • The service had suitable premises and equipment and looked after them well. Patients were cared for in suitable intensive care units. There was enough suitable equipment that had been adequately maintained.

  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary. At the previous inspection in 2014, we found the safety culture was variable across the units. On this inspection, we found that ward rounds on both intensive care units were excellent and there was good communication and risk assessment processes in place. Records were clear, up to date and easily available to all staff providing care.

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

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Systems were in place for information sharing and learning.

  • The service used safety monitoring results well. Safety thermometer results were reported back to the units and used to improve quality of care.

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. At the previous inspection in 2014, the service was unable to demonstrate results from audit participation. At this inspection, the general ICU was able to demonstrate results from relevant national audits. Managers monitored the effectiveness of care and treatment and used the findings to improve them.

  • Patients had their nutrition and hydration needs met and were provided with sufficient pain relief.

  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary.

  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.

  • The service made sure staff were competent for their roles. Nurse educators supported units well.

  • Staff of different kinds worked together as a team to benefit patients. Healthcare professionals worked well together and communicated effectively to provide effective care.

  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them with kindness. Staff provided emotional support to patients. Staff involved patients and relatives in decisions about their care and treatment.

  • The trust planned and provided services in a way that met the needs of local people. At the previous inspection in 2014 we found the service was not always responsive to patients’ needs such as providing information or allowing visits from friends and relatives to be flexible. At this inspection we found a responsive service working with patients and relatives with flexible and extended visiting hours.

  • The service took account of patients’ individual needs. Individual needs were considered in assessment and plans of treatment and care.

  • People could access the service when they needed it. At the previous inspection in 2014 we found that due to limited capacity, admissions and transfers to the critical care units were often delayed and patients were sometimes cared for in inappropriate areas. At this inspection we found that admissions were non-delayed.

  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. We found good protocols for listening to patient’s and relative’s concerns.

  • There were clear governance processes and reporting lines in place.
  • Managers at all levels in the trust had the right skills and abilities to run a service. Managers provided good leadership.

  • The trust had a systematic approach to continually improving the quality of its services. There were good governance processes in place.

  • At the previous inspection in 2014, we found that the lack of bed capacity had been on the risk register since 2008 and there was no completion date for resolving this. At this inspection we found this had been resolved.
  • Managers across critical care services promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. We found a positive staff culture that promoted good quality care.

  • The trust engaged well with patients, relatives, and staff.

However:

  • At the previous inspection in 2014, we found nursing and medical staffing levels were stretched on some units and not always in line with national guidance. At this inspection, the service was non-compliant with intensive care staffing standards in some areas but were working towards resolution through ongoing review. However, De Wardener ward were not benchmarking themselves against intensive care standards and were unaware whether they fell short of these.
  • Non-invasive ventilated patients were being cared for outside of intensive care units, often in side rooms and without a nurse or doctor present all of the time. This placed level 2 patients at potential risk due to inconsistent staffing.
  • Poor signage did not help navigation. The hospital was made up of an amalgamation of different buildings. Routes to wards and units were not well signposted and we observed many confused visitors asking staff for directions as did we. We found all staff were helpful in this respect. However, navigation was not helped by poor signage.
  • There had been some cases where the NEWS proforma had not been fully completed by wards referring to the critical care outreach team. As a result, the team had seen patients who should have been escalated sooner. Some wards did not always act on the plans the outreach team gave them.
  • On cardiac ICU, pharmacy support did not attend ward rounds and were unable to provide sufficient pharmacy time. The unit was looking at getting more funding to support this.
  • ICNARC data was only collected from the general ICU. Both the cardiac ICU and the level 2 renal beds were not included in national audits.
  • The critical care outreach team were not providing a 24-hour service. They were not currently meeting critical care staffing standards for an outreach service.
  • There were three different directorates and leadership structures for critical care and there appeared to be a lack of collaborative working across the three units.
  • A critical care steering group was established in Hammersmith Hospital four weeks before our inspection. This was to standardise compliance with critical care standards through workstreams and identify a strategy and an appropriate governance structure. This conversation did not include De Wardener ward.
  • The trust was in the process of developing a vision and strategy for what it wanted to achieve with its critical care service. Critical care was now two years old as a directorate. Trust leads were in the process of developing a strategy which was awaiting ratification at the time of our inspection.
  • The trust had systems for identifying risks, planning to eliminate or reduce them. There were several risks within critical care services that were being monitored but remained ongoing.

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 and diagnostic imaging

Good

Updated 31 May 2017

Surgery

Good

Updated 28 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

People with long term conditions

Good

Families, children and young people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good