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Provider: Homerton University Hospital NHS Foundation Trust Good

On 10 August 2018, we published a report on how well Homerton University Hospital NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Good  
  • Combined rating: Good  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Good

Updated 10 August 2018

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

  • Overall, we rated Homerton University Hospital as ‘good’.
  • We took into account the current ratings of the four core services that were not inspected at this time and aggregated the ratings with the four core services we did inspect at Homerton University Hospital.
  • We rated urgent and emergency services as ‘outstanding’ overall, with an ‘outstanding’ rating applied to the caring, responsive and well-led domains. We also rated medical care (including care of the older person) as ‘outstanding’ overall, with an ‘outstanding’ rating applied to responsive and well-led domains.
  • All other services at Homerton University Hospital we rated ‘good’. However, we rated the well-led domain in maternity services as ‘requires improvement’.
  • We carried out a well-led review of the trust and gave an overall rating of ‘good’ for this domain and considered this when aggregating the overall trust rating.
  • We inspected community health services in 2017. Both adult community health services and community health services for children, young people and families were rated ‘good’ across all domains and this was considered when aggregating the combined overall rating for the trust.
  • We also inspected the Mary Seacole Nursing Home in 2017 and rated this as ‘good’.

Inspection areas

Safe

Good

Updated 10 August 2018

  • Incidents were investigated and learning was used to improve the delivery of care across services. Staff were encouraged to be open and report incidents and raise concerns.
  • The trust had implemented the national early warning score (NEWS) to effectively assess and escalate deteriorating patients, and most staff we spoke with had good knowledge of what to do in the event of a patient deteriorating.
  • Staffing was well managed in medical care and the emergency department. Although many services were reliant on bank and agency doctors and nurses to staff wards, local and divisional leadership mitigated the risks associated with temporary staff well.
  • We observed good medicines management, including the management of controlled drugs, across services.
  • Staff we spoke with demonstrated good knowledge and understanding of the needs of people living with dementia or learning disabilities.
  • Theatre staff were compliant with completing safety checks before, during, and after surgery using the World Health Organization (WHO) surgical safety checklist.
  • Women had a choice of where to give birth and the proportion of home and birth centre births was rising and almost all women had one to one care during labour.
  • The emergency department assessment of patients from time of their arrival was better than the overall England average. It was 87% for paediatric patients and 92% for adult patients.
  • The environment across services was mostly clean and clutter free.

However:

  • We had concerns regarding the capacity and sustainability of the trust’s adult safeguarding team to ensure timely completion of safeguarding referrals and Deprivation of Liberty Safeguards (DoLS) assessments, monitor incidents, provide engagement with other agencies, and ensure consistent delivery of training for staff due to vacancies and workload.
  • In surgery and maternity services, mandatory training completion rates for medical staff was below the trust target of 90%. Nursing staff in the surgery service also did not meet trust targets for most mandatory training modules. However, senior leaders acknowledged this and were working to address it.
  • Although we observed good adherence with infection prevention and control across most services when delivering patient care, we saw inconsistent hand hygiene carried out by doctors and midwives in maternity services.
  • We found varying understanding and gaps in the compliance of the WHO surgical safety checklist and its use among staff in maternity services.
  • Although we observed good examples of record keeping, supported by an electronic patient records system that had been introduced across the trust, we also found examples of inconsistent compliance with record keeping in maternity and medical services.

Effective

Good

Updated 10 August 2018

  • There was evidence that patient care was delivered in accordance with good practice and national guidelines, such as National Institute for Health and Care Excellence (NICE).
  • The effectiveness of care and treatment was monitored through local and national audits across services.
  • Trust policies were reviewed regularly and new clinical guidelines were shared with staff appropriately.
  • We saw evidence that pain was well managed across services.
  • Staff mostly spoke positively about the training and development opportunities that the trust offered. We saw examples in urgent and emergency services of a well-developed and supported training and development programme for doctors and nurses of all grades.
  • There was good multi-disciplinary working amongst clinical staff across services.
  • We saw examples of good engagement with patients and the public to promote good health.
  • Medical wards performed above the England average in a number of national patient outcome audits. The trust was graded as ‘A’ for the Sentinel Stroke National Audit Programme (SSNAP).
  • The hospital was a regional centre for bariatric surgery. The service was actively involved in clinical research and in regional teaching of bariatric surgery doctors in training.

However:

  • Staff appraisals rates in medical and surgery services were lower than the trust target of 90%.
  • Although staff we spoke with in urgent and emergency services understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 (MCA), staff understanding of MCA and Deprivation of Liberty safeguards (DoLS) was variable across other services.
  • Recording of capacity assessments and decisions on deprivation of liberty were not found to be consistently or appropriately documented in patient records that were reviewed within medical services.
  • The maternity service did not meet expected standards in some patient outcomes, for example, the rate of caesarean section was 32% in the first three months of 2018 which was high.

