King's College Hospital Denmark Hill Site - Care Quality ...

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Ratings

Overall rating for this hospital Requires improvement –––

Urgent and emergency services Good –––

Medical care Good –––

Surgery Requires improvement –––

Critical care Requires improvement –––

Maternity and gynaecology Requires improvement –––

Services for children and young people Good –––

End of life care Requires improvement –––

Outpatients and diagnostic imaging Good –––

King's College Hospital NHS Foundation Trust

King'King'ss ColleColleggee HospitHospitalalDenmarkDenmark HillHill SitSiteeQuality Report

Denmark HillLondonSE5 9RSTel: 020 3299 9000Website: https://www.kch.nhs.uk

Date of inspection visit: 13-17 April 2015Date of publication: 30/09/2015

1 King's College Hospital Denmark Hill Site Quality Report 30/09/2015

Letter from the Chief Inspector of Hospitals

King's College Hospital Denmark Hill Site is part of King's College Hospital NHS Foundation Trust. The trust provideslocal services primarily for people living in the London boroughs of Lambeth, Southwark, Bromley and Lewisham. King'sCollege Hospital Denmark Hill Site provides acute services to an inner city population of 700,000 in the Londonboroughs of Southwark and Lambeth, but also serves as a tertiary referral centre in certain specialties to millions ofpeople in southern England.

King's College Hospital NHS Foundation Trust employs around 11,723 whole time equivalent (WTE) members of staffwith approximately 8,785 staff working at King's College Hospital Denmark Hill Site.

We carried out an announced inspection of King's College Hospital Denmark Hill Site between 13 and 17 April 2015. Wealso undertook unannounced visits to the hospital on 25 and 28 April 2015.

Overall, this hospital requires improvement. We found that urgent and emergency care, medical care, services forchildren and young people and outpatients and diagnostic services were good. However surgery, critical care, maternityand gynaecology services and end of life care required improvement.

The effectiveness of care, care of patients and the leadership at this hospital were good overall. However, the hospitalrequired improvement in order to provide a safe and responsive service towards patients and their carers.

Our key findings were as follows:

Safe

• There was an open and transparent approach to the investigation of incidents. Staff were encouraged to reportincidents when they occurred.

• There were largely adequate medical and nursing staff on duty to provide safe care to patients apart from medicalcare, maternity and neonatal intensive care services.

• There were effective arrangements in place to minimise risks of infection to patients and staff.• Medicines were stored, recorded and administered safely to protect patients.• The support provided by the iMobile team for deteriorating patients was excellent.• The critical care service did not meet basic safety standards in some areas, particularly on the high dependency

units.

Effective

• Staff followed accepted national and local guidelines for clinical practice.• There was a multidisciplinary, collaborative approach to care and treatment that involved a range of health and

social care professionals.• Some newly qualified midwifery staff had not received appropriate training to enable them to carry out their roles

effectively.• Patients were given timely pain relief and pain scoring tools were consistently used.• The nutritional needs of patients had been assessed and patients were supported to eat and drink according to their

needs.• Understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards was variable and some groups

of staff needed to improve their knowledge in these areas.

Caring

• Patients were cared for by staff who were kind, caring and compassionate in their approach. Patients weresupported, treated with dignity and respect and were involved as partners in their care.

• Patients felt that they were listened to by health professionals, and were involved in their treatment and care.

Summary of findings


• Staff respected patients’ choices and preferences and were supportive of their cultures, faith and background.

Responsive

• Services were planned to meet the needs of the local population.• The emergency department (ED) was often overcrowded. Patient flow required improvement and waiting times were

above the national average, due to capacity constraints and the trust’s arrangements for making decisions to admitpatients.

• Referral-to-treatment times were not being met in a number of surgical and outpatient specialties. Surgicalprocedures were cancelled and not always rescheduled and undertaken within 28 days.

• There was a lack of critical care beds, which affected patients’ length of stay and delayed discharges.• Outpatient services were not organised in a manner that responded promptly to ensure that patients’ needs were

met.

Well-led

• The leadership, governance and culture of the hospital promoted the delivery of high quality, person-centred care.• Robust governance arrangements were in place to monitor, evaluate and report back to staff and upwards to the

trust board.• Most staff were proud of working for the department and staff worked well together as a team.

We saw several areas of outstanding practice, including:

• Trauma nurse coordinators tracked pathways and the progress of trauma patients by visiting them daily on thewards. 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 waseffective in supporting vulnerable young people. Staff could refer young people to the service, although engagementwas voluntary. The service also supported young people to access specialist services, such as housing support andaccess to social workers.

• The iMobile outreach service was innovative and there was evidence that it was producing positive outcomes bothfor 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 monochorionictwin pregnancies.

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

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

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

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

Importantly, the trust must:

• 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.

Summary of findings


• 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 current trust policy around syringe drivers affords optimum protection for patients against the risk of

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

In addition, the trust should:

• 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 Settingsrecommendations.

• Identify and mitigate risks to patients attending the ED, such as the development of pressure sores, falls and poornutrition.

• Improve the uptake of training on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards for staffworking 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 practiceand 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.

Summary of findings


• 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.

Professor Sir Mike RichardsChief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Urgent andemergencyservices

Good ––– Staff demonstrated an open and transparentculture about incident reporting and patient safety.Staff understood their roles and responsibilities andwere empowered to raise concerns and to reportincidents and near misses actively to promotelearning and improvement.There were adequate medical and nursing staff onduty to provide safe care to patients. Medicineswere stored, recorded administered safely toprotect patients from the risk of medicine misuse.Patients were safeguarded from abuse. Staff wereaware of their responsibilities to protect vulnerableadults and children, although some improvementswere required in documentation relating tosafeguarding and staff training.Staff followed accepted national and localguidelines for clinical practice. The department haddeveloped a number of pathways to ensure thatpatients received treatment focused on theirmedical needs. The trust participated in nationalCollege of Emergency Medicine audits so that theycould benchmark their practice and performanceagainst best practice and other emergencydepartments.There was a multidisciplinary, collaborativeapproach to care and treatment that involved arange of health and social care professionals.Patients were given timely pain relief and painscoring tools were consistently used.Patients in the ED were supported, treated withdignity and respect and were involved as partnersin their care. Patients felt that they were listened toby health professionals, and were involved in theirtreatment and care. Staff treated patients withrespect. Patients and their relatives and carers toldus that they felt well-informed and involved in thedecisions and plans of care. Staff respectedpatients’ choices and preferences and weresupportive of their cultures, faith and background.The emergency department was oftenovercrowded. Patient flow required improvementand waiting times were above the national averagedue to capacity constraints and the trust’s

Summaryoffindings

Summary of findings


arrangements for making decisions to admitpatients (DTA). This meant patients were nottransferred to areas treating their speciality, butwere accommodated in the ED for longer thannecessary. There were no trust guidelines foradmission to the children’s CDU, which did not fulfilthe criteria for a ward area. It was not clear whychildren were admitted to the CDU rather than theshort stay paediatric unit. Admission to the CDUavoided breaches relating to length of stay in thedepartment.The leadership, governance and culture of the EDpromoted the delivery of high qualityperson-centred care. Clear governance structureswere in place and were designed to enhance patientoutcomes. Staff were proud of working for thedepartment and staff worked well together as ateam. There was an effective and comprehensiveprocess in place to manage risks.

Medical care Good ––– Patients received care based on the best availableevidence and national guidance. The hospitalscored highly in most of the patient outcomemeasures which indicated good adherence toevidence-based measures, which improvedoutcomes for patients. Patients gave their consentfor care and treatment and were involved indecision making. There was an effectivemultidisciplinary approach to care and good teamworking.Patients were cared for by staff, who were kind,caring and compassionate in their approach.Patients praised the staff, for their attitude andapproach, using adjectives, such as “wonderful,”and “absolutely fabulous”. Patients were involved indecisions about their care and treatment. Theservice was planned to meet the needs of thepeople it served and care was responsive topeople’s individual needs and wishes. Systems werein place to manage and learn from complaints.There was strong and passionate leadership and aculture of openness, with an enthusiasm to furtherdevelop and improve services for the future.Regarding safety, there were many aspects of goodpractice, including the reporting and managementof incidents and infection prevention and control.The iMobile critical care outreach service provided

Summaryoffindings

Summary of findings


excellent support to wards, but, in some areas, theidentification and escalation of deterioratingpatients was inconsistent. In addition, nursestaffing in some wards and the environment withinthe renal dialysis unit needed improvement.There was no formal approach to identifying thepossibility of sepsis or implementation of Sepsis Sixin the medical assessment centre or acute medicalunit.

Surgery Requires improvement ––– Referral-to-treatment times were not being met in anumber of surgical specialties. Surgical procedureswere cancelled and not always rescheduled andundertaken within 28 days. Theatre utilisation wasnot always maximised and there were cancelledprocedures and delays in arranging surgery withinexpected timeframes. Patient flow through thesurgical services was limited by availability of bedslinked, at times, to delayed discharges.Staff had not been able to complete all the requiredmandatory training, which supported the deliveryof safe patient treatment and care. There was a lackof understanding regarding Mental Capacity Act2005 and Deprivation of Liberty Safeguards. Therecording of required safety checks for surgicalpatients was not always completed to a consistentstandard.There were good arrangements in place forreporting adverse events and for learning fromthese. Staffing arrangements in surgical areas weremanaged to ensure sufficient numbers of skilledand knowledgeable staff were on duty during dayand night hours.Consent was sought from patients prior totreatment and care delivery. Consultants led onpatient care and there was access to specialist stafffor advice and guidance. Procedures were in placeto continuously monitor patient safety and surgicalpractices and patient care reflected professionalguidance.Surgical outcomes were generally good and resultswere communicated through the governancearrangements to the trust board. Patientexperiences were positive with regard to thetreatment and care by doctors, nurses and otherstaff.

Summaryoffindings

Summary of findings


Surgical staff spoke positively about theirdepartmental leadership and felt respected andvalued. Staff were generally aware of the trust’svalues, but had not been made aware of thestrategic plans. Staff reported the surgicaldirectorate as being a good place to develop theirskills and expertise.The governance arrangements supported effectivecommunication between staff and the trust board.Risks were continuously reviewed and discussed.The trust board was informed and updated withregard to service delivery and performance. Theviews of the patients and staff were sought inrespect to improving and developing services.

Critical care Requires improvement ––– Although the critical care service at the hospital hadpositive patient feedback, produced better thanaverage outcomes for patients, were involved ininnovative practice and treated highly complexpatients, due to its transplant and trauma services,there were fundamental areas of the service thatrequired improvement.Although there was work in place to build a new setof critical care units, current facilities were notadequate, with a lack of bed and storage space.There was a lack of bed capacity and a lack ofinfection control facilities. The HDU did not alwaysmeet patient to nurse ratio standards.Medicines management was not appropriate in anumber of areas, particularly storage. There was ahigh, but improving rate of pressure ulcers. Patientrecords were haphazard, although there were alsoplans to improve this via a new electronic system.Mental Capacity Act 2005 awareness and recordingwas not always in place. There wasmultidisciplinary working, but it was not takingplace across all the staff groups. Governancearrangements were fragmented.There was an innovative iMobile service (whoprovided the outreach service), patient outcomeswere better than peer services, incident reportingand learning was in place, patient harms (otherthan pressure ulcers), were well managed, publicengagement was proactive, and staff developmentwas positive.

Summaryoffindings

Summary of findings


Maternityandgynaecology

Requires improvement ––– Maternity inpatient care and treatment was notalways received in the right place and/or at theright time at times of peak demand. These issueswere long standing, and had not been resolved atthe time of our inspection, in spite of action to dealwith the flow of women through inpatient areas.Midwifery, support and medical staff worked hardto keep women safe, but sickness levels amongmidwives had risen. Consultant leave was notcovered, and this caused additional pressures onmedical staff.It was recognised that medical cover at night, whichwas provided across gynaecology and maternityinpatient services, was insufficient to guaranteeprompt review and treatment of patients.There were a number of innovative andground-breaking services in maternity andgynaecology. Care and treatment wasevidenced-based and the audit programmemonitored adherence to guidelines and goodpractice standards. Actions were identifiedfollowing audits and these were re-audited.There were robust care pathways for pregnantwomen to access appropriate services.Gynaecology services were responsive to women’sneeds.The safety of maternity and gynaecology serviceswas enhanced because reporting of, and learningfrom, incidents was promoted. There wassystematic, multidisciplinary review of incidents.Risks were recorded and plans put in place toaddress, or mitigate these risks. The risk registerwas used to respond reactively to issues that hadbeen recorded, and not to anticipate risks thatmight arise.Senior management in women’s services hadsucceeded in establishing integrated clinicalgovernance structures, including risk management,across the newly merged trust, which now includedPrincess Royal University Hospital.There were clear reporting routes to the trust-widecommittees and the board. There had been changesto the delivery of gynaecology services at theDenmark Hill site as a result of the merger, andsenior management in maternity services had spenttime supporting and developing maternity services

Summaryoffindings

Summary of findings


at Princess Royal University Hospital. Following thestructural reorganisation, the aim of the women’sservice was to achieve stability and the delivery ofhigh quality care.

Services forchildren andyoungpeople

Good ––– Nursing staff levels were seen to be in line withnational standards in the majority of clinical areas,except for the neonatal intensive care unit wherenursing levels were such that one-to-one care couldnot always be provided in line with nationalstandards.Continued increased capacity within the neonatalintensive care unit meant that the number ofconsultants and junior doctors employed was notsufficient to meet the needs of the unit. The existingmodel of medical cover was not sustainable in thelong term, as there was a reliance on the good willof a small number of doctors to work additionalhours.The environment in which children and neonateswere cared for was, in the main, appropriate.However, the increased capacity of the neonatalintensive care unit meant that space between cotspaces was sometimes cramped, which meant thataccess to cots was sometimes restricted or limited.The uptake of mandatory training in someprofessions was far below the trust standard. Staffdemonstrated an open and transparent cultureabout incident reporting. A culture of optimisingpatient safety was apparent amongst nursing andmedical staff alike. Staff understood their roles andresponsibilities in reporting incidents and describedhow they learnt from incidents.Patients were safeguarded from the risk of abuse.Staff were well versed in the trust’s localsafeguarding policies and could describe nationalbest practice guidance. Staff adopted a truly holisticapproach to assessing, planning and deliveringcare. Staff developed and advocated the use ofinnovative and pioneering approaches to care,especially for those children with complex liverconditions and those who required surgery asneonates. Additionally, the service hosted nationalspecialist multidisciplinary bariatric services forchildren with obesity issues.Clinical teams were committed to workingcollaboratively to enhance the provision of care to

Summaryoffindings

Summary of findings


children. The service led on a range of nationalmedical and surgical initiatives and worked inconjunction with a range of third party peers todrive forward advancements in paediatric surgeryand medicine. Paediatric mortality rates were seento be in line, or better than peer averages across arange of specialties. The service participated in arange of local and national audits, including clinicalaudits and other monitoring activities, such asreviews of services, benchmarking, peer review andservice accreditation. Accurate and up-to-dateinformation about effectiveness was sharedinternally and externally and was understood bystaff. Information from local and national auditprogrammes was used to improve care andtreatment and people’s outcomes, but some workwas required regarding the management of patientswith asthma and diabetes. When people were dueto move between services their needs wereassessed early, with the involvement of allnecessary staff, teams and services. People’sdischarges or transition plans took account of theirindividual needs, circumstances, ongoing carearrangements and expected outcomes.Staff acknowledged that the demands on theservice were increasing year-on-year and thatcapacity had proven to be difficult to manageduring peak times. This was especially pertinent tothe neonatal intensive care unit (NICU), whoseactivity had been seen to be increasing annually.The organisation recognised the need to extendchildren's services over the coming years to ensurethat it could continue to meet the needs of thepopulation it served. Plans had commenced tobuild a new children's hospital on the Denmark Hillsite and local initiatives had commenced, includingthe opening of a paediatric short stay unit to helpalleviate capacity problems in the short term.Staff were aware of the trust vision and values. Staffhad been provided with information on trustdevelopments that had been cascaded down fromtheir line managers. The service had a child healthspecific strategy, which was aligned to thetrust-wide strategy. The strategy was driven byquality and safety and took into account therequirement for the service to be fiscallyresponsible. There were governance arrangements

Summaryoffindings

Summary of findings


in place, for which a range of healthcareprofessionals assumed ownership. Further workwas being undertaken to strengthen thegovernance relating to children who received careor treatment outside the auspices of child healthservices. There was evidence that risks weremanaged and escalated accordingly.Nursing staff reported good management supportfrom their line managers. Changes to themanagement team within the NICU was said tohave a had a positive impact on the service.Innovation and long-term sustainability were seenas key priorities for the leaders of the service.Participation in national and international researchwas a driving motivation for clinical staff in orderthat the wellbeing and clinical outcomes of childrencould be enhanced.

End of lifecare

Requires improvement ––– Current trust policy around syringe drivers wasinconsistent across the sites and did not protectpatients from adverse incidents. The cover for theconcealment trolley was in poor repair and was aninfection control risk. We saw little evidence of thedocumentation of preferred place of care/preferredplace of death or the wishes and preferences ofpatients and their families. Although there was aunified do not attempt cardio-pulmonaryresuscitation (DNA CPR) policy, orders were notconsistently completed in accordance with thepolicy. There were also no standardised processesfor completing mental capacity assessments.Staff at King's College Hospital (the Denmark Hillsite) provided compassionate end of life care topatients. The specialist palliative care team (SPCT)provided face-to-face support, seven days a week,with a palliative care consultant providingout-of-hours cover. There was strong clinicalleadership of the SPCT and chaplaincy teamresulting in well-developed, strong and motivatedteams.Bereavement support was available from the socialworkers, chaplaincy and bereavement office staff,who were able to provide support for carers andtheir families following the death of their relative.The teams worked well together to ensure that endof life policies were based on individual need and

Summaryoffindings

Summary of findings


that all people were fully involved in every part ofthe end of life pathway. However, we did not seeany evidence of a long-term vision around end oflife care across the trust.Relatives of patients receiving end of life care wereprovided with open visiting hours and were alsooffered ‘keepsakes’ from the deceased patient.There was excellent spiritual/religious awarenessby staff across the hospital and facilities were inplace to support the different cultures and religionsof the local population.End of life care was embedded in all the clinicalareas and staff we spoke with were passionateabout end of life care and the need to ensure thatthe wishes and preferences of their patients andfamilies were met as they entered the last stage oftheir life.There was a multidisciplinary team approach tofacilitate the rapid discharge of patients to theirpreferred place of care or preferred place of death.Patients were cared for with dignity and respectand received compassionate care. Medicines wereprovided in line with guidelines for end of life care.

Outpatientsanddiagnosticimaging

Good ––– Patients received a caring service, as staff treatedthem with compassion, kindness and respect.Positive feedback had been received by the trustfrom patients using the outpatients and diagnosticand imaging departments. The service wasdelivered by trained and competent staff who hadbeen provided with an induction as well asmandatory and additional training specific for theirroles.The leadership, governance and culture with theoutpatient and diagnostic imaging servicespromoted the delivery of person-centred care. Staffwere supported by their local and divisionalmanagers. Risks were identified and addressed atlocal level or escalated to divisional or board-level ifnecessary. The trust promoted a good workingculture. However, some clinical staff we spoke withdid not feel supported by their line managers.Many patients complained about the waiting timesin the outpatient clinics. They said they had littleinformation about the waiting times and staff werenot always open with them about it. There was nosystematic template of clinic schedules for the

Summaryoffindings

Summary of findings


hospital. Different clinics used different templatesand some templates allowed for the over bookingof clinics and multiple bookings of appointmentsunder one time slot.Outpatient services were not organised in a mannerthat responded promptly to ensure patients’ needswere met. Some patients experienced long delays inwaiting times to their first outpatient appointment.The booking team were taking action to addresswaiting times and monitored patients who did notattend for appointments.The liver clinic environment presented challengesfor staff and patients, particularly in relation to thespace required for patients to sit comfortably whilewaiting for their appointments. Seating areas werecramped and, throughout our inspection, we sawpatients standing in areas of the clinic, who wereunable to find a seat. Access for patients andvisitors with mobility issues was challenging, due totight spaces in corridors and seating areas in someareas of the clinic.

Summaryoffindings

Summary of findings


King'King'ss ColleColleggee HospitHospitalalDenmarkDenmark HillHill SitSitee

Detailed findings

Services we looked atUrgent and emergency services; Medical care (including older people’s care); Surgery; Critical care;Maternity and gynaecology; Services for children and young people; End of life care; Outpatients anddiagnostic imaging


Contents

PageDetailed findings from this inspectionBackground to King's College Hospital Denmark Hill Site 17

Our inspection team 17

How we carried out this inspection 17

Facts and data about King's College Hospital Denmark Hill Site 18

Our ratings for this hospital 20

Findings by main service 22

Action we have told the provider to take 184

Background to King's College Hospital Denmark Hill Site

King's College Hospital Denmark Hill Site is one of threeregistered acute hospital locations of King's CollegeHospital NHS Foundation Trust, which we visited duringthis inspection. The other registered hospital locationsthat we visited were Princess Royal University Hospitaland Orpington Hospital.

King's College Hospital Denmark Hill Site has 1001 beds.The hospital is in the London Borough of Lambeth, butthe lead clinical commissioning group is Southwark,which co-ordinates the commissioning activities onbehalf of the other local clinical commissioning groupssuch as Lambeth, Lewisham and Bromley. The hospitalserves the population living in the South East of London.

Our inspection team

Our inspection team was led by:

Chair: Kathy Mclean, Medical Director, NHS TrustDevelopment Authority

Head of Hospital Inspections: Alan Thorne, CareQuality Commission (CQC)

The hospital was visited by a team of 56 people,including: CQC inspectors, analysts and a variety of

specialists. There were consultants in emergencymedicine, medical care, surgery, haematology, cardiologyand palliative care medicine, an anaesthetist and twojunior doctors. The team also included midwives, as wellas nurses with backgrounds in surgery, medicine,paediatrics, critical care and palliative care, board-levelexperience, a student nurse and two experts byexperience.

How we carried out this inspection

To get to the heart of patients’ experiences of care, wealways ask the following five questions of every serviceand provider:

• Is it safe?• Is it effective?• Is it caring?

• Is it responsive to people’s needs?• Is it well-led?

The inspection team always inspects the following coreservices at each inspection:

• Urgent and emergency services• Medical care (including older people’s care)

Detailed findings


• Surgery• Critical care• Maternity and gynaecology• Services for children and young people• End of life care• Outpatients and diagnostic imaging

Before our inspection, we reviewed a range ofinformation we held and asked other organisations toshare what they knew about the hospital. Theseorganisations included the clinical commissioninggroups, NHS Trust Development Authority, HealthEducation England, General Medical Council, Nursing and

Midwifery Council, Royal College of Nursing, NHSLitigation Authority and the local Healthwatch. We alsoreceived information from the trust's council ofgovernors.

We observed how patients were being cared for, spokewith patients, carers and/or family members andreviewed patients’ personal care or treatment records. Weheld focus groups with a range of staff in the hospital,including doctors, nurses, allied health professionals,administration and other staff. We also interviewed seniormembers of staff at the hospital.

Facts and data about King's College Hospital Denmark Hill Site

Context• King's College Hospital Denmark Hill Site is based in

South East London and serves an inner city populationof 700,000 in the London boroughs of Southwark andLambeth, but also serves as a tertiary referral centre forcertain specialties to millions of people in southernEngland.

• The hospital offers a range of local services, including: a24-hour emergency department, medicine, surgery,paediatrics, maternity and outpatient clinics. Specialistservices are available to patients, which providenationally and internationally recognised work in liverdisease and transplantation, neurosciences,haemato-oncology and foetal medicine.

• In the 2011 census the proportion of residents whoclassed themselves as white British was 40.1% inSouthwark and 39.6% in Lambeth.

• Lambeth ranks 29th out of 326 local authorities fordeprivation (with the first being the most deprived).Southwark ranks 41st.

• Life expectancy for women in Southwark (83.1) is slightlyhigher (better) than the England average (83). However,life expectancy for men in Southwark (78) is slightlylower (worse) than the England average (79.2).

• Life expectancy for women in Lambeth (83) is the sameas the England average (83). However, life expectancyfor men in Lambeth (78.2) is slightly lower (worse) thanthe England average (79.2).

• In Southwark, rates of obese children, acute sexuallytransmitted infections, smoking-related deaths and theincidence of tuberculosis are worse than the Englandaverage.

• In Lambeth, rates of obese children, acute sexuallytransmitted infections, smoking-related deaths, infantmortality and incidence of tuberculosis are worse thanthe England average.

