The Care Quality Commission
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Barking, Havering and Redbridge University Hospitals NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings

All Inspections

7 to 10 November 2022

During a routine inspection

Barking, Havering and Redbridge University Hospitals NHS Trust is a large provider of acute services, serving a population of approximately 800,000 in outer North East London and Essex. The trust operates from two sites; Queen's Hospital and King George Hospital, with approximately 900 beds across both sites. The trust employs over 8000 permanent staff, sees over 300,000 attendees through their emergency departments and delivers over 7000 babies a year.

This inspection was part of a follow up on our previous system wide review of urgent and emergency care services across the North East London (NEL) integrated care system that was carried out in November 2021. At that time, we identified issues with flow in and through the urgent and emergency (UEC) pathway and had significant concerns regarding the impact of this on safety and quality of care. Due to ongoing concerns regarding the UEC pathway and patient safety, during November 2022 we inspected all four urgent treatment centres (UTC) provided by the Partnership of East London Cooperatives (PELC), and both emergency departments (ED) and medical care provided by Barking Havering and Redbridge University Hospitals NHS Trust (BHRUT).

Subsequent to significant concerns that were identified at these locations, the Commission found that the challenges these services faced were also complicated by wider challenges within the health and social care system. A Quality Summit with NHS England and system wide partners was convened to devise an action plan to address the concerns identified.

Overall summary

  • The trust faced continued challenges with access and flow into and out of the emergency department. Patients who accessed the emergency pathway did not always receive timely treatment when needed and were not always cared for in the best place for their treatment needs. Patients in the emergency department could not be moved promptly to specialist wards or mental health facilities due to lack of capacity.
  • The trust had declared a serious incident in August 2022 relating to the accuracy of their patient tracking list (PTL), where it was found that patients who should have been on the PTL awaiting an appointment for diagnostic imaging had not been. it was not clear at the time of inspection what the outcome of any clinical harm review was, either in relation to the extent of the harm or the number of people impacted.
  • The trust had committed to fostering an open culture where patients, their families and staff could raise concerns without fear. However, some staff did not always feel respected, supported and valued.
  • Senior leaders and teams used systems to manage performance. However, they did not always identify and escalate relevant risks and issues, and initiate actions to reduce their impact, in a timely way. The effectiveness of divisional risk management and oversight was variable.
  • The trust was improving the way staff could find the data they needed in more easily accessible formats, to understand performance, make decisions and improvements. However, the current information systems were not well integrated, and the use of paper records meant that patient’s records were not completely secure.

However:

  • Services had enough nursing staff to care for patients, although there were some gaps in medical staffing provision.
  • Senior leaders had the skills and abilities to perform their roles. They understood and managed the priorities and issues the trust faced. They were visible and approachable to staff and patients.
  • The trust had a vision for what it wanted to achieve and was developing a strategy to turn it into action, through engaging with relevant stakeholders.
  • The trust promoted equality and diversity in daily work and were developing opportunities and strategies for staff career development.
  • Senior leaders were reviewing and redesigning governance processes throughout the trust and with partner organisations. The effectiveness in monitoring quality and risk was being assessed and the trust was working to identify how to improve processes.
  • The trust planned care to meet the needs of local people and engaged well with other healthcare providers and system partners to plan and manage care.
  • There was improved engagement from senior staff in understanding the financial challenges the trust faced.
  • Staff treated patients with compassion and kindness. We found examples of staff delivering good care in a difficult working environment. However, ensuring privacy and dignity within the busy environment of the emergency department was not always possible.
  • Senior leaders were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them.

03 Sep to 10 Oct 2019

During a routine inspection

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

  • We inspected three core services at Queens Hospital. The change in rating of these services did not affect the overall rating of the hospital which remained Requires Improvement. Caring remained Good and we rated safe and responsive as Requires Improvement. However, well led Improved to Good. We also rated the end of life care services at the hospital as Outstanding.
  • We inspected five core services at King George Hospital. The change in rating of these services did not affect the overall rating of the hospital which remained Requires Improvement. Safe, responsive and well led remained Requires Improvement and caring remained Good. However, the effective domain improved to Good.
  • Following out assessment of well-led, we rated well-led for the trust overall as Good.
  • Overall, we rated the trust as Requires Improvement for safe and responsive. Effective, caring and well led were rated Good.

