During a routine inspection

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.

During a routine inspection

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

• We rated safe, responsive and well-led as requires improvement. We rated effective and caring as good. Following this inspection we rated two of the trust’s 10 services at KCH as good and one as requires improvement. A further service was not rated on this occasion. At the PRUH as a result of this inspection we rated two of the 10 services as good and three as requires improvement. In rating the trust, we took into account the current ratings of the other services not inspected this time.
• We rated well-led for the trust overall as requires improvement.

During an inspection looking at part of the service

King's College Hospital NHS Foundation Trust is a large provider of acute and specialist services that serves a population of over 1,000,000 in south east London and Kent. The trust operates from three acute sites; King's College Hospital Denmark Hill, Princess Royal University Hospital Bromley and Orpington Hospital.

The trust has over 1300 beds including 1050 acute, 125 maternity and 144 critical care beds. The trust receives over 250,000 emergency attendances, 115,000 inpatient spells and 960,000 outpatient attendances. All core services are provided from King's College Hospital Denmark Hill and Princess Royal University Hospital while outpatient and surgical services are provided from Orpington Hospital.

The trust provides services to a population from the significantly deprived boroughs of Lambeth and Southwark and also the more affluent borough of Bromley. Specialist services are also provided on a regional and national basis.

We carried out an announced inspection between 13 and 17 April 2015. We also undertook unannounced visits to the hospital on 25 and 28 April 2015. This was the first inspection of the Denmark Hill location under the new methodology, however we had previously inspected the Princess Royal University Hospital in December 2013 detailing specific concerns around the emergency department, patient flow and the overall engagement of staff in service improvement. Just prior to the 2013 inspection Princess Royal University Hospital and Orpington Hospital were acquired by King's College Hospital NHS Foundation Trust as a consequence of south east London service re-configuration.

Recently the trust has been placed under investigation by the foundation trust regulator Monitor as a result of a deterioration in both financial and access target performance.

Overall, this trust requires improvement. We found that King's College Hospital Denmark Hill and Princess Royal University Hospital require improvement and that Orpington Hospital is rated as good. Overall the trust requires improvement in the safe, effective, responsive and well led domains whilst caring was rated overall as good.

Our key findings were as follows:

Safe

• Incident reporting processes were well developed but feedback was reported as intermittent by staff in some areas..

• Infection control polices and procedures were in place and adhered to however the design of some patient areas compromised patient care and experience.

• Duty of candour was well developed and communicated.

• Safeguarding processes and resource largely provided for the protection of vulnerable patients and would be enhanced by increased training uptake, particularly from medical staff.

• Staffing levels across the trust were largely appropriate, however some areas had high vacancy rates and agency usage.

Effective

• Best practice protocols and policies were in place and accessible.

• National audit performance was largely positive.

• Staff appraisal levels were below target in some areas.

• Processes and documentation for DNA CPR require standardisation across the trust.

Caring

• Care was largely compassionate and afforded patients and carers privacy and dignity.
• The approach to improving dignity and ward based care was well developed and having impact.
• Patients and carers indicated that they were appropriately involved in planning care.

Responsive.

• Some services require attention in terms of future capacity planning.
• Services take good account of individual needs particularly for vulnerable patients, however information designed for the locally diverse population needs consideration.
• The trust has significant challenges in terms of access and flow through both emergency and planned services.
• The quality and timeliness of complaints inhibits the learning opportunities from such events.

Well-led

• Acquisition has led to significant improvements in governance and staffing at Princess Royal Hospital however, further investment in leadership and engagement is required to further the achievement of the trust vision.
• A positive and proud attitude with a focus on clinical excellence are features of the organisational culture of the trust.
• A strong governance structure is in place that could potentially benefit from a structure that supports greater non executive challenge.
• The trust delivers innovative care in a number of clinical areas.

We saw several areas of outstanding practice, including:

At King's College Hospital Denmark Hill

• Trauma nurse coordinators tracked pathways and the progress of trauma patients by visiting them daily on the wards. This role also included networking with other trusts and coordinating repatriation in advance.
• The ED had an established youth worker drop in scheme operated by a London-based organisation, which was effective in supporting vulnerable young people. Staff could refer young people to the service, although engagement was voluntary. The service also supported young people to access specialist services, such as housing support and access to social workers.
• The iMobile outreach service was innovative and there was evidence that it was producing positive outcomes both for patients and the critical care service as a whole.
• The pioneering work being done by neurosciences, liver and haematology specialist services.

• The surgical directorate had set up the first national training for a trauma skills course in the country.

• There were well-established pathways for pregnant women, which provided appropriate antenatal care, including access to specialist clinics for women with medical needs.

• The foetal medicine unit provided interventions, such as foetal blood transfusions, fetoscopic insertions of endotracheal balloons and laser separation procedures of placental circulations for complicated monochorionic twin pregnancies.

• The enhanced scanning programme included combined screening for chromosomal abnormalities at 12 weeks, with women being given the results on the same day.

• The gynaecology and urogynaecology services offered a one-stop service with diagnostics carried out by a specialist doctor. The hospital was a regional training unit for this service and the unit was recognised as a gold standard unit by The British Society of Urogynaecologists.

• For children with complex liver conditions and those who required surgery as neonates, staff developed and advocated the use of innovative and pioneering approaches to care.

At Princess Royal University Hospital

• Recent data from the Royal College of Physicians’ Sentinel Stroke National Audit Programme (SSNAP), had given the PRUH stroke service a Level A ranking. This is the highest possible rank and only eight per cent of stroke units in the country currently achieve it. This is a significant achievement as the hospital was previously rated as Level D and has risen to level A in just 18 months, making it one of the most improved stroke services in the country.

