Royal Free London NHS Foundation Trust

This was the first inspection of The Royal Free Hospital NHS Foundation Trust under the new methodology. We have rated the hospital trust as Good overall. We inspected the three acute sites: Barnet Hospital, Chase Farm Hospital and the Royal Free Hospital, alongside the Child and Adolescent Mental Health Services (CAMHS). We rated the Barnet and Chase Farm sites and the Royal Free site as Good. We rated CAMHS as Requires Improvement.

We carried out an announced inspection between 2 and 5 February 2016. We also undertook unannounced visits during the following two weeks.

We inspected eight core services: Urgent and Emergency Care, Medicine (including older people’s care, Surgery, Critical Care, Maternity and Gynaecology, End of life Care, Services for Children and Outpatients and diagnostic services, as well as CAHMS at the Royal Free site. We have accounted for CAHMS within the overarching provider level ratings.

Our key findings were as follows:

Safe

• Staff were proactive in reporting incidents and we saw evidence of learning taking place as a result of incidents. Learning was shared with all staff via safety briefings and posters were displayed.
• Staff were aware of the safeguarding policies and procedures and had received training. Most staff understood their responsibilities under the Duty of Candour and were able to provide examples.
• Staff were able to speak openly about issues and serious incidents. However, staff told us they didn’t always report an incident as they were too busy and did not always receive feedback.
• Patients arriving via ambulance did not consistently receive an assessment within 15 minutes of arrival, which was not in line with the Royal College of Emergency Medicine (RCEM) guidance. Use of the trust's early warning score system to identify deteriorating patients in the Emergency Department (ED) was not consistent, which could lead in a delay in identifying deteriorating patients.
• There were concerns at the Royal Free site regarding infection prevention and control practices, such as variable hand hygiene, staff wearing nail varnish and jewellery and doors left open to patients in isolation.
• At the Royal Free site the safety thermometer data and many patient risk assessments or records, including fluid balance charts, were not always complete.
• On the Barnet Hospital site we found where patients were unable to consent to restraint, no mental capacity assessment had been undertaken and no best interest decisions had been recorded. This meant that patients had their liberty restricted without hospital staff being able to evidence that the patient did not have the capacity to agree to the treatment plan.

Effective

• Patients achieved good outcomes due to receiving evidence-based care from suitable numbers of competent staff who enjoyed their work and were well supported.
• Departments performed frequent audits such as the theatre checklist and hand hygiene. Audits were analysed and the results cascaded to staff through staff meetings, notice boards and safety briefings.
• Clinical practice was benchmarked against national guidance from organisations such as   the National Institute for Health and Care Excellence (NICE) and Royal College guidelines. However following the acquisition of Barnet Hospital by the Royal Free Hospitals NHS Foundation Trust staff were still able to access the policies and procedures from the Barnet and Chase Farm NHS Hospitals Trust which could lead to confusion.

Caring

• Staff were caring, compassionate and respectful and the staff we spoke with were positive about working in the hospital.
• The Hospital and its staff recognised that provision of high quality, compassionate end of life care to its patients was the responsibility of all clinical staff that looked after patients at the end of life. They were supported by the palliative care team, end of life care guidelines and an education programme.

Responsive

• An interpreting service was available for both in-patients and out-patients within the hospital.
• The needs of people living with dementia were being met, staff showed good understanding of the condition.
• There was very effective multidisciplinary team working between doctors, nurses, physiotherapists and other allied health professionals.
• At the Royal Free site ambulance turnaround time did not meet the national target of handover.
• The trust’s ED performance on waiting times for treatment was inconsistent but they often met the 4-hour target.
• The trust had consistently not met the referral to treatment time standard or England average for the past ten months. The time to triage referrals as to their priority varied between specialities and could take as long as 34 days.
• There had been a deterioration in performance of the 62 day cancer performance compared to the national standard.
• The hospital cancelled 35% of outpatient appointments in the last year. From October to January 34% of short notice cancellations were due to annual leave, which was not in line with trust policy.
• Patients’ individual needs and preferences were mostly considered when planning and delivering services.
• There were poor post-operative recovery facilities on the Royal Free site for children exposing them to potentially upsetting sights and sounds.
• On the Barnet site the theatre recovery area is regularly used to accommodate patients overnight.