23 January 2018

During a routine inspection

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

  • We rated safe, effective, responsive, and well-led as requires improvement; and caring as good.
  • We took into account the current ratings of the four core services across the two locations not inspected at this time. Hence, six services across the trust are rated overall as requires improvement, and the remaining two services are rated good.
  • The overall ratings for each of the trusts acute locations remained the same.

Queens Hospital

  • We inspected Urgent and Emergency services during this inspection to check if improvements had been made since our last inspection in 2016. The overall rating for the service was requires improvement. The rating for effective and caring improved to good. Safe, responsive and well led remained requires improvement.
  • We inspected Medical care (including older people’s care) and found the service had improved since we last inspected in 2016. We rated the service good overall. The rating for safe and responsive both improved from requires improvement to good.
  • We inspected Surgery and rated the service good. The rating for safe and effective improved to good; however the rating for well-led remained requires improvement.
  • We previously inspected Maternity services in 2015. On this occasion we rated the service overall as good, with the rating for responsive and well-led improved from requires improvement to good.

King George Hospital

  • We inspected Urgent and Emergency services during this inspection as we wanted to see what improvements and changes had been made to the service. We rated the service overall as requires improvement, although the rating for effective improved from requires improvement to good.
  • We inspected Medical care (including older people’s care) and found the service had improved from requires improvement to good since out last inspection in 2016. The rating for effective improved to good.
  • We previously inspected Surgery services in 2015. On this occasion, we found the service had overall improved from requires improvement to good. Safe and responsive had improved to good; however the rating for well led went down one rating to requires improvement.

7 - 8 September; 11 - 12 October 2016

During an inspection looking at part of the service

Barking, Havering and Redbridge University Hospitals NHS Trust is a large provider of acute services, serving a population of over 750,000 in outer North East London. The trust operates from two sites; Queen's Hospital and King George Hospital.

Queens Hospital is the trust’s main acute hospital and opened as a private finance initiative (PFI) in 2006, bringing together the services previously run at Oldchurch and Harold Wood Hospitals. It is the main hospital for people living in Havering, Dagenham and Brentwood. The hospital has over 900 beds, including a hyper acute stroke unit (HASU). The Emergency Department (ED) treats over 150,000 walk-in and ambulance emergencies each year.

King George Hospital opened at its current site in Ilford in 1995 and provides acute and rehabilitation services for residents across Redbridge, Barking & Dagenham, and Havering, as well as providing some services to patients from South West Essex. The hospital has approximately 450 beds.

The trust had an annual revenue of around £560 million and projected year-end deficit of £11.9 million, at the time of the inspection. The trust employs 5,713 staff, with a budget for 6,676 staff. The trust provides a full range of adult, older people’s and children’s services across medical and surgical disciplines.

Over a twelve month period the trust reported activity figures of 101,685 inpatient admissions, which is made up of 52,536 emergency admissions and 49,149 elective admissions. Between the period of October 2015 and September 2016 there were 829,011 outpatient attendances, 280,795 attendances through the Accident and Emergency (A&E) department.

The CQC undertook a comprehensive inspection of Barking, Havering and Redbridge University Hospitals NHS Trust in October 2013 and found serious failures in the quality of care and concerns that the management could not make the necessary improvements without support. Following this inspection, the trust was placed in special measures in December 2013.

A further comprehensive inspection took place in March 2015. In this inspection it was recognised that progress had been made, however the trust continued to carry significant risks and therefore remained under special measures. Overall the trust was rated as requires improvement, with the responsive domain rated as inadequate.

We carried out an unannounced inspection of three core services between the 7th and 8th September 2016. We then carried out a further announced core service inspection, alongside a well led assessment between the 11th and 12th October 2016.

In March 2015 we rated the organisation as requires improvement. Following the recent core service inspection and well led review, the trust remains rated as requires improvement.

This inspection was specifically designed to test the requirement for the continued application of Special Measures to the trust. Prior to inspection we risk assessed services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment led us to include four services (emergency care, medical services, outpatients and diagnostics and services for children and young people) in this inspection which were inspected at Queens Hospital and the King George Hospital. The remaining services were not inspected as they had indicated strong improvement at our last inspection and our information review indicated that the level of service seen at our last inspection had been sustained.