• Pets as Therapy (PAT) dogs is an initiative to help patients who may be feeling low after suffering a disability following a stroke, or who may have been in hospital for a long period of time. The stroke ward had introduced pet therapy and a dog and their owner visited the ward weekly. They visited patients who were unable to communicate and found they often made huge efforts to communicate with the dog.

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

Importantly, the trust must:

Trust Wide

• Work with key stakeholders to improve patient flow throughout the hospital to reduce waiting times in the ED, cancellation of operations and delayed discharges
• Improve the documentation of patient care including Do Not Attempt Cardio Pulmonary Resuscitation orders.

At King's College Hospital Denmark Hill

• Review its facilities within critical care so that it meets both patient needs, and complies with building regulations. This includes bed spacing and storage facilities, particularly for IV fluids and blood gas machines.
• Ensure that the 'Five steps to safer surgery' checklist was always fully completed for each surgical patient.

• Re-configure the Liver outpatient clinic in order to avoid overcrowding.
• Ensure patients referral to treatment times do not exceed national targets.
• Improve patient waiting times in all outpatients’ clinics.
• Review the capacity of the maternity unit so that women and their babies are receiving appropriate care at the right place at the right time.
• Implement a permanent solution to the periodic flooding following heavy rain of the renal dialysis unit and endoscopy suite areas.

• Ensure that the trust policy around syringe drivers affords optimum protection for patients against the risks of adverse incidents.

• Ensure the cover for the concealment trolley for deceased patients is in good repair and not an infection control risk.

At Princess Royal University Hospital

.

• Continue to work to improve the availability of medical records in the outpatients department and medical care wards.
• Work with key stakeholders to improve patient flow throughout the hospital to reduce waiting times in the ED, cancellation of operations and delayed discharges.
• Improve the system for booking and managing waiting times in outpatient clinics to reduce delays for patients and clinics running over time.
• Improve the environment in the surgical assessment unit.
• Review and improve record documentation to ensure it is fully completed and in line with national guidance including DNACPR orders.

At Orpington Hospital

• Ensure patients are seen in outpatient clinics, with their full set of medical notes.

In addition, the trust should:

At King's College Hospital Denmark Hill

• Fully complete controlled drug registers in the ED.
• Complete safeguarding flowcharts for children attending the ED.
• Improve the number of senior ED medical staff trained in safeguarding children training at level 3 to meet Intercollegiate Committee for Standards for Children and Young People in Emergency Care Settings recommendations.
• Identify and mitigate risks to patients attending the ED, such as the development of pressure sores, falls and poor nutrition.
• Improve the uptake of training on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards for staff working in the ED, medical care, surgery and services for children and young people.
• Review staff understanding of the Mental Capacity Act 2005 in critical care and end of life care, to ensure their practice and documentation reflects the legislation.
• Develop guidelines for admission to the children’s clinical decision unit (CDU).
• Review the area used for the children’s CDU to ensure the environment fulfils the criteria for a ward area.
• Review the practice of undertaking adult consultations in the children’s ED.
• Improve patient flow and waiting times in the ED, including their arrangements for making decisions to admit patients.
• Take action to improve the percentage of ED patients seen, treated and discharged within four hours.
• Consider ways of improving the documentation of patient safety checks.
• Improve attendance at mandatory training.
• Improve theatre utilisation and a reduction in cancellations.
• Improve the referral to treatment times.
• Improve patient flow through the surgical pathway.
• Consider ways of improving the discharge process by engaging with external agencies.
• Consider how staff can be made aware of the broader strategy for the surgical division.
• Review the systems for checking equipment to ensure that they are in date, in working order and stock is effectively rotated.
• Ensure it continues to review its critical care bed capacity so that it can meet its expected admissions.
• Review its patient record documentation to ensure it is fully completed and information between wards is seamless.
• Review its use of the Waterlow assessment to ensure those patients that need pressure-relieving support, receive it.
• Review the nursing, consultant and junior doctor levels on the neonatal intensive care unit.
• Review the space between cot spaces on the neonatal intensive care unit as they were sometimes restricted or limited.
• Provide clear and up-to-date information on outpatient clinic waiting times.
• Monitor the availability of case notes/medical records for outpatients and act to resolve issues in a timely fashion.
• Review medical cover for gynaecology and obstetrics.
• Stop overbooking outpatient clinics including the liver outpatients department clinic.
• Share outpatients and diagnostic imaging performance data with clinical staff.

• Make sure the preferred place of care/preferred place of death, or the wishes and preferences of patients and their families is documented.

• Ensure there is a unified DNA CPR policy and orders are consistently completed in accordance with trust policy.

At Princess Royal University Hospital

• Continue to recruit to substantive posts and ensure that there is always an appropriate skill mix of staff on duty
• Continue to embed the processes for monitoring and improving the quality and safety of care provided including incident reporting and learning from incidents
• Continue to improve the rate of staff appraisal and attendance at mandatory training
• Ensure all medicines are stored and secured in line with trust policy
• Improve the monitoring of hand hygiene in services for children and young people
• Ensure all equipment (including resuscitation trolleys) is cleaned, maintained, checked and secured in line with trust and national policies
• Continue to work to resolve the problems with IT system to ensure patient information is managed effectively and safely.
• Improve multidisciplinary working in medical care and services for children and young people.
• Improve staff awareness and understanding of their role and responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards
• Continue to work with commissioners to ensure there is adequate funding and resources for the End of Life service

At Orpington Hospital

• Undertake medication audits in the outpatients and diagnostic imaging department.
• Ensure that a radiation protection supervisor is onsite.
• Conduct audits of the radiology reporting times.
• Undertake daily safety checks of the imaging and diagnostics department

Professor Sir Mike Richards

Chief Inspector of Hospitals