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Provider: Barts Health NHS Trust Requires improvement

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 12 February 2019

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

  • All three hospitals we inspected on this occasion were each rated requires improvement overall.
  • Services at Whipps Cross University Hospital had improved. The previous Section 29a Warning Notice (Health and Social Care Act 2008), issued to the surgery service had been addressed. We rated the hospital as good in the effective and caring domains, and requires improvement in the safe, responsive and well-led domains.
  • The Royal London Hospital saw improvements across the services we inspected. We rated the hospital good in the effective and caring domains, and requires improvement in the safe, responsive and well-led domains.
  • We were disappointed to find that concerns in the maternity services at Newham University Hospital persisted and rated the service inadequate overall and issued the trust a Section 29a Warning Notice (Health and Social Care Act 2008) to address our concerns of poor quality care and leadership. We also rated the diagnostic service inadequate for the well-led domain. Overall, we rated the hospital requires improvement in the safe, effective, responsive, and well-led domains. Caring was rated as good.
  • We aggregated the rating for each domain at each location and then subsequently collated the overall aggregation to determine the trust rating across the safe, effective, caring and responsive domains. The effective and caring domains were aggregated as good, whereas the other domains were aggregated as requires improvement.
  • Between 9–11 October we carried out a ‘well-led’ review of the trust. Despite recognition there remained areas for improvement, partly evidenced by the concerns we found in maternity and diagnostics services at Newham University Hospital, we found demonstrable improvements to the leadership, governance and culture of the organisation and determined the trust well-led domain as good overall.
  • A follow up inspection of maternity services at Newham University Hospital on 14 and 15 January 2019 assessed progress in response to the Section 29a Warning Notice we issued to the trust. We found that appropriate steps to address these concerns had been taken and there was evidence of improvement to the safety and governance of the service.
Inspection areas

Safe

Requires improvement

Updated 12 February 2019

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

  • We were not assured that risk assessment tools, such as modified/national early warning score, were accurately completed or acted upon in some areas.
  • Staff awareness of incident reporting and how to raise concerns had improved across most services. However, we still found examples where incident investigations were not carried out in a timely way and staff did not always receive feedback. Results from the staff survey indicated staff had a poor perception of incident investigation in the trust.
  • Mandatory training compliance for staff varied across services, particularly medical staff. This included low levels of compliance in basic life support training in some services. Not all services were able to provide the relevant data.
  • Midwives at Newham University Hospital regularly worked through breaks and beyond the end of their shift.
  • Improvements were required in the management of medicines across services, although the trust had made significant changes following concerns we raised when we last inspected in April 2018.
  • The standard of record keeping across services was variable.
  • Infection control and the cleanliness of equipment was variable across services. Some areas had made sustained improvement; however, we found examples in other services where this was poor.
  • Equipment was not stored safely or securely in some areas.
  • Staff understanding and practice in relation to the control of substances hazardous to health (COSHH) was variable.

However, we also found:

  • Staffing levels had improved across most services. Although services were still reliant on bank nurses, the use of agency nurses had decreased.
  • Staff understood their role in identifying and reporting safeguarding concerns to keep patients safe. They understood how to protect patients from avoidable harm and abuse.
  • Staff demonstrated an understanding of Duty of Candour regulation and we saw evidence of its application.
  • Business continuity plans were in place.

Effective

Good

Updated 12 February 2019

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

  • Services sought to deliver care according to best available evidence, such as national guidelines.
  • There was greater participation in quality improvement initiatives, such as peer reviews and accreditation schemes.
  • Outcomes for people’s care and treatment were routinely monitored and collected, although the data suggested that further improvements across services were required.
  • Staff were predominantly aware of their responsibilities as set out in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).
  • Multi-disciplinary working across services was largely effective. Although, we found examples where this could be improved.
  • Specialist training opportunities, including simulations and interactive workshops had been introduced for staff to access across some services.
  • Staff understanding of sepsis had improved.
  • Staff engagement with health promotion was predominantly better embedded across services.

However, we also found:

  • Women in maternity services at Newham University Hospital did not have timely epidurals out of hours, and at times during hours. We raised this at our previous inspection and it had still not improved.
  • The end of life service at Newham University Hospital was not meeting the NICE guidelines for adults to provide palliative care services face-to-face seven days a week. This had not changed since the last inspection in November 2016.
  • The recording of capacity assessments and decisions on deprivation of liberty safeguards (DoLS) in patient records was inconsistent in some areas.
  • Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms were not always found to have been completed correctly at Newham University Hospital.
  • The regularity and quality of internal audits were variable across services.
  • Most services updated policies and procedures, although we found examples across services where they were out of date or were not easily accessible by staff.
  • The trust had improved its support and training opportunities for staff, although we still found areas where staff engagement with training and routine appraisals was low.