Activity• The hospital has approximately 836 beds; 633 general

and acute beds, 100 critical care beds and 103 maternitybeds.

• The hospital employs 8,785 staff. The workforce wassupported by 6% bank/agency staff and locum medicalstaff between March 2014 to April 2015.

• There are approximately 70,781 inpatient admissions,including day case activity per annum.

• There are approximately 671,544 outpatientappointments per annum.

• There are approximately 168,413 urgent and emergencycare attendances per annum.

• There were 3,983 births in the first three quarters of2014/15.

• There were 805 deaths at the hospital between April andDecember 2014.

Detailed findings


Key intelligence indicatorsSafety

• There were five Never Events between February 2014and January 2015. (Never Events are serious, largelypreventable patient safety incidents, which should notoccur if the available, preventable measures have beenimplemented.)

• The Strategic Executive Information System (STEIS)recorded 114 serious untoward incidents betweenFebruary 2014 and January 2015.

• Overall, there were six cases of Methicillin-resistantstaphylococcus aureus (MRSA) (against a target of zero)from April 2014 to March 2015.

• Overall, there were 6.4 cases of C. difficile from April2014 to March 2015 (against a target of 4.8).

Effective

• The Hospital Standardised Mortality Ratio (HSMR)indicator was produced at trust level only. The ratio was87.65, which is lower (better) than the national averageof 100 from 1 July 2013 to 30 June 2014. There was noevidence of risk.

• The Summary Hospital-level Mortality Indicator (SHMI)was produced at trust level only. The SHMI was 0.91,which is lower (better) than the national average of 1. 1from July 2013 to 30 June 2014. There was no evidenceof risk.

Caring

• The NHS Friends and Family Test for urgent andemergency care (for January 2015) showed thepercentage of respondents who would recommend theemergency department was 83%, which was worse thanthe national average of 88%. The response rate was22%, which was better than the national average of20%.

• The NHS Friends and Family Test for inpatients (January2015) showed the percentage of respondents whowould recommend the inpatient wards was 97%, whichwas better than the national average of 94%. Theresponse rate was 37%, which was better than thenational average of 36%.

• The NHS Friends and Family Test for maternity (January2015) showed the percentage of respondents whowould recommend the antenatal service was 100%,which was better than the national average of 95%.Response rate figures were not available. The

percentage of respondents who would recommendgiving birth at the hospital was 98%, which was betterthan the national average of 97%. The response ratewas 16.8%, which was worse than the national averageof 22.9%. The percentage of respondents who wouldrecommend the postnatal service was 80%, which wasworse than the national average of 93%. Response ratefigures were not available.

• The Cancer Patient Experience Survey 2012/13 showedthe trust as a whole was amongst the bottom 20% oftrusts for the majority of the questions in the survey. Thetrust as a whole had an 83% rating for ‘Patients’ rating ofcare’ as being ‘excellent’ or ‘very good’ in the survey.This was lower than the 92% rating for the top 20% oftrusts.

• The CQC Adult Inpatient Survey for 2013/14 showed thetrust performed about the same as other trusts for allindicators in the survey.

Responsive

• The cancer two-week wait standard for April 2014 toMarch 2015 was met by the hospital. The two-weekstandard was met for 97.7% of patients, against a targetof 93%.

• The breast symptom two-week wait for April 2014 toMarch 2015 was met by the hospital. The two-weekstandard was met for 98.7% of patients, against a targetof 93%.

• The 31-day first treatment for tumours for April 2014 toMarch 2015 was met by the hospital. The 31-daystandard was met for 98.4% of patients, against a targetof 96%.

• The 31-day subsequent treatment (treatment group)drug treatments was met by the hospital. This 31-daystandard was met for 100% of patients, against a targetof 98%.

• The 31-day subsequent treatment (treatment group)radiotherapy treatments for April 2014 to March 2015was met by the hospital. The hospital met this 31-daystandard for 99.6% of patients against a target of 94%.

• The 31-day subsequent treatment (treatment group) forsurgery for April 2014 to March 2015 was met by thehospital. The hospital met this 31-day standard for97.7% of patients, against a target of 94%.

• The 62-day standard cancer plan for tumours for April2014 to March 2015 was met by the hospital. Thehospital met this 62-day standard for 85% of patients,against a target of 85%.

Detailed findings


• CRS The 62-day screening standard for tumours for April2014 to March 2015 was met by the hospital. Thehospital met this 62-day standard for 95.5% of patients,against a target of 90%.

• The emergency department, four-hour waiting timetarget of 95% was not met by the hospital between April2014 and March 2015. Eighty-nine point five per cent ofpatients were seen, treated, admitted or discharged inunder four hours.

• The referral-to-treatment times were as follows: 80.4%of patients who were admitted were seen within the18-week target. Of the patients who were not admitted,96.1% were seen within the 18-week target. Of thepatients whose pathways were incomplete, 92.6% wereseen within the 18-week target.

Well-led

• The overall engagement score for the Department ofHealth NHS Staff Survey for 2014 (for the trust as awhole) was 3.79, which was slightly better than theEngland average of 3.75.

• The results of the 2014 Department of Health NHS StaffSurvey demonstrated that for the King’s CollegeHospital NHS Foundation Trust most scores were withinexpectations, in line the national average over the 29key areas covered in the survey. These included thefacts that the trust scores were:

- Within expectations in 13 key areas.

- Better than average in five key areas.

- Worse than average in 11 key areas.

• The response rate for the staff survey was 30%, whichwas lower than the national average of 42%.

Inspection historyThis is the first comprehensive inspection of King'sCollege Hospital Denmark Hill Site.

Our ratings for this hospital

Our ratings for this hospital are:

Detailed findings


Safe Effective Caring Responsive Well-led Overall

Urgent and emergencyservices Good Good Good Requires

improvement Good Good

Medical care Requiresimprovement Good Good Good Good Good

Surgery Requiresimprovement Good Good Requires

improvementRequires

improvementRequires

improvement

Critical care Requiresimprovement Good Good Requires

improvementRequires

improvementRequires

improvement

Maternity andgynaecology

Requiresimprovement Good Good Requires

improvementRequires

improvementRequires

improvement

Services for childrenand young people

Requiresimprovement Good Good Good Good Good

End of life care Requiresimprovement

Requiresimprovement Good Requires

improvementRequires

improvementRequires

improvement

Outpatients anddiagnostic imaging Good Not rated Good Requires

improvement Good Good

Overall Requiresimprovement Good Good Requires

improvementRequires

improvementRequires

improvement

Detailed findings


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Requires improvement –––

Well-led Good –––

Overall Good –––

Information about the serviceThe accident and emergency department is also knownas the emergency department (ED). It is a designatedMajor trauma centre and provides a 24 hour a day,seven-day a week service to the local area.

There were 165, 422 attendances in the ED at King'sCollege Hospital, Denmark Hill site between January andDecember 2014. Around 22% of patients were agedbetween zero and 16 years old.

Patients presented into the department by walking intothe reception area, or arriving by ambulance into aseparate entrance. Patients arriving on foot were initiallyseen by a nurse, who would then direct them to theappropriate area, where they were booked in byreception staff before being seen by a triage nurse.(Triage is the process of determining the priority ofpatients’ treatments based on the severity of theircondition). If the patient arrived by ambulance, they werethen initially assessed by a senior nurse in an assessmentarea before being taken to the most appropriate area inthe department to receive their care and treatment.

The ED was divided into areas depending on the acuity ofpatients. The resuscitation area had 10 trolley spaces,including one designated bay for paediatrics and acubicle with a door.

There were 15 cubicles/rooms in the Majors ‘A’ areas andfive cubicles/rooms in the Majors ‘B’ areas. Severalcubicles had doors for extra privacy. Three cubicles inminor injuries (Minors) and a cubicle in the children’s areawere used by general practitioners (GPs) in the integrated

Urgent Care Centre (UCC). There were four trolley cubiclesand three chair spaces in the ‘Minors’ area and additionalchairs provided an ambulatory decision unit (ADU) wherepatients could wait comfortably pending the results ofinvestigations. The clinical decision unit (CDU) had eightmale and eight female beds in gender specific areas.

Children up to 16 years of age attending the ED werestreamed as they arrived and directed to the children’sarea of the ED, where they received their care andtreatment by appropriately trained staff. The children’s EDhad four cubicles and four bays, which couldaccommodate trolleys as well as two seated cubicles.Two cubicles in the children’s department were assignedto a paediatric CDU. There were two cubicles adjacent tothe reception for the assessment and triage ofnon-ambulance patients.

We visited the ED over three weekdays during ourannounced inspection and one evening during anunannounced inspection. We observed care andtreatment and looked at 31 sets of patient records. Wespoke with 49 members of staff, including nurses,consultants, doctors, receptionists, managers, supportstaff and ambulance crews. We also spoke with 18patients and relatives who were using the service at thetime of our inspection. We received comments from ourlistening events and from people who contacted us to tellus about their experiences. We also used informationprovided by the organisation and information werequested.

Urgentandemergencyservices

Urgent and emergency services


Summary of findingsStaff demonstrated an open and transparent cultureabout incident reporting and patient safety. Staffunderstood their roles and responsibilities and wereempowered to raise concerns and to report incidentsand near misses actively to promote learning andimprovement.

There were adequate medical and nursing staff on dutyto provide safe care to patients. Medicines were stored,recorded administered safely to protect patients fromthe risk of medicine misuse. Patients were safeguardedfrom abuse. Staff were aware of their responsibilities toprotect vulnerable adults and children, although someimprovements were required in documentation relatingto safeguarding and staff training.

Staff followed accepted national and local guidelines forclinical practice. The department had developed anumber of pathways to ensure that patients receivedtreatment focused on their medical needs. The trustparticipated in national College of Emergency Medicineaudits so that they could benchmark their practice andperformance against best practice and other emergencydepartments.

There was a multidisciplinary, collaborative approach tocare and treatment that involved a range of health andsocial care professionals. Patients were given timelypain relief and pain scoring tools were consistentlyused.

Patients in the ED were supported, treated with dignityand respect and were involved as partners in their care.Patients felt that they were listened to by healthprofessionals, and were involved in their treatment andcare. Staff treated patients with respect. Patients andtheir relatives and carers told us that they feltwell-informed and involved in the decisions and plansof care. Staff respected patients’ choices andpreferences and were supportive of their cultures, faithand background.

The emergency department was often overcrowded.Patient flow required improvement and waiting timeswere above the national average due to capacityconstraints and the trust’s arrangements for makingdecisions to admit patients (DTA). This meant patients

were not transferred to areas treating their speciality,but were accommodated in the ED for longer thannecessary. There were no trust guidelines for admissionto the children’s CDU, which did not fulfil the criteria fora ward area. It was not clear why children were admittedto the CDU rather than the short stay paediatric unit.Admission to the CDU avoided breaches relating tolength of stay in the department.

The leadership, governance and culture of the EDpromoted the delivery of high quality person-centredcare. Clear governance structures were in place andwere designed to enhance patient outcomes. Staff wereproud of working for the department and staff workedwell together as a team. There was an effective andcomprehensive process in place to manage risks.




Are urgent and emergency services safe?

Good –––

Staff demonstrated an open and transparent cultureabout incident reporting and patient safety. Staffunderstood their roles and responsibilities and wereempowered to raise concerns and to report incidents andnear misses actively to promote learning andimprovement.

There were adequate medical and nursing staff on dutyto provide safe care to patients. Medicines were stored,recorded and administered safely to protect patientsfrom the risk of medicine misuse.

Patients were safeguarded from abuse. Staff spoken withwere aware of their responsibilities to protect vulnerableadults and children, although some improvements wererequired in documentation related to safeguarding andstaff training.

Incidents• All incidents were reported through a trust wide

electronic reporting system called Datix. This allowedfor management overview of incident reporting and anability to analyse any emerging themes or trends.

• We spoke with medical, nursing and allied healthprofessionals who told us they knew how to reportincidents and ‘near misses’ using the Datix system.

• There was evidence of learning from incidents, not justfrom within the ED, but also trust wide. Trends orlessons learned from incident reporting were sharedeffectively during staff ‘handovers or ‘huddles’ and alsothrough newsletters and staff meetings. We sawdocumented evidence of action taken in relation toincidents in the department’s patient safety report (April2015).

• All the staff we spoke with said they were supported andencouraged to raise any concerns with the clinical andnursing leads on the department.

• Information provided by the trust showed 624 adverseincidents (AI) were reported by staff in the ED between 1September and 31 December 2014. Informationprovided included action taken in response to AI.

Incidents were graded by severity. Of the 624 incidentsreported, 168 were investigated at departmental level,15 were investigated at divisional level and three weretreated as Serious Incidents.

• The Serious Incidents related to medication, clinicalassessment/diagnosis and the deterioration of a patientduring transfer home. Following investigation, actionplans were implemented to reduce the likelihood ofsimilar events occurring in the future.

• Summaries of actions taken by the trust includedsending ‘Duty of Candour’ letters to tell the relevantperson that a notifiable safety incident has occurredand provide support to them in relation to the incident.Training records provided by the trust showed that noneof the ED staff had attended training sessions in Duty ofCandour. However, the trust told us ED consultants andregistrars had received ED specific duty of candourtraining from the Head of Risk so did not attended thegeneric central training sessions.

• There were no Never Events in the ED in the 12 monthsprior to the inspection. (Never Events are serious, largelypreventable patient safety incidents that should notoccur if the available preventative measures have beenimplemented).

• We looked at minutes of meetings of the mortalitymonitoring committee (MMC), which demonstrated amultidisciplinary review of the care of patients who hadhad complications, or an unexpected outcome, to sharelearning and inform future practice.

• In the 2014 NHS staff survey, the trust scored higher thanother trusts nationally for the percentage of staffreporting errors, near misses or incidents and about thesame as other trusts nationally for the fairness andeffectiveness of procedures for reporting errors, nearmisses and incidents.

Cleanliness, infection control and hygiene• A labelling system was in use to indicate that an item

had been cleaned and was ready for use. Theequipment we looked at was clean.

• The treatment areas had adequate hand-washingfacilities. We observed staff washing their handsbetween seeing each patient and using hand-sanitisinggel. The ‘bare below the elbows’ policy was observed byall staff.




• We observed that staff complied with the trust policiesfor infection prevention and control. This includedwearing the correct personal protective equipment,such as gloves and aprons.

• Side rooms were available for patients presenting with apossible cross-infection risk.

• The department was clean and tidy. We saw supportstaff cleaning the department throughout the day anddoing this in a methodical and unobtrusive way.

• Sixty-four per cent of nursing and 68% of medical staffworking in trauma, emergency and acute medicine atthe Denmark Hill site had received training in infectioncontrol against the trust’s own target of 80%.

• We looked at the ED infection control scorecards forthree months between December 2015 and February2015, which recorded the results of audits.Environmental cleanliness audits for the nurseresponsible, as well as the contracted cleaning service,did not meet the trust’s target. Hand hygiene audits didnot meet the trust’s target and care of intravenous lineaudits did not meet the trust’s target for two of the threemonths.

• We noted that the trust policy was followed for themanagement of a patient presenting with a risk of viralhaemorrhagic fever.

Environment and equipment• There was sufficient seating in the waiting room and

reception staff had a direct line of sight of the area.There was a dedicated area to accommodate trolleys forthe handover of patients arriving by ambulance. Therewas a streaming desk and two triage cubicles near thereception area.

• The resuscitation area had 10 cubicles, including onedesignated for the resuscitation of children. Thiscontained a wide range of equipment so that patients ofall ages could be immediately resuscitated.

• Equipment was clean and ready for use. We found thatequipment checklists for the resuscitation area werechecked and signed for sporadically. There were gapseach week where checks were not documented.

• The department had two ‘Majors’ areas. Majors A had 15cubicles. This area was used 24 hours a day. Majors Bhad five cubicles. Between 10am and 6pm, this area wasused as a rapid assessment and treatment (RAT)processing area. Outside of these hours, Majors B wasused to increase the capacity of the ED.

• There was a separate children’s ED with a separatewaiting room for children inside the department wherestaff at the workstation were able to monitor the area.

• A room was available for private and quiet discussionswith relatives and an adjoining room was availablewhere relatives could spend time with their loved one inthe event of their death.

• Electronic locks maintained a secure environment.There was a facility to ‘lock down’ the department in theevent of an untoward incident.

• Each bed space within the resuscitation area weredesigned and configured in exactly the same way. Thisallowed staff working within that area to be familiar withthe bed space, which ultimately led to improvedworking during trauma and resuscitation events.

• A room with two exits was designated for interviewingpatients presenting with mental health needs.

• The X-ray department and computerised tomography(CT) scanning facilities were adjacent to the ED and waseasily accessible.

Medicines• We saw that locks were installed on all storerooms and

most cupboards and fridges containing medicines andintravenous fluids. Keys were held by nursing staff. Insome areas of the department, such as the resuscitationarea, cupboards and fridges were left open to facilitateaccess to medicines in emergencies, for example, rapidsequence intubation (RSI). Risk assessments wereundertaken for these.

• We found controlled drugs were checked daily by staffworking in the department. We audited the contents ofthe controlled drug cupboard in the resuscitation areaand Majors areas against the controlled drug registersand found they were correct.

• We noted that the controlled drug register requiredentries for the amounts of medicine supplied,administered and destroyed. Although there werealways two signatures, we saw gaps in recording.Nursing staff told us it was sometimes difficult to getmedical staff to confirm how much of a controlled drugwas administered to a patient in an emergency.

• The patient allergy status was recorded on each of the31 records we looked at.

• Eighty-two per cent of medical staff working in trauma,emergency and acute medicine at the Denmark Hill sitehave had mandatory medicines management trainingagainst the trust target of 80%.




• Nursing staff told us it was mandatory for them tocomplete medicine training and have their knowledgeand competency checked before they were allowed toadminister medicines.

• Competency was certified as level 1 (nursing staff canadminister oral (non-controlled) medication to adultson their own without a second registered nurse/midwifebeing present); level 2 (administration of oral medicinesunder the supervision of a second registered nurse/midwife) and level 3 (nurses do not administermedicines and are required to attend a study day beforeresitting the drug administration assessment).

Records• A paper record was generated by reception staff

registering the patient’s arrival in the department torecord the patient’s personal details, initial assessmentand treatment. All healthcare professionals recordedcare and treatment using the same document.

• An electronic patient system ran alongside paperrecords and allowed staff to track patients’ movementsthrough the department and to highlight any delays.

• A risk of inappropriate treatment arising from theexistence of clinical information in multiple places (bothpaper and electronic) was identified as a high risk in theEDs risk register. The hospital was managing the risk ofinformation in multiple places safely.

• Specific pathway documentation was available forpatients presenting with specific conditions. Forexample, a fractured neck of femur. The documentswere clear and easy to follow. There was space to recordappropriate assessment, including assessment of risks,investigations, observations, advice and treatment anda discharge plan.

• Eighty-six per cent of nursing staff and 76% of medicalstaff working in trauma, emergency and acute medicineat the Denmark Hill site have had mandatory ‘HealthRecord Keeping’ training against the trust’s target of80%.

• Seventy-three per cent of administrative staff and 80%of nursing staff in the ED at Denmark Hill had completedinformation governance training against a trust target of80%.

Safeguarding• There were appropriate systems and processes in place

for safeguarding patients from abuse. Staff spoken withwere aware of their responsibilities to protect vulnerableadults and children. They understood safeguardingprocedures and how to report concerns.

• Staff had access to patients’ previous attendance historyand to the child risk register. Electronic flags identified‘at risk’ children when they were booked in andnotifications of ED attendance were made to localauthority social services for children with a childprotection plan. We noted that although staff obtainedconsent verbally to undertake background checks, thiswas not documented. However, the trust told us that thepaper flowchart was no longer in use as thesafeguarding questions were mandatory fields on thenursing triage in the symphony computer system for allchildren. One of the fields in the electronic safeguardingassessment record was a verbal consent to informationsharing taken by the triage nurse.

• ED staff were represented at a weekly multidisciplinarychild safeguarding meeting. The ED had a nominatedlead consultant and nurse who were responsible forsafeguarding children’s notes were reviewed by a healthvisitor to screen for children at risk of harm.

• Eighty-two per cent of nursing and 44% medical staffworking in trauma, emergency and acute medicine atthe (Denmark Hill site) had received training insafeguarding vulnerable adults against the trust’s owntarget of 80%.

• Eighty-three per cent of nursing and 63% medical staffworking in trauma, emergency and acute medicine atthe Denmark Hill site had received training insafeguarding children at level 2 against the trust’s owntarget of 80%.Eighty-three per cent of nursing staff hadreceived training in safeguarding children at level 3.

• Twenty per cent of senior ED doctors (ST4 or equivalentand above) of senior ED medical staff (specialty registrarand above) had undertaken training in safeguardingchildren training at level 3. This meant the trust couldnot demonstrate they met the IntercollegiateCommittee for Standards for Children and Young Peoplein Emergency Care Settings recommendations. Theserecommendations were in accordance with the RoyalCollege of Paediatrics and Child Health’s publication‘Facing the Future: Standards for Acute General




Paediatric Services: “All children and young people[must] have access to a paediatrician with childprotection experience and skills (of at least safeguardinglevel 3 training)”.

• Over several days, we observed that GPs operating anurgent care service from a cubicle in the children’s areabrought adult patients for consultation in betweenseeing paediatric patients. This compromised the safetyof children attending the department.

Mandatory training• Compliance with statutory and mandatory training was

generally good. For example, 79.6% of staff working intrauma, emergency and medicine (which includes ED)had completed fire training, 91% had completed healthand safety training and 73% had completed moving andhandling training against a trust target of 80%.

• Seventy-six per cent of paediatric nurses and 6% adultnurses had undertaken paediatric life support training.The trust told us PILS was identified as a high risk areaat both sites and training dates were established.

• Sixty-eight per cent of nursing staff and 53% of medicalstaff working in trauma, emergency and acute medicineat the Denmark Hill site had completed resuscitationtraining against the trust’s own target of 80%.

Assessing and responding to patient risk• Patients presented at the department by walking into

the reception area or arriving by ambulance into aseparate entrance.

• Data for meeting the standard for initial assessment ofpatients within 15 minutes was not collected. Patientsarriving at the ED were seen immediately by ahealthcare professional.

• Patients arriving by ambulance as a priority (blue light)call were transferred immediately through to theresuscitation area, or to an allocated cubicle space.Such calls were phoned through in advance, so that anappropriate team could be alerted and prepared fortheir arrival.

• Other patients arriving by ambulance were assessed bya nurse assigned to ambulance triage, who took a‘handover’ from the ambulance crew. Based on theinformation received, a decision was made regardingwhich part of the department the patient should betreated in.

• If a patient arrived on foot, they were initially seen by anurse who would then direct them to the appropriatearea where they were registered by reception staff

before being seen by a triage nurse. This meant patientshad a clinical assessment as soon as they arrived, ratherthan waiting in a queue for registration. The trust told usthey operated this system because “patients can wait upto 15 minutes for registration, especially at busy times,and we want to ensure that all patients in ED have animmediate clinical review regardless of departmentalpressures/waits”.

• Data provided by the trust for January 2015 showed thatambulance patients were triaged before registration.Triage was undertaken in accordance with theManchester Triage System. This is a tool used widely inemergency departments to detect those patients whorequire critical care or who are ill on arriving at thedepartment. Trained triage nurses followed a pathway,or algorithm and assigned a colour coding to the patientfollowing initial assessment. Red being the labelassigned to those patients who needed to be seenimmediately, then orange (very urgent), yellow (urgent),green (standard) through to blue (non-urgent).

• There were two adult triage cubicles adjacent to themain reception area and waiting room. Having beentriaged, patients were then prioritised for treatment andclinical intervention in the most appropriate area withinthe department for their ongoing management.

• Children attending the ED were streamed at the mainreception and while this was not undertaken by apaediatric nurse, children were directed to thededicated children’s ED, where triage was undertakenby a paediatric nurse consistently, within 15 minutes.

• The department utilised Physiological ObservationTrack and Trigger System (POTTS) system to detectdeterioration in adult patients. However, the children’sdepartment did not have a scoring system in use tomonitor deterioration, but depended on the clinicaljudgement of the staff.

• We saw evidence of rapid assessment and treatment ofadult patients by a designated team of staff in theMajors B area of the department between 10am and6pm daily.

• The triage cubicles and the bays in Majors B being usedfor rapid assessment and treatment, were also used tocommence investigations that would assist withdiagnosis and treatment. For example, blood was taken,electrocardiograms (ECG) carried out, analgesiaadministered and x-rays ordered.




• Trust-wide, the median time to treatment for patientswas between 55 and 72 minutes. This meant that, attimes, the trust exceeded national guidelines of 60minutes time to treatment in the year up to November2014.