In our most recent inspection we were particularly encouraged by the significant improvements that have been made by the trust since March 2015. Our overall rating for the trust is now requires improvement and there are no areas rated Inadequate.

We were particularly encouraged by the improvements made in a number of areas.These were

  • Improvements in a number of domains within the services that we inspected since our last inspection.
  • Improvements in the overarching governance processes.

Queens Hospital

In March 2015 we rated the urgent and emergency care service as requires improvement overall, with an inadequate rating for the safe domain. Following our recent review we have rated urgent and emergency care at Queens Hospital as requires improvement across the five domains.

In March 2015 medical care was rated as requires improvement within the safe, responsive and well led domains. Following the September inspection we recognised the progress made within the well led domain, along with the continued performance in the effective and caring domains, which we rated as good. The safe and responsive domains remain as requires improvement, resulting in an overall rating of requires improvement for medical care.

In March 2015 we rated services for children and young people as requires improvement, with an inadequate rating for the responsive domain. Following the October inspection we rated services for children and young people as good, with the safe domain rated as requires improvement.

In March 2015 we rated outpatients and diagnostics as requires improvement , with an inadequate rating for the responsive domain. Following the September inspection we rated this service as good, recognising progress in the safe, caring and well led domains which we rated as good.

King George Hospital

In March 2015 urgent and emergency care was rated as requires improvement across all domains. Following the September inspection we rated this service as requires improvement, recognising the progress made within the caring and responsive domains which we rated as good.

In March 2015 medicine was rated as requires improvement across four domains (safe, effective, responsive and well led). Following the September inspection we rated medical services as requires improvement, with the caring and well led domains rated as good.

In March 2015 outpatients and diagnostics was rated as inadequate. This service received two ratings of inadequate under the safe and responsive domains. Following the September inspection we rated the service as requires improvement, recognising progress in the caring and well led domains which we rated as good.

The rating for well led has remained at requires improvement as ascribed in the 2015 inspection. However, the senior leadership team were visible and involved in clinical activity. Time and resource had been invested into improving clinical governance structures and risk management and the trust actively promoted innovation and improvement to the patient experience.

It is apparent that the trust is on a journey of improvement and significant progress is being made both clinically and in the trust’s governance. It is also clear that there is still further work to do to ensure that these improvements are sustained and that further progress is made.

Our key findings were as follows:

​ Are services safe?

  • Compliance with infection prevention and control (IPC) practices across the services we inspected were found to be inconsistent.
  • Rates of Methicillin-resistant Staphylococcus aureus (MRSA) infections had breached the trust zero tolerance target for the year.
  • Fire safety standards in CYP services, including areas around the NICU were not always maintained.
  • The emergency department (ED) cooling system at the King George Hospital had been out of order for at least three weeks prior to our inspection. This made it difficult to regulate safe temperatures within which to store drugs.
  • Although nursing staffing levels had improved since the last inspection, some areas still had significant vacancy and turnover rates. 
  • We found high usage of locum across the organisation. Feedback from some locums was that access to training was poor and we had concerns that this meant they might not be appropriately skilled with up to date competencies.
  • Since our previous inspection in March 2015 the organisation had improved its’ processes around incident reporting across both sites and staff told us that they were encouraged to record incidents.
  • The inspection raised concerns about the diagnostic imaging department at the King George Hospital not comply with all the policies and procedures based on the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) and the Ionising Radiation Regulations 1999 (IRR99).

Are services effective?

  • We found a number of clinical guidelines on the trust intranet were out of date. There was also issues with access to trust policies and guidelines for agency staff who had no computer access.
  • The ED's performed worse than the national average in a number of Royal College of Emergency Medicine (RCEM) audits, including sepsis and septic shock, asthma in children, and paracetamol overdose.
  • In medicine at Queens Hospital we found there was a backlog of National Institute for Health and Care Excellence (NICE) guidance that was awaiting confirmation of compliance across the trust.
  • For non-elective medicine admissions, the standardised relative risk of readmission was high, particularly for geriatric medicine.
  • Clinical staff completed a variety of local audits to monitor compliance and improvement. Staff of all levels told us that these led to meaningful change across the service.
  • The standardised relative risk of readmission for all elective procedures was slightly lower than expected when compared to the England average. This meant that patients were less likely to require unplanned readmission after non-emergency procedures.
  • In the National Diabetes Inpatient Audit (NaDIA) 2015, the hospital scored better than the England average for nine indicators out of sixteen indicators. Actions had been taken to improve the service in those measures where they were underperforming.

