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Provider: King's College Hospital NHS Foundation Trust Requires improvement

On 12 June 2019, we published a report on how well King's College Hospital NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Inadequate  
  • 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 12 June 2019

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

  • We rated safe and responsive as requires improvement. Effective, caring and well-led as good at King’s college Hospital. Safety was rated as requires improvement in six core services, and two as good. One core service was rated requires improvement, and six as good for effectiveness. One was not rated. All eight core services were rated as good for caring. Three core services were rated as requires improvement for responsive, and five as good. The ratings for well-led were; two core services as requires improvement, and six as good.

  • We rated safe, effective, responsive and well-led as requires improvement at Princess Royal University Hospital and caring as good. Four core services were rated as requires improvement for safety, one as inadequate and three as good. Two core services were rated as requires improvement for effectiveness, one was not rated and five were rated as good. Seven core services had a good rating, with one a requires improvement for caring. There were three requires improvement, one inadequate, three goods and one outstanding for responsive. Well-led had five good ratings, one inadequate, and two requires improvement.

  • We rated five of the trust’s services at King’s College Hospital as good and three as requires improvement.

  • We rated one service as inadequate, three as requires improvement and four as good at Princess Royal University Hospital.

  • We rated well-led for the trust overall as requires improvement.

    In rating the trust, we considered the current ratings of the four services not inspected this time.

    We rated the trust as requires improvement because:

  • The provider had not ensured the required mandatory training was completed by its staff to the expected target. This was the same as our previous findings.

  • Staffing levels in some key areas did not always meet the needs of the services being delivered.

  • Environmental and equipment risks related to patient safety were not always fully considered and acted upon.

  • The trusts expected infection prevention and control standards and practices were not consistently applied across some areas.

  • Medicines optimisation was not always managed in the safest possible way.

  • The learning arising from investigations was not always communicated effectively, and opportunities to improve were not always taken in a timely manner.

  • Patient outcome information and performance targets were not always meeting the expected standards.

  • Information used by staff to inform their practices was not always up to date.

  • The responsiveness of services did not always meet patient’s needs with regards to some of the expected targets, including timely access, appointments and surgery.

  • Work was still required to ensure staff across all services understood the trust vision and its strategy, and for all specialties to develop their own strategies.

  • Further work was needed to ensure risk registers were fully understood, were reviewed and updated.

  • From what we heard in some of the core services there was a disconnect between what the executive did and how this was perceived by staff.

    However:

  • Patients in most areas inspected were treated by compassionate staff who showed kindness, empathy and respect.

  • Patients individual needs were assessed, including where patients lacked capacity, and care was generally delivered in accordance with these needs and their preferences. Patients families and loved ones were involved where appropriate.

  • Staff continued to have a good understanding of their responsibilities for safeguarding vulnerable people and could demonstrate their knowledge and awareness in this area.

  • Technical equipment and other resources were readily available to support the delivery of treatment and care. Maintenance and routine electrical safety checks were carried out at regular intervals.

  • Opportunities for staff development and progression had been improved, and the trust worked hard to retain staff.

  • The incident reporting process was well-established and was widely used by staff. There was a positive culture around reporting and the value of learning from the investigative process. Formal systems were regularly used to review serious incidents and unexpected deaths, with findings reported through the well-developed governance arrangements.

  • Information of importance was shared with patients, and other providers of services including, GP, and community services.

  • There was a good level of awareness of the complaints process. Where the duty of candour principles applied to unexpected incidents or complaints, this generally happened.

  • The local governance arrangements had been strengthened since our previous inspection

    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/RJZ/reports.

Inspection areas

Safe

Requires improvement

Updated 12 June 2019

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

  • Although mandatory safety training subjects were provided for staff, the required training was not always completed to the trust’s targets. This had not improved since our previous inspection.
  • Patient risk assessments were not always completed and updated as expected in surgery. This had not improved since our previous inspection findings.
  • Although there were safe practices for staff to follow for keeping the environment and equipment suitably clean, and minimising infection control risks, staff did not always follow these. Risks related to infection control were not fully considered and managed with consistency across all areas.
  • Patients attending the Outpatients and Emergency Departments (ED) at the Princess Royal University Hospital (PRUH) and King’s College Hospital (KCH) received care in areas which were not always sufficiently safe and where risks had not been fully considered.

  • The layout of the ED at the PRUH was not suitable for the number of admissions the service received. There was significant overcrowding, and, at times, patients were being cared for on trolleys along corridors. At times, two patients were nursed in cubicles designed for only one person.