• In the 12 months up to February 2015, there were 144occasions when an ambulance waited over 30 minutesto hand over a patient to the ED at Denmark Hill, butthis was still significantly better than some trustsnationally during the same period.

• The ED was a major trauma centre and part of the SouthEast London, Kent and Medway Trauma Network. Anyexpected ambulance admissions to the departmentwere announced via the tannoy system indicating theircolour status and anticipated time to arrival. Thisenabled the relevant and appropriate staff to be readyand waiting.

• A risk assessment booklet was available with tools toassess patient risks associated with falls, manualhandling, developing pressure sores and poor nutrition.Risk assessments were not completed in six of the eightpatient records we reviewed in the CDU.

Nursing staffing• There were sufficient numbers and a skills mix of nurses

on duty in the ED over each 24-hour period to care forpatients safely given the acuity of patients and thegeographical layout of the department.

• We interviewed the deputy head of nursing (HoN) for theED who told us there were 137 adult nurses, 53paediatric nurses, 12 emergency nurse practitioners(ENPs) and 11 technicians for the department.

• The trust considered Royal College of Nursing BaselineEmergency Staffing Tool (BEST) recommendations andNational Institute for Health and Care Excellence (NICE)draft guidance in reviewing nurse staffing establishmentfor the ED in March 2015. The usual staff complement forthe ED was 26 registered nurses (RN) during the day and24 RNs at night. Generally, the department was staffedwith the planned numbers.

• The department utilised a staffing algorithm, whichproduced a Red/Amber/Green (RAG) rated riskassessment for the number of staff on duty. On the daysof our inspection, the actual numbers of registered andunregistered nurses on duty did fall below the plannednumber of RNs. However, the skills mix and flexibility of

staff on duty was such that they were able to deploythemselves as demand and workload dictated so therewas no obvious detriment to the standard of care beingdelivered and the RAG rating was ‘green’.

• The nursing vacancy rate was 25.1% at the Denmark Hillsite at the time of our inspection. The deputy HoN toldus there were 20 vacant posts, although fiveappointments were being processed at the time of ourinspection. Nursing staff told us it was difficult to recruitband 7 staff.

• Six point eight per cent (6.8%) of the total adult nursestaffing and 2.5% of paediatric nurse staffing wasprovided by bank or agency staff between January andDecember 2014. We saw evidence of an inductionprocess for agency staff.

Medical staffing• There were emergency medicine consultants on duty in

the department between 8am and midnight on a dailybasis, with ‘on-call’ cover outside of these hours sevendays a week. The trust met the College of EmergencyMedicine (CEM) recommendation that an ED shouldprovide emergency cover 16 hours a day, seven days aweek.

• The 24 hours a day, seven days a week trauma rota wasstaffed by a pool of 30 trauma consultants who workedat least 12 shifts per year to maintain theircompetencies.

• We examined the medical staffing rota and spoke withconsultants, as well as middle grade and junior doctors.The department employed:▪ Seventeen point seven whole time equivalent (WTE)

emergency consultants in post, which exceeded theestablishment of 16.7 WTE. This included threelocums, two covering maternity leave and onecovering the PGME (Post Graduate MedicalEducation).

▪ Seven WTE specialist registrars in post against anestablishment of nine.

▪ Seven point eight WTE senior clinical fellow postsagainst an establishment of 10.

▪ Three point eight WTE specialist trainees in postagainst an establishment of two.

▪ Sixteen point five WTE junior clinical fellows in postagainst an establishment of 17.5.

▪ The numbers of other grades of medical staff were upto establishment; FY1: 2 WTE, FY2: 13 WTE, StaffGrade one WTE, ST3 Paediatric EM: one WTE.




• There was a GP rota, which provided three GPs between8am and 8pm daily to staff the urgent care area of thedepartment.

• The medical vacancy rate was zero at the Denmark Hillsite.

• Locum usage in the ED was 7.5 to 12.1% between 1September and 31 December 2014 at the Denmark Hillsite.

Major incident awareness and training• The trust had a major incident plan, which was last

reviewed in May 2014. This was available for all staff onthe trust’s intranet pages.

• Staff that we spoke with had an understanding of theirroles and responsibilities with regard to any majorincidents.

• Decontamination equipment was available to deal withcasualties contaminated with chemical, biological orradiological material, hazardous materials or items(HAZMAT). Forty-seven of 160 (29%) nursing staff, 10 ofthe 18 consultants and 11 of the 27 customer careofficers in post held current HAZMAT certificates.

• An isolation unit was available in the department forpatients presenting with infection risks. It was in use fora patient with suspected viral haemorrhagic fever at thetime of our inspection.

• The trust employed 21 security staff at the Denmark Hillsite against a proposed establishment of 28. Securitystaff held Security Industry Authority (SIA) licences for‘manned guarding’, ‘door supervision’ or ‘security guard’(SIA is the organisation responsible for regulating theprivate security industry in the UK). Seventy-six per centof security staff had received training in control andrestraint and 81% had completed conflict resolutiontraining. They also had additional training provided bythe trust for the patient groups they worked with. Forexample, 71.5% security staff had completed dementiaawareness training.

• Sixty-two per cent of staff working in the trust’s trauma,emergency and medicine division (which included theED) had completed conflict resolution training againstthe trust’s target of 80%.

• The department had good links with local police, whohad a presence in the ED from 9am to 5pm, Monday toFriday.

• CCTV was in use in some of the publicly accessible andhigh risk areas in the department, such as corridors andwaiting rooms. Patient areas were not subject tosurveillance.

Are urgent and emergency serviceseffective?(for example, treatment is effective)

Good –––

Staff followed accepted national and local guidelines forclinical practice. The department had developed anumber of pathways to ensure that patients receivedtreatment focused on their medical needs.

The trust participated in national College of EmergencyMedicine audits so that they could benchmark theirpractice and performance against best practice and otheremergency departments.

There was a multidisciplinary, collaborative approach tocare and treatment that involved a range of health andsocial care professionals.

Patients were given timely pain relief and pain scoringtools were consistently used.

There was a low rate of appraisal for nursing staff.

Evidence-based care and treatment• Policies and procedures were developed in conjunction

with national guidance and best practice evidence fromprofessional bodies, such as the College of EmergencyMedicine (CEM), the National Institute for Health andCare Excellence (NICE) and the Resuscitation Council(UK).

• Guidelines were easily accessible on the trust intranetpage and were up to date. Junior doctors were able todemonstrate ease of access and found them clear andeasy to use.

• Clinical guidelines were accessible electronically. Wesaw an example of a printed copy in the case notes of apatient presenting with an overdose of mirtazapine.

• Adherence with guidelines was encouraged through thedevelopment of illness specific proformas to promptuse of best practice guidelines. For example, we sawevidence of use of the fracture neck of femur guidelinesand sepsis guidelines.




• We saw guidelines for admitting patients to the CDU.Comprehensive antimicrobial guidelines were alsoavailable.

• The trust had no audits in place for patients withlearning disabilities.

Pain relief• The trust performed about the same as other trusts in

the 2014 CQC ED survey responses to effective painmanagement.

• We observed that an assessment of pain wasundertaken on a patient’s arrival in the department. Allof the patients we spoke with told us that they wereoffered, and/or provided with, appropriate pain relief.Patients’ records confirmed this.

• Age appropriate pain scoring tools were used in thedepartment. A score was recorded in all of the recordswe looked at.

• We did not see any patient displaying verbal ornon-verbal signs of pain during our inspection that werenot being addressed by the staff.

Nutrition and hydration• We observed staff providing drinks and snacks to

patients during our inspection. We were told that 'Grabboxes' of food were available for patients outside of setmeal times.

• The integrated patient care documentation bookletprovided staff with a prompt to carry out a nutritionalrisk assessment using the malnutrition universalscreening tool (MUST).

• Following the assessment of a patient, intravenousfluids were prescribed and recorded, as appropriate.

Patient outcomes• The ED at Denmark Hill had mixed results in the College

of Emergency Medicine (CEM) audit for fractured neck offemur audit published in 2013. The ED performed abovethe national average for analgesia provided within 60minutes of arrival, analgesia provided in accordancewith need and time to imaging. Areas identified forimprovement included re-evaluation of analgesia, timeto admission and time from arrival to surgery.

• The ED at Denmark Hill performed above the nationalaverage for the majority of standards audited in the CEMaudit for the treatment of renal colic published in 2013.

• In the CEM audit for pain management in childrenpublished in May 2012, the ED at Denmark Hillperformed above the national average for time after

arrival in the ED that analgesia was provided, recordingof pain scores, patients accepting analgesia and lengthof time after arrival that a patient was taken to x-ray.Areas for improvement included improving the processfor documenting the re-evaluation of pain scores,revising the paediatric analgesia guideline and trainingand reviewing the patient process in paediatricemergency.

• In the CEM audit for severe sepsis and septic shockpublished in 2014, the ED at Denmark Hill performedabove the national average for the majority of criteriaaudited. However, performance was the same as, orbelow, the previous for the majority of criteria that werere-audited.

• In 2014/15 the attendances resulting in admission(18.9%) were less than the national average (21.9%).

• The Trauma Audit and Research Network (TARN) datapublished in 2014 demonstrated mixed results for theED at Denmark Hill against the major trauma dashboardcriteria compared to the national average. Areas forimprovement included the proportion of patients:▪ Transferred to the major trauma centre (MTC) within

two days of a referral request.▪ With a Glasgow Coma Scale (GCS) score of nine (a

head injury is usually classed as being moderate ifsomeone has a GCS score of 9-12), with definitiveairway management within 30 minutes of arrival inED.

▪ Directly admitted patients receiving a CT scan within30 minutes of arrival at the MTC.

▪ With an injury severity score (ISS) of more than eightthat have a rehabilitation prescription completed.

• The trust’s monthly trauma performance meeting andtrauma board review TARN data review areas of belowaverage performance, monitor performance againstactions set for the trust and co-ordinate a joint actionplan to ensure successful data submission across bothtrust sites.

• The TARN clinical report III for the South East London,Kent and Medway Trauma Network (published inNovember 2014) recorded that the ‘Most senior doctorseeing patients in the emergency department’ had a79.8% ratio for all patients directly admitted (for allspecialties) at the trust as a whole. These patients werealso seen by a consultant between April 2014 andSeptember 2014, compared to the mean 31.6% for theSouth East London, Kent and Medway Trauma Network.




• The TARN clinical report III for the South East London,Kent and Medway Trauma Network published inNovember 2014 documented the median time to givinga patient a CT scan. All direct admissions, excludingpatients taken directly to theatre, took 0.6hrs betweenApril 2014 and September 2014, which was the bestperformance in the South East London, Kent andMedway Trauma Network.

Competent staff• The department complied with nursing and clinical

staffing guidance published by The IntercollegiateStandards for Children and Young People in EmergencyCare Settings. Nurses working in the children’s ED had aminimum level of knowledge, skills and competence inboth emergency nursing skills for the care of childrenand young people. Clinical staff working in the children’sED had a minimum level of knowledge, skills andcompetence in caring for children and young people, forexample, recognition of serious illness, basic lifesupport, pain assessment and identification ofvulnerable patients.

• There were four (2.6 WTE) practice development nurses(PDNs) in post at the Denmark Hill site.

• We saw evidence of development programmes fornurses at varying grades. The department alsosupported a number of nurses to develop their skillsand competencies as emergency and advanced nursepractitioners.

• Information provided by the trust showed that 8% ofnursing staff in the ED at the Denmark Hill site had anappraisal between April and December 2014. In 2013/14,11% nursing staff had an appraisal and in 2012/13 it was4%.

• Junior doctors told us they were well supported andhad weekly training sessions.

Multidisciplinary working• GPs were included on the clinical rota to support the

effectively integrated urgent care service within the ED.• Medical and nursing staff worked across the ED with

other specialists and therapy staff to providemultidisciplinary care. We observed team workingbetween medical and nursing staff throughout ourinspection. There were examples of multidisciplinaryworking both within the ED and within the widerhospital. For example, the advanced nurse practitionersworked alongside the medical staff and were includedon their duty rota.

• Timely assessment and support was generally availablefor people presenting with mental health issues asmental health practitioners were based on site. Staff hadaccess to the mental health crisis team to assess andtreat patients with acute mental health needs, 24 hoursa day.

• The Intercollegiate Standards for Children and YoungPeople in Emergency Care Settings recommenddepartments seeing more than 16,000 children per yearemploy play specialists at peak times or have access toa play specialist service. The children’s ED did not have adedicated play worker, but had access to a play workerfrom the children’s short stay unit.

Seven-day services• The trust was committed to the vision of seven-day

services with consistent quality of care, optimal patientflow and consistent access to high quality emergencycare at all times of the day and week.

• Seven/seven (7/7) initiatives were in place at DenmarkHill to support a 24 hours a day, seven day a weekworking strategy, which included: a weekend rota for thematron and acute medicine consultant, ward-basedsocial workers and acute medicine service manager and7/7 pharmacy, phlebotomy, enhanced bedmanagement, enhanced therapy cover across theTrauma, Emergency and Acute Medicine division,clinical administration and 24 hours a day, seven day aweek laboratory services.

Access to information• The department had a computer system that showed

how long patients had been waiting, their location inthe department and what treatment they had received.

• A paper record, referred to by departmental staff as aCentral Alerting System (CAS) card, was generated byreception staff registering the patient’s arrival in thedepartment to record the patient’s personal details,initial assessment and treatment. All healthcareprofessionals recorded care and treatment using thesame document.

• Staff could access records, including test results on thetrust’s computerised system.

• Electronic Patient Records (EPR) were in use for patientsadmitted to the hospital, including the CDU.




Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards• We observed patients being asked for verbal consent to

care and treatment. Patients told us that interventionswere explained in a way that they could understandbefore they were carried out.

• Staff we spoke with were clear about theirresponsibilities in relation to gaining consent frompeople, including those people who lacked capacity toconsent to their care and treatment.

• Seventy-nine point eight per cent of staff working in thetrauma emergency and medicine division, whichincluded the ED, had completed consent trainingagainst a trust target of 80%.

• Forty-six per cent of nursing and 19% medical staffworking in trauma, emergency and acute medicine atthe Denmark Hill site have received training onDeprivation of Liberty Safeguards (DoLS) and the MentalCapacity Act 2005 against the trust’s own target of 80%.

• There were no Deprivation of Liberty Safeguardsapplications made through ED in 2013/14 or the year todate.

Are urgent and emergency servicescaring?

Good –––

Patients in the ED were supported, treated with dignityand respect and were involved as partners in their care.

Patients felt that they were listened to by healthcareprofessionals, and were involved in their treatment andcare. Staff treated patients with respect. Patients andtheir relatives and carers told us that they feltwell-informed and involved in the decisions and plans ofcare. Staff respected patients’ choices and preferencesand were supportive of their cultures, faith andbackground.

Compassionate care• The NHS Friends and Family Test results for the trust for

the 12 months up to November 2014 showed between82% and 87.5% people were ‘extremely likely’ or ‘likely’to recommend the ED compared to an England averageof between 86.5 and 88.5%.

• Throughout our inspection of the ED, we observed stafftreating patients with compassion, dignity and respect.

Patients’ privacy was respected by curtains being drawnwhen personal care was given. Staff lowered their voicesto prevent personal information being overheard byother patients.

• Patients responding to the CQC ED survey 2014 said theywere treated with respect and dignity while they were inthe ED, which was about the same as other trustsnationally.

• The patients and relatives we spoke with during ourinspection were positive about the way staff treatedthem. Their comments included: “I’m happy with thecare. It was good and it was fast,” and, “Everyone madesure I understood what was happening; that made itless frightening.”

Understanding and involvement of patients andthose close to them• Patients responding to the CQC A&E survey 2014 said

they were given information about their condition ortreatment and they felt involved in decisions about theircare, which was about the same as other trustsnationally. However, the trust performed worse thanother trusts nationally when asked about relatives beinggiven an opportunity to talk to a doctor if they wantedto.

• Patients and relatives we spoke with told us their careand treatment options were explained to them in waythey could understand.

• We observed staff responding quickly when relatives ofcritically ill patients arrived, which meant relatives werenot left waiting for information about patients’ progressand were offered comfort from staff.

Emotional support• We spoke with staff about caring for the relatives or

others close to them when patients died in thedepartment. They said family members were taken tothe relatives’ room to be informed of the death inprivate. Where possible, relatives were given theopportunity to spend time with the deceased person ifthey wished to.

• We observed staff giving emotional support to patientsand their families. Staff made use of the designatedrelatives’ room so that people had privacy when theywere receiving upsetting news about their relatives’condition.

• Staff had access to the hospital’s chaplaincy service andcould request support when needed.




Are urgent and emergency servicesresponsive to people’s needs?(for example, to feedback?)

Requires improvement –––

The ED was often overcrowded. Patient flow requiredimprovement and waiting times were above the nationalaverage, due to capacity constraints and the trust’sarrangements for making decisions to admit patients(DTA). This meant patients were not transferred to areastreating their specialty, but were accommodated in theED for longer than necessary.

There were no trust guidelines for admission to thechildren’s CDU, which did not fulfil the criteria for a wardarea. It was not clear why children were admitted to theCDU rather than the short stay paediatric unit. Admissionto the CDU avoided breaches relating to length of stay.Children admitted to the CDU were seen by the relevantspecialists.

Service planning and delivery to meet the needs oflocal people• The ED at Denmark Hill serves an inner city population

of 700,000 in the London boroughs of Southwark andLambeth.

• The trust introduced streaming of all patients atreception to include screening for patients withsuspected viral haemorrhagic fever. The ED had goodfacilities for isolating these patients, which we saw inuse during our inspection.

• The department had an established youth worker dropin scheme operated by a London-based organisation,which was effective in supporting vulnerable youngpeople. Staff could refer young people to the service,although engagement was voluntary. The service alsosupported young people to access specialist servicessuch as housing support and social workers.

• Patient information and advice leaflets were available inEnglish, but were not available in any other language orformat. Telephone translation services were availablefor patients for whom English was not their firstlanguage and some staff spoke more than onelanguage.

Meeting people’s individual needs• There were 3,105 people with dementia admitted to the

trust during the year 2014/15. On average, there wereapproximately 78 inpatients with dementia at any onetime. The trust did not have an electronic flaggingsystem for people with dementia.

• There were three dedicated dementia and deliriumspecialist nurses on the Denmark Hill site and aregistered mental nurse as a part of the Older Person'sLiaison Team within medicine to support the care ofolder patients admitted with mental health problems.All patients aged over 75 years admitted as emergenciesto the trust were screened for dementia and delirium.The team received a list of these patients electronicallyand, in addition, electronic referrals could be madeusing Electronic Patient Records (EPR) to the Dementiaand Delirium (DAD) team, who worked closely with thepsychiatric liaison team.

• In the National Audit of Dementia Care in GeneralHospitals 2012/13, the Denmark Hill site performed inline with, or above, the national average for 80% of theapplicable criteria audited across six domains. An actionplan was in place to improve patient managementfurther. This included the development of a carepathway and guidelines for patients with delirium anddementia, an improved discharge planning process andimproved training on the assessment anddocumentation of delirium and dementia. Dementiawas a 2013/14 quality priority at the Denmark Hill site.

• There were 538 patients with a learning disabilityadmitted to the trust last year. On average, there wereapproximately seven or eight inpatients with a learningdisability at any one time.

• There was no universal flagging system in place forpatients with a learning disability. However, the trusthad a well-established learning disability service at theDenmark Hill site and all patients presenting in the EDwith a learning disability had a 'Special Case'notification on Symphony (The electronic system formonitoring the progress of patients through the ED).

• The trust employed one learning disability nurse at theDenmark Hill site. Clinical staff sent an alert wheneveran adult with a learning disability was admitted orattended the ED. Referrals were sent either as asafeguarding concern with the safeguarding adults teamor as a routine notification of a learning disabilityadmission.




• Adjustments for patients with learning disabilitiesvaried, but could include: increased visiting hours,extended ward rounds or specific multidisciplinary teammeetings in addition to the usual clinical discussion, useof a Health Passport to aid handover from carers toclinical teams and joint working with communitylearning disability teams.

• There was a CDU in the children’s ED. This comprisedtwo cubicles in the middle of the children’s ED, adjacentto the nurse’s station. The cubicles did not have en-suitefacilities and did not fulfil the criteria for a ward area.There were no trust guidelines for admission to thechildren’s CDU. It was not clear why children wereadmitted to the CDU rather than the short staypaediatric unit. Admission to the CDU avoided breachesrelating to length of stay. Children admitted to the CDUwere seen by the relevant specialists.

• Trauma nurse coordinators tracked pathways andprogress of trauma patients by visiting them daily on thewards. This role also included networking with othertrusts and coordinating repatriation in advance.

• Staff had access to the mental health crisis team toassess and treat patients with acute mental healthneeds, 24 hours a day. A Child and Adolescent MentalHealth Services (CAMHS) worker was available between9am and 5pm, however, there were problems gettingassessments for children ‘out of hours’, which causedlong waits for these children in the ED.

• A social worker, occupational therapist andphysiotherapist were based in the CDU to supportpeople’s needs.

Access and flow• Capacity and waiting times were an ongoing problem in

the ED. The issue of overcrowding had been presentedas an issue at the patient safety committee. Nursing stafftold us that, although infrequent, there were occasionswhen patients were ‘doubled up’ in cubicles. Screenswere used to mitigate risks to privacy and dignity, butstaff recognised it was not ideal.

• The ED Quality Indicators Scorecard showed 782patients waited in the ED (trust wide) for 12 hours ormore after a decision was made to admit (DTA) betweenJanuary and December 2014. These 12-hour breacheswere measured from the time of DTA. However, wefound that a DTA was often delayed so there were manymore patients spending excess time in the ED. It was

trust policy for DTA to be made by speciality teams andnot by emergency medicine consultants. This furtherdelayed patients’ pathway through the hospital. Welooked at the nurse in charge handover sheet for 28March 2015 which recorded 28 unvalidated breaches.

• On the morning of one of our inspection days, therewere 23 patients with a DTA waiting for a bed on a ward.On a different inspection day, a 92 year old patientarrived at 10.27pm , DTA was 5.17am the following day.The patient was still in the ED in the afternoon of ourvisit.

• At 6pm during our unannounced inspection visit on 28April, 10 of the 35 patients in Majors and theresuscitation area had waited more than six hours. Six ofthese patients had been referred to specialty and a DTAhad been made for two patients. It was trust policy toescalate to the clinical site manger (CSM) for all patientsawaiting beds at four hours from the DTA.

• The specialties with longer lengths of stay in the EDwere medicine (top), mental health and paediatrics,often because a bed on a ward was not available.

• Nursing staff took action to mitigate risks associatedwith long stays in the ED. For example, patients weretransferred from trolleys onto beds andpressure-relieving mattresses were available.

• There were 165,422 attendances at the Denmark Hill sitebetween January and December 2014. Around 22% ofthese patients were aged between zero and 16 yearsold.

• The ED at the Denmark Hill site consistently failed tomeet the target to see, treat and discharge 95% patientswithin four hours between January and December 2014.The 95% target was reached in only eight out of the 52weeks in this period. The weekly performance rangedbetween 88% and 96%. The average for the period was93.3%.

• The total time in the ED (average per patient) for thetrust was consistently significantly higher than thenational average. In the 12 months up to September2014, patients spent an average of 150 and 180 minutesin the department .The national average for the sameperiod was less than 140 minutes.

• In the 12 months up to September 2014, the unplannedre-attendance rate to the ED within seven days was4.35%, which was below the England average (between7% and 7.5%) and the CEM standard (5%).

• The percentage of patients who left the departmentbefore being seen was recognised by the Department of




Health as potentially being an indicator that patientsare dissatisfied with the length of time they are havingto wait. Between 1.97% and 3.08% of patients left thetrust without being seen compared to between 0.2%and 3% nationally.

Learning from complaints and concerns• Information about how to complain was displayed in

the department. Information leaflets were available toall patients. They contained information about how toaccess the Patient Advice and Liaison Service and howto make a complaint. The department followed thetrust’s complaints policy.

• Informal complaints could be received by any memberof the team. These were dealt with by the mostappropriate person. Staff were aware that if they couldnot resolve an issue they should advise the patient/relative as to how to use the formal complaints policy.

• Information received from the trust showed 66complaints were received by the ED in the last 12months. The top areas of complaint were diagnosis (11),care (9), attitude (7) and communication (6).

• The trust’s ‘Review of Complaints at King’s CollegeHospital NHS Foundation Trust’ (Update BriefingFebruary 2015) showed that 43% of complaints in 2013/14 were responded to within 25 working days on theDenmark Hill site.