Are services caring?

  • The majority of patients were positive about the care they received and we observed courteous interactions between staff and patients.
  • Patients and relatives told us staff were respectful and helpful and gave them regular updates.
  • We observed some negative interactions in the ED at Queens Hospital. We also observed a patient calling out for help and was ignored until we escalated to the nurse in charge.

Are services responsive?

  • The percentage of patients being seen and treated within the ED recommended four hour timeframe at both hospital sites and the number of patients who left the department without being seen was worse than the national average.
  • In medicine at the King George Hospital patients were not always able to be located on the specialist ward appropriate for their condition. In some wards, bed moves were consistently occurring out of hours (between 10pm and 6am).
  • Environments on some wards in the King George Hospital were not ideal, with high levels of noise and heat observed and reported. There was a lack of bedside televisions or radios across the wards, which some patients reported made them feel isolated and bored.
  • The trust was consistently failing to meet NHS waiting time indicators relating to 62-day cancer treatment. This issue had been added to the corporate risk register and actions had been undertaken to improve performance. 
  • The trust was not meeting 18-week waiting time indicator for non-urgent referral to treatment (RTT) times.
  • The Patient Advice and Liaison Service (PALS) did not always respond to complaints in a timely manner.
  • The ED’s at both sites worked closely with local GP’s to stream patients effectively, including back to their own GP.
  • People living with dementia received tailored care and treatment. Care of the elderly wards at the King George Hospital had been designed to be dementia friendly and the hospital used the butterfly scheme to help identify those living with dementia who may require extra help.

Are services well led?

  • Senior Leadership was visible and involved in clinical activity. Staff were positive about changes and were starting to feel more optimistic.
  • Time and resource had been invested into improving clinical governance structures and risk management since the past inspection in March 2015.
  • Quality improvement and research projects took place that drove innovation and improved the patient experience.

We saw several areas of outstanding practice including:

  • The hospital provided tailored care to those patients living with dementia. The environment in which they were cared for was well considered and the staff were trained to deliver compassionate and thoughtful care to these individuals. Measures had been implemented to m ake their stay in hospital easier and reduce any emotional distress.
  • The trust had awarded the neonatal and community teams for their work in providing babies with oxygen home therapy, which improved the quality of life for families.
  • A dedicated paediatric learning disability nurse had introduced support resources for patients, including a children’s hospital passport and visual communication tools. This helped staff to build a relationship with patients who found it challenging to make themselves understood. This had been positively evaluated and received a high standard of feedback from parents and patients.
  • Child to adult transition services were comprehensive and conducted with the full involvement of the patient and their parents. This included individualised stages of empowering the person to gradually increase their independence, the opportunity to spend time with paediatric and adult nurses together and facilities for parents to spend the night in adult wards when the young person first transitioned.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure all patients attending the ED are seen by a clinician in a timely manner.
  • Take action to improve levels of resuscitation training.
  • Ensure there is oversight of all training done by locums, particularly around advanced life support training.
  • Take action to improve levels of resuscitation training.
  • Take action to improve the response to patients with suspected sepsis.
  • Take action to address the poor levels of hand hygiene compliance.
  • Ensure fire safety is maintained by ensuring fire doors are not forced to remain open.
  • Ensure staff have a full understanding of local fire safety procedures, including the use of fire doors and location of emergency equipment
  • Ensure hazardous waste, including sharps bins, is stored according to related national guidance and EU directives. This includes the consistent use of locked storage facilities.

