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Provider: Royal Free London NHS Foundation Trust Requires improvement

On 10 May 2019, we published a report on how well Royal Free London NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires improvement  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

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 10 May 2019

Our rating of the trust went down. We rated it as requires improvement because:

  • We rated effective and caring as good and safe and responsive as requires improvement.
  • We rated well-led for the trust overall as good.
  • We rated six of the 12 services inspected this time as requires improvement. In rating the trust, we also took into account the current ratings of the services not inspected this time.
  • Some of the issues identified during the previous inspection, which impacted on the safety and responsiveness of services, had not been yet been addressed by the trust.
  • Mandatory training for staff in key skills, including safeguarding, fell below the trust’s target for compliance.
  • Staff did not consistently follow best practice when prescribing, giving, recording, storing and disposing of medicines.
  • Services did not always have sufficient numbers of staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment.
  • We were not assured that there were effective systems and processes in place to prevent avoidable patient safety incidents from reoccurring.
  • People did not always have prompt access to services when they needed it.
  • Best practice guidelines for the care and treatment of patients with additional support needs were not always consistently followed.
  • Whilst the trust had effective systems for identifying risks and planning to reduce them, risks were not always being dealt with in a timely way.
  • Whilst the majority of staff felt the culture of the organisation had improved and described the leadership team as accessible and supportive, there remained a culture of bullying within the operating theatres.

However:

  • The service managed patient safety incidents well.
  • The hospital generally controlled infection risk well.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • Staff worked together as a team to deliver effective, patient-centred care and improve patient outcomes.
  • Staff treated patients with kindness, dignity and respect.
  • Most staff felt well supported by managers and told us that they encouraged effective team working across the hospital.
  • The trust was committed to improving services by learning, promoting training, research and innovation.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RAL/reports.

Inspection areas

Safe

Requires improvement

Updated 10 May 2019

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

  • Mandatory training for staff in key skills, including safeguarding, fell below the trust’s target for compliance.

  • We were not assured that there were effective systems and processes in place to prevent avoidable patient safety incidents from reoccurring. Evidence of completed actions in response to serious incidents, was not always robust. There were gaps in the outcomes divisional teams thought they had achieved and the information understood or used by staff delivering care.

  • Staff did not consistently follow best practice when prescribing, giving, recording, storing and disposing of medicines. Documentation indicated patients did not always receive the right medication at the right dose at the right time. Medicines management was inconsistent and audits repeatedly found areas of unsafe practice in relation to documentation and storage. Medicines were not always stored securely and managed appropriately.

  • Services did not always have sufficient numbers of staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. In some areas, turnover and vacancy rates were high amongst nursing staff and services were reliant on temporary staff to fill shifts.

However:

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

Effective

Good

Updated 10 May 2019

Our rating of effective stayed the same. We rated it as good because:

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff delivered care and treatment in line with national guidance. Audits and quality outcomes were conducted at departmental level to monitor the effectiveness of care and treatment.

  • Staff worked together as a team to deliver effective, patient-centred care and improve patient outcomes. Treatment was planned and delivered in line with current evidence-based guidance and patients were supported by staff to take ownership of their own recovery.

  • The trust-wide clinical pathway group (CPG) model aimed to standardise clinical pathways by using evidenced-based practice to remove unwarranted variation in patient care in order to deliver better outcomes for patients.

Caring

Good

Updated 10 May 2019

Our rating of caring stayed the same. We rated it as good because:

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Patients and their families were treated and cared for with compassion, patience and respect. Feedback from patients about their experience of care was consistently positive.

  • Staff provided emotional support to patients to minimise their distress. Feedback from patients confirmed that staff treated them with respect and with kindness and our observations of interactions between staff and patients and relatives showed staff were sensitive and respectful.

  • Staff involved patients and those close to them in decisions about their care and treatment. Most patients we spoke with said they felt involved in their care and had the opportunity to ask questions. We observed staff listening to patients and discussing aspects of their care.