• A survey of complainants from at the Denmark hill sitebetween April and October 2013 showed that only onethird of respondents were satisfied with the time takento investigate their complaint and only half ofrespondents were confident that their complaint hadbeen taken seriously. Less than half of respondents feltthat their complaint response was open and honest andonly one third felt that their response addressed theirconcerns or resulted in learning.

• The ED complaint rate for 2012/13 and 2013/14 was 0.6per 1,000 ED attendances and 0.5 per 1,000 in 2011/12.

• There was a 20% increase in complaints at the DenmarkHill site in 2013/14 compared to the previous year andan overall organisational increase of 52%.

• Two per cent of Denmark Hill complaints were referredby complainants to the Parliamentary and HealthService Ombudsman.

• Patient experience data, including complaints, wasreported to the trust board monthly, and more detailedtrend information and analysis was reported on aquarterly basis through the board quality and

governance committee (which had full boardmembership) and subsequently to the board ofdirectors. A patient story or complaint formed the firstitem on each agenda. There was a quarterly patientexperience report to the board.

• A monthly trust patient experience report collatedinformation about complaints with patient feedbackfrom Patient Advice and Liaison Service, the ‘How AreWe Doing’ survey, patient comments and NHS Friendsand Family Test results. This was reported through thepatient issues committee and widely through theorganisation.

• Complaints, issues and performance were reviewed atmonthly performance meetings with divisions chairedby the chief operating officer, and attended by themedical and nursing directors. Complaints were alsoreviewed at the governors patient issues and safetycommittee.

• At divisional level, patient complaints were reported sixmonthly at governance meetings, with trends andthemes highlighted.

• Following the Francis Report (the Mid Staffordshire NHSFoundation Trust Public Inquiry), the trust established aserious complaints committee in February 2014 chairedby a non-executive director also appointed as thenon-executive director (NED) Patient ExperienceChampion. The membership included many of theexecutive team, senior consultant staff and seniornurses. The committee’s purpose was to championimprovements in complaints handling, provide a degreeof independent challenge and to improveorganisational learning from complaints.

Are urgent and emergency serviceswell-led?

Good –––

The leadership, governance and culture of the EDpromoted the delivery of high quality, person-centredcare.

Clear governance structures were in place designed toenhance patient outcomes. Staff were proud of workingfor the department and staff worked well together as ateam




There was an effective and comprehensive process inplace to manage risk.

Vision and strategy for this service• The ‘King’s Values’ were developed and defined by staff

and stakeholders in 2009. They were: ‘Understandingyou, inspiring confidence in our care, working together,always aiming higher and making a difference in ourcommunity’. The ED did not have an individualdepartmental vision or values, but staff we spoke withduring the course of our inspection were aware of thetrust values.

Governance, risk management and qualitymeasurement• The trust maintained a system of scorecards for

monitoring targets; for example, national performancetargets, patient experience and clinical quality. Thesewere accessible for staff reference.

• We looked at the governance structure for trauma andemergency medicine division. The schedule of clinicalgovernance and risk meetings included trauma, ED andtherapists to ensure comprehensive clinical andoperational oversight at divisional and departmentallevel. We looked at minutes of governance meetings forthree months before the inspection and attended an EDcore group meeting, which provided further assuranceof robust governance.

• An ED patient safety report was produced monthly andincluded moderate and high risks identified on thedepartment’s risk register. Highest risks were identifiedas overcrowding, absconding patients, inappropriatetreatment because both paper and electronic systemswere in place for recording clinical information and thefact that an outdated version of the Manchester TriageSystem was being used on Symphony. The risk registerreflected key concerns for the service.

• There was consistency between what frontline staff andsenior staff said were the key challenges faced by theservice. Staff were clear on the risks and areas in thedepartment that needed improvements.

Leadership of service• The ED was included in the trust’s trauma, emergency

and medicine (TEAM) division. The service had a clearmanagement structure both at divisional anddepartmental level. The structure of the departmentincluded a clinical lead (an emergency care consultant),head of nursing and an operational manage .

• There was positive feedback from trainee doctors whohad been on placement in the department. They saidthey had been made to feel part of the team and staffensured that they were fully involved in all aspects ofpatient care and treatment.

• Staff within the department spoke positively about thecare they provided for patients. Quality and patientexperience were seen as everyone’s responsibility.

Culture within the service• King’s College Hospital (Denmark Hill site) is located in

one of the most diverse areas in London. Forty-five percent of trust staff were from Black and Minority Ethnic(BME) backgrounds. Information in the trust’s annualreport 2013/14 stated there were three staff-led diversitygroups active in taking forward the trust’s work on thenational Equality Delivery System and they participatedin King’s Hospital Staff Engagement Group. These werethe Cultural Diversity Network, Disability InclusivityNetwork and the Lesbian, Gay, Bisexual andTransgender Forum. The trust had worked closely withexternal partners, such as Stonewall. Over 1,000 staffhad been trained in Stonewall’s 'Train the Trainer'scheme.

• The trust was accredited as a nationally recognisedPositive About Disabled People ‘Two Ticks’ employer.

• Equality and diversity training was mandatory for allnew staff and training records showed 88.8% of staffworking in trauma, emergency and medicine divisionhad completed equality and diversity training.

• Staff had 24 hours a day, seven day a week access to twosupport services. The first was the Dignity at WorkPartnership helpline, which supported staff in relation tobullying and harassment, and workplace options, whichoffered telephone, online and web-based advice on arange of matters, including: legal matters, financialmanagement, and general counselling. The second wasKingsflex, King’s College Hospital’s working scheme,which helped staff balance family and workcommitments.

• The sickness rate was 3.9% among nursing staff at theDenmark Hill site for the 12 months up to December2014.

• There was a sickness rate of 0.8% among medical staffat the Denmark Hill site for the 12 months up toDecember 2014.




• The turnover rate was 23.1% among nursing staff at theDenmark Hill site between April and December 2014.There was a year on year upward trend in turnoveramong nursing staff. In 2012/13 it was 11.8% and in2013/14 it was 18.

• There was turnover rate of 58.5% among medical staff atthe Denmark Hill site between April and December 2014.

Public and staff engagement• The 2014 response rate to King’s College Hospital’s

participation in the national NHS staff survey was 30%,which was worse than the previous year (42%) and thenational average (42%). Overall, the trust performedbetter than other trusts nationally for five surveyresponses (out of 31) and worse than other trustsnationally for 12 responses (out of 31).

• The response rate from the NHS Friends and Family Testin the ED was 82.5% and 84.5% between April andNovember 2014, which was worse than the Englandaverage of 87% to 88% for the same period.

• In the 2014 ED survey, 63% of staff agreed that feedbackfrom patients was used to make informed decisions intheir directorate/department, which was significantlybetter than 56% nationally.

• We saw a quality board displayed in the CDU to showstaff, patients and visitors how the department wasperforming and to celebrate their achievements.

Innovation, improvement and sustainability• Helicopter ambulances landed in the local Ruskin Park

(which is a Civil Aviation Authority recognised landingsite) in order to take emergency patients to the ED fortreatment. This involved disruption to the park andrequired the presence of the police to secure the site.The London Ambulance Service also provided theambulances to transfer patients. The trust’s planningproposal for a helipad on top of the Ruskin Wing wasapproved and we saw construction in progress duringthe inspection. The helipad will facilitate landings ofhelicopters and the transferring of patients to theDenmark Hill site, by shortening transfer times from theexisting landing zone.

• Although ED redevelopment plans (such as the plan tocreate a dedicated area for mental health patients)existed, the implementation of this had been delayed.




Safe Requires improvement –––



Responsive Good –––



Information about the serviceMedical services provided at the King's College HospitalDenmark Hill Site included specialist renal, liver,haematology, cardiology and stroke services, as well asother medicine and care of the elderly services.

We visited 16 medical wards/units, the cardiac catheterlaboratory and a surgical and a gynaecology ward to reviewmedical outliers. Wards/units visited were, the medicalassessment centre, Davidson Ward (haematology), AnnieZunz Ward (general medicine), endoscopy unit, coronarycare unit (CCU) and Sam Oram Ward (cardiology), OliverWard (acute medical unit), Cotton Ward (cardiovascular),RD Lawrence Ward (acute medical unit), Byron Ward(health and ageing unit), Mary Ray Ward (health and ageingunit), Fisk Ward (renal), Cheere Ward (renal), and TwiningWard (general medicine, diabetes and endocrine).

There were 68,542 admissions to medical services betweenJuly 2013 and June 2014.

We spoke with 64 staff in addition to attending a meetingwith twelve managers and consultants from medicalservices. We also spoke with 30 patients and three relatives.We observed the care provided and interactions betweenpatients and staff. We reviewed the environment andobserved infection prevention and control practices. Wereviewed care records and attended handovers. Wereviewed other documentation from stakeholders andperformance information from the trust.

Summary of findingsPatients received care based on the best availableevidence and national guidance. The hospital scoredhighly in most of the patient outcome measures whichindicated good adherence to evidence-based measures,which improved outcomes for patients. Patients gavetheir consent for care and treatment and were involvedin decision making. There was an effectivemultidisciplinary approach to care and good teamworking.

Patients were cared for by staff, who were kind, caringand compassionate in their approach. Patients praisedthe staff, for their attitude and approach, usingadjectives, such as “wonderful,” and “absolutelyfabulous”. Patients were involved in decisions abouttheir care and treatment. The service was planned tomeet the needs of the people it served and care wasresponsive to people’s individual needs and wishes.Systems were in place to manage and learn fromcomplaints. There was strong and passionate leadershipand a culture of openness, with an enthusiasm tofurther develop and improve services for the future.

Regarding safety, there were many aspects of goodpractice, including the reporting and management ofincidents and infection prevention and control. TheiMobile critical care outreach service provided excellentsupport to wards, but, in some areas, the identification

Medicalcare

Medical care (including older people’s care)


and escalation of deteriorating patients wasinconsistent. In addition, nurse staffing in some wardsand the environment within the renal dialysis unitneeded improvement.

There was no formal approach to identifying thepossibility of sepsis or implementation of Sepsis Six inthe medical assessment centre or acute medical unit.

Are medical care services safe?


There was a high nursing vacancy rate and, while this didnot directly impact on the safety of care in most wards, wehad concerns that the high vacancy rate combined withinexperienced staff on Cotton Ward could compromise thesafety of care provided.

Improvements were also needed in the identification ofdeteriorating patients in some areas, although the supportprovided by the iMobile team for deteriorating patients wasexcellent. We found the layout of the renal wards wascramped with little storage room and there was a risk thatthis would have an impact on the safety of patients.

There was an open and transparent approach to theinvestigation of incidents. Staff were encouraged to reportincidents when they occurred. Learning from incidents wasgiven a high priority.

Infection control scorecards enabled the performance ofeach ward to be monitored against infection preventionand control priorities. Generally, the wards appeared to beclean and patients told us cleaning was regular andthorough.

Incidents• There were no “Never Events” reported in medical

service between February 2014 and January 2015. NeverEvents are serious, largely preventable patient safetyincidents that should not occur if proper preventativemeasures are taken.

• An online computer incident reporting system was usedto report incidents and staff told us it was easy to reportincidents when they occurred. Staff were encouraged toreport incidents and they felt there was a good cultureof reporting. One person said that during training theywere told they were “not to keep quiet if you witness anincident”, but to escalate and report it. We checkedwhether a fall which had occurred the previous day hadbeen reported and saw that it was recorded on theincident reporting system.

• Most staff we talked with said they received goodfeedback when they reported incidents and action wastaken to reduce the risk of similar incidents occurring inthe future. Staff gave us examples of incidents which

Medicalcare



had been reported and the action taken to preventrecurrence. For example, a doctor told us of an incidentin which a person had received the wrong dose of adrug. They described the steps taken to ensure thesafety of the patient, the investigation process and theaction put into place to prevent recurrence, includingthe provision of additional training and changes to theprocedures for the administration of the drug. However,three nurses and a junior doctor said they had notreceived any feedback following incidents and no actionwas taken. One person said they had raised concerns to“all levels in the chain” and said, “They are alwaysfriendly, but they never do anything about it. It’s likehitting your head against a brick wall.”

• One hundred and thirty-five serious incidents werereported in the medical service between February 2014and January 2015. Of these, 84 related to pressure ulcersand 27 related to slips, trips and falls. The nurses wespoke with were aware of the trust’s focus on reducingpressure ulcers and falls and told us of some of theinitiatives that had been introduced across the trust toreduce the incidence. However, wards did not havespecific action plans to address the factors pertinent totheir individual ward. We saw the prevalence of newpressure ulcers was variable, but it appeared to bereducing from October 2014 onwards.

• Safety goals had been set to reduce the number ofpressure ulcers and falls, but we did not see evidence ofnumerical values being attached to these. There wereclearer targets for the improvements in compliance withinfection prevention and control performanceindicators.

• A process was in place for the investigation andescalation of incidents. We saw examples of theinvestigations and root cause analysis (RCA) which hadbeen carried out in relation to pressure ulcers. A rangeof relevant professional groups were included in theRCA. Staff told us incidents were discussed at monthlymultidisciplinary governance and risk meetings and thegrading of the incident agreed on.

• Staff were aware of the ‘Duty of Candour’ which ensurespatients and/or their relatives are informed of incidentsthat have affected their care and treatment and they aregiven an apology. They told us of incidents that hadoccurred which they had discussed with patients.

• Medical staff told us there was a robust approach takenat meetings to review mortality and morbidity. We sawevidence of mortality review meetings for each division,which appeared to be comprehensive.

Safety Thermometer• The NHS Safety Thermometer is an improvement tool to

measure patient “harms” and harm free care. It providesa monthly snapshot audit of the prevalence ofavoidable harms in relation to new pressure ulcers,patient falls, venous thromboembolism (VTE) andcatheter-associated urinary tract infections. SafetyThermometer data had been collected from all thewards on a monthly basis and the results were madeavailable to the ward managers. Safety Thermometerresults were not displayed centrally on the wards, butsome wards kept the results in the folder of informationfor the nurse in charge.

• When asked about the action taken to improve, we weretold of steps taken to increase the nurse presence inpatient bays to provide better monitoring of patients atrisk of falls.

Cleanliness, infection control and hygiene• All the wards we visited were visibly clean. Cleaning

schedules were in place and the housekeeping staffwere conversant with the requirements of cleaning theirarea.

• Patients told us they felt the wards were very clean andwe received positive comments from patients such as,“There is lots of cleaning, which is thorough andregular,” and, “Immaculate, bed tables are cleaned andde-cluttered daily,.” Another person said, “Yes, it is veryclean. They’ve cleaned under my bed, including therails, the floor and the locker top.” There was oneadverse comment on cleanliness from a patient on therenal dialysis unit. They said, “The only thing that is notright is the toilets. When I come here at 4pm they areusually filthy, all over the floor and the bowl.” Wechecked the toilets and found the female toilet had anodour of stale urine, the toilet was un-flushed and therewas no hand soap in the dispenser. A member ofhousekeeping was informed and 10 minutes later thesoap had been replenished but the toilet remainedun-flushed.

Medicalcare



• Adequate hand washing facilities and hand gel wereavailable for use at the entrance to the wards/clinicalareas and within the wards. There was prominentsignage reminding people of the importance of handwashing.

• We saw staff using the appropriate personal protectiveequipment (PPE) and following “bare below the elbows”guidance in the clinical areas. Clear signs were in placeat the entrance to side rooms which were being used forpatients with infections, giving information on theprecautions to be taken when entering the room.

• There was an outbreak of norovirus (winter vomitingvirus) on the medical wards at the time of theinspection. One ward was closed to all new admissionsand several other wards had bays closed to newadmissions to reduce the spread of infection.Appropriate steps were being taken contain theoutbreak and the situation was reviewed on a dailybasis. The Infection Prevention and Control Team werevisible in the affected areas, providing advice andensuring adherence to control measures. We visited oneward where there was only one bay in which patientswere not symptomatic. We saw nurses were allocated toeither an affected or unaffected bay, but we found thatwhen patients required more than one nurse to movethem in the unaffected bay, they had to use staff from anaffected bay to provide care. This increased the risk ofthe spread of the virus to the unaffected bay.

• Staff on one ward told us they ran out of supplies of redalginate bags (used for contaminated linen) anddisposable washbowls on a regular basis. There did notappear to be appropriate contingency plans in place forthis and staff said they used disposable bed pans whenthey ran out of washbowls.

• Most of the equipment we examined was visibly cleanand labelled to indicate it had been cleaned. There wasa visual guide to indicate which group of staff wasresponsible for cleaning which equipment. We sawthis displayed on some of the wards.

• The trust had an infection control score card givingperformance against a range of infection controlindicators, including hand hygiene compliance andadherence to the high impact interventions known toreduce infections and cleanliness audits. The wards hadlarge display boards with key infection prevention andcontrol messages and the performance score card fortheir ward.

Environment and equipment• There was sufficient equipment available to meet the

needs of the patients receiving care. There was a centralequipment library and staff told us equipment notavailable on the ward was provided in a timely manner.

• Resuscitation equipment was stored on resuscitationtrolleys on each ward. According to the trust policy, theresuscitation trolleys should be checked daily. We foundthe checks were carried out inconsistently on seven ofthe twelve wards where we reviewed the records ofchecks. On two wards either the security tag was brokenor not in place, meaning that the contents could betampered with.

• Fisk Ward and Cheere Ward were renal wards and caredfor high dependency patients and those requiringdialysis. We identified a number of concerns with theenvironment when taking into account the mix ofpatients on the wards. The layout of the wards wascramped without a separate room for the cleaning ofequipment. There was a lack of storage areas on thewards and the narrow main corridor was cluttered, witha range of equipment and patient information boardsfor the high dependency patients. The two toilets on theacute ward were away from the bays and accessed via anarrow corridor. This meant it was difficult to monitorpatients in the toilets and if an emergency occurred andequipment was required to assist the patient, therewould have been considerable difficulties inmanoeuvring it into place. The room that was used forstoring intravenous fluids was glass fronted and subjectto large fluctuations in temperature. We did not seeevidence of the temperature of the room beingmonitored and on one day when we visited, the roomfelt very hot. This may have impacted on the shelf life ofthe fluids. In addition, the room was not locked andinspectors entered the room unobserved andunchallenged on one occasion.

• The renal dialysis unit and endoscopy suite areas wereprone to flooding following heavy rain. The ward area inthe dialysis unit was also prone to flooding with sewagefollowing heavy rain, or inappropriate material beingflushed in the ward above. This happened on the day ofthe inspection and we were told this was the secondtime it had happened this year. There was a contingencyplan in place to deal with it and the risk was recorded onthe trust risk register. Patients were accommodatedelsewhere when necessary, but they found it unsettlingand disorientating.

Medicalcare



• Systems were in place for the segregation, storage andlabelling of waste and we saw the appropriate disposalfacilities in place in the clinical areas.

Medicines• Medicines were stored in locked cupboards or

medicines trolleys. However, we found intravenousfluids were stored in rooms that were unlocked at thetime of the inspection on Byron Ward and the renalwards.

• We observed medicines rounds in progress and sawstaff checked the identity of patients prior toadministering their medicines. We observed themtalking to patients about how they liked to take theirmedicines during administration.

• An electronic prescribing and administration systemwas in place. This facilitated communication betweenthe pharmacy and ward staff, which improved patientflow. We were told it had brought benefits in relation topatient safety, but there were some limitations in itsability to accommodate some requirements. Forexample, while warfarin was prescribed on theelectronic system, staff identified issues in relation totheir prescriptions when they needed to be changed ona daily basis and the visibility of these on the electronicsystem. We were told there had been two incidents inrelation to warfarin in a month.

• To reduce the possibility of doses being missed a'warfarin reminder' (which prompts review of thepatient’s INR and the need to review warfarin doses) wasprescribed and appeared on the worklist manager.

• Pharmacists checked that the 'warfarin reminder' hadbeen prescribed and add it if it had not. Changes werealso made to the timing of blood tests for patients onwarfarin to enable results to be available earlier.

• Pharmacist support to the medical wards was good andpharmacists completed the medicines reconciliationprocess. Pharmacists played a proactive role inchecking the prescriptions charts and identifying issues.

• Nurses completed a training and competencyassessment prior to administering medicines withoutsupervision. However, the increased use of temporarystaff and a high percentage of newly qualified nurses,limited the number of staff able to administer medicineson some shifts on some wards and this created pressureon the staff that were competent to administermedicines.

• We spoke with the clinical nurse specialists and theytold us of the problems they encountered with beingable to use their prescribing qualification. This was asource of frustration as it inhibited their practice andimpacted on the care they could offer patients.

• There was a medicines safety committee within theclinical governance structure and when medicinessafety issues were identified, communication was sentto the relevant areas in the form of alerts, emails, orposters to raise awareness and ensure key messageswere received.

Records• An electronic patient record (EPR) was in use and each

profession involved in the care of the patient recordedinformation in chronological order in the clinical notessection. This section included the medical plan for thepatient. The clinical notes provided a good descriptionof the patient’s progress.

• Nurses used paper documentation to record a standardrange of risk assessments and care plans. We were toldthe documentation for this had been introduced twoweeks prior to the inspection and had been piloted atthe Princess Royal University Hospital prior to this. Wefound the completion of this documentation wasvariable and was particularly poor in the medicalassessment unit and the acute medical unit (OliverWard). We reviewed six risk assessments in these unitsand five were only partially completed, despite thepatients having been in the unit for more than six hours.We found care plans had not been initiated for threepatients and had only been partially completed for theother three. As a result, it would have been difficult toidentify the nursing care the patient required from thecare record. For example, a patient who was a diabeticwas receiving sliding scale insulin. There was acomprehensive chart to provide details of their insulinrequirements in relation to the blood glucose results,but the nutritional care plan was not completed andthere was no flag on the nutritional assessment toindicate the person was a diabetic. The risk assessmentson the other medical wards were generallyappropriately completed and reviewed. However, wefound a bed rails assessment had been undertaken forone person, which indicated in the body of theassessment that bed rails should not be put in place,but the final recommendation was to use bed rails.There was no explanation for this.

Medicalcare



• Staff had been involved in the development of the EPRand were very positive about its benefits. Mechanismswere in place to improve compliance with protocols andreduce risk. Staff said they found it helpful to see theinput of all professionals at a glance. The mix ofelectronic and paper records increased the risk ofomissions and duplication, but staff told us thedocumentation was continually being reviewed toreduce this.

• The electronic patient record required password accessto ensure security. Patients’ previous medical notes(hard copies) were stored in trolleys on the wards.Entries in the patient records were legible, dated andsigned. However, some entries were not timed,particularly the nursing risk assessments.

Safeguarding• Staff had access to an adult safeguarding policy and an

adult safeguarding team were available to provideadvice and guidance, when required. Safeguardingtraining was mandatory for staff and different levels oftraining were provided according to the job role. Thetraining records indicated at least 72% of staff hadattended safeguarding training on each of the medicalwards. The target for the trust was 80%.

• Staff were able to identify the potential signs of abuseand the process for raising concerns and making areferral. We were given examples of concerns they hadidentified and referrals made. Staff said they did notusually receive any feedback on the outcome ofreferrals. The adult safeguarding lead nurse for the trustsaid obtaining feedback from social care on theoutcomes of referrals was difficult when it did not havean impact on the person’s discharge and this thereforeimpacted on their ability to provide feedback to staffwho had initiated the referral.

Mandatory training• Mandatory training records were available on the

intranet. Training records were graded red (trainingrequired), amber (training due and booked), or green(training undertaken). We reviewed the training recordson several wards and saw there were a number of redtraining blocks. We were told there was a delay inattendance being added to the training database andcompliance was slightly higher than the databasesuggested.

• Mandatory training covered a range of topics, including:health and safety, fire record keeping, infection control,information governance, moving and handling safeguarding adults and safeguarding children. There was atarget for 80% of staff to have attended training.Compliance with mandatory training for bloodtransfusion, conflict resolution and fire were low (below60%) on medical wards but the other topics were amberor green. On Cotton Ward only 50% of staff had attendedresuscitation training. However, following a seriousincident on the ward, there was an action plan for staffto attend resuscitation and ILS training and the wardmanager took us through each of the staff who wereshowing on the database as requiring training,indicating the planned dates for their attendance.

Assessing and responding to patient risk• An Early Warning Score (EWS) was in use to aid

identification of deterioration in a patient’s condition.When the vital sign observations were recorded in theEPR, the EWS was automatically generated. The staff wespoke with were fully conversant with the procedure forescalation when the score increased.

• We identified an inconsistent approach to escalation onByron Ward, where one patient had an EWS whichmoved from one to five and should have triggeredescalation, but the patient was not reviewed until thefollowing day. Another patient’s score increased fromone to four, however, the nursing notes stated that theobservations were stable.