In addition the trust should:

  • Endeavour to recruit full time medical staff in an effort to reduce reliance on agency staff.
  • Ensure there is sufficient number of nurses and doctors with adult and paediatric life support training in line with RCEM guidance on duty.
  • Improve paediatric nursing capacity.
  • Improve documentation of falls.
  • Document skin inspection at care rounds.
  • Document nutrition and hydration intake.
  • Review arrangements for the consistent sharing of complaints and ensure that learning is always conveyed to staff.
  • Make repairs to the departmental air cooling system.
  • Ensure policies are up to date and reflect current evidence based guidance and improve access to guidelines and protocols for agency staff.
  • Take action to improve the completion of early warning scores.
  • Improve appraisal rates for nursing and medical staff.
  • Regularise play specialist provision in the paediatric ED.
  • Consider how to improve ambulance turn around to meet the national standard of 15 minutes.
  • Ensure staff and public are kept informed about future plans for the ED.
  • Restructure the submission of safety thermometer data to match the current divisional structure.
  • Monitor both nursing and medical staffing levels. Follow actions detailed on corporate and divisional risk registers relating to this.
  • Monitor and improve mandatory training compliance rates for medical staff. Improve completion rates for basic life support for nursing and medical staff.
  • Review out-of-hours provision of services and consider how to more effectively provide a truly seven day service.
  • Continue to work to improve endoscopy availability and service, as detailed on the corporate risk register.
  • Make patient information leaflets readily available to those whose first language is not English.
  • Ensure leaflets detailing how to make a formal complaint are available across all wards and departments.
  • Ensure consent to care and treatment is always documented clearly.
  • Ensure each inpatient has an adequate and documented nutrition and hydration assessment.
  • Ensure there are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.
  • Ensure there are appropriate processes and monitoring arrangements in place to improve the 31 and 62 day cancer waiting time indicator in line with national standards.
  • Ensure the 18 week waiting time indicator is met in the outpatients department.
  • Ensure the 52 week waiting time indicator is consistently met in the outpatients department.
  • Ensure percentage of patients with an urgent cancer GP referral are seen by a specialist within two weeks consistently meets the England average.
  • Ensure the number of patients that ‘did not attend’ (DNA) appointments are consistent with the England average.
  • Ensure the number of hospital cancelled outpatient appointments reduce and are consistent with the England average.
  • There is improved access for beds to clinical areas in diagnostic imaging.
  • Address the risks associated with non-compliance in IR(ME)R and IRR99 regulations.
  • Ensure the number of hospital cancelled outpatient appointments reduce and are consistent with the England average.
  • Ensure diagnostic and imaging staff mandatory training meets the trust target of 85% compliance.
  • Develop a departmental strategy in diagnostic imaging looking at capacity and demand and capital equipment needs.
  • Improve staffing in radiology for sonographers.

Professor Sir Mike Richards

Chief Inspector of Hospitals

2 March 2015

During an inspection looking at part of the service

Barking, Havering and Redbridge University Hospitals NHS Trust is a large provider of acute services, serving a population of over 750,000 in outer North East London. The trust operates from two sites; Queen's Hospital and King George Hospital.

The trust has a total of 1,084 beds consisting of 972 general and acute, 80 maternity and 32 critical care. The trust receives around 73,00 inpatient admissions, 592,000 outpatient attendances and 245,000 emergency department attendances. all core services are provided from both sites with the exception of birthing services which are provided from the Queen's Hospital site only.

The trust covers a population of around 750,00 across three local authorities; Barking & Dagenham which has very high levels of deprivation (ranked 8th of 326 local authorities) and is also rated as worse for a higher number of public health indicators including obesity and smoking , Havering (ranked 177th) and Redbridge (ranked 116th).

We inspected the trust in October 2013, and found there were serious failures in the quality of care and concerns that the management could not make the necessary improvements without support. I recommended to the Trust Development Agency (TDA) that the trust be placed in special measures in December 2013.

Since the inspection a new executive team has been put into place including a new chair, new members of the board, a chief executive, medical director, deputy chief executive, chief operating officer and a director of planning and governance. The executive team has been supported by an improvement director from the TDA.

The trust developed an improvement plan ('unlocking our potential') that has been monitored and contributed to by all stakeholders on a monthly basis and published. The purpose of this re-inspection was to check on improvements, apply ratings and to make a recommendation on the status of special measures.

Overall, this trust requires improvement. Both Queens Hospital and King George Hospital are rated as requires improvement. Of the five key questions that CQC asks, we rated the trust as requires improvement for caring, safe, effective, and well-led and responsive was inadequate.

Our key findings were as follows:

  • Improvements had been made in a number of services since our last inspection.

