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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.

Reports


Inspection carried out on 7th November

During a routine inspection

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 carried out on 7th - 9th March 2017

During an inspection to make sure that the improvements required had been made

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.

Medicine and specialist medicine at Hammersmith Hospital sat under two directorates in the hospital; with the majority of the medical wards under the division of medicine and integrated care. The medical services include including renal, haematology, cancer and cardiology care and provides a regional specialist heart attack centre.

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 medicine and elderly care services because we had information giving us concerns about the quality of this service.

We last inspected the medicine and elderly care service in September 2014 as part of our comprehensive inspection program and rated the service as requires improvement. 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 overall quality of the medicine and elderly care services had stayed the same, but there were some positive changes. The service was rated as requires improvement. We rated safe and responsive as requires improvement, and we rated effective, caring, and well-led as good.

Our key findings were as follows:

  • Signage on site was poor and therefore, there were many visitors and members of the public lost and wondering how to get to their desired location.

  • We found the environment on some wards was poor. Staff submitted requests for repairs but the work took a long time to be carried out. Some wards had identified the areas requiring repair as a potential infection prevention and control risk in their risk registers. Staff on one ward told us they had been able to make some changes, which improved patient observation but the environment remained on the directorate risk register.

  • The trust was not monitoring compliance with the Faculty of Medicine’s Core Standards for Pain Management Guideline (2015).

  • Liquid medicines on two wards did not have a date recorded for when they were opened.One of those medicines was used to relieve severe pain and should be used within 90 days of opening. Staff were not following the trust’s policy, which stated that the date of opening should be recorded.Ten boxes of medicines and fluids for intravenous administration were out of date on one ward. The expiry date of one medicine was nine months before our inspection.

  • The results of the national diabetes audit showed patient experience was rated below the national average and the rate of foot assessments was worse than other services.

  • Patients could not access the patient advice and liaison service at Hammersmith Hospital. The service was advertised as being available but the office was closed and the telephone number provided was not manned.

  • Some cardiac patients were not able to access cardiac rehabilitation because the service did not have adequate capacity.

  • Some patients experienced delays in receiving their chemotherapy medicines. Staff told us about one patient whose chemotherapy infusion could not be fully administered because it had exceeded the time period in which the medicine was effective. There were problems preparing some medicines on the Hammersmith site and these were being transferred from another site in the trust.

  • Staff told us patient transport between sites was a problem and patients were unhappy about the length of time they waited for transport between sites and for going home after treatment.

  • Staff told us executive directors did not often visit the site.The Chief Executive had met with senior staff to discuss the trust’s strategy. They said they valued receiving information because major changes were taking place, which affected the hospital.

However,

  • The service managed patient safety incidents well. Staff received feedback from incidents they had reported. Learning from incidents was included in a staff bulletin, which was circulated to staff in the medicine and integrated care division.

  • Results of patient safety monitoring were displayed on ward noticeboards for patients and visitors.

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

  • Patients’ records were mostly electronic and staff described the benefits of medical staff being able to review test results or prescriptions from anywhere in the trust. Some wards were liaising with social services via email as part of planning patients’ discharge.

  • Services participated in a wide range of national audits and benchmarked performance against other hospitals.

  • Staff followed clinical guidelines and pathways, which were up to date and accessible on the trust’s intranet.

  • Patients’ needs were planned and reviewed by multidisciplinary teams.Care of the elderly consultants worked with cardiology, renal and cardiac colleagues to plan the care provided to older patients.

  • Governance arrangements were robust and had been revised to take account of recent changes in the management structure.

  • The provider was working with commissioners and partners to plan services, which met the needs of the local population in Hammersmith and Fulham.

  • Renal and haematology patients could contact the service day or night to discuss their symptoms and any care, which might be required.

  • Patients with cardiac symptoms could access services at a new heart attack centre dedicated to provide specialist investigation and treatment.

  • The complaints service was reviewed, resulting in improvements to the quality and timeliness of responses.

  • Nurse managers described how services were co-ordinated and managed within the new multi-site divisional structure. They told us there was a site manager with responsibility for the operational co-ordination of services on the hospital site and between sites.

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

Importantly, the trust must:

  • The trust must ensure all wards and departments 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 trust must improve the proportion of medical staff completing mandatory training, level 2 adult safeguarding training in particular.

In addition the trust should:

  • The trust should ensure patients and carers have the same access to the trust’s PALs service as patients on other sites.
  • The trust should ensure the cardiac catheter lab complies with the World Health Organisation (WHO) safer surgery checklist.
  • The trust should develop plans for addressing problems with the preparation of oncology treatments at the Hammersmith site and ensure staff and patients are informed. The trusts should also monitor the number of treatments adversely affected by delays in providing oncology medicines.
  • The trust should clarify and implement a pathway for access to Level 2 beds for Haematology patients
  • The trust should support clinicians and managers to develop the planned investigation unit and to review how specialty medicine beds and wards were configured across the site.
  • The trust should improve signage and the environment on the wards by addressing the backlog maintenance programme.
  • The trust should improve the provision of cardiac rehabilitation services.
  • The trust should ensure patients with diabetes are able to access foot care.
  • The trust should ensure all staff particularly those caring for older people fully understand and follow the requirements of the Mental Capacity Act (2005).
  • The trust should ensure adequate overnight SHO rota cover for clinical haematology.
  • The trust should review the recording of patients’ own controlled drugs to make sure stock levels and administration can be clearly documented.