• There was no formal approach to identifying thepossibility of sepsis or implementation of Sepsis Six inthe medical assessment centre or acute medical unit.Staff we spoke with were aware of the signs of sepsis,but were not familiar with Sepsis Six and the importanceof commencing antibiotics within an hour of admission.This meant there was the possibility of a suboptimalapproach to the identification and management ofsepsis.

• A team called iMobile provided critical care outreachservices and were available 24 hours a day, seven days aweek. The service provided by the team wasoutstanding. The team consisted of specialist registrarsand nurses (with at least five years critical careexperience). During office hours, a critical careconsultant was also part of the team. In addition toresponding when a patient’s condition deteriorated, theteam was also able to help when a patient required a

Medicalcare



high level of respiratory support, such as non-invasiveventilation or continuous positive airway pressure(CPAP) for a short period. The team would set up theequipment and a nurse could provide one-to-onesupport for the patient for up to four hours. If thepatient’s condition did not improve in this timescale, theiMobile team would facilitate the patient’s transfer to theintensive care unit. The team could also review the EWSfor individual patients through the EPR.

• All staff we spoke with were extremely positive aboutthe support the iMobile team provided. A ward managersaid they felt the service was exceptional and that it was“one of the things that makes King's an excellent centre”.

Nursing staffing• A tool to assess the nurse staffing requirements (the

Safer Nursing Care Tool) was in use in the trust and thenurse staffing levels had been reviewed using this tool inconjunction with professional judgement. As aconsequence, the ward nurse staffing levels had beenincreased on some of the medical wards. There was anincrease in band 6 nurse posts to provide four band 6nurses on each ward in the last financial year and thecomplement of band 5 nurses had been increased withthe aim of providing a 1:5 registered nurse to patientratio. However, we were told recruitment to the postshad been challenging and, at the time of the inspection,there were vacancies on most of the wards. Arecruitment campaign had been undertaken, but therewas some concern voiced that the recruitment processwas very lengthy and the turnover such that therecruitment campaign had had a limited impact.

• A RAG (Red/Amber/Green) rating approach was useddaily to assess the safety of staffing levels and used toinform escalation to the duty matron.

• Although we saw that most wards had shifts when theywere operating at less than optimum nurse staffinglevels, there was no visible impact on the safety of careprovided. However, in some wards the percentage ofnewly qualified nurses was high, which impacted on theskills mix. This, combined with a high vacancy factor,resulted in high levels of stress reported by nursing staff.

• Cotton Ward had 50 % of their posts vacant and six ofthe registered nurses on the ward were newly qualifiedwithin the past six months. The newly qualified nurseshad not completed their preceptorship competenciesand felt they had received a lack of support when theyhad reported their concerns about the expectations

placed on them and their need for additional training.There had been three serious untoward incidents on theward, which identified deficits in nursing care. Wediscussed these with the ward manager, who describedthe action plan in place to address the issues. Theseincluded the need for staff to complete resuscitationtraining and Intermediate Life Support (ILS), to increasethe numbers of staff able to administer medicines andto reduce the high usage of temporary staff. Additionalsupport had recently been provided to the wardmanager, but we were not confident that the issueswere being resolved in a timely way.

• The trust limited the responsibilities of agency nursesuntil they had completed competency assessments. Forexample, agency staff were required to undertake thesame competency checks as permanent staff prior toadministering medicines. This reduced the risk ofmedicines errors occurring, but placed additionalpressure on permanent staff by limiting the number ofpeople able to give medicines.

• A pool of healthcare assistants had been created toprovide one to one care (specials) for people whorequired close observation. Guidance had beenprovided for staff on how to manage the risks and thecircumstances when one to one care might be required.Staff told us, managers were responsive when theyidentified the need for an additional person to provideone to one care for a patient and the creation of thispool had enabled them to secure additional supportwhen it was necessary.

• A structured, standardised approach to handover hadbeen introduced on the acute medical wards called‘One Best Way’ to ensure key issues were covered andensure handovers were concise and focused. Staff wespoke with said the handovers provided the informationthey needed to progress the care of the patients theywere responsible for.

Medical staffing• There were enough junior doctors to fill the medical

roster. Junior doctors felt they had good support fromsenior medical staff and other foundation doctors. Theysaid staffing was good and there was good cover.

• The proportion of consultants was slightly less than thenational average. However, the staff we interviewed feltconsultant cover was adequate in medicine generally.There were three unfilled vacancies in acute medicine,

Medicalcare



which the consultants felt resulted in a high workloadand impacted on the continuity of care, but not onpatient safety. Some consultants’ job plans had notbeen reviewed for over two years.

• A consultant trained in general or acute internalmedicine was on call at all times and was able to reachthe unit within 30 minutes.

• There was on-site consultant cover for acute medicinebetween 8am and 9pm Monday – Friday and 8am – 8pmSaturday and Sunday. There was 24 hour on-callconsultant support for medical patients.

• We observed the handover to the Hospital at Night teamand found there was good attendance from juniordoctors from each specialty and there was effectivehandover of necessary information. However, therewere multiple evening handovers at different locations,giving a fragmented approach.

• We observed two board rounds and two ward roundsand found they were carried out efficiently andeffectively, with the appropriate staff present.

Major incident awareness and training• Staff were aware of the trust’s major incident procedure

and how to access it via the intranet. There were actioncards giving guidance for ward areas, and the wardskept a copy of their action card in their “Nurse inCharge” folder.

• There was a bed management system to ensurepatients were placed appropriately when there was anincreased demand on beds. When beds were notavailable on medical wards, patients were placed onsurgical wards. There were procedures in place toensure these patients were reviewed regularly by aconsultant.

• When bed capacity was critical, senior managersresponded by providing support to wards inaccelerating patient discharge by liaising with otherdepartments to ensure investigations and other issuescausing blockages were progressed. .

Are medical care services effective?

Good –––

Patients received care based on the best available evidenceand national guidance. The hospital scored highly in mostof the patient outcome measures including National Heart

Failure Audit, National Diabetes Inpatient Audit, SentinelStroke National Audit Programme (SSNAP) and ChronicObstructive Pulmonary Disease (COPD) audit programme.These results indicated good adherence to evidence-basedmeasures, which improved outcomes for patients.

However, there was no formal approach to identifying thepossibility of sepsis or implementation of Sepsis Six in themedical assessment centre or acute medical unit. Also,readmission rates were worse than the England average forelective cardiology and non-elective general medicine andstroke medicine.

Patients gave their consent for care and treatment andwere involved in decision making. Understanding of theMental Capacity Act 2005 and Deprivation of LibertySafeguards was variable and needed to be improved forsome groups of staff, but we saw some good discussionsand decision making in multidisciplinary teams in relationto this. There was an effective multidisciplinary approachto care and treatment and good communication betweenteams.

Evidence-based care and treatment• Staff were aware of National Institute for Health and

Care Excellence (NICE) guidance in relation to theirspecialty and we saw there was good access to theguidance on the intranet. There was a good range oflocally produced evidence-based guidelines on theintranet, which were updated regularly. These werebased on NICE guidance, where relevant. Staff told usthey found the guidelines easy to access,comprehensive and clear.

• From the minutes of clinical governance meetings wesaw that adherence to NICE guidance was discussedand any changes in practice disseminated. For example,we saw care pathways based on best practice in use incardiology in relation to congestive cardiac failure andballoon valvuloplasty (the widening of a stenotic aorticvalve using a balloon catheter inside the valve). We weretold the care pathway for myocardial infarction wascurrently being updated.

• The endoscopy department had been accredited byJoint Advisory Group (JAG) and in the last six monthshad been recognised as a training centre.

Pain relief• The nursing risk assessment documentation in use

included a pain assessment tool.

Medicalcare



• Patients told us that they were always asked about painduring medication administration rounds. The patientprescriptions we reviewed indicated that as requiredmedication was prescribed for pain, where appropriate.

Nutrition and hydration• A nutritional assessment was included in the nursing

risk assessment document. We found an assessmentwas completed for most patients whose care records wereviewed, with the exception of patients in the medicalassessment unit. A visitor on Mary Ray Ward told us theassessment recorded for their relative had beencompleted incorrectly indicating their relative had agood appetite when this was not the case. They hadpointed it out to staff and it had been changed. We sawthe score had been changed on the documentation, butwhen we discussed it with the nurse in charge they wereunaware and told us they would look into it.

• Most patients said the food was good, but two peoplesaid the portions were too large. One person said theyhad been told they could ask for a small portion, butwhen they did they were told: “This is how it comes.”Another person said despite asking for a small portionthere was too much on the plate and this was "offputting".

• A jug of water was provided for each patient andchanged daily. Hot drinks were provided at intervalsthroughout the day. Fluid balance charts were generallycompleted well with the balance being recorded whenfluids were recorded. However, we found the totals werenot always documented on the cardiac ward (Sam OramWard), but patients were weighed daily when required.

Patient outcomes• The hospital scored highly in the National Heart Failure

Audit, scoring above the average for all but one of themeasures.

• There was good performance in the National DiabetesInpatient Audit. These results indicated good adherenceto evidence-based measures, which improvedoutcomes for patients.

• The hyper acute stroke unit (HASU) at the hospitalachieved the fourth highest overall score compared toall national peers in the Sentinel Stroke National AuditProgramme (SSNAP).

• The hospital achieved the highest organisational scorecompared to 15 national and London peer trusts andninth out of 198 units nationally in the national ChronicObstructive Pulmonary Disease (COPD) auditprogramme.

• Performance in all national audits were analysed andactions to improve performance were identified for allaudits in which the scores were at, or below, thenational average. As a result, 45% of audits for trauma,emergency and acute medicine had action plans.

• Monthly mortality review meetings were undertakenwithin each division and the mortality data was brokendown at ward/team level looking at deaths as aproportion of total discharges. Deteriorating patientincidents were also discussed at the meetings and theroot cause analysis information examined.

• Readmission rates were worse than the England averagefor elective cardiology and non-elective generalmedicine and stroke medicine. The hospital episodestatistics for 2013/14 on Standardised Relative Risk ofReadmission indicated how services comparednationally in providing care that was effective, such thatpatients recover and do not require a return visit tohospital. We spoke with the senior medical staff aboutthis and there appeared to be reasons relating to themanagement of patients and coding when theyreturned for further investigations, which may haveaccounted for the raised rates.

Competent staff• Junior medical staff said weekly training sessions were

provided and they were normally able to attend these.They said there was a good mix of practical versusclassroom teaching. They received good support andmet with their clinical supervisor regularly.

• The senior medical staff we spoke with were conversantwith the requirements for revalidation and all had datesfor this. They all had received an appraisal within theprevious year.

• Newly qualified nurses underwent a twelve-monthperiod of preceptorship and had assessments to checktheir competency in key areas of the staff nurse’s role. Allnursing staff were required to undertake medicinestraining and a competency assessment prior toadministering medicines unsupervised.

• Specialist nurses were available to provide advice andguidance on the care of specific groups of patients, suchas those with diabetes and tissue viability issues. A

Medicalcare



specialist nurse was available to review all those over 75years of age who were being cared for on a generalmedical or acute medical ward and facilitated theirmove to a care of the elderly ward when it wouldimprove their management. An Acute CoronarySyndrome (ACS) nurse had been appointed and wasable to provide specialist advice to patients with ACS onoutlying wards

• Staff on the coronary care unit said there were plans toaccept level 2 (high dependency) patients onto the unit.For example, those who had had a tracheostomy. Thestaff we spoke with said there had been good trainingand support in preparation for this.

• Staff were scheduled to have their annual appraisalwithin the forthcoming month.

• Practice development nurses (PDNs) provided trainingand support to staff on the medical wards. Staff werepositive about their input, but there sometimesappeared to be some uncertainty as to the division ofresponsibility between the ward manager and the PDNsfor some aspects of training and assessment.

• A clinical housekeeper said they had undertakeninduction and mandatory training, including:safeguarding, manual handling and infection control.They said they had been able to become involved inhand hygiene audits, infection control andenvironmental audits to facilitate their development.

Multidisciplinary working• Staff we spoke with said there was good

multidisciplinary working and support. Themultidisciplinary EPR ensured good communicationabout the input of each professional in the care ofindividual patients.

• We observed good communication between differentprofessionals and a respect for each other’s expertiseand input. We observed multidisciplinary meetingstaking place and these were well attended andeveryone’s contribution was valued. A pharmacist said,“There’s a big emphasis on equality of all the teammembers.”

• There was good pharmacist support on the medicalwards.

• We saw regular consultant-led multidisciplinary rounds.Patients' care and treatment were reviewed daily inward areas, with action being taken to progress care.

• Staff on Sam Oram Ward said there was a five-day waitfor occupational therapy following a referral. Thiscaused delays into the progress of some patients.

• Medical staff felt there were good transitional servicesfrom paediatric to adult services in haematologythrough the teams working together.

• A dedicated social worker provided support in acutemedicine and this facilitated safe and timely discharge.

• There was a multidisciplinary team for the homelessconsisting of a nurse, a doctor, a social worker, avolunteer, and a housing worker specifically funded andworking across King's College Hospital NHS FoundationTrust and Guy’s and St Thomas’ NHS Foundation Trustto facilitate timely and appropriate discharge andprevent readmission.

Seven-day services• Consultants provided a seven-day service across

medicine. They carried out ward rounds seven days aweek in acute medicine areas. Care of the elderly areaspiloted the delivery of weekend ward rounds over theprevious winter period.

• A general medicine consultant covered the acutemedical unit seven days a week and a care of the elderlyconsultant was contactable by telephone when out ofhours and at weekends, and could get to the hospitalwithin half an hour.

• In the acute medical unit there was pharmacist,occupational therapist and physiotherapist cover sevendays a week. Therapists were moving towards a fullseven day service, but some services were reduced atthe weekend.

• In cardiology, there was a three tier consultant rota.There was access to echocardiology on a Saturday andthere was an on-call, out of hours service covered by theregistrar. Consultants said they had never had aclinically necessary scan delayed, but routine scanswould wait until the Monday.

• There were two CT scanners working full-time at theweekend and neuroradiology reporting at the weekend.

• We were told the stroke service had no weekendtherapist cover, which had an impact on their ability todischarge patients at the weekend when there wasuncertainty about whether the patient was safe to gohome.

Access to information• On our visits to the medical wards we saw there was

good access to computer terminals for staff and past

Medicalcare



medical records were stored in notes trolleys on theward. We were told there was no access to hard copiesof past medical notes at the weekend, but more recentadmission information was on the electronic system.

• Staff were positive about the EPR and said that, overall,it worked well but at times the system was very slowand would occasionally crash. We found it was slow attimes when we reviewed some records during theinspection.

• Access to clinical guidelines through the intranet waseasy and logically organised.

• A proforma in the nursing documentation was used toensure key information was provided when a patientwas transferred between wards. We saw this had beencompleted for a patient who had moved from anotherward.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards• Consent was taken from patients appropriately. We

observed consent for a procedure being taken by aconsultant in endoscopy and found it was carried out inaccordance with guidelines. We were told some nurseshad been trained to take consent for minor proceduresin endoscopy.

• We saw documents were in place for consent todiagnostic scans and interventions. These werecompleted appropriately to show that patientsunderstood the procedure and relevant risks.

• We observed staff explaining what they were about todo and checking their wishes prior to providing care.Patients told us staff sought their consent prior toproviding care and treatment.

• We asked staff on the wards about the Mental CapacityAct 2005 and Deprivation of Liberty Safeguards. Staffknowledge was variable and most of the nursing staffsaid the medical staff were responsible for mentalcapacity assessments. They did not appear to haveconsidered the need for capacity assessments inrelation to the provision of the care they provided. Forexample, a patient with a brain injury on a cardiac wardwas provided with a one-to-one special to provideconstant observation and the implications had not beenrecognised. Staff on the care of the elderly wards weremore knowledgeable about the Mental Capacity Act2005 and we observed some good discussion and

decisions about capacity in multidisciplinary teammeetings. We saw evidence of a Deprivation of LibertySafeguards application and authorisation for onepatient.

• The adult safeguarding lead for the trust told us theyhad introduced training for staff on the Mental CapacityAct 2005 and Deprivation of Liberty Safeguards and hadprioritised the care of the elderly wards for training.

Are medical care services caring?

Good –––

People were cared for by staff who were kind, caring andcompassionate in their approach. All the patients we spokewith, praised staff for their attitude and approach, callingthem “angels” and using adjectives such as “amazing”,“absolutely fabulous” and “wonderful”.

Patients felt involved in decisions about their care andtreatment and told us staff explained everything to them. Aproactive approach was being taken to assess theexperience of carers of people living with dementia whowere admitted to hospital. This identified areas whereimprovement was needed and an action plan was in placeto bring about improvement.

Compassionate care• Medical services had introduced a compassionate care

initiative to promote compassionate care and recognisegood practice in relation to this. Seventeen behavioursor actions to demonstrate compassion in practice wereidentified. Staff were recognised for promoting anddelivering compassionate care through monthly staffawards.

• All wards asked patients to complete a ‘How Are WeDoing’ patient survey prior to discharge to obtainfeedback from patients on their experience. Each wardhad the results of the surveys displayed within the ward.Wards also identified the actions they were taking toimprove.

• The hospital achieved a 42.4% response rate in the NHSFriends and Family Test in comparison to a nationalresponse rate of 30.1% (December 2013 to November2014). Only two medical wards had a lower responserate than the national average, these were Cotton Ward(21%) and Mary Ray Ward (20%). The scores for the NHS

Medicalcare



Friends and Family Test for the medical wards rangedfrom 67 out of 100 (Adult Cystic Fibrosis Unit) to 97(Annie Zunz Ward and The Friends Stroke Unit) inNovember 2014.

• All the patients we spoke with said the nursing staff werekind, caring and cheerful. One person said, “Staff areamazing, absolutely fabulous, brilliant,” and, “They areso amazing and caring. Day shift, night shift, right downto the cleaners,” and, “Staff tell you their name, it makesthings more cheery and makes you happier. Even myhusband said ‘Wow’ about the staff.” Another patientsaid, “The nursing staff are angels. They will do anythingfor me.”

• Patients were also complimentary about the medicalstaff. One person said, “The doctors have a wonderfulbedside manner.” Another person said, “The doctors arevery friendly and quite open.” However, one patient saidtheir consultant was very arrogant and they did not feelable to ask questions.

• We observed staff interacting with patients with a warmand caring attitude and when one patient called out, anurse attended to them immediately, trying to calm theperson in a respectful manner. We also observed twodoctors talking to the relative of a person who wasseriously ill. They talked to the person with compassion,answered questions and addressed their concerns.

Understanding and involvement of patients andthose close to them• Patients told us they felt involved in the decisions about

their care and staff explained everything to them in away they could understand. One person said, “Mynamed consultant talked through the procedure andtreatment.” They went on to say, ”Continuity isimportant and it’s important to know who is takingresponsibility, for example, nurse, consultant, etc; Theyhave been very helpful.”

• However, one person said that although they had beenprovided with information about the plan for their care,the procedures hadn’t happened in the timeframeplanned. The patient said medical staff did not returnfollowing their procedure as they had indicated theywould and nurses were left with insufficient informationon the management plan and the doctors could not becontacted. Two other patients commented on being

given information as to when investigations andtreatments would happen but there were delays andthings did not happen as planned. They did not appearto have been given any reason for this.

• Patients requiring renal dialysis were shown a video ofsomeone undergoing dialysis and then invited to theward to see someone undergoing dialysis. They weregiven the opportunity to talk to current patients. Thisenabled them to gain an idea of what to expect.

• The endoscopy waiting room had had a displayproviding information on the waiting times.

• Each ward had a range of information leaflets available.This included generic trust information on topics suchas infection control, bereavement support, chaplaincy,Patient Advice and Liaison Service (PALS), complaintsand VTE, plus some relevant diagnosis/conditionspecific information, such as the sickle cell service,asthma and chronic obstructive pulmonary disease(COPD).

• The trust was taking a proactive approach to improvingthe experience and support offered to carers of peopleliving with dementia. A Dementia Carers Audit wascarried out in each quarter of 2014/15 to assess progressand obtain the views of the carers of people withdementia on the information provided and theopportunities offered to them to be involved in theperson’s care. The results from quarter three (October toDecember 2014) indicated that 93% of carers feltinvolved in the care of the person with dementia whilein hospital ‘sometimes’ or ‘always’, but only 57% felt fullyinvolved in the person’s care. Less than 40% of carerswere offered information on carer support or on acarer’s assessment and less than 10% were given theKing's College Hospital dementia leaflet. Further actionshad been identified to improve.

Emotional support• Staff on a haematology ward (Davidson Ward) told us

they had access to a psychosocial worker, who providedsupport and counselling as needed. They would seepatients, relatives and nursing staff either individually oras a group. The staff said they knew the patients well asthey attended over a long period and it was helpful tohave the opportunity to debrief, particularly when therewas a bereavement.

Medicalcare



• The chaplaincy also provided emotional support topatients, relatives and staff. The chaplains wereavailable to people of all faiths and no faith if theywished to speak to them.

• The support provided by staff was appreciated bypatients in general. However, one person said, they hadbeen visited weekly by the chaplaincy and counsellorand also a volunteer and they did not want this. Theysaid, “I feel the volunteer has be-friended me –it’s notwhat I am after.” They went on to say they had talked toa nurse about it and were hoping that it wouldn’tcontinue. This illustrated the importance of staff notmaking assumptions about the support a person wouldlike.

Are medical care services responsive?

Good –––

The medicine division planned their services to meet theneeds of the local population. They had responded to theincreases in numbers of emergency admissions anddeveloped services to improve patient flow. Some patientswere cared for in wards outside their specialty, but whilethis was not ideal, the safety of the patients was notcompromised.

A number of initiatives had been developed to ensure theservice met people’s individual needs and those ofvulnerable groups. Systems were in place to manage andlearn from complaints.

Service planning and delivery to meet the needs oflocal people• The medical assessment centre was opened in March

2014 to improve flow through the ED and reduceavoidable admissions. Most GP admissions entered thehospital through the ED prior to being allocated to anappropriate ward. The medical assessment centre hadspace for seven patients on trolleys and an additionalambulatory care area, where people were treated inchairs. The assessment areas were open from 8am –10pm, accepting new patients up to 8pm. There was aspecific ambulatory care clinic which operated Monday– Friday 8am – 5pm. The medical assessment centrewas able to progress treatment of patients who werelikely to need to stay less than eight hours and eitherfacilitate their discharge, or admit them to an

appropriate medical ward. Staff told us the ambulatorycare area had allowed them to safely discharge patientswith arrangements to attend the centre for furthertreatment or investigations, providing an effective safetynet and reducing admissions.

• Comprehensive protocols for the management of sicklecell disease were developed in response to theincreased number of patients in the local area with thiscondition.

• The trust had experienced issues in repatriating patientsfrom neurosciences to their local area for rehabilitation,due to a lack of suitable community rehabilitation beds.There was ongoing communication with stakeholdersand lobbying to look at improving the situation.

• A Family Stroke Group was developed to help familieswith decision making in relation to dischargedestination.

• The population living in or around Bromley wanted tosee development of the Orpington Hospital site toenable care to be provided locally. A decision was madeto develop neurology step down beds at OrpingtonHospital, but some patients were reluctant to transfer toOrpington Hospital. The needs and wishes of peoplewere taken into account in the development.

Access and flow• The hospital admitted most emergency patients

through the ED, meaning there was unpredictability inthe flow of patients. The MAC had been created to dealwith some of the pressure this created and there wereseveral pathways for patients requiring medical services,either through MAC, the acute medical unit (AMU),directly to a medical ward, or a combination of these.This provided flexibility for the service, but resulted inseveral moves for some patients through theiradmission.

• The creation of an ambulatory care area had increasedthe ability to prevent a hospital admission, but somepatients highlighted the fact they were asked to attendat 9am and waited for extended periods before they hadtheir investigations/treatment, resulting in a visit whichlasted for most of the day.

• There was a clear bed capacity escalation plan toensure optimal management when bed capacity was anissue. A RAG rating (red/amber/green) was used toidentify the level of escalation and roles andresponsibilities of staff were clearly defined. The plan

Medicalcare



had to be put into action during the inspection andoperational managers provided support to wards tofacilitate the discharge of patients who were delayed fornon-clinical reasons.

• We found there were 19 patients who were not placed inthe appropriate specialty ward (outliers) on one day ofthe inspection. Two of these were placed on a surgicalor gynaecology ward, while the remainder were placedon specialty medical wards, such as haematology orrenal wards. We were told this was not an unusualsituation. As a result, some consultants had patients onseveral wards and some wards had patients for up tofive consultants, creating logistical issues in the timelyreview of the patients. However, we saw there werearrangements in place to ensure patients were seen bytheir own specialty consultant on a daily basis.