Responsive

Requires improvement

Updated 10 May 2019

Our rating of responsive went down. We rated it as requires improvement because:

  • People did not always have prompt access to the service when they needed it. Waiting times from referral to treatment and decisions to admit patients were not always in accordance with best practice recommendations. Long waits in A&E and out of hours discharges, demonstrated issues with access and flow across many areas of the trust.

  • Best practice guidelines for care and treatment of patients with additional support needs were not consistently followed. Systems and processes to support patients with additional needs were not always in place or used effectively.

However:

  • The needs and preferences of different people, including the local population, were taken into account when designing and delivering services. At the newly re-developed Chase Farm Hospital, the design of the new barn theatres, the introduction of the new EPR system and the new electronic nurse calling system were just some of the ways technology and new developments were being implemented to improve patient safety, drive efficiency and improve patient experience.

Well-led

Good

Updated 10 May 2019

Our rating of well-led stayed the same. We rated it as good because:

  • Most staff felt well supported by managers and told us that they encouraged effective team working across the hospital. Senior staff were visible, approachable and supportive. Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. Most staff spoke positively about their local leadership and line management and said relationships were supportive.

  • The trust was committed to improving services by learning, promoting training, research and innovation. Staff were positive about the support they received to challenge existing practice and try out new ideas.

  • The trust board was a dedicated, highly-experienced and capable leadership team with the skills, abilities, and knowledge to provide high-quality services. Leadership structures were well-embedded and leaders demonstrated a deep understanding of issues, challenges and priorities in their service and beyond.
  • We found a strong organisational pride and culture of collaboration, team-working and support with a focus on improving the quality and sustainability of care and people’s experiences. Staff were proud to work for the trust and spoke highly of the leadership team.
Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 10 May 2019

Combined rating

Combined rating summary

Requires improvement
Checks on specific services

Specialist community mental health services for children and young people

Requires improvement

Updated 15 August 2016

Overall we rated mental health services for children and young people as requires improvement because;

The general CAMHS tier two service was part of the wider children’s directorate. At the time of the inspection the team didn't have a service manager and staff felt this was unusual for such a large service. However, the clinical director had recently made a proposal to get a specific service line lead for CAMHS which was a clinical leadership role for the whole of CAMHS.

The site environment was small and staff had problems in accessing space to conduct sessions. We did not find evidence of alarms fitted in therapy rooms for use in an emergency.  The rooms did not provide adequate sound proofing and discussions could be heard outside of rooms.

The CAMHS services did not have a formal caseload management system and did not have a system for regularly monitoring non urgent young people on the waiting list to detect an increase in the level of risk. 

Transition from CAMHS to adult services was poor and staff agreed that there was a lack of joint care planning and working. However, the operational service manager was actively negotiating with commissioners to improve the transition for young people to adult services. The service did not collect information for waiting times from assessment to treatment.

Parents/carers of young people were not aware of how to access an advocate and felt facilities could be improved.

However;

Staff had a good understanding of risk and reported all incidents. Staff discussed feedback and learning at team meetings. Staff completed assessments in a timely manner and were responsive to young people’s physical health needs. Clinicians used a range of outcome measures to rate outcomes and the severity of illness for young people using the service.

Staff greeted patients in a friendly and supportive manner and young people and parents/carers said staff behaved with respect and were polite. Staff made themselves available and communicated with young people and parents/carers regularly. Staff involved the families and carers of young people and invited them to appointments.

Young people and parents/carers could give feedback on the service in surveys. Young people and parents/carers felt that staff were flexible with appointment times. Parents/carers said they were fully informed by staff and received information about the service. Parents/carers of young people said they knew how to complain and that staff provided feedback.

Staff were experienced and qualified to provide therapeutic interventions to young people. Staff had good access to specialist training and had strong links to external agencies. Staff were aware of and had understanding of Gillick competency and Fraser guidelines.

The team provided young people and their parents/carers with information about how to keep safe and gave them contact information for an out of hours response.

The team had rapid access to a psychiatrist for urgent referrals. Care plans were holistic and recovery focused but there was difficulty in accessing patients records and knowing where to find key documents.