Caring

Good

Updated 10 August 2018

  • We observed examples of kind and compassionate care delivered to patients across services.
  • Patients and relatives we spoke with mostly shared positive experiences where staff had treated them with dignity and respect.
  • A number of support groups and services were in place to provide emotional support for patients. Bariatric patients had access to specific psychological support.
  • We observed staff in urgent and emergency services specifically working hard to ensure that people’s privacy and dignity needs were always respected, including during physical or intimate care and examinations. Staff made great efforts to engage patients’ relatives and included them in planning of care.
  • Staff in urgent and emergency services understood and respected the personal, cultural, social and religious needs of patients. They actively engaged with elders of the community to ensure that particular sensitivities were recognised.

Responsive

Good

Updated 10 August 2018

  • Urgent and emergency services evidenced consistently good performance against national indicators. The percentage of patients admitted, transferred or discharged within four hours was consistently better than the England average between February 2017 and January 2018. The percentage of patients waiting between four and 12 hours from the decision to admit until being admitted was consistently better than the England average. No patients waited more than 12 hours from the decision to admit until being admitted between February 2017 and March 2018.
  • There was good patient flow through the hospital. Patients were appropriately streamed through urgent and emergency services and effective bed management ensured admissions and discharges were addressed in a timely way. The Emergency Surgery Ambulatory Clinic (ESAC) helped to avoid unnecessary admissions and to further take the pressure off the emergency department.
  • Discharge planners and coordinators provided a seven-day service and worked closely with the multi-disciplinary teams across services, which included the patient, specialist nurses and social workers.
  • Integration of acute and community services helped ensure that the trust was effective in delivering responsive and consistent care across inpatient wards and the community.
  • The trust delivered a number of highly specialised surgical services; for example, the Homerton Anal Neoplasia service (HANS) which was the only one of its kind in the UK and one of very few in the world.
  • Arrangements were in place across services to support patients with specific and individual needs.
  • Between 2015/16 to 2017/18, the percentage of cancelled operations was consistently lower than the England average.

However:

  • There were some delays in elective caesareans which appeared to result from poor planning and communication processes, as well as staff shortages.
  • Theatre lists did not always start on time, which meant they over ran. Although the divisional management team had taken appropriate actions to address this, more time was required to embed the changes.
  • There were few facilities for relatives in the surgical wards. Staff told us they used the staff room or office to communicate sensitive news to families.
  • Although the trust had suitable arrangements in place for translation and advocacy, some patients we spoke with gave a mixed response to being aware of these services.
  • The trust’s adult safeguarding team and learning disability acute liaison was not sufficiently resourced and there was concern as to the effectiveness and sustainability of the service.

Well-led

Good

Updated 10 August 2018

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

  • We found a strong and cohesive senior leadership within the emergency department that provided a high level of interaction and good communication across all staff groups. Each member of staff we spoke with within this service told us how the leadership team was visible, supportive, and encouraging. They said they felt their views and contributions were valued by managers.
  • The culture within urgent and emergency services was generally seen both within and outside the department to be progressive, with consideration given to patient care, comfort and safety at all times.
  • Multidisciplinary working across the trust was effective. The urgent and emergency service worked closely with specialties from other parts of the trust. This led to a collective response to the improvement of patient flow out of the emergency department along a variety of recognised patient pathways.
  • Staff across services commented that divisional and senior leadership were visible and spoke positively about working with the trust. For example, midwifery staff we spoke with emphasised that they were proud to work in a maternity service that was well-respected by women and families locally.
  • Since previous inspection, the midwifery team had worked successfully to improve staff awareness of guidelines, incidents and risks.
  • The trust had responded to address whistleblowing incidences in both theatres and pre-operative assessment areas. At the time of our inspection, the trust’s interventions and development work were ongoing
  • The trust had a number of leadership programs to support the development of managers, and staff felt encouraged by their managers to apply for positions. The trust offered a nine-month leadership development programme which included formal teaching and mentoring.
  • The trust had implemented an electronic patient records system that was working effectively across most services, although intrapartum records in maternity services did not automatically interface with the hospital’s electronic patient record, which led to documentation errors.