• We observed board rounds and found them to beeffective, with input from different members of themultidisciplinary team. Expected dates of dischargewere discussed and patients’ progress assessed.

• Medical services were achieving the national target oftreating 90% of patients within 18 weeks of referral in allspecialties except gastroenterology, where theyachieved 87.3% (April 2013 to November 2014).

• The average length of stay was longer than the Englandaverage in non-elective general medicine andcardiology. The challenging local demographics werefelt to contribute to this in general medicine and incardiology the complex case mix (the hospital provideda highly specialised tertiary service), was also a factor.

• Discharge summaries were sent to family doctors (GPs)electronically.

Meeting people’s individual needs• The hospital was working with a local charity which was

based on the acute medical unit (Oliver Ward); and theywere providing support to vulnerable people followingdischarge. They provided help with shopping, collectingprescriptions, signposting people to other services, andcontacting social services or the housing department,when required. It was not available to people with ahistory of violence or challenging behaviour. Staff toldus they usually saw approximately 40 people a month.

• A learning disabilities liaison nurse sitting within theadult safeguarding team was able to provide advice and

support to staff when caring for a person with a learningdisability. They encouraged the use of the ‘This is me’documentation to help communication about theperson and their individual needs.

• We saw a side room had been converted to anadolescent room with age appropriate furnishings andactivities on the haematology ward (Davidson Ward) tocater for the needs of younger patients.

• In order to ensure people over 75 years of age who werenot placed on a specialist care of the elderly wardreceived appropriate support, a King's Older People'sAssessment and Liaison (KOPAL) nurse reviewed allpatients who were over 75 years old on a general oracute medical ward. They also provided dementia/delirium support for general nurses and facilitatedadmission to elderly care wards.

• Staff told us they were able to access a telephoneinterpretation service or face-to-face interpreters whenpatients were unable to understand or communicate inEnglish. However, two staff we spoke with said theywould only use an interpreter if the person did not havea relative to interpret for them.

• At the time of the inspection, there was a patient on themedical assessment centre who only spoke Mandarin.There were several references within the patient’srecords that reliance had to be placed on theinformation obtained when the patient’s relative waspresent on admission as further information could notbe obtained from the patient. No consideration hadbeen given to obtaining an interpreter for the patient.This meant the patient received little information abouttheir progress and they could not contribute to theongoing assessment of their condition.

• The trust told us they had a leading edge dementiaward to meet the needs of people with dementia.However, we were not able to see this in action as theward was affected by the winter vomiting virus(Norovirus) during the announced visit of the inspection.

• The hospital used a cook chill system and patients wereable to choose from the full menu each day, providing awide range of choices. Menus were available in Brailleand other languages. One patient said, “There is a lot ofchoice and it looks lovely on the menu, but it is hospitalfood. After three weeks it’s difficult to choosesomething.” Another patient receiving chemotherapysaid they were able to choose from three menus:

Medicalcare



normal, cultural, and additional snacks forchemotherapy patients. They said the choice was verygood, but it was not explained to them andcommunication was poor.

• Patients with liver failure had a special diet and hadsupplements prescribed. There was good access to adietician when required.

• Following feedback from a recent ‘How Are We Doing’patient survey, one ward manager told us of the stepsthey were taking to reduce noise at night.

Learning from complaints and concerns• We saw leaflets on how to make a complaint and about

the PALS, that were in the information leaflet racks oneach ward. One of the patients we spoke with said theyknew how to make a complaint and had been given aleaflet on admission to the ward.

• Staff told us they tried to resolve complaints andconcerns at the time wherever possible. They told usthey received feedback about complaints and thelearning from them.

• A consultant described learning from a complaint inendoscopy. As a result of the complaint, they hadworked with endoscopy user groups to explore theissues and now ensured patients were asked whatsignal they would like to use to alert staff if they wantedtheir procedure stopped.

• The matrons were responsible for coordinatingcomplaints responses for their areas and hadundertaken training in communication led by anexternal trainer. This was received very positively.Recently, medicine had moved towards telephoningcomplainants and offering more family meetings, aspersonal contact with the complainant helped toresolve issues and was viewed positively bycomplainants.

• Performance in respect of complaint response timeswas variable in trauma, emergency and acute medicine,across all sites. We discussed this with the head ofnursing and they identified the importance of ensuringthere was input from all the professions involved and aresponse which met the complainant’s needs.

Are medical care services well-led?

Good –––

There was strong leadership and management withinmedical services. Managers were visible and approachable.There was clarity of direction for the future and strategies inplace to define this. The opportunities and challenges forthe service were recognised and there was an enthusiasticand committed approach to addressing these.

Governance structures and processes were in place andthere was evidence of a commitment to continuousimprovement.

Vision and strategy for this service• The divisions within medical services had developed

five-year strategies prior to the start of the new financialyear. The strategies included further developing crosssite and working with the Princess Royal UniversityHospital for acute medicine and working with otherproviders and community services in each of thedivisions. The strategies included a commitment tofurther improve and extend seven day working.

• Staff were aware of the work carried out to define thetrust’s values and of the broad aims but found it difficultto articulate the specific values.

Governance, risk management and qualitymeasurement• A clinical governance structure was in place in medicine

and staff felt it was effective. Each division held monthlyclinical governance and risk meetings. We reviewed theminutes of three of the meetings and saw there wasgood attendance from the multidisciplinary team.Adverse incidents, infection control indicatorsperformance indicators and patient feedback and/orcomplaints were reviewed.

• We saw evidence of a robust approach to root causeanalysis being undertaken in response to seriousuntoward incidents. We reviewed three root causeanalysis reports. There was a detailed analysis of thecauses and contributory factors. Actions to preventrecurrence were identified and action plans put intoplace. Reviews had been completed to examineprogress against the action plans.

Medicalcare



• We heard about the work being done throughoutmedicine to reduce falls. This included review of staffbreaks, increasing staff presence in the bay areas, andreducing clutter.

• We saw the risk register for the medicine division datedFebruary 2015. Each risk had the ‘RAG’ rating, controls inplace, the review date and the risk owner.

• The medical wards had quality performanceinformation on display. This included an infectioncontrol scorecard and performance in the patientfeedback survey. We saw evidence of a report for each ofthe wards bringing together information on theirperformance in relation to a range of indicators ofquality and throughput.

Leadership of service• A good structure was in place to provide support to staff

at ward level through the ward manager, matrons,deputy head of nursing and head of nursing. We sawgood communication structures were in place to ensurestaff were involved, and aware of the priorities anddevelopments within the service.

• Staff said managers were supportive and approachableand when they raised issues they were listened to andtheir concerns addressed. The exception to this was onCotton Ward, where staff said they had raised theirconcerns about staffing, skills mix and training at anumber of levels, but they did not feel their concernshad been addressed.

• Staff said the director of nursing visited their ward onceor twice a year but they were not aware of visits fromother board members.

• Medical staff were also positive about the support theyreceived from their senior colleagues and peers.

• Ward managers and senior clinicians were visible on thefrontline and closely involved with problem solving andthe smooth running of the service.

Culture within the service• Staff were proud to work at the trust and talked about

the reputation of the trust for the provision of leadingedge services. They said there was an open andtransparent culture where people were encouraged toreport incidents and where the emphasis was onlearning from mistakes.

• We found staff were enthusiastic and committed toimproving services for patients.

• There was an emphasis on the “King's way” of doingthings and on effective team working. Staff felt valuedfor the contribution they could bring to the overall careof patients.

Public and staff engagement• Staff we spoke with were knowledgeable about the

plans for their service and the trust as a whole. At ameeting we held with the directorate managementteam including consultants and other professionalleads, it was clear there was ownership of the issuesfacing the trust and a recognition of need to worktogether to take the service forward,

• The consultants we spoke with identified thechallenges, which the trust had faced in merging withthe Princess Royal University Hospital and said this hadstretched human and financial resources, but overallthey viewed it positively and identified theimprovements at the Princess Royal University Hospitalthat had occurred as a result.

• The comments and results from feedback surveyscompleted by all patients prior to discharge werereviewed at governance meetings and used to identifychanges needed.

Innovation, improvement and sustainability• An extensive research programme has been developed

in cardiology with participation in international,national and local research projects being undertaken.

• The stroke service were early adopters of the use ofintermittent calf compression to reduce the risk of deepvein thrombosis (DVT).

• A project to reduce errors in medications at the point ofdischarge was initiated by pharmacy. A baseline audithad been carried out and there were plans to introducea checklist for nurses to complete to identify if thisbrought improvement.

• There were pioneering specialist services inneurosciences, liver and haematology.

Medicalcare







Well-led Requires improvement –––

Overall Requires improvement –––

Information about the serviceKing's College Hospital Denmark Hill Site is part of theKing’s College Hospital NHS Foundation Trust. Located inSouth East London on Denmark Hill and serving apopulation from London's inner city of 700,000 in theLondon boroughs of Southwark and Lambeth. The hospitalis recognised internationally and nationally as a centre ofexcellence for treating patients with liver problems. Thetrauma and orthopaedics service is a tertiary centre,accepting complex referrals from surrounding areas.

The surgical directorate is divided into liver, renal andsurgery division and theatres are part of the critical careand diagnostics division. There are nine surgical wardsproviding 199 surgical beds, 18 theatres and associatedanaesthetic and recovery areas. There is a separatestandalone day surgical unit with seven theatres. Surgicalspecialties include: neurosurgery, trauma and orthopaedic,cardiothoracic and maxillofacial surgery. Livertransplantation also takes place.

We visited a number of surgical areas, including: KatherineMonk Ward (general surgery), Kinnier Wilson Ward(neurosurgery), Coptcoat Ward (short stay surgery), TrundleWard (general orthopaedic and maxillofacial) and MatthewWhiting Ward (orthopaedic and general surgery). We alsovisited preassessment, the day surgery unit (DSU) andoperating theatres.

We spoke with 19 patients, which included general surgicalpatients being cared for on Brunel Ward and Cotton Ward.We spoke with 32 staff from a range of roles and grades andreviewed 14 electronic patient records and associated

nursing documentation. We observed staff interaction withpatients and general activity in all areas. In addition, wereviewed formal documented information supplied to us inrespect to meetings, audit and duty rotas.

Surgery

Surgery


Summary of findingsReferral-to-treatment times were not being met in anumber of surgical specialties. Surgical procedures weresometimes cancelled and not always rescheduled andundertaken within 28 days. Theatre utilisation was notalways maximised and there were cancelled proceduresand delays in arranging surgery within expectedtimeframes. Patient flow through the surgical serviceswas limited by availability of beds linked, at times, todelayed discharges.

Staff had not been able to complete all the requiredmandatory training, which supported the delivery ofsafe patient treatment and care. There was a lack ofunderstanding regarding Mental Capacity Act 2005 andDeprivation of Liberty Safeguards. The recording ofrequired safety checks for surgical patients was notalways completed to a consistent standard.

There were good arrangements in place for reportingadverse events and for learning from these. Staffingarrangements in surgical areas were managed to ensuresufficient numbers of skilled and knowledgeable staffwere on duty during day and night hours.

Consent was sought from patients prior to treatmentand care delivery. Consultants led on patient care andthere was access to specialist staff for advice andguidance. Procedures were in place to continuouslymonitor patient safety and surgical practices andpatient care reflected professional guidance.

Surgical outcomes were generally good and results werecommunicated through the governance arrangementsto the trust board. Patient experiences were positivewith regard to the treatment and care by doctors, nursesand other staff.

Surgical staff spoke positively about their departmentalleadership and felt respected and valued. Staff weregenerally aware of the trust’s values, but had not beenmade aware of the strategic plans. Staff reported thesurgical directorate as being a good place to developtheir skills and expertise.

The governance arrangements supported effectivecommunication between staff and the trust board. Risksthat had been formally identified were continuously

reviewed and discussed. The trust board was informedand updated with regard to service delivery andperformance. The views of the patients and staff weresought in respect to improving and developing services.

Surgery

Surgery


Are surgery services safe?


Staff had not received all the mandatory safety trainingrequired to support the delivery of safe care and treatmentto patients. The recording of required safety checks forsurgical patients were not always completed to aconsistent standard.

There was a formal process for reporting incidents and nearmisses, which was embedded in staff practice. The sharingof information, including learning from incidents, tookplace verbally and via electronic messages, in addition tominutes from meetings. Staff understood theirresponsibilities under the Duty of Candour legislation.

The surgical divisions reviewed mortality and morbidityoutcomes in order to identify where improvements orchanges needed to be made.

Performance was measured against required safety targetsin respect to patient safety and risks. Where risks topatients were identified, these were acted upon. Staffmonitored each patient’s well-being in line with an earlywarning alert system and this was acted upon where adeterioration in the patient was identified.

There were effective arrangements in place to minimiseinfection risks to patients and staff. There was sufficientequipment to support the delivery of treatment and care.Medicines were managed safely. Arrangements were inplace to ensure staffing numbers and the skills mix wereappropriate to support the delivery of patient care safely.

Incidents• Incidents were reported under different categories,

ranging from general adverse incidents (AI) up to seriousincidents (SI). A SI is a serious incident requiringinvestigation and we saw information whichdemonstrated that, where SIs occurred, these wereinvestigated and reported to the Care QualityCommission (CQC) and other external agencies. Thethird category were Never Events, which is a ‘serious,largely preventable patient safety incident that shouldnot occur if the available preventative measures havebeen implemented by healthcare providers’ (SeriousIncident Framework, NHS England, March 2013).

• All staff we spoke with were aware of, and were able todescribe, the reporting process for incidents, includingactual or near miss situations. Medical staff told us theydid not get any feedback from reported AIs, which theyfound 'frustrating', as they did not always know whataction had been taken.

• Clinical staff understood the incident investigatingprocess and even if not involved in this, reported havingfeedback as part of shared learning. Examples of theways in which shared learning took place includedthrough the monthly anaesthetic and surgical bulletinsand through the Surgical Safety Improvement Group.We noted improvements had been discussed in relationto positive patient identification in the latter groupmeeting minutes held on 2 March 2015.

• A newsletter titled ‘Safety in Anaesthesia and Learningfrom Incidents’ (SALI) April 2015 was provided to us. Thisincluded detailed information around many aspects ofanaesthetic matters relating to safety and best practice,including learning from incidents.

• We reviewed the information generated via the formalreporting system for the hospital and noted that thisidentified the location, type of incident, category andsubcategory. For example: the ward name, pressureulcer, where it was acquired and the grade of the ulcer. Adescription was seen, along with action taken andprogress of the investigation. We noted that, where aserious incident occurred, this was referred fordiscussion at the surgery quality and risk committee.Serious incidents were also reported to the NationalReporting and Learning System (NRLS).

• Minutes from the surgery quality and risk committeeheld on 19 May 2014 were provided to us todemonstrate learning from incidents. We could notidentify from these any specific learning, as the level ofrecorded information was limited. Similarly, the minutesfrom the surgical governance meeting of 1 January 2014did not specifically identify any learning from incidentreview. We did, however, see information which weconsidered to be informative for staff within the surgeryquality and risk committee minutes recorded for the 16February 2014. For example, information relating topatient weights and wound management.

• A 'mystery shopper' audit had been carried out inDecember 2013, related to surgical safety. This identifiedthe progress on actions taken at the time, and included

Surgery

Surgery


for example, a site marking policy and revision ofsurgical count policy. Recommendation included theaudit of compliance as part of the divisional scorecardsfrom March 2014.

• Divisional scorecards were viewed for January, Februaryand March 2015, and it was noted there was noinformation related to safe surgical checks having beenmonitored. Further, we noted from the March 2015medical record-keeping audit, that the completion ofsafety checklists was not included in the reviewprocess.

• Safer surgery audit results for December 2014 provideda summary of surgical Never Events for the periodJanuary 2012 to November 2014. The majority of whichhad occurred in oral and ophthalmic surgery, eachhaving three incidents, followed by two in anaesthetics.The three ophthalmic surgery Never Events werereported between September and October 2014 andrelated to two wrong lens implants and one wrong sitesurgery. A further Never Event took place in January2015 in ophthalmology and on this occasion it was awrong patient.

• Staff working in the theatre departments, including theday surgical unit (DSU) were aware of the Never Events.We observed evidence on display in the DSU staff room,which described the Never Events related to theophthalmic incidents and the action plan for avoidingsimilar occurrence.

• There had been 40 serious incidents (SI) reportedbetween the period of February 2014 and January 2015.Each incident was graded in terms of seriousness andwas accompanied by root cause analysis, contributoryfactors and recommended actions.

• We noted from information provided to us that patientfalls and pressure ulcers were tracked by ward. Theseincidents were also rated as ‘avoidable’ or ‘unavoidable’,with avoidable incidents generating an action planreview. A pressure ulcer adverse incident summary wasreviewed by us and we saw that the formal process forinvestigating the matter was detailed and thorough.Actions arising from this had been generated andincluded staff education.

• Mortality and morbidity meetings were taking place aspart of the audit half days held on a monthly basis.

• We reviewed the divisional updates respecting themortality monitoring committee meeting presentationfor plastics, orthopaedics, trauma and ENT for Januaryto December 2014. This reported on 21 deaths, of which

19 were expected. Quality issues identified within thereview related to venous thromboembolism, wherepatients were day case admissions or those who hadimmobilised lower limbs.

• The divisional update for general and colorectal surgeryfor the same period indicated that there had been 20deaths in a period of six months and in urology, fourdeaths. Information reviewed within the reportidentified case mix issues and quality issues, some ofwhich had been subsequently resolved. Key actions tobe taken forward related to the development of morerobust governance arrangements. It was also noted thatthe directorate was making good progress with regardto the governance and reporting process.

• We also reviewed the minutes of the mortalitymonitoring committee for 16 July 2014. It was reportedthat for the 12 months up to May 2014, the SummaryHospital-level Mortality Indicator (SHMI) for in-hospitaldeaths at the Denmark Hill site was 58, which was thesame as the peer average and the hospital rankingremained at eighth compared to the peer group of 14trusts at the time.

• We saw there was a ‘Duty of Candour – Being Open’policy, which was accessible to staff. Staff had anawareness of the Duty of Candour. For example, oneoperating department practitioner said it was about,“Accepting responsibility, apologising and rectifyingwhat could be done.” A ward nurse said it was abouttransparency and honesty. For example, if a patient fell,having a responsibility to tell the family.

Safety Thermometer• The NHS Safety Thermometer is a local tool used for

measuring, monitoring and analysing patient harm and'harm free' care at a particular point in time. The trustalso collected data on all incidents of harm free careand reported on this via the divisional score cards andother reports.

• Variable rates in respect to falls, pressure ulcers andcatheter and urinary tract infections were reported to usas part of the pre-inspection information. We saw onwards we visited that information was displayedregarding quality indicators. For example, on KatherineMonk Ward there had been eight hospital-acquiredpressure ulcers in the last three months up to our visit.On Coptcoat Ward there had been onehospital-acquired pressure ulcer in the three monthsprior to our visit.

Surgery

Surgery


• Pressure ulcers were also recorded as part of thesurgical division performance metrics. January andFebruary metrics indicated that there had been fivehospital-acquired pressure ulcers in both months, whichexceeded the target set at two.

• Performance metrics for the surgical directorateindicated there had been one patient fall in January2015 and none in February 2015.

Cleanliness, infection control and hygiene• Staff working on wards and in theatres told us they had

infection prevention and control (IPC) link nurses. Theirrole was said to include attending IPC meetings andchecking that staff followed policies and procedures. Inaddition, they undertook IPC checks, such as handhygiene monitoring and checks on the cleanliness of theenvironment.

• We observed that there were dedicated staff forcleaning ward areas and they were supplied withnationally recognised colour-coded cleaningequipment, which allowed them to follow best practicein respect to minimising cross contamination.

• Domestic staff told us they had enough equipment toundertake their duties and they showed us guidance asto their responsibilities on each shift. Cleaning scoreswere displayed on wards and we saw, for example, onKatherine Monk Ward the score ranged from 98% inJanuary 2015 to 99% in March 2015.

• Operating theatres were found to be clean oninspection. There were separate clean preparation areasand facilities for removing used instruments from theoperating room ready for collection for reprocessing bythe external decontamination service.

• Theatre staff told us the theatres were cleaned at nightand theatre staff cleaned theatres between cases duringthe day. Technical theatre equipment was cleaned bystaff and we observed items were clean and recorded asready for use.

• A cleaning audit was completed in respect to theatresand we reviewed an example of this for October 2014.This indicated that the overall cleanliness was 95%.Corrective action had been recorded within an actionplan and subsequent reaudit carried out in November2014.

• Theatre staff received cleaning updates within the maintheatre newsletter and we saw evidence of this in thenewsletter for November 2014 that was supplied to us.

• The surgical wards we visited were clean and patientswe spoke with all provided positive feedback on thelevel of cleanliness and their satisfaction with thestandards. There were formal arrangements in place todirect domestic staff as to the required levels ofcleanliness and routines. We saw cleaning results scoresdisplayed on wards. For example, on Trundle Ward theyachieved 98% in January and 96% in March 2015.

• As part of the ‘Commit 2 Care’ award, which surgicalwards were participating in, we reviewed audit resultsfor Coptcoat Ward that indicated 100% compliance inthe November 2014 audit of infection control and theenvironment.

• We observed that there was access to personalprotective equipment, including gloves and aprons in allareas visited and staff used these during the course oftheir activities.

• There was access to Infection Prevention and Control(IPC) policies and procedures via the trust intranet andwe sampled these and found they were up to date.

• Staff compliance with local infection control policieswas noted to be good, with all staff 'bare below theelbows' to enable thorough hand washing. Staff hadgood access to hand washing and drying facilities. Weobserved regular use of these facilities by nursing andAllied Health Professionals. We observed that medicalstaff did not gel their hands on entry or exit on KatherineMonk Ward. However, we saw they used hand gel beforeattending to a patient.

• Hand hygiene audit results were displayed on somewards. We saw that, on Kinnier Wilson Ward(neurosurgery) results of the most recent auditindicated 97% compliance. On Coptcoat Ward theresults displayed indicted 97% compliance on 7 April2015.

• Hand hygiene results were included in the surgicaldirectorate performance metrics. We saw results forJanuary and February 2015. These indicated a score of78% and 80% respectively, which was less than theexpected target of 95%.

• We observed staff complying with the policy in respectto the handling and management of clinical anddomestic waste. We saw bed linen was handled inaccordance with best practices and sharps weredisposed of safely.

• We observed the handling and management of surgicalspecimens in theatres was done in a safe manner.

Surgery

Surgery


• Surgical staff working in theatres were seen to followNational Institute for Health and Care Excellence (NICE)guideline CG74, ‘Surgical site infection: Prevention andtreatment of surgical site infection (2008)’.

• We saw there was a protocol for staff to follow in respectto identifying and responding to sepsis. During wardhandover, staff reported a patient who would need to becared for as per the sepsis pathway if their temperaturewas elevated when next checked.

• Infection control scorecards provided to us showed thatpatients were screened preoperatively for MRSA, in linewith local policy. In the November 2014 scorecard forsurgery, we noted that 100% of elective patients hadbeen screened and 99% of emergency patients. Weobserved one patient arrive in theatre, while we werepresent, having had their MRSA swab carried out theprevious day and the results were not known. This wasnot picked up by the staff member and was pointed outby our specialist adviser.

• Isolation signage was in place, where required, on thedoors to patient rooms.

• Equipment used by patients, including shower stoolsand commodes, for example, were inspected and foundto be clean. Labels had been attached to itemsindicating when they had been cleaned and by whom.

• There was a standard operating procedure (SOP) inplace regarding the arrangements for adecontamination service providing surgicalinstrumentation. The SOP also provided instruction tostaff as to when to raise an incident, such as whenoperations had to be cancelled because of dirtyinstrumentation or instrument rust. We noted frominformation provided that one patient had beencancelled because instrumentation was not available inMarch 2015.

• Data reviewed on the November 2014 infection controlscorecard indicated that in surgery there had been noMRSA bacteraemias, no vancomycin-resistantenterococci (VRE) and one meticillin susceptiblestaphylococcus aureus (MSSA) bacteraemia. There hadbeen two clostridium difficile cases in the month andtwo the previous month, which remained under thetargets for the whole year.

• Performance metric information for January andFebruary 2015 indicated that there had not been anyMRSA, VRE or clostridium difficile in either month.

• Wards displayed information which indicated thenumber of infections. For example, on Katherine MonkWard they had not had any MRSA infections butindicated the two cases of clostridium difficile hadoccurred there.

• Infection prevention and control training was part ofmandatory training for nursing staff. Infection controltraining attendance for theatres was provided to usduring the visit. We saw 89% of the orthopaedic staffand 81% of general theatre staff had completed training,against a target of 80%.

