Updated 22 February 2023
We carried out this unannounced inspection of medicine, including elderly care and children and young people at King’s College Hospital to check on the safety and quality of care in those areas. In addition to these two core services, we inspected the well-led key question for the trust overall. This part of the inspection was announced to assist in arranging for the right people to be available to speak with us.
We inspected services for children and young people in order to check that learning from an adverse event had been acted upon and was now embedded in daily practices.
Our inspection of medicine, including elderly care was carried out to check if recent learning from inspection of this service at the trusts other locations had been shared and embraced in practices.
One of the triggers for our well-led inspection was as a result of our findings following recent maternity core service inspections. We wanted to review how joined up the governance arrangements were at a service level with the broader trust systems and processes.
We did not inspect the following services at King’s College Hospital, which were previously rated requires improvement: Urgent and emergency services because we undertook a winter pressures inspection earlier in the year; surgery and outpatient, as we have been monitoring progress through our routine engagement. Maternity services have recently been inspected and the report has been published. We did not inspected gynaecology as we had no concerns or risks to respond to.
At our last inspection we rated the trust overall as requires improvement and we were checking to see if improvements we knew about would change the trust’s rating.
Our rating of services stayed the same. We rated them as requires improvement because:
We rated safe, effective, responsive and well-led as requires improvement and caring as good. We rated well-led at provider level as good, which is an improvement on the previous inspection.
Our comprehensive inspections of NHS trusts have shown a strong link between the quality of overall management of a trust and the quality of its services. For that reason, we look at the quality of leadership at every level. We also look at how well a trust manages the governance of its services – in other words, how well leaders continually improve the quality of services and safeguard high standards of care by creating an environment for excellence in clinical care to flourish.
At King’s College Hospital we rated 1 of the trust’s 10 services as good and 1 as requires improvement. In rating the trust overall, we considered the current ratings of the 8 services we did not inspect this time and those which were previously combined with another service.
Our rating of well-led at the trust improved. We rated well-led as Good because:
- The trust had improved the strength, strategic focus and accountability of its leadership team. It was now led by experienced and knowledgeable executive and non-executives. They had developed objectives and plans to meet these and made sure the people under them carried out their responsibilities effectively.
- The newly developed strategy was directly linked to the trust’s visions and values. The trust involved clinicians, patients and groups from the local community in developing the strategy. From this they had a clear plan to provide outstanding care for their patients, with financial and environmental stability.
- The trust had committed to be a clinically led organisation and had a model of clinical leadership through its care group structure. This was designed to improve outcomes and deliver high quality care for patients.
- Leaders worked with representatives of the wider system for health care provision in order to bring about improvements to patient experiences.
- Staff understood the service’s vision and values. Most staff felt respected, supported and valued and were able to focus on the needs of their patients. Staff were clear about their roles and accountabilities. The service planned and managed services to meet demands, considering the challenges affecting health care provision, including inequalities.
- Leaders ran services well using reliable information and now had improved and effective governance procedures to oversee performance and quality. They engaged with staff, patients and other stakeholders to understand the experience they had to bring about positive changes.
- There had been significant improvements in risk management and in the corporate risk register and Board Assurance Framework. These were now dynamic documents, used appropriately by the Board and sub committees to review risks to delivery of the strategic and operational objectives.
- There were improved systems and processes to identify, mitigate and monitor risks, which were understood and implemented. The value of learning from adverse events and complaints was understood by staff and had improved.
- Leaders recognised the training needs of managers at all levels, including themselves, and worked to provide development opportunities for the future of the organisation. There were arrangements to support staff with mandatory safety and professional training.
However:
- Safe staffing levels were sometimes difficult to achieve, despite best intentions. Junior doctors did not always have compliant rotas and on occasion inaccurate information about trainee doctors was supplied.
- Like the previous inspection, some staff reported not being listened to and were frustrated that concerns, including cultural issues raised were not responded to as they expected.
- Board members recognised they had work to do to improve diversity and equality across the trust and at board level. The Workforce Disability Equality Standards were not being met and a few Workforce Race Equality Standards needed further work to be achieved.
- There was no clinical lead for sepsis.
- Outcome measures to improve the action areas related to the staff survey were not stated for all care groups.
- The incident process and complaints handling did not always get completed as quickly as expected. Learning from incidents was not always shared across different care groups.
How we carried out the inspection
This inspection was overseen by Nicola Wise, head of hospital inspection and was undertaken by inspectors, an inspection manager and specialist advisers for the core services. Additionally, we had specialist advisers for the well-led inspection.
For our children and young people inspection, we spoke with 25 parents and 6 children, as well as over 30 members of staff, including: nurses; student nurses; matrons; play specialists; clinical nurse specialists; doctors; consultants and support staff. We observed care and treatment being provided and reviewed 26 patient records. After the site visit, we interviewed the clinical director; nursing leads; the acting general manager and the deputy clinical director and patient safety & governance lead.
During our medicine core service inspection, we observed one nursing shift handover, observed three multidisciplinary board rounds and sampled four patient records. We spoke with 31 members of staff, including: nurse staff; physiotherapists; discharge coordinators; consultants; registrars; ward managers and senior leaders in the division. We spoke with 14 patients and 5 relatives.
For the well-led inspection, we spoke with non-executive directors and 32 members of the executive team, as well as union representatives from staff side. We spoke with several staff who worked in clinical areas who contacted us to raise matters of concern. Following up on these matters, we visited one department in December 2022 and spoke to several staff. We reviewed a range of formal documentation provided during and after the site visit and considered information shared with us by staff before and during the inspection period. We had discussion with external stakeholders and sought information from Healthwatch.
You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.
What people who use the service say
People said staff mostly treated them well and with kindness and supported them to make informed decisions about their care. Some patients told us staff were sometimes not as caring towards them and did not attend as quickly as they would normally when staffing levels were low. Most patients told us staff made sure they and those close to them understood their care and treatment. Patients and relatives told us staff gave up to date information about their medicines and treatments and explained things in a way they could understand.