  • The endoscopy unit at PRUH had not been improved since our previous inspection. There were insufficient procedure rooms to meet the demands for the service. Endoscopy decontamination was carried out in a room used for both clean and dirty equipment. Since the inspection the trust informed us there was a considerable backlog of patients waiting for urgent and routine endoscopies. We have reviewed the Trust's action plan and will continue to monitor its progress in reducing this backlog.

  • In the trauma and orthopaedics (fracture) clinic at KCH, there was no separate waiting area for adults and children.

  • There were inconsistencies in checking equipment was suitable for use and was within its expiry date in the Emergency Departments at both King’s College and Princess Royal University Hospitals, and in Outpatients at KCH.

  • Within the ED and King’s College Hospital and Princess Royal University Hospital staff did not always follow best practice when storing, supplying, preparing or administering medicines. Medicine audit results in surgery at PRUH showed the service performed below trust standards for several indicators.

  • Although there was a strong culture around incident reporting, and staff recognised the value of learning from such events. Staff working in some areas reported not receiving information following the investigation process, including actions to take and learning arising from the investigation.
  • The Emergency Department at the PRUH did not manage patient safety incidents well. Whilst staff recognised the types of incidents they should report, including near misses, lessons learned were not always effectively introduced across the department resulting in similar incidents occurring.
  • Patients arriving into the PRUH Emergency Department were not always protected from avoidable harm. There were significant handover delays for patients arriving by ambulance. The management of patients requiring resuscitation was poor due to flow challenges across the emergency care pathway.
  • Staffing levels and skill mix within the PRUH ED was not sufficient to meet the needs of patients as a result; patients did not have their care and treatment carried out in a timely manner.
  • Vacancy, turnover and sickness rates for nursing staff in KCH Outpatient Department were higher (worse) than the trust target, although it should be noted that this varied by clinical speciality as outpatients was managed by several divisions.
  • Although gaps in doctor’s rotas were usually filled by locum and agency staff, vacancy rates for medical staff were worse than the trust’s target, and junior doctors informed us they were overworked.
  • Patient treatment folders were not always stored securely due to a lack of storage space at Dartford Dialysis Unit.

However:

  • Other core service areas inspected were generally staffed to a level which maintained the safety of patients, and enabled safe treatment and care to be delivered
  • Patient records, including care plans, safety checks and medicines charts were mostly completed to the required standards.
  • Staff understood their responsibilities for safeguarding vulnerable people and could demonstrate their knowledge and awareness in this area.
  • The ward pharmacists conducted medicines reconciliation, discharge prescriptions and handled any medicines related concerns. (Medicines reconciliation is the process of identifying an accurate list of a person's current medicines and comparing it with the current list in use.) The trust had implemented a system which provided assurance that blood glucose testing kits were calibrated before use.
  • The management of prescription charts used within the Outpatient Department at PRUH had improved since our last inspection.
  • There were enough equipment resources to support the delivery of treatment and care, and items were subject to maintenance and routine electrical safety checks. Improvements had been made in the assessment of equipment and its availability for end of life care since the last inspection.
  • Training was provided on the duty of candour to staff. In most areas there was a good level of awareness of what the duty of candour related to and how it was applied in practice. The principles of duty of candour had mostly been applied in the serious incident review process and complaints, where applicable.
  • There were well defined guidance documents to inform staff of the action to take where safeguarding concerns were identified. Staff understood their responsibilities and could demonstrate their knowledge in this area.
  • Incidents of a serious nature were fully considered and reviewed through various committee meetings. Learning was communicated back through several channels, although there was a degree of reliance on staff having the time and commitment to read information.
  • The trust was working hard to ensure vacancies were recruited to, and to promote internal development opportunities as a means of improving retention.

Effective

Requires improvement

Updated 12 June 2019

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

  • Care and treatment was generally delivered in clinical areas in line with evidence based national and professional guidance, and trust protocols. We noted however, some policies were out of date.
  • Professional information was mostly used to inform decisions around patient diagnosis, treatment and care, and staff in most services worked well together to deliver effective care and treatment. However, staff who worked in the ED at the PRUH did not always work together as a team, and there was a lack of consistency in working practices, dependent on who was leading the team. There were challenges when referring patients to individual specialties, with patients often waiting a significant length of time to be seen.
  • The surgical outcome targets did not meet the national benchmark and the trust were not performing well in key areas.
  • Trauma and orthopaedics patients had a lower expected risk of readmission for elective surgery when compared to the England average.
  • There were a range of maternity outcome indicators that were not meeting the trust’s standards and actions in response to these were not always timely.
  • It was not clear from the recorded information that patient’s needs related to pain management in KCH Emergency Department were being met.
  • Although the trust had made significant improvements in the appraisal rates for staff since our previous inspection, the target was not yet being achieved in this area.