However:

  • We found variations in the application of governance processes across core services and the divisions they were aligned to. For example, urgent and emergency services had a robust governance structure in place, which was organised in such a way as to provide full oversight of each area of the department and anticipate potential issues. However, we found that governance processes within maternity services did not provide sufficient assurance that senior staff had an overview of all performance and safety issues within the service.
  • We found variations in how risks were managed across services. The previous inspection of maternity services found there were some risks that staff told us about which were not recorded on the service risk register. We found this was still the case. In addition, some risks were not clearly articulated in documentation, particularly around medical and midwifery staffing levels and links were not made between risks.
  • Staff we spoke with mostly reported a positive working culture at the trust. Staff spoke of good multidisciplinary working and emphasised that the culture was one that “put the patient first”. Staff were generally dedicated and passionate about the work they carried out. However, staff we spoke with across the trust told us they felt stretched in their roles and raised concern as to the longer-term sustainability of staff morale.
  • Results from the Workforce Race Equality Standards (WRES) survey showed that there was an under-representation of BAME staff in posts that were Band 8a and above, and there was no representation of BAME staff in Bands 8d and 9 at the time of inspection.
Checks on specific services

Community health services for adults

Good

Updated 26 May 2017

We found that community health services for adults at Homerton University Hospital NHS Foundation Trust were 'good' in terms of safety, effectiveness, caring, responsiveness and well-led. This was because:

  • There was a good overall safety performance across community adults services and effective processes for identifying and managing risks. There were very low levels of reported serious incidents and incidents resulting in harm. Staffing levels, infection prevention and control, medications and completion of mandatory training were overall well managed.
  • Practitioners across services demonstrated effective evidence based care and treatment in accordance with national guidelines and good practice. Services measured outcomes using objective and patient reported measures. Staff had good access to training and development. There was good multi-disciplinary working between staff and with external partners.
  • Patients reported positive feedback about the care and treatment they received. Staff treated patients in a kind and compassionate manner. Patients and their relatives were encouraged to be partners in their care planning and were enabled to participate in care activities.
  • Community adults services had a model of integrated community teams across health and social care to ensure patients received joined up working. Staff were responsive to the needs of different communities and vulnerable patients. Community adults services demonstrated learning from complaints.

  • There were appropriate plans in place to develop the community adults service. There were effective governance and reporting structures in place for the escalation of performance and risk information. Senior leaders had a clear understanding of their services, local risks and challenges and realistic plans to develop their services. Staff told us managers were accessible and supportive. Patients were involved in service development. There were some areas of innovation including the introduction of extended scope practitioners.

However:

  • Overall compliance with completion of mandatory safeguarding level 2 training (and Mental Capacity Act and Deprivation of Liberty Safeguards training which was incorporated in the same module) needed to improve to meet the trust's local target. The trust was aware of this and had put in place actions to improve training completion.

  • The trust’s new online appraisal reporting system did not provide sufficiently accurate data to present a complete record of completed staff appraisals. The trust was aware of this and was working to identify those staff who needed to have their appraisal.
  • There were separate electronic record systems used in the hospital and community teams. Staff told us this could sometimes lead to problems with effective transfer of information from acute to community practitioners.
  • Some of the trust's staff and partners identified a need for greater out of hours community nursing input, which was not provided by the trust.

Community health services for children, young people and families

Good

Updated 26 May 2017

Overall rating for this core service is good because:

  • The community health services for children, young people and families (CYP) service had systems for identifying, reporting, and managing safeguarding risks. The child safeguarding team provided good support to staff across CYP services through supervision, training and monitoring of incidents.

  • Professionals from different teams in the service worked well with each other and those from external organisations to make sure each child had the best possible care. Health centres housed a variety of services, which meant CYP was able to work closely with partners such as GPs. CYP staff provided competent care in line with best practice and national guidance.

  • The trust health centres and children centres we inspected were clean, tidy, and clutter free. Waiting rooms and clinic rooms were child friendly with toys, books and other resources appropriate for different ages. CYP services completed regular infection control audits across locations and most staff demonstrated good hygiene and infection control procedures.

  • Staff supported the patients and families they worked with, and provided patient-centred support in clinics and in homes. Staff planned and delivered services in line with local needs including for vulnerable patients and those who spoke limited English.

  • Staff told us they could find policies easily on the trust intranet. Staff who worked in the CYP service followed the trust’s lone working policy. Staff we spoke with had good awareness of lone working arrangements.

  • Patients we spoke with told us they were very happy with the care and treatment provided and had good access to translation services.

  • Staff told us they valued working for the trust and said the trust had involved staff in different ways such as through focus groups. Staff told us that service leaders were supportive, accessible and approachable.

However:

  • The CYP service completion rate for infection prevention and control level two was 61 % against the trust’s mandatory training target of 90%. Similarly, the service's completion rate for paediatric basic life support (PBLS) was below the trust target and averaged at 51%.

  • Staff did not always recognise the terminology of ‘duty of candour’ although they had an honest approach and were open with patients when things went wrong.

  • The trust-wide response rate for the NHS Friends and Family Test was 2% for September and October 2016, which is lower than the national response rate at 3.5%. Most patients told us that staff did not encourage them to give feedback on the care they received or provide any information on how to make a complaint if needed.