Professor Ted Baker

Chief Inspector of Hospitals

Inspection carried out on 22, 23 and 24 November 2016.

During a routine inspection

Hammersmith Hospital is an acute teaching hospital located in East Acton, London. the hospital was founded in 1912 and is currently a part of Imperial College Healthcare NHS Trust. 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 Hammersmith 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 Hammersmith Hospital as good overall.

Our key findings were as follows:

  • Outpatient staff learned from incidents by monitoring and discussing them at departmental meetings. The senior sister sent a newsletter staff in the department which included information about the results of incident investigations and the key learning points.
  • Staff we spoke with were aware of the: ‘Ionising Radiation Protection - Dealing with Medical Exposures to Ionising Radiation Greater than Intended IR(ME)R trust policy, and how to access it.
  • The trust’s Executive Quality Committee monitored the number of IR(ME)R incidents. Incidents were investigated and actions were put in place to reduce similar incidents occurring in future.
  • 83% of staff working in outpatients felt encouraged to report errors and near misses.
  • Clinical areas in the outpatient department were clean and tidy and staff told us they were responsible for ensuring clinic rooms were cleaned daily. Managers had been unhappy with the cleanliness of the department and had put a cleaning programme in place.
  • There were hand-washing facilities and hand gel dispensers in every consultation room and we observed staff washing their hands and using hand gel between treating patients.
  • There were warning signs informing staff and patients not to enter rooms when x-rays and other diagnostic test were underway. These were illuminated when the room was in use so that staff and patients knew not to enter.
  • We found that medicines at the location were stored securely and appropriately. Keys to medicines cupboards and treatment rooms were held by appropriate staff. There was restricted access to rooms where medicines were kept via an electronic keypad. Medicines were stored in a safe manner.
  • At our inspection in September 2014 we found records were not always available in clinic when patients attended for their appointment. At this inspection we found the trust were moving towards an electronic system for all patient records and the retrieval of paper records had improved.
  • Arrangements were in place to safeguard patients from abuse.
  • Nursing and medical staff accessed advice from the medial assessment unit. Patients were admitted if their condition required the level of care which could only be provided on a ward.
  • The diagnostic imaging service used diagnostic reference levels (DRL’s) as an aid to
  • optimising patients exposure to radiation. The levels of radiation for procedures were on display.
  • Managers were auditing incidents where the diagnostic reference levels were exceeded.
  • Staff in diagnostic imaging were aware of NICE guidelines and evidence based guidelines were in place.
  • The diagnostic imaging department were working towards achieving the Royal College of Radiologist Imaging Accreditation scheme.
  • Staff in the outpatient department used pathways which were based on national guidance. For example smoking cessation was discussed with patients attending the cardiology clinic.
  • At our previous inspection we found clinics often started late but the trust were not monitoring this. At this inspection we found the trust had started to monitor when clinics started and how long patients were waiting.
  • Staff had developed a process for updating patients every thirty minutes if a clinic was running late and patients appreciated being kept informed.
  • A strategy had been developed for diagnostic imaging setting out a five year plan which included amongst other things, a plan to extend the service during weekdays and introduce weekend working.
  • The outpatient improvement programme was having an impact on bringing about change.
  • An outpatient service level agreement had been developed which set out how the central outpatient service and specialist teams would work together to meet the targets in a new performance framework.

We saw areas of outstanding practice including:

  • The trust was transforming outpatient service across the trust through the outpatient improvement programme. A Patient Service Centre was being set up as the first point of contact for patients and plans had been developed for improvements to clinic environments, improving the quality and content of patient communication, increasing the availability of patient notes and monitoring clinic start and finish times.

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

  • The trust should improve performance against the two week wait (2WW) GP referral to first outpatient appointment standard for cancer and the 62-day GP referral to first treatment standard.
  • The trust should improve performance against referral to treatment time (RTT) for non-admitted pathways for outpatient services.
  • The trust should improve performance agains treferral to treatment time (RTT) for non-admitted pathways for outpatient services.
  • The diagnostic imaging service should ensure they comply with updated guidance; for example, the Royal College of Radiographers guidance on x-raying patients with longstanding lower back pain.
  • The trust should reduce waiting times for patients in outpatient clinics.
  • The trust should reduce the number ofoverbooked or cancelled clinics.
  • The trust should ensure the temperature of the outpatients clinic department is a comfortable temperature for patients.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 2-5 September 2014

During a routine inspection

Hammersmith Hospital is part of Imperial College Healthcare NHS Trust. It is an acute hospital and provides medical care, surgery, critical care, services for children and young people, end of life care and outpatient services. These are six of the eight core services that are always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection. The accident and emergency department was going to close the week following our inspection to be replaced with an urgent care centre; therefore we made the decision not to inspect it. The other core service that is not provided by this hospital is maternity and family planning. Maternity and neonatal services for this trust are reviewed in our inspection report for Queen Charlotte’s & Chelsea Hospital.