However:

  • Patient outcomes continued to be monitored and actions were taken to address areas which required improvement.
  • Staff had opportunities to update their existing skills and develop new ones through a range of training methods, which was what we previously found.
  • Patients nutrition and hydration needs were identified by staff and met.
  • Most staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • There was good documentation of do not resuscitate decisions, an improvement on our previous findings.

Caring

Good

Updated 12 June 2019

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

  • Patients told us they were treated well and with kindness and care, and staff provided information and support in a timely way.
  • We observed staff to be compassionate and caring towards patients and their relatives in most areas inspected.

  • Patients individual care needs were assessed and acted upon. There was access to staff with expertise where additional support was needed. Volunteers provided support and help in most service areas.

  • There was access to multi-faith chaplaincy and the bereavement team.

However:

  • Patients attending the ED at PRUH were not always being involved in discussions and their treatment was not always delivered with compassion and kindness. Patients were not always treated with dignity and respect.

Responsive

Requires improvement

Updated 12 June 2019

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

  • The trust did not always plan and provide services in a way that met the needs of local people. Waiting times in some specialties were lengthy, and the waiting times for referral to treatment were less than expected for some services. The trust failed to meet several key national targets across referral to treatment and cancer waits.
  • Outpatient appointment contact information was not always responsive for services at King’s College Hospital.
  • People could not always access surgical service when needed. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with good practice.
  • There were significant numbers of non-surgical patients on surgical wards and patients were sometimes recovered in theatres due to a lack of surgical beds.
  • Patients could not access care and treatment in a timely way at PRUH Emergency Department. Waiting times for treatment and arrangements to admit, treat and discharge patients were worse than the England average and national standard.
  • The Outpatient facilities at KCH were not always appropriate and patient centred, due to restrictions on space. The ophthalmology waiting area often became overcrowded, and about half of the self-check in screens were broken.
  • Patients we spoke with in KCH Outpatient services told us they did not always have a choice of appointment times, and they were not kept informed of waiting times when they arrived at clinics.
  • Privacy and dignity of patients was not always maintained in the Outpatient services at the Princess Royal University Hospital because of the environment.
  • There was a well understood process for handling complaints, and staff were involved with this where applicable. Improvements had been made in response times for closure of minor complaints, but there remained some delays with final response letters for some more complex matters.

However:

  • The trust had several services which had been designed and adapted to suit demand in the local population. This included an expansion in the dialysis programme and the introduction of a virtual fracture clinic.
  • End of life care pathways were designed and managed with full consideration of the wishes of patients and their families.
  • Services were planned, delivered and co-ordinated to take account of the needs of different people, including those with protected characteristics, and in vulnerable circumstances.
  • The Maternity service at KCH recognised the rights and choices of women receiving care and met these as far as they were able.
  • Peoples discharge summaries detailed the verbal and written information provided to patients about the medicines they were given. Pharmacy teams and ward staff provided appropriate medicines counselling.
  • Where learning was identified from the complaints review process, staff were made aware of this using a range of methods.

Well-led

Requires improvement

Updated 12 June 2019

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

  • There was a lack of effective leadership in the ED at Princess Royal University Hospital. This impacted on the departments capacity and capability to deliver high-quality, sustainable care, as well as staff morale. This had got worse since our last inspection.

  • Morale amongst administrative staff across most Outpatient services at King’s College Hospital was low. Staff in some clinical areas did not feel valued or respected.

  • Most staff in other core service areas across the trust’s sites reported having good level of leadership and support at a local level. There remained however, a concern about the visibility and connectivity of trust executives with some core service teams on both sites, particularly at the PRUH, which and had not improved since our previous inspection.

  • Some staff reported a disconnect between the executive team and clinical leaders within surgery services.

  • Service level vision and strategies were not always clearly stated, this included Maternity services at King’s College Hospital and Outpatient services. As a result, staff in these areas were not clear on priorities, plans or timescales.

  • The governance structure for Outpatient services at the PRUH and the south sites was not always clear and consistent. Lines of accountability and management were not clear, and there was a lack of a systematic or consistent approach to improving the quality of services.

  • Local risk registers were not consistently reviewed, as a result it was not clear if all risks were being identified and addressed.

However:

  • The committee structures generally supported a strong and well-defined approach to enable effective reporting on performance, review such information and to bring about positive changes.

  • There were more opportunities to hold local team meetings in areas where staffing levels had improved.

  • Most managers at all levels in the surgical division had the right skills and abilities to run a service providing high-quality sustainable care. Many staff felt motivated and were proud to work for the trust.

  • The ED at King’s College Hospital engaged with a variety of stakeholders to plan and manage appropriate services.
Assessment of the use of resources

Use of resources summary

Inadequate

Updated 12 June 2019

Combined rating

Combined rating summary

Requires improvement