Well Led

• The trust had developed a clear vision and strategy to lead a large, complex, multi-site organisation with cultural site differences.
• There was a visible management executive team, who were cognisant of the operational and clinical challenges faced by each location.
• The trust promoted and encouraged both local and national innovations to improve patient care and treatment.
• We observed dynamic nursing leaders who supported clinical environments are were essential in the development and achievement of best practice models
• On the Chase Farm site the UCC was a good nurse led service. We found that there was strong and effective clinical leadership. The UCC was well organised and consistently delivered safe and timely care and treatment. Patient outcomes were good.
• The neonatal unit at Barnet hospital had level 2 UNICEF accredited baby friendly status where breast feeding was actively encouraged and mothers are given every opportunity to breast feed their babies. The department was very well equipped and offered outstanding levels of compassionate care delivered by all grades of staff from across the whole of the multidisciplinary team.
• The palliative care team was highly thought of throughout the three hospital sites. The Specialist Palliative Care team worked closely with the practice educators at the hospital to provide education to nurses and health care assistants. Medical education was led by the medical consultants and all team members contributed to the education of the allied healthcare professionals.
• Particular praise must be given to the volunteers who provided additional caring activities such as massages for patients and supported patients with dementia.
• However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Amalgamate clinical guidelines and procedures and ensure consistency across all sites.
• Ensure the 62 day cancer wait times are met in accordance with national standards.
• Ensure the theatre swab, needle and instrument policy is ratified and new practices are embedded in all relevant departments across all sites.
• Improve the recovery area of the operating theatre, at the Royal Free site, to protect children from witnessing upsetting sights and hearing frightening sounds.
• Ensure that all theatre recovery staff receive PILS training.
• Ensure nursing staffing levels on the children’s ward on the Royal Free site are in line with acuity and recommended standards.
• Address the issue of the day surgery unit on the Barnet site being used to accommodate patients overnight.
• Reduce the number of outpatients appointments it is cancelling with less than six weeks notice, across all sites.
• Embed the fresh eyes for review of CTGs, at the Barnet site.
• Ensure that emergency drugs such as Sodium Bicarbonate and Adrenaline are removed from the Rescusitaires.
• Remove the inconsistencies that existed in patient’s assessments for DNACPR and the recording of Mental Capacity Act assessments.

In addition the trust should:

• Ensure that all staff, all across all sites, undertake mental capacity assessments and record best interest meetings to ensure that they can evidence that staff are working the legal framework of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberties Safeguards (DoLS) training.

• Ensure that good standards hygiene practices are followed in clinical areas such as hand hygiene and bare below area.

• Ensure that there is an electronic system in place to flag patients who may require additional support

• Ensure that medical and nursing records are fully completed without gaps or omissions.

• Ensure that risk assessment documentation is completed consistently across all areas of the organisation to include risks such as falls risk assessments, nutrition charts and fluid balance charts.

• Continue with its work around implanting the 5 steps of safer surgery until embedded and audited to ensure full compliance.

• Ensure a safer surgery policy is produced and ratified.

• Ensure that RTT is met in accordance with national standards

• Ensure all staff interacting with children have the appropriate level of safeguarding training.

• Ensure security of prescriptions forms is in line with NHS Protect guidance.

• Ensure emergency medication is stored safely and access to these drugs is controlled.

• Ensure arrangements around equipment storage are reviewed so that shower rooms are not used.

• Ensure grading of surgical referrals occurs within acceptable timescales.

• Ensure that the ‘low risk’ pathway for women identified as suitable for birth centre care is used consistently.

• Identify a dedicated bereavement facility for women and families to use in or near the labour ward at the Royal Free site.

• Use lessons learned from Barnet Hospital in reducing Caesarean section rates.

• Undertake a maternity acuity assessment for the new service.

• Improve antenatal risk assessments.

• Ensure appropriate staggering of arrival times with the day surgery units to minimise the time patients are prohibited from eating and drinking.

• Replace fridges are on Damson ward.

• Ensure that a  “you’re welcome” and 15 step challenge audit is undertaken within children’s services.

• Ensure appropriate storage of medicines in the day surgery unit at the Barnet site.

• Introduce the use of POSSUM scoring.

• Ensure the call bells in theatres at the Barnet site are improved to be louder.

• Ensures that staff mandatory training, across all areas, meets the trust target of 95%.

• Ensure that the ward environments on the Barnet site is improved for individuals living with dementia.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.