Safe

  • Safety was not a sufficient priority. There was a backlog of serious incidents and the quality of investigations into serious incidents lacked detail to ensure failings were understood and lessons were learned.
  • There were insufficient systems, processes and practices to keep patients safe. Lessons were not learned and improvements were not made when things went wrong.
  • Recruitment had been on-going however there was not always enough medical and nursing staff to meet the needs of patients.
  • The management of medicines needed improving to ensure safe administration and a reduction in medication errors.
  • The majority of clinical areas were visibly clean and staff adhered to good infection control practices.
  • Most staff groups achieved completing 85% of mandatory training.

Effective

  • Patients needs were assessed and care and treatment was delivered in line with evidenced-based guidance.
  • Patient outcomes were varied.
  • Some staff were not competent in carrying out their roles.
  • Pain relief and nutrition and hydration needs were assessed and met.
  • Consent, Mental Capacity Act 2005 and Deprivation of Liberty Safeguards were well understood by the majority of staff and part of a patients plan of care.

Caring

  • Some national surveys have found that staff are not always compassionate. In response, staff had focussed on involving patients, keeping them informed and treating patients with dignity and respect.
  • During our inspection we saw and heard of compassionate and kind care and emotional support being provided.

Responsive

  • Urgent and emergency, children and young people and outpatients services were not responsive to meet patients needs.
  • The emergency department was not meeting the national four-hour waiting time target introduced by the Department of Health.
  • The hospital was persistently failing to meet the national waiting times target. Some patients were experiencing more than 18 weeks from referral to treatment time (RTT).
  • The access and flow of patients throughout the hospital had improved since our last inspection. The introduction of the Elderly Receiving Unit (ERU) met patients needs.

Well-led

  • The new executive team was making improvements. The board was visible and engaging with patients and staff.
  • The leadership and culture were open, transparent and focussed on improving services.
  • At an executive level there was a vision and strategy in development to deliver good care and ensure sustainability. At a service level staff were less clear and many told us they were "fire-fighting".
  • The governance structures did not ensure that responsibilities were clear and that quality, performance and risks were understood or managed.

We saw several areas of outstanding practice including:

  • The values of the trust - passion, responsibility, innovative, drive and empowerment (PRIDE) were well known and embedded in the culture of the people working at the trust.
  • The new executive team were visible and engaged.
  • There was lots of involvement from the local community and voluntary organisations. The foyer had lots of people giving information for patients and visitors about services in the local area. For example dementia care, stop smoking and healthy eating.
  • Radiotherapy was one of the top five units in the country.
  • The genitourinary medicine (GUM) clinic had an excellent service with appropriate protocols and processes and support for patients.
  • There had been a number of initiatives to provide a responsive service for general surgery patients. The surgical assessment unit provided a timely service in emergencies and the 'hot clinic' reduced delays for patients.
  • The hospital was a regional centre for upper gastro-intestinal conditions. Outcomes for patients receiving o esophago-gastric cancer services were good.
  • There were good outcomes for stroke patients and the stroke service demonstrated good team work.
  • Play specialists had developed a way to distract children awaiting MRI scans which involved joining other children and families on a ‘train journey’ from the outpatient’s clinic down through the hospital corridors, using storytelling and positive reinforcement on the way. This had proved a good distraction for children and reduced their anxiety. We walked with one child and found them to be very engaged in the trail.
  • Consultant paediatricians undertook short notice or ‘HOT clinics’, whereby GPs could make a consultant to consultant referral reach a joint decision on action including if needed early assessment. GP’s reported positively to their commissioners on the success of this system.
  • The consultant led critical care outreach team’s seven day service had improved the outcome for patients through appropriate identification of deterioration and appropriate escalation.
  • The critical care outreach team provided a ‘critical care follow up outpatient clinic’ for patients who required support after leaving hospital. This ensured patients were making progress in the months following their discharge.
  • Neuro-intensive therapy unit encouraged diaries for patients who were staying for longer periods of time in the unit. Patient’s families kept a record of daily activities such as visits, progress and treatments, items of news and the weather. A free newspaper was offered to patients in general critical care to help orientate them.
  • The development of the Elder’s Receiving Unit had improved frail, elderly patient care.
  • A dedicated team to support patients living with dementia . Wards could book a dementia trained health care assistant to support one or more patients in a bay on the ward. We were told this was, “A huge improvement” as they were dementia trained. Previously this role was done by a different bank nurse every day.
  • The nurse led oral chemotherapy service was the first in the country.
  • The hospital performed well in the National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme carried out in 2014.
  • The end of life care service was patient focussed and end of life care needs was well understood by the majority of staff from all staff groups.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Have clear governance with integrated systems and processes to support staff to provide care and treatment safely.
  • Ensure serious incidents are understood, investigated and lessons are learned promptly.
  • Review systems for sharing good practice across the divisions and trust wide.
  • Ensure compliance with all national guidelines and trust policies for medicines management.
  • Improve the service planning and capacity of outpatients by continuing to reduce the 18 week non-admitted backlog of patients as well as ensure no patients waiting for an appointment are coming to harm whilst they are delayed, reduce the did not attend, hospital cancellation and hospital changes rates and improve the 31 day cancer wait target.
  • Improve the IT systems so they are up to date and the IT strategy is implemented and supports clinical staff to carry out their duties.
  • Ensure all services for neonates, children and young people are responsive to their needs.
  • Ensure that radiology is fit for purpose and fulfils its reporting timescales, particularly for CT scans.
  • Continuously review staffing levels and act on them at all times of the day.
  • Include a dietician as part of the critical care multidisciplinary team in line with the core standards for intensive care guidance.
  • Comply with the Duty of Candour legislation.
  • Display the numbers of staff planned and actually on duty at ward entrances in line with department of help guidelines.
  • Ensure safe management and administration of medicines.
  • Ensure that all incidents including patient falls are accurately reported.
  • Ensure that patients who sustain a fall receive a medical review in a timely manner.
  • Ensure that medical outlying patients have an identified medical team to review their care and an agreed escalation plan in place.
  • Ensure that speech and language therapists are trained and competent to care for patients who have tracheostamies.
  • Ensure that entries made by medical staff in patient records comply with the expected professional standards.
  • Ensure that medical staff in the emergency department receive appropriate supervision.
  • Ensure adequate provision of resuscitation equipment in outpatients.
  • Ensure compliance with COSHH regulations
  • Ensure patient records are kept securely and that patient confidentiality is maintained.
  • Comply with infection control code of practice in respect of hand hygiene audits, training and monitored improvement.
  • Ensure locum and agency staff are competent and implement a formal induction process for all locum and agency staff in the relevant areas they care for patients.
  • Ensure processes are in place for locum and agency staff in respect of accessing and using IT systems required for their role.
  • Ensure patient risk assessments are acted upon.
  • Review the general medicine on-call rota to ensure it meets the needs of patients.
  • Meet the Emergency Care standards in the Elder’s Receiving Unit.
  • Audit and monitor the patient outcomes from the trust discharge strategies.
  • Comply with the National Dementia Strategy.

In addition the trust should:

  • Consider increasing the target rates for mandatory training.
  • Review the effectiveness of the rota co-ordination for junior doctors
  • Review the accessibility of the radiology services and consider a duty radiographer structure.
  • Review the service level agreement for accessing therapies to ensure it meets patients needs promptly.
  • Continue to improve patient record availability at outpatient clinics.
  • Assess the culture of staff within radiology and the anti-coagulation service to ensure they feel part of the organisation.
  • Review the environment in outpatients to improve the waiting and reception areas.
  • Review the environment and the staffing levels of the day-care surgery unit.
  • Review nurse staffing levels and skill mix on surgical wards, particularly out-of-hours.
  • Review the medical staff cover for the medical wards at night at King George Hospital.
  • Review the staffing levels on Ash Ward.
  • Ensure that nurses understand the importance of the recommendations stated by the speech and language therapy team.
  • Review it's response to major incidents including equipment, staff training and practical testing.
  • Review the availability and presence of consultant obstetricians and speciality registrar level doctors so that labour ward cover is in line with local and national recommendations.
  • Consider an increase in establishment in the dementia team and the pain team.
  • Review the audit programme in surgery so that internal audits are completed and implemented.
  • Consider ways to increase multidisciplinary team working within critical care.
  • Consider ways to make the overnight accommodation for visitor to patients in general intensive care less austere.
  • Consider ways to engage patients in providing feedback specifically related to critical care services.
  • Continue to increase the availability of medical records.
  • Monitor the impact on patients from the reduction in Coronary Care Unit beds.
  • Review the processes for medicines to take away on discharge.
  • Consider undertaking a needs analysis in respect of those whose first language is not English.
  • Improve engagement between junior doctors and management.