• Theatre staff also undertook aseptic non-touchtechnique training regarding wound management.There was 100% attendance from orthopaedic theatrestaff and 62% at the half year target for general theatrestaff.

• We saw in training figures supplied that the attendancerate for infection control was set at 80% within the liver,renal and surgical division. The attendance rateachieved overall was indicated as 75%. Ward specifictraining information was also supplied to us and thisindicated that, for example, 61% of Coptcoat Ward staff,65% of Matthew Whiting Ward staff and 90% of TrundleWard staff completed this training in the year prior to theinspection.

• A brief summary of IPC was seen to be included in theannual report and accounts for 2013/14.

Environment and equipment• Ward areas were not always designated for specific

types of surgery. For example, Brunel Ward was generalsurgery and gynaecology.

• The separate day surgical unit (DSU) had 27 trolleys andseven operating theatres, with three anaesthetic rooms.There was also a chair area used for ophthalmicpatients who did not have a general anaesthetic (GA).The DSU was designed to facilitate flow from arrival inthe admissions lounge through the trolley-based wardarea, where patients were prepared for surgery, prior tobeing taken directly into the anaesthetic room andtheatre. They were not required to move on to aseparate operating table, except if they were having eyesurgery under a GA. Patients were recovering in a smallarea outside of theatres before going back to the wardarea.

Surgery

Surgery


• There were ten main surgical theatres and threeneurosurgical theatres. Laminar flow was available inorthopaedic theatres. Separate recovery areas wereprovided and these were seen to afford privacy.

• Wards and theatres were accessible to individuals withdisabilities and technical equipment was available tosupport individuals, where required. This includedhoists, adjustable beds and bariatric chairs andcommodes.

• Emergency equipment for resuscitation was available ineach area and we found this had been routinelychecked. There was access to emergency equipment intheatres, such as items required for emergencyintubation.

• The Association of Anaesthetists of Great Britain andIreland safety guidelines Safe Management ofAnaesthetic Related Equipment (2009) was beingadhered to. This included electronic safety checks ofanaesthetic machines at the beginning of operatingsessions, results of which were recorded on a centralserver.

• Arrangements were in place to service equipment viathe Medical Equipment Management Service (MEMS),including portable electrical items and we saw evidenceof such checks on equipment. Staff told us they hadenough equipment to enable the safe and effectivedelivery of care. Equipment was accessed through thelibrary, with a delivery and collection service to supportthis.

• Single use equipment, such as: syringes, needles,oxygen masks and suction tubes were readily availableand stored in an organised, efficient manner. We didfind some items of equipment had expired on MatthewWhiting Ward and that stock rotation was not managedeffectively. Items that had expired included: bloodculture bottles, spiral manometers, shaving cream andsurgical scrub solution.

• Staff told us the corporate induction covered equipmentuse and the practice development nurse did a three-dayinduction with newly qualified staff, during which theywent through use of intravenous pumps and otheritems.

• Surgical instrumentation which requireddecontamination between patient use was outsourcedto an accredited unit, with a service level agreement inplace.

• Staff had access to training regarding medicalequipment. We saw, for example, training information

pertaining to Matthew Whiting Ward staff, whichindicated average training attendance was 56%. Wenoted from the information supplied that two staffnurses had not completed any training on the use oftechnical equipment.

Medicines• We made checks regarding the ordering, storage,

administration and disposal of medicines on surgicalwards and in theatres. Staff told us there was regularcontact with the pharmacy staff in order to top upsupplies and for ordering. We observed that medicineswere stored safely and appropriately, including itemswhich needed to be stored in refrigerated conditions.Temperature checks had been carried out on fridges.

• Medicine trolleys were locked securely and could not beaccessed by anyone other than staff. Controlled drugswere stored in locked cupboards, which were secured tothe wall within a locked room. We checked controlleddrug registers on wards and in theatres and recordkeeping regarding checks and administration were inorder.

• Pharmacy staff had undertaken an audit of staffcompliance, with requirements around controlled drugmanagement in February 2015. We saw audit results fora number of surgical wards, which were rated as ‘green’for satisfactory and ‘red’ for unsatisfactory. We noted byway of example that, in respect to each entry beingcomplete and having a signature by two nurses, foursurgical wards were unsatisfactory in quarter one (2014/15), two of which were also unsatisfactory in theprevious quarter. Staff were made aware of the need toimprove in areas indicated by the audits.

• Information on the results of theatres audit for quarterfour had been communicated to theatre staff via themain theatre newsletter in November 2014. We sawthere were three areas which were identified asrequiring attention. This included each entry needing tobe signed by two nurses, errors needing to be signed bytwo nurses and dated and to be crossed out with asingle line, or bracketed. The audit for February 2015indicated general improvement in theatres, with only alimited number of identified theatres requiring furtherimprovement. Recommendations were identified withinthe audit.

• Nursing staff explained how the pharmacy reviewed themedication needs of new patients and completed theelectronic patient record. Prescribing of regular

Surgery

Surgery


medicines, as required medicines and take home itemswas undertaken by medical staff. Coptcoat Ward had anefficient system in place for ordering and managing thepatients’ take home medicines. Pre-packed take homemedicines were placed in a designated cupboard andan entry was made of this on a wipeable board. Oncethe medicines were given to the patient, the name wasremoved from the record. Pre-packed medicines werechecked by the pharmacy staff weekly.

• We observed medicines were given to patients bynursing staff in accordance with the prescription andthat safety checks were carried out during medicinesadministration. Patients told us staff always checkedtheir name band and confirmed their personal detailsbefore giving them medicines.

• Staff had access to up-to-date guidance on medicinesand received advice from pharmacy staff, as well asnewsletter information.

• We were informed by a new member of nursing staffthat they were required to complete a medicinesadministration test before they could administermedicines to patients.

• The Theatre User’s Medicines Management Groupmeeting held on the 2 February 2015 indicated thatmedicine stock was discussed, along with risk reports,trends and action plans. It was noted that adverseincidents related to medicines were to be discussed atthe clinical governance and risk meeting being held on 4February 2015.

• Antibiotic stewardship was taking place and informationreviewed by us for the period November 2014 indicatedthat clinical indications for antibiotics was recorded in99% of patient records and stop/review dates had beenrecorded in 94% of cases. In both indicators this wasbetter than the target.

Records• The surgical areas used a combination of electronic

patient records (EPR) and paper documentation forrecording information. We found the EPRs were detailedand provided clear information regarding the patientjourney, investigations and treatment. Similarly, paperrecords had been completed to a standard, whichenabled staff to follow the information.

• There was multidisciplinary input to EPRs whererequired, which included entries made by

physiotherapists, occupational therapists anddieticians. We noted evidence of referral to specialistadvice, including the speech and language therapyteam (SALT).

• The EPRs contained evaluation and progress notes, aswell as information regarding discharge planning.

• We observed that separate nursing records were held atthe patients’ bed ends. These included riskassessments, such as assessment of moving andhandling, skin integrity, nutrition, use of bed rails andvenous thromboembolism (VTE). Intentional roundingat regular intervals provided an opportunity for nursingstaff to check the status of the patient and to update riskassessments accordingly.

• We reviewed formal documentary records regardingspecific care plans which were being used. For example,care plan for the management of orthopaedic patientsand patients who had undergone maxillofacial surgery.Staff reviewed progress against these plans andupdated the EPR to indicate any changes.

• We reviewed an audit of the completion of paper andelectronic patient records, which included consent. Theresults were reported on 23 March 2015 and indicatedthat there was a higher level of compliance with theelectronic record completion than paper records.Conclusions and recommendations were identifiedwithin the report, which were to be shared with thepatient safety committee and the medical director’soffice.

• Record keeping was part of mandatory training and wesaw that within the renal, liver and surgical directorateattendance by nursing staff had exceeded the target,with attendance at 89%.

• We observed theatre staff following the ‘five steps tosafer surgery’ procedures (Patient Safety First campaign)– an adaptation of some of the steps in the WHOsurgical safety checklist, which included team brief, signin, time out, sign out and debrief. However, theatre staffwere not fully completing the checklists based on theWorld Health Organization (WHO) safety procedures tosafely manage each stage of a patient’s journey fromward through anaesthetic, operating room andrecovery. There was an absence of signatures againststaff names on five out of eight of the WHO chartschecked. WHO checklists were not complete for daysurgical patients in the DSU.

• We noted that theatre site safety checklists were notcompleted for all surgical patients, despite there having

Surgery

Surgery


been three never events related to failure in the safetychecking processes. This section of the patient recordforms part of the pre- and postoperative patient journeyfrom ward to theatre and back. The discrepanciesrelated to the absence of recording of the site to beoperated on.

• Patient records contained evidence of attendance at thepreoperative assessment, where relevant. Informationincluded, for example: patient demographics, previousmedical and surgical history, allergies, and medicines,along with baseline observations. Anaesthetic riskscores were used to ensure that only those patientssuitable for day surgery were admitted as such.

Safeguarding• The majority of nursing staff had a good level of

understanding and knowledge around this subject.They were able to indicate the transfer of knowledgefrom training by responding to our questions aroundindications of possible safeguarding concerns. Staffwere clear about the escalation process andaccessibility of the safeguarding team.

• Staff had access to a safeguarding protocol and namedstaff who were able to support staff in this area.

• Information provided indicated compliance with level 1safeguarding training by ward. For example, it wasreported that there had been 100% attendance by staffon Trundle Ward and 50% on Coptcoat Ward.

• The training figures supplied to us indicated that therewas a target attendance rate set at 80% for level 2safeguarding children and that 79% of nursing staff inthe liver, renal and surgical directorate had attendedthis. At level 3, it was reported that 82% of nursing staffhad attended the training, which was above the 80%target.

• Adult safeguarding training at level 2 had been attendedby 79% of nursing staff in the surgical and liver division,against a target of 80%.

Mandatory training• Staff confirmed they completed a range of subjects as

part of mandatory training, with varying frequency,depending on the subject. For example, informationgovernance annually, manual handling once only, slips,trips and falls every three years and venousthromboembolism once only.

• Wards held training records that indicated the individualstaff who had completed training. The records alsoindicated training that was due to expire and those who

were out of date or had not completed their training. Allwards had gaps of varying degrees. For example, KinnierWilson Ward had staff who were out of date with trainingin moving and handling, information governance,resuscitation and safeguarding. Staff on MatthewWhiting Ward and Katherine Monk Ward were out ofdate with training regarding information governance,resuscitation and end of life care.

• Mandatory training information supplied indicated abroad range of subjects covered, including health andsafety, moving and handling and resuscitation. Targetattendance rates were set at 80% and we saw that, inmost subjects, this target had not been achieved in theliver, renal and surgical directorate. For example,resuscitation training had been attended by 74% of staff,moving and handling by 66%, health and safety by 79%.

Assessing and responding to patient risk• Nursing staff undertook a range of patient observations

and recorded physical measures as part of an earlywarning score monitoring system. Recordings wereentered into an electronic tool, which calculated theresults so that any negative changes within a range ofparameters prompted staff to raise an alert. Staff told usthey called medical staff and that they were veryresponsive to requests to review patients whodeteriorated. We were also told that the electronicsystem enabled medical staff to see the results directlyand they were able to respond occasionally, even beforecalled.

• Safety briefings took place as part of the staff handoverbetween changes in shifts. Information regardingpatient condition and particular risks was discussed.

Nursing staffing• Clinical staffing on wards and in theatres was managed

in a manner which minimised risks to patients,particularly where there were vacancies or staffabsences.

• Each ward area we visited had an identified member ofstaff taking charge of the ward. Optimum staffing levelswere displayed on wards, with the number of qualifiedstaff and healthcare support workers on each shift. Wesaw actual staff numbers displayed, which indicated ifthe optimum levels were being met or not, with staff topatient ratios stated on some areas. For example, wesaw on Katherine Monk Ward, they were short of ahealthcare support worker on the early and late shifts ofthe 13 April 2015. On Trundle Ward the optimum levels

Surgery

Surgery


had been met for the days of our visits, based on havingfour trained nurses on the early and late day shift andtwo on night duty. There were two healthcare supportworkers per shift. The ratio of patients to nurse was saidto be 1:5 on days and 1:8 on nights. On Coptcoat Wardthe ratio of nurse to patients was 1:4.

• We reviewed information supplied regarding thenumber of agency nursing staff used on each ward tosupplement substantive staffing. We saw that allsurgical wards relied on agency staff to varying degrees.For example, on Coptcoat Ward, agency use rangedbetween 10% in June, November and December 2014up to 35% in August 2014. Christine Brown Ward used12% of agency staff to support the service in December2014 and used 35% agency in July 2014. Although wewere told on our visit to Kinnier WilsonWard(neurosurgery) that they never used agency staff,we saw from the data supplied that Kinnier Wilson Ward,along with Matthew Whiting Ward (orthopaedic andgeneral) were noted to be the most dependent onagency staff, with figures frequently above 20% of thenursing workforce during 2014.

• Agency staff worked alongside substantive staff, andtherefore had access to support and guidance ifrequired.

• We were told by theatre staff the main theatres at theDenmark Hill site were using regular agency to covermaternity leave and vacancies. Figures supplied to usindicated that the percentage of agency staff usedranged from 3% in October 2014 up to 5% in March2015.

• We were shown the induction documentation, whichwas completed for agency staff working in theatres. Thiscovered, for example: orientation to the environment,emergency equipment and accessing trust policies andprocedures.

• Bank staff, who, in the main, were substantive staff whoworked on their days off, were also used to supplementthe staffing levels in theatres. We saw from theinformation provided, 13% of shifts were filled by bankstaff in November 2014. Duty rotas provided for theatresindicated where bank staff were required to bring thestaffing levels up to the required numbers.

• Use of agency staff to support the day surgery unitranged between 4% in March 2015 up to a maximum of6% in November 2014. Bank staff usage ranged between11% in December 2014 up to 17.5% in March 2015.

• Staffing figures were supplied to us by ward and werebased on bed numbers. Trundle Ward had 28.30 wholetime equivalent (WTE) staff, Coptcoat Ward had 26.49WTE, Matthew Whiting Ward had 40.38 WTE and ListerWard the highest WTE number of 48.82. Specialistnursing made up 11.91 WTE. In orthopaedics there were47.46 WTE and in urology, 13.25 staff.

• Theatre staffing figures provided indicated that inanaesthetics there were 38.90 WTE and recovery had32.45 WTE. There were 146.95 WTE scrub staff.

• Vacancies across the liver, renal and surgical divisionwere 35.92 out of the total number of nurses required.

• We attended a nurse handover from night staff to daystaff on Trundle Ward and found this was a very wellstructured means of communicating patient sensitiveinformation and each patient’s condition. In addition tothis, there was discussion of the ‘big six’ issues, whichincluded, for example: focussing on fridge temperatures,completing new admission documentation andchecking expiry dates on blood bottles.

• Office based handover was followed by bedsidehandover, during which, staff introduced themselvesand updated the electronic patient records. Awhiteboard, placed above the patient bed, was alsoupdated to reflect the named nurse responsible for thepatient’s care during the shift.

Medical staffing• Medical staff skills mix in the surgical divisions was

made up of 39% consultant grade, 53% registrars, 7%juniors and 1% middle grade, the latter of which relatedto doctors who had at least three years as a juniordoctor or a higher grade within a chosen specialty.

• Although the proportion of junior doctors was reportedas being lower than the England average, we reviewedduty rotas provided for the surgical directorate. Theseindicated consultant and substantive doctors by gradecovering the day hours and on-call periods. We sawwhere a locum doctor was rostered, that this wasindicated and generally this locum was the sameindividual, ensuring continuity and familiarity. Therewere identified individuals covering out-of-hoursweekends and nights.

• Figures on the percentage of medical locum use wassupplied to us. These indicated that within the liver,renal and surgical directorate, 4% of the medical staffingworkforce was made up of locums in September 2014and in December 2014, 8%.

Surgery

Surgery


• Handovers took place between outgoing andon-coming medical staff, ensuring the communicationand transfer of relevant patient information.

Major incident awareness and training• A new member of nursing staff said that major incidents

and continuity plans had not been discussed in theirinduction. As a result, they were not aware of whataction, if any, would need to be taken on the ward theywere on.

• There was formal guidance available to staff regardingthe actions to be taken in the event of a major incident.This included the cancellation of elective work toprioritise unscheduled emergency procedures.

Are surgery services effective?

Good –––

There was a lack of understanding regarding the MentalCapacity Act 2005 and Deprivation of Liberty Safeguards.Patients had been assessed, treated and cared for in linewith professional guidance. The majority of patientsreported effective pain management and monitoring ofthis.

The nutritional needs of patients had been assessed andpatients were supported to eat and drink according to theirneeds. There was access to dieticians and the speech andlanguage therapy team. Special medical and/or culturaldiets were catered for. Patient surgical outcomes had beenmonitored and reviewed through formal national and localaudit.

Staff caring for patients had undertaken training relevant totheir roles and completed competence assessments toensure safe and effective patient outcomes. Staff receivedan annual performance review and had opportunities todiscuss and identify learning and development needsthrough this and supervision meetings.

Consultants led on patient care and there werearrangements in place to support the delivery of treatmentand care through the multidisciplinary team andspecialists. There was access to diagnostic services out ofhours.

Evidence-based care and treatment• Information reviewed from data supplied and seen

during our inspection indicated that patients' treatmentand care complied with National Institute for Health andCare Excellence (NICE) guideline CG124, ‘Hip fracture:The management of hip fracture in adults’. Thisincluded, for example, patients being operated on theday of, or day after, admission and having a bone healthassessment.

• We saw, from care records reviewed, and found in ourdiscussion with staff they were following NICE guidanceon falls prevention, the management of patients with afractured neck of femur, pressure area care and venousthromboembolism. The latter included guidancerelated to anticoagulant therapy.

• We observed that patients who had attended apreadmission assessment had preoperativeinvestigations and assessment carried out inaccordance with NICE clinical guidelines. This includedfollowing guidance regarding medicines being taken bythe individual patient.

• There were processes in place for patients receivingpostsurgical care to be nursed in accordance with theNICE guidance CG50, ‘Acutely ill patients in hospital:Recognition of and response to acute illness in adults inhospital’. This included recognising and responding tothe deteriorating condition of a patient.

• Within the theatre areas, we observed that staff adheredto the NICE guideline CG74; ‘Surgical site infection:Prevention and treatment of surgical site infection’,relating to surgical site infection prevention. Nursingstaff followed recommended practice in respect tominimising the risk of surgical site infections. There wasa sepsis pathway to follow where patient needsindicated.

• We noted from the Divisional Effectiveness Report forCritical Care, Theatres and Diagnostics (updatedJanuary 2015) that action was required in respect toadherence with NICE clinical guideline CG65,‘Inadvertent perioperative hypothermia: Themanagement of inadvertent perioperative hypothermiain adults’, which concerned perioperative hypothermia.The report indicated this was in progress and would beachieved by October 2014.

• Within anaesthetics, an audit had been carried out aspart of the Sprint National Anaesthesia Project (SNAP-1).This was done to profile compliance with standards forperioperative care described in the Association of

Surgery

Surgery


Anaesthetists of Great Britain and Ireland (AAGBI)guideline, the Management of Proximal FemoralFractures 2011. The hospital reported mixed results fromthe audit with results below the national average for fiveareas. An action plan had been developed and wasbeing progressed.

• During our observations on ward and theatre areas, wesaw staff were adhering to local policies andprocedures. For example, in respect to moving andhandling patients, infection control and medicines.

• Information provided to us indicated that the traumacentre achieved best practice payment tariffs at level 1between April 2014 and January 2015.

• Staff had access to guidance on theatre activity andusage from the ‘Inpatient Theatre Emergency Pathwayfor Operating Procedure'. The information thereinoutlined the importance of providing a service to allspecialties, as well as supporting the major traumaservice and organ retrieval and donation.

Pain relief• Staff reported that they had access to the pain team, if

required, with direct referrals being made via theelectronic patient record. The response from the painteam was described as quick and they supported staffby making suggestions for helping patients deal withtheir pain. We found there was consideration of thedifferent methods of managing patients’ pain, includingpatient-controlled analgesia pumps. The hipreplacement protocol included directives around painrelief.

• The fractured neck of femur analgesia pathway includedusing the Fascia Iliaca block for pain relief, wherepatients were suitable. Fascia Iliaca block is used for thelocalised administration of pain relief as an alternativeto other pain management methods.

• We observed, and heard, staff asking patients if they hadany pain. We also saw them act on this where patientsindicated they had pain. Pain relief, including controlleddrugs, were only administered after nursing staffchecked patient details against their electronicprescription. Information was recorded directly into theEPR of pain relief given and pain scores as indicated bythe patient.

• We asked patients about their experiences of havingtheir pain assessed and responded to by nursing staff.One patient on Brunel Ward said their pain had been“managed well” overall, but said they had waited over

an hour for pain relief on one occasion, as a strongermedicine was needed and had to be prescribed. Thispatient also said they were surprised that one of thenight staff “seemed irritated by my request for painrelief”.

• Another patient on Brunel Ward said they had waitedeach time they requested pain relief. They confirmedstaff had checked their wrist band before givingmedicines, but also said that staff did not check if thepain relief had worked.

• A patient on Cotton Ward said staff had been responsiveto them when they had pain.

• Patients on Matthew Whiting Ward and Trundle Wardtold us they had good pain management. One patientsaid, “All the time I‘m being asked about pain.” Painrelief was said to be given quickly and that the nurseschecked their name band and date of birth before givingtablets. Another patient on Trundle Ward said they neverhad to wait for pain relief and staff always asked themabout their pain.

Nutrition and hydration• Preadmission assessment of patients included dietary

plans for bariatric and colorectal patients. A patientconfirmed in their discussion with us they had a numberof visits preoperatively in respect to their diet as part ofthe planning for their surgery.

• Patient’s comments on the provision of food variedaccording to their level of wellness and the length oftheir stay. One patient said they had been 'nil by mouth'when the menu selection had been brought, which theywere unable to choose at the time. As a result, once theywere told they could eat there was limited choice.Another patient said, in relation to food, “I waspleasantly surprised and was expecting the worst,”adding, “I had a good choice as a vegetarian.” Food wassaid to have been served well and to have been at agood temperature. A patient on Coptcoat Ward said thefood had been “excellent” and confirmed theirvegetarian needs had been met, with good choice andfood served at the right temperature. Other positivecomments included, “Food is alright, fine, I think, lots ofchoice, served nicely and at the right temperature.”Negative comments included: “Hot food is tasteless andbadly presented.”

• We were told by more than one patient that drinks andsnacks were available in between meals. A patient whohad been in the hospital for an extended period of time

Surgery

Surgery


said they did not like the food as there was a “lack ofchoice, taste and variety”. This patient said they had tobuy their own food and we saw them eating food whichthey had purchased.

• Where patients required intravenous fluids these hadbeen prescribed by the doctor. We observed fluidbalance charts were provided and used by staff tomonitor the patient intake and output. However, thesehad not always been completed as required.

• We observed risks assessments in place for patient’snutritional needs and these had been reviewed as partof the progress reports.

Patient outcomes• Relative risk of readmission performance was reported

to be better than the England average. Informationsupplied for the period of June 2013 to May 2014indicated the risk of readmission for the top threeelective surgical specialties was as follows:neurosurgery 94, urology 91 and general surgery 98. Ineach case, the England average score was 100. Fornon-elective surgery, the one area where there was arelative risk of readmission was in trauma andorthopaedics, which was 11, against the Englandaverage of 100.

• Patient Reported Outcome Measures (PROM) were used.These were responses from a number of patients whowere asked whether they felt things had ‘improved’,‘worsened’ or ‘stayed the same’ in respect to foursurgical procedures. The majority of responsesindicated the surgical areas to be generally in line withthe England averages. The one exception was in respectto knee replacement, which performed less well thanthe England average.

• As a nationally and internationally recognised centre ofexcellence for integrated liver services we saw a reporton the annual report (2013/14) for five-year survivalfollowing transplantation. Between 1 April 2004 and 31March 2014 1,029 transplants were performed atDenmark Hill. Five-year survival rates for adults havingtheir first transplant was seen to be the highestcompared with other centres, at 82%.

• The trust was one of five London trusts awarded theorthopaedic Commissioning for Quality and Innovation(CQUIN) payment framework award for complex hip andknee surgery and revision of hip and knee surgery byNHS England. This is due, in part, to performance in theNational Joint Registry.

• Information on comparative surgical outcomes,submitted for the National Joint Registry for the period1 April 2014 to 1 July 2014, was reviewed. The datashowed, for example, that the 90-day mortality ratefollowing hip surgery, was based on the type of patientsthe hospital had seen. The national average 90-daymortality rate following primary hip replacementsurgery is around 0.4%. The hospital’s results for hipsurgery did not indicate a higher mortality rate thanexpected.