Hammersmith Hospital has 346 beds and is based in the London Borough of Hammersmith and Fulham. The hospital provides a range of elective and non-elective inpatient medical and surgical services as well as 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, responsive and well-led as ‘requires improvement’.

We rated services for children and young people and end of life care as ‘good’ but medicine, surgery, and critical care as ‘requires improvement’. We rated outpatients as ‘inadequate’.

Our key findings were as follows:

Safe:

  • Patients were asked for their consent before procedures were carried out and staff knew how to report concerns related to alleged abuse or neglect.
  • The specialist palliative care team (SPCT) involved family members in decisions that related to patients’ care and treatment.
  • Most areas were clean and there were good infection prevention and control measures.
  • Staff had received safeguarding training, was able to identify potential abuse, and were aware of how to report this.

Effective

  • Pathways used for the assessment and management of patients’ medical conditions were informed by appropriate national guidance.
  • Patients were given pain relief when needed, prescribed in line with their individual requirements.
  • There was good communication and multidisciplinary team involvement among all staff involved in patients’ care and treatment.
  • Pain relief was well-managed and the nutritional needs of patients were catered for.

Caring

  • Staff were caring and compassionate and spoke to patients in a dignified manner.
  • The privacy and dignity of patients were respected.

Responsive

  • The provision in theatres was satisfactory. The surgical admissions lounge was a suitable environment and allowed for patient comfort, dignity and confidentiality.
  • Single side rooms were available on wards for patients receiving end of life care and people’s spiritual needs were met.

Well-led

  • Local line management of staff was good, supportive and visible.
  • Staff worked well as a team and were motivated to do their job.
  • There was an open and accessible culture that created positive teamwork among staff.
  • Translational clinical research is embedded in some clinical services with close working relationships with academic departments of Imperial College.
  • However, there were also areas of poor practice where the trust needed to make improvements.

The trust must:

  • Correct the high number of vacant nursing and healthcare assistant posts on the medical wards.
  • Address the problems associated with the administration of outpatient appointments which was leading to unnecessary delays and inconvenience to patients.

The trust should:

  • Improve patient transport from the outpatients department so that patients are not waiting many hours to be taken home.
  • Improve the management of medicines on the medical wards.
  • Ensure patients’ records are always appropriately completed.
  • Ensure learning from investigations of patient falls and pressure ulcers is proactively shared trust-wide.
  • Ensure cleaning of equipment is always carried out.
  • Improve access to the one pain clinic that is available in the trust.
  • Reduce the number of out-of-hours transfers and discharges.
  • Monitor the clinical impact of cancellations and delays in surgery.
  • Ensure that surgical patients are not cared for in inappropriate areas such as in the theatre overnight.
  • Improve the responsiveness of the outpatients department with regards to clearing the backlog of GP letters from the gastroenterology clinic and reducing the waiting times for patients to get an initial appointment.
  • Avoid cancelling outpatient clinics at short notice.
  • Ensure there is accurate performance information from the outpatients department.
  • Ensure that quality and risk issues in the outpatients department are managed effectively.
  • Consider reviewing the processes for the capturing of information to help the service to better understand and to measure its overall clinical effectiveness.
  • Consider reviewing the current arrangements for the provision of children’s outpatient services to ensure there is parity across the hospital campus.
  • Consider reviewing the operating times of the David Harvey Unit to ensure the service is accessible to the local population to which it serves, at the right time of day.

Professor Sir Mike Richards Chief Inspector of Hospitals

Inspection carried out on 16 November 2012

During a routine inspection

We visited an acute medical assessment and care of the elderly ward, the emergency department and wards, and the heart attack centre (which took emergency admissions). We spoke to people in all the departments we visited.

People told us that they had been asked for consent to operations or procedures during their time in hospital. We saw that consent had been properly recorded. Where people lacked capacity, staff arranged assessments of mental capacity in line with current legislation and to ensure people’s safety and involvement.

Almost all the people we spoke with were positive about the quality of care and treatment they had received. They said staff took time to assess and meet their needs. We looked at patient records, which were clear, accurate and up to date. They included care and treatment plans, risk assessments and plans for safe discharge.

There were policies and procedures in place for staff to deal with foreseeable emergencies and any adverse incidents and staff had the necessary skills and experience to deal with emergencies.

There were sufficient skilled and experienced staff to meet people’s needs.. Patients told us that staff checked on them regularly and responded quickly when called. Staff told us they were generally satisfied with staffing levels. The hospital systematically adjusted staffing numbers and skill mix according to patient need.

There were clear policies and procedures for medical record keeping which staff followed.