Significant progress has been made over the past year by the trust for which the leadership team should be commended. In particular we observed a marked improvement in the culture within the trust. However, considerable further improvement in quality and safety of care is still required across multiple services before these can be considered ‘good’. In addition further work is needed to ensure robust governance systems are in place across the trust. I am therefore recommending that the trust should remain in special measures. CQC will re-inspect key aspects of care within the next six months to make a further determination on this.

Professor Sir Mike Richards

Chief Inspector of Hospitals

14–17 October 2013

During a routine inspection

Barking, Havering and Redbridge University Hospitals NHS Trust (the trust) is a large provider of acute services, serving a population of over 750,000 in outer North East London.

The trust has two acute hospitals: Queen’s Hospital and King George Hospital. Accident and emergency (A&E) departments operate from both of these hospitals. King George Hospital was built in 1993 and is the main hospital for Barking and Dagenham and Redbridge. Queen’s Hospital opened in 2006 and brought together the services previously run at Oldchurch and Harold Wood Hospitals. It is the main hospital for Havering.

The trust covers three local authorities: Barking and Dagenham which has very high levels of deprivation, and Havering and Redbridge which are closer to the national average. Havering has a relatively elderly population by London standards.

The purpose of this report is to describe our judgment of the leadership of the trust and its ability to deliver safe, effective, caring, responsive and well led services at each of its locations. Our judgment will refer to key findings at each location, for a more detailed understanding of the hospital findings please refer to the relevant location report.

The trust was included in the first wave of the new CQC hospital inspection programme, as it had been shown to be at ‘high risk’ on several indicators in the new Intelligent Monitoring tool. Over recent years the trust has faced significant financial challenges and has been a persistent outlier on some key quality of care indicators, including:

  • Poor results on the CQC inpatient survey and on the cancer patient experience survey.
  • Achievement of the four-hour accident and emergency waiting time standard.
  • Poor results on the national staff survey.
  • High weekend mortality in some areas.
  • Non-compliance with regulations recorded on several CQC inspections since it was registered especially in the A&E departments.

The latest NHS staff survey shows encouraging improvement in key areas, for example, the number of staff having appraisals and staff feeling satisfied with the quality of work and patient care they are able to deliver.

The trust has demonstrated that it can bring about significant changes as in the maternity services which have undergone a huge transformation over the last two years. More importantly they have been able to maintain the improvements.

The trust has undergone significant change in recent years and previous cost improvement programmes have significantly reduced key corporate functions such as HR and governance departments. The trust also has a history of frequent changes at executive level which has impacted on its ability to rapidly deliver improvements to quality and safety.

The trust Board is now entering a period of improved stability and is starting to work together as a team to address longstanding significant problems. However many initiatives to improve quality and safety have only started very recently and it is too early to tell if they will deliver the required improvements quickly. Information about patient quality of care and patient safety is reported at trust Board meetings and they are aware of many of the issues highlighted in these reports. There have been attempts to address the problems, particularly in the A&E departments, but they have had little success.

The Chief Operating Officer with support from some senior medical staff is now trying to address these challenges, but progress has been slow mainly due to a lack of engagement and support from all senior clinical staff. The longstanding history of the problems and lack of progress indicates that the leadership is inadequate to address the scale of the challenges that the trust is facing and additional support is required.

The trust must ensure the following actions are taken to improve:

  • Ensure the Chief Operating Officer has clinical and management support to deliver improvements to patient safety and quality. The improvement plan should be agreed at Board level with progress monitored at each Board meeting.
  • Ownership for improvement must be embedded at every level of the trust and the visibility of the Executive Team at Queens Hospital and King George Hospital must be improved.
  • The trust needs to urgently focus on resolving problems in the A&E departments of King George and Queen’s Hospitals which are resulting in unsafe care. A clear and unambiguous protocol must be put in place for the transfer of patients between trust locations. All care must be documented.
  • The trust must also address its discharge planning and patient flow problems which will require improved working with local partners.
  • Infection control procedures must be implemented consistently in every ward and theatre across the trust.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.