Caring

Good

Updated 12 February 2019

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

  • The standard of care across core services had fundamentally improved. We found that staff were more consistent in delivering patient care with kindness and dignity.
  • We saw many examples of staff offering emotional support to patients and their relatives.
  • Staff across services predominantly included patients and their relatives in decisions about their care and treatment.
  • Most patients and relatives that we spoke with spoke favourably about the way staff treated them. However, a few people we spoke with described examples of where they had been spoken to in a way perceived as rude.

Responsive

Requires improvement

Updated 12 February 2019

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

  • The trust was not meeting national waiting time standards across urgent and emergency care, although services had introduced pathways to improve this.
  • Referral to treatment times (RTT) were improving, although the trust was still not meeting constitutional standards.
  • Patient flow across the trust was variable. For example, out of hours and delayed discharge rates were high at Newham University Hospital critical care service; whereas, patient access and flow in surgery services at The Royal London Hospital had significantly improved since the last inspection.
  • The premises and clinical environment varied across hospital location and was not always suitable for patients and their relatives.
  • Timely response to complaints varied across services.

However, we also found:

  • The trust endeavoured to plan and provide services that met the needs of a diverse local population.
  • Teams were in place to help avoid the need for admission in the old and frail, and support the discharge process for those with complex needs who would be better cared for in the community.
  • Specialist nursing teams were in place across services to provide care to patients and support staff. For example: dementia teams, psychiatric liaison, critical care outreach, palliative care team, and various oncology nurse specialists.
  • Surgery services at The Royal London had addressed the concerns regarding theatre utilisation, access and flow, bed management, bed availability and had reduced referral to treatment backlogs.

Well-led

Good

Updated 12 February 2019

Our rating of well-led improved. We rated it as good because:

  • The trust had further developed and embedded a leadership and governance structure that was better established across the hospital locations. Although there was evidence for further improvement, the structure had allowed for better oversight and improvement to the quality of care across many core services.
  • Staff mostly spoke of visible and engaging leaders, at core service and hospital board level.
  • Staff across core services and locations spoke of how the organisational culture had improved. We found examples of significant improvement in some services. Although, we still found areas where a negative culture that included perceived bullying persisted.
  • Significant investment had been made into the trust ICT systems that had improved since our last inspection, although staff commented that some issues remained.
  • Data quality had overall improved compared to previous inspection, although there was still some variability across services and locations.
  • Some services had taken steps to better engagement with patients and their relatives.

However, we also found:

  • The hospital management boards were at different levels of maturity. This had allowed for variations in quality of services between hospital sites as exampled by the concerns we found in maternity services at Newham University Hospital where, despite raising several concerns at our last inspection regarding the maternity service at Newham University Hospital, we found on this inspection that many issues and concerns had not been adequately addressed.
  • We had concerns at our previous inspection as to the oversight and management of risk across core services. Although, we found on this occasion that this had predominantly improved, and services had better established governance structures that improved identification of risk, we found examples where there was insufficient oversight in some core services, raising concern that the trust board did not receive sufficient assurance.
  • Most clinical divisions were dynamically led and the majority of core services were developing or progressing a vision and strategy that aligned with the overall trust vision and strategy. However, we still found variations in development across services and hospital location.
  • Serious incident investigations were not being completed within agreed timeframes. The trust recognised that further steps were needed to improve the review and learning process.
  • The trust was not addressing all complaints within agreed timescales and there was considerable variation across sites.
  • The trust had considered the efficacy of Clinical Support Services directorate and had decentralised some services to ensure better oversight; however, we found that in some areas there remained scope for further improvement to address governance, quality and cultural concerns.
Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 12 February 2019

Combined rating

Combined rating summary

Requires improvement
Checks on specific services

Community health inpatient services

Insufficient evidence to rate

Updated 16 January 2017

Essential elements to keeping the service safe were being routinely collected and regularly monitored. Individual assessments monitored specific areas of patient risk although subsequent action plans had not always been documented. The trust had taken appropriate action over safeguarding concerns that had been raised and had acted on poor practice.

Referrals came from the trust’s local acute hospital and consultants worked across both sites for continuity of care. Therapy teams worked with patients and their families towards more independent living and the service was hoping to improve upon discharge processes and had taken on a discharge coordinator.

We observed staff and patients interacting in a positive way. All of the patients we spoke with were positive about the friendliness of staff and their readiness to offer help and support. We also came across examples where people had not been treated or spoken to with due dignity and respect. Senior staff had recently taken action on this and expressed a desire to raise standards of kindness and compassion.