• The King’s College Hospital (Denmark Hill site) scoredbetter than the England average for eight of the ten hipfracture audit indicators. This included, for example, thenumber of patients having a preoperative assessmentby an orthogeriatrician was being achieved in 75% ofcases, against an England average of 52%. Areas wherethe location did not perform as well included admissionto orthopaedic care within four hours, which was onlyachieved by 37% in 2014, against an England average of48%. The mean length of stay was considerably longer,at 29.2 days, compared to the England average of 19.

• The Denmark Hill site participated in the NationalEmergency Laparotomy Audit 2014. Results from thisindicated a number of policies not being available. Thisincluded, for example: the policy for deferment ofelective activity to prioritise emergencies and a pathwayfor the management of patients with sepsis. The latterhad subsequently been put in place.

• The hospital also participated in a national bowelcancer audit and scored better than the Englandaverage in relation to three areas: 100% of patients hada CT scan reported on and were discussed by themultidisciplinary team, compared with the Englandaverage of 89% and 99% respectively. Overall, 98% ofpatients were seen by a clinical nurse specialist, againstthe England average of 88%.

• The hospital participated in the South East London,Kent and Medway Trauma Network. Informationsupplied to us demonstrated they had contributed datato the ‘Trauma Audit & Research Network’, clinicalreport. This compared core measures for all patientswith thoracic and abdominal injuries and patients inshock. Data had been submitted for the periods 1 April2013 to 31 March 2014 and 1 April 2014 to 31 December2014. As a major trauma unit, the greatest number ofadmissions in all categories were accepted by theDenmark Hill site. In year one of the data collection, 80%of patients were seen within five minutes of arrival by a

Surgery

Surgery


consultant and, in year two, 77% of patients were seenby a consultant. In both instances this was far higherthan other trauma network units. The median time tooperation was noted to be earliest at Denmark Hill: 6.7hours in year one and 11.8 in year two.

• There was evidence that the surgical division followedthe Royal College of Surgeons standards forunscheduled care, which included havingconsultant-led care, prioritising the acutely-ill patientand ensuring that preoperative, perioperative andpostoperative emergencies led to appropriateoutcomes.

Competent staff• Clinical staff told us there was a new system in relation

to the annual appraisals, which was linked to payincrements. On Katherine Monk Ward we were told allstaff that were due to be appraised had been completedwith the exception of one staff member who was on sickleave. There were thirteen appraisal reviews due later inthe year and these had been planned. Coptcoat Wardstaff appraisals were said to be up to date, with theexception of those on sick or maternity leave.

• Nursing staff told us they had a preceptor whosupported them through their initial year afterqualifying. This included sign off of variouscompetencies. A recently appointed member of nursingstaff said they had completed their induction theprevious week. This had been corporate inductionfollowed by a ward-based period where they were notcounted in the staffing numbers. This staff member saidthey had “great mentors”. They also told us they weregoing through a period of preceptorship, which includedcompleting competencies. A study day was attendedevery two months and assessments took place alongthe programme.

• We saw information that demonstrated there wereplanned clinical updates for dates in May, June and Julythis year. Content of these study days covered skillsrelated to life support and infection control, forexample.

• Nursing staff on Coptcoat Ward took responsibility fordesignated areas, such as: dementia, infection control,manual handling and tissue viability. A team away daytook place on an annual basis with band 7 and band 6staff, during which they discussed the link nurse roleand changes in responsibility to facilitate developmentof skills and expertise.

• Ward staff told us they had regular supervision and hadpractical training during the course of their work. Weobserved teaching taking place in the DSU theatre andin various multidisciplinary team meetings andhandovers.

• In main theatres, anaesthetic staff said they had limitededucational and training opportunities once theycompleted their formal anaesthetic course. A memberof staff who worked in both scrub and anaesthetic rolesinterchangeably said their depth of knowledgeregarding surgical specialties was not as good as theywould like, due to inconsistencies in practice.

• Staff undertaking adaptation training in theatres so theycould be band 5 staff, said they had gained a lot ofexperience and were working through variouscompetencies under the supervision of staff.

• Information from the revalidation team indicated thatthere were 137 doctors due for revalidation and 87 whowere not due for revalidation. The number of doctors atthe Denmark Hill site who had been revalidated wassaid to be 30.

• Medical staff reported having had an annual appraisaland that their job plan was reviewed yearly. Theappraisal process was recognised as a positiveopportunity to have a “two way conversation betweencolleagues”. One member of medical staff said there washuge support for medical staff who wished to undertakeresearch.

• Information on comparative outcomes by clinician forneurosurgery and orthopaedic specialties was reviewedon the NHS choices website and we did not identify anyconcerns.

Multidisciplinary working• We observed high levels of positive engagement

between members of the multidisciplinary team. Thisincluded active working on ward areas and participationin multidisciplinary team meetings. We saw wardrounds taking place on, for example, the trauma wardround, which was attended by doctors, physiotherapistsand nurses. Similarly, the ward round on KatherineMonk Ward was multidisciplinary with the presence ofthe physiotherapist. Ward rounds provided anopportunity to review each patient and discusstreatment, progress and discharge arrangements. Therewas good input from all members of themultidisciplinary team.

Surgery

Surgery


• We attended the trauma multidisciplinary teammeeting, which took place at 8.30am daily. This wasattended by 13 staff, including the major traumaconsultant, consultant radiologist, general surgicalconsultant, a trauma fellow who was a senior specialistregistrar (SpR), trauma nurses and the local traumatherapist. In addition, there were representatives fromsurgical specialties. Discussion took place around anumber of patients who had been admitted through theurgent care department and any problems highlighted.The meeting was well run and included contributionsfrom all staff.

• The lead nurse for trauma was a nurse consultant anddemonstrated a passion for the service, staff educationand networking with the South East London and Kentregion.

Seven-day services• There was provision of emergency theatres out of hours.

For cardiac and neurosurgical cases there was anon-call scrub team and anaesthetic practitioneravailable. Orthopaedic, musculoskeletal and trauma aswell as maxillofacial was delivered by the emergencyconfidential enquiry into patient outcome and death(CEPOD) team, with additional support from an on-callspecialist orthopaedic practitioner.

• Out-of-hours physiotherapy was provided between thehours of 4pm and 8.30am Monday to Friday and on aSaturday and Sunday between 8.30am and 4.30pm. Aphysiotherapist told us that, when it came to weekendand out-of-hours provision it was done on a prioritybasis only.

• There was 24 hours a day, seven day a week access tointerventional radiology cover for all specialties, whichwas delivered on site. The following medical staff wereavailable to support the service: two radiology SpRs onsite for out-of-hours, on-call consultant of interventionand an on-call consultant for non-intervention.

• An out-of-hours pharmacy service was available as anemergency service only for patients who urgentlyrequired medicines or advice. This was provided by asingle pharmacist who was not based on-site, but whocould be accessed via the main switchboard at King’sCollege Hospital through a senior member of staff.

• Patients were reviewed by consultants at weekends andwere contactable out of hours. This was importantfor first year doctors, who said they were covering allsurgical patients at night.

Access to information• Staff had access to information through the intranet.

They also received newsletters, copies of which we saw.Staff also attended departmental meetings, whereinformation was communicated.

• Staff told us that audit mornings were used as anopportunity to cover learning and development, as wellas to share information.

• Patients who had attended the preadmissionassessment clinics reported positively on the service.For example, “It was very good, all was explained veryclearly.” One patient said they had been seen by thephysiotherapist, who explained exercises and they alsoattended the ‘escape sessions’ with regards to exercisesas part of the enhanced recovery pathway.

• A patient on Trundle Ward said, “I have had plenty ofinformation and know what is going on.”

• Patients on Brunel Ward told us they had been giveninformation from nursing staff. For example, one patientsaid the nurse had spent a “lot of time going througheverything with me”. They told us they had been seen bythe physiotherapist who had explained the exercisesthey had to follow. This patient also told us they did notget to speak to the doctor until 24 hours after theirsurgery. They were aware of what had been done duringtheir operation to a certain extent, but wanted moredetail and to see their x-rays so they could understandbetter. Another patient on Brunel Ward told us they didnot get much information while in the urgent caredepartment, but had since been well informed. They didsay, however, that there was poor communicationbetween diagnostics and the ward in respect to a scanthey were due to have. They said, “I waited all day onlyto be told I couldn’t have a scan.”

• Other comments included, “Excellent nurses anddoctors who have kept me informed and discussedeverything fully.” One patient said they had been seenby the dietician, who had provided advice to them,which they found useful.

• A patient on Coptcoat Ward said, “Information provisionhas been very good.” They said they liked the‘whiteboard’ above the bed, which, although they hadnot used it themself, they appreciated that they couldwrite on it if they wished to.

• We found there was access to a range of information onthe public trust website. Leaflets were readily available

Surgery

Surgery


in ward and preassessment areas. For example, we sawleaflets on bimaxillary surgery, abdominal aorticaneurysm repair and femoral popliteal distal bypassgrafts.

• Coptcoat Ward had a welcome pack for patients, whichwas commented on positively by a patient. They alsoprovided laminated, double-sided informationdocument. This explained to patients amongst othermatters how they could work the bed, use the call bell,provided information about volunteers and advice onhow they had permission to challenge staff in respect tohand washing. A 'leaving hospital' information leafletwas also given to patients on Coptcoat Ward.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards• We noted patients who had a surgical procedure had

completed a formal consent record and a copy had alsobeen given to them to retain. We noted that informationrecorded on consent forms often containedabbreviations and jargon, which we were unable todecipher and which patients may not have understood.

• Patients told us they had been given information aboutthe benefits and risks of their surgery prior to signing theconsent form. They also told us staff explained aspectsof their treatment and care and sought their consentbefore proceeding. One patient who had been admittedas an emergency confirmed the consent process hadincluded the fact that the surgeon did not know exactlywhat would need to be done until they explored theoperative area. This patient added, “I was seen by theanaesthetist who was especially comforting andexplained about the anaesthetic and the risks.”

• A patient on Coptcoat Ward told how they had beenseen by medical staff and their operation had been fullydiscussed in respect to consent. Further discussion hadtaken place the following day to make sure that, “[Thepatient] hadn’t changed [their] mind or had furtherquestions.”

• However, a patient on Katherine Monk Ward told us thatwhile they were on Twining Ward staff proceeded towash them, even when they had not given their consent.

• There was a limited range of understanding about theMental Capacity Act 2005 and Deprivation of LibertySafeguards amongst the nursing and theatre staff. Moststaff below band 7 could not answer questions aboutthese areas. Higher grade staff had a betterunderstanding. Staff who were able to respond to our

questions about mental capacity said they were able tomake a direct referral to the respective teams. They saidthey would involve the patient's next of kin regardingconsent where an individual had difficulties associatedwith mental capacity. They were aware the family couldnot sign consent on the patient’s behalf.

• Training figures supplied to us indicated that there wasa target of attendance was set at 80% with regards tothe Mental Capacity Act 2005. The figures indicated forthe liver, renal and surgical directorate that 525 staffneeded to complete this training and 181 had done so in2014/15. This represented 34% of the total. We saw fromward-level information provided to us showed gapsrelating to Mental Capacity Act 2005 training. Forexample, on Matthew Whiting Ward, this once onlytraining had not been completed by 17 out of 39 staff. Ofthe 33 staff on Kinnier Wilson Ward, nine staff had notattended this training and on Katherine Monk Ward, 25staff out of 45 were yet to complete the training.

• Regarding theatre staff attendance at Mental CapacityAct 2005 training, 125 of the 373 staff required to attendhad done so in 2014/15. This represented a total of 33%.

Are surgery services caring?

Good –––

Feedback from patients was overwhelmingly positive whenit came to the quality and standards of care they receivedfrom doctors and nurses. Patients reported that theirprivacy and dignity was respected and they were involvedin decisions about their treatment and care.

We observed, and heard, staff treating patients courteously,with respect and professionalism. Staff were kind andcaring in their dealings with patients.

Patients reported that their relatives and those closest tothem were involved and kept informed as much as theywished them to be.There was access to counselling andother services where patients required additionalemotional and psychological support.

Compassionate care• The NHS Friends and Family Test response rates

achieved at Denmark Hill location were above theEngland average. The response rate was 42% and thiscontributed to a 40% trust-level response, against the

Surgery

Surgery


England average of 32%. The scores for all wards werealso, generally, very good in November 2014 and we sawupdated results on some of the wards visited. Thisincluded a score of 97% on Trundle Ward for February2015. We saw ‘How are we doing’ comments, whichindicated they did well at caring and not so well withregards to patient bed moves. On Kinnier Wilson Ward,Coptcoat Ward and Katherine Monk Ward, 100% ofrespondents to the NHS Friends and Family Test inFebruary 2015 said they recommended the hospital.Slightly lower scores were achieved on Lister Ward andMatthew Whiting Ward.

• Patients who spoke with us were satisfied with theprovision of care and the manner in which they weretreated by ward and theatre staff, although one patientsaid, “Some nurses were better than others.” Commentsmade included the staff being, “Very good regardingrespect and dignity,” and, “Staff have been considerateto my needs.” One patient said the staff had been “verycalm” when dealing with another patient who waschallenging. Theatre staff were said by one patient to be“Great, jolly in approach, which dispelled any fears.”They also said they were professional and, “I felt I was inthe right place.”

• A patient who spoke with us on Katherine Monk Wardreported that when they were on Twining Ward, whichthey had moved from, staff were “rude and did whatthey wanted to”. They said they were woken up between5am and 6am so staff could attend to their needs, eventhough they did not want this at that time.

• One patient said it had “all gone as planned, perfect,"and added that, regarding being treated with dignityand respect, “Definitely, they have done their best.”Another patient said they had always been treated withdignity and respect and, as far as possible, staff affordedthem privacy.

• A patient on Trundle Ward said the care had been“Excellent” and “better than before.” When asked inwhat way was it better, they said staff on this occasionhad been more caring, both on days and nights. Thedoctors were described by this patient as being: “Veryunderstanding and they do more than is expected.”Another patient on this ward said, “I think it iswonderful, everyone is so kind.” They added that theyfelt well cared for.

• Other comments from patients included, “Absolutelywonderful, wonderful nurse and nothing is too muchtrouble.” On Coptcoat Ward, a patient said they had

been, “Genuinely impressed, staff are absolutelysuperb.” They added that, regarding respect and dignity,staff had been discreet in their questions and ensuredtheir privacy. Another patient on this ward said, it hadbeen, “Amazing, the quality of the ward, space,environment, happiness of staff and general level ofcare.”

• A number of patients on Kinnier Wilson Ward andMatthew Whiting Ward confirmed that their individualcare needs had been met and that they felt safe andhappy about the care provided.

• Patients told us the nursing staff came to the bed tohandover between shifts and they were made aware ofthe nurse who would be responsible for their care. Wewere able to observe a bedside handover, which tookplace between off-going night and on-coming day staff.The communication was informative and includedintroductions and brief discussion with the patient.Patients were addressed by their preferred name andstaff spoke with them in a respectful and professionalmanner, using humour, where appropriate.

• Patients reported the hardest thing about their stay wasthe noise at night. They did tell us and we saw that earplugs had been provided to address this. Eye maskswere also provided to reduce disturbance.

• A long stay patient described having moved wards onnumerous occasions so they could have a side room.Overall, they said, “Staff here are quite good and arelovely, although temporary staff not so good.” Whenasked in what way they were not so good we were told,“They take a while to come and don’t see much of themespecially at night.”

• Overall, patients reported being happy and said theywould recommend the wards they were on and thehospital.

• We made many observations of staff interactions withpatients across all areas visited. Staff were seen to becourteous, attentive and kind in their approach. Patientswere not hurried for example, when we saw aphysiotherapist walking a patient on the corridor, themanner in which they provided support was very caringand encouraging.

• We also followed a patient from the ward area throughinto theatre in the day surgical unit, having gained theirpermission. We observed staff to be respectful of thepatient’s choice not to know too much detail about theiroperation, but at the same time to make sure safetychecks were carried out. The patient was treated in a

Surgery

Surgery


calm and respectful manner by all staff and time wastaken to explain procedures once in the operating room.At all times staff made sure the patient’s dignity wasrespected.

Understanding and involvement of patients andthose close to them• Patients reported that they felt involved in decision

making around their treatment and care and, whererelevant, family or next of kin were included too. Onepatient explained how they had been seen by thephysiotherapist every day and how they had been“taught a lot”. Another patient said, “My wife, son anddaughter have been involved.”

• A patient on Coptcoat Ward said their partner had beenable to ask questions and was kept informed about theirtreatment and care. Another patient on Trundle Wardcommented on the improved level of communicationfrom the previous time they had been in the hospital.They said the level of “education provision” was muchgreater.

• ‘How are we doing’ comments on Coptcoat Ward forMarch 2015 indicated the results to be above thebenchmark except in regard to question: ‘Patients beinginvolved as much as they wanted to be in decisionsabout their care’, where they scored slightly under the 85benchmark.

Emotional support• There was access to a range of clinical nurse specialists,

including the stoma nurse who was said to reviewpatients prior to surgery. The enhanced recovery nursealso saw patients prior to their joint replacement,advising on, for example, pain control. There was accessto tissue viability nurses, diabetic expertise andoncologists for the provision of expert advice andsupport.

• We saw information was displayed in areas indicatingthere was access to chaplaincy.

• Patient admission assessments included informationabout their psychological wellness and any previousissues, which would need to be considered within theirtreatment and care. Staff also said they observedpatients for signs of depression.

• The involvement of the psychiatric and social careteams was found to be very good, with the formerpresent and reviewing a patient during our visit toKatherine Monk Ward.

• There was access to the renal counselling andpsychotherapy team. Breast care nursing staff provideda counselling service to women with breast-relatedproblems. Patients requiring additional informationabout their medicines could also be referred to themedicines counselling service. Regarding retrievinglivers and providing a donor organ, there was access toan appropriate counselling service.

Are surgery services responsive?


Referral-to-treatment times were sometimes not being metin a number of surgical specialties. Surgical procedureswere sometimes cancelled and not always rescheduledand undertaken within 28 days. Theatres were not alwayseffectively utilised and this impacted on performance.

Patient flow through the surgical services was limited bythe availability of beds, which was linked, at times, todelayed discharges. The individual care needs of patientswere fully considered and acted on by staff. Arrangementswere in place to support people with disabilities andcognitive impairments, such as dementia. Translationservices were available and information in alternativelanguages could be provided on request.

The complaints process was understood by staff andpatients had access to information to support them inraising concerns. Where complaints were raised, these wereinvestigated and responded to, and where improvementswere identified, these were communicated to staff.

Service planning and delivery to meet the needs oflocal people• The majority of surgical activity at the Denmark Hill site

was a day case at 53%, elective surgery contributing27% of activity and emergency procedures 20%. Generalsurgery accounted for 22% of work with trauma andorthopaedic and ophthalmology both 15% respectivelyand other procedures were 48% collectively.

• The Denmark Hill site was also recognised, bothinternationally and nationally, as a centre of excellencefor managing surgical and medical patients with liverdisease.

Surgery

Surgery


• As a member of the South East London, Kent andMedway Trauma Network, the Denmark Hill siteprovided emergency access and treatment to patientswho had major injuries, not only from the local area, butfurther afield.

• Patient needs had been assessed and their treatmentand care was planned, in order that these could be metsafely and effectively.

Access and flow• Access to surgical services was via GP referral, subject to

consultation review or via the urgent care department.Patients who had been referred by the out-of-hours GPreported that the process had been organised well andtheir assessment and subsequent admission via theurgent care department had been managed well.

• There was provision for preadmission assessment and anumber of patients confirmed they had beenpreassessed in one of the formal clinics set up for this.There was an admissions nurse based on Trundle Ward,who started their shift at 7am in order that they couldadmit and prepare patients for surgery. They also had aresponsibility for screening the admission list for thefollowing day and for liaising with patients regardingtheir admission or any delays.

• Patients who met the admission criteria and were notidentified as being ‘at risk’ were treated in the daysurgical unit (DSU). The DSU ran theatre lists on aSaturday in response to demand, which initially hadbeen ad hoc, but were now scheduled routinely.

• Referral-to-treatment time (RTT) performance wasbelow both the standard and the England average sinceApril 2013. Seven of the 10 specialties were not meetingthe standard, including, for example: general surgery,trauma and orthopaedics, urology and neurosurgery.Two surgical areas were meeting the 18-week RTT targetfor the start of consultant-led treatment, which wereoral surgery and plastics.

• More recent figures were provided to us in relation toRTT by month, which indicated fluctuations. Forexample, in December 2014, we saw the RTT wasachieved in 70% of general surgical patients, in 83% ofurology patients, 71% of trauma and orthopaedicpatients and 97% of oral surgery patients. Specialtieswhere the RTT was less well achieved included:neurosurgery at 56% and cardiothoracic surgery at 37%.However, in the February 2015 figures, only oral surgeryachieved above 80%.

• One surgical patient who spoke with us told us they hadnot been booked in for their treatment within the18-week target and they waited an extra month.

• There had been a big increase in cancelled operationssince October 2013, both in terms of numbers andpercentages. The number of patients not treated within28 days of a cancelled procedure for the trust indicateda higher than England average over the period October2013 to September 2014. Between January and March2014, 92 patients had their operations cancelled andwere not treated within 28 days. Figures related to theDenmark Hill location indicated there had been 18cancelled surgical procedures, which were not treatedwithin 28 days between the periods of April 2014 toMarch 2015.

• Information provided to us indicated that 13 patients inFebruary and 18 patients in March 2015 had theirsurgery cancelled, as emergencies took priority.

• We asked nursing staff about the cancellation ofpatients through the DSU and were told cancellationsusually happened because patients did not attend. Theyself-cancelled, were not medically fit, or had not fasted.We were told data for cancellations was not alwaysaccurate because of communication problems. For theweek of the 13 April 2015 up to our visit there had beenfour cancelled operations on the 13 April, two on the 14April and five on the 15 April.

• Between the periods of June 2013 and July 2014, thelength of stay (LOS) at site level was as follows forsurgery: the top three elective patients havingneurosurgery stayed an average of 5.9 days againstEngland average of 4.1. In trauma and orthopaedics(T&O) the average LOS was 4.3, compared to theEngland average at 3.5 days and hepatobiliary andpancreatic surgery patients stayed on for an average of8.5 days, against the England average of 5.8. Fornon-elective work LOS was higher in general surgery,T&O and neurosurgery.

• Delayed discharges were associated with arrangingrehabilitation and social care needs, which could notalways be arranged or funded in a timely manner.

• Readmission rates for the Denmark Hill locationregarding elective and non-elective surgery were lessthan the England average in all specialties, with theexception of non-elective trauma and orthopaedics,which were slightly above the England average.

Surgery

Surgery


• Theatre utilisation for the periods of October toDecember 2014 was provided to us. The utilisationrange for all theatres on the Denmark Hill sitevaried between 66.4% at the lowest (theatre 12) up to94.3%, (neurosurgery theatre 2).

• We observed from patient records reviewed thatdischarge planning commenced as early as possibleand involved the multidisciplinary team. We saw too,from recorded information and heard informationdiscussed in board rounds about patient needs ondischarge, progress with making arrangements. Thisincluded the provision of equipment, social support orrehabilitation beds.

• Nursing staff told us there was a discharge coordinator,who concentrated on the more complex discharges.This included liaising with social services and workingwith the physiotherapy and occupational therapyteams.

• Patients told us they were involved in discussionsaround their discharge. For example, a patient onTrundle Ward said they were in the process of discussingtheir discharge and they had seen the physiotherapistsand occupational therapists with a view to ensuring theywere safe to go home. Another patient on this ward saiddischarge planning had included arranging theirmedicines and follow-up appointments.

• Other patients confirmed, in their discussions with us,that there were arrangements taking place foradaptation of their home environment in preparationfor leaving hospital. One patient said they were waitingto see the occupational therapist in regard to theinstallation of rails in their toilet.

• A patient from another ward said their discharge hadbeen delayed, as they required a rehabilitation bed andthis could not be funded at the time. This had resultedin a lengthy hospital stay.

• Discharge arrangements included provision ofinformation to patient GPs and community nurses,where relevant.

• The Denmark Hill site scored better than the Englandaverage for eight of the ten hip fracture audit indicators.This included, for example, 76% of patients having theirsurgery on the day, or day after admission, against anEngland average score of 74%.

• Surgical outliers were identifiable through the bedmanagement system. We saw there was a pathway inplace for the management and repatriation of surgicalpatients who were on wards outside of the specialty.

Meeting people’s individual needs• During our visit, we found that there was single-sex

accommodation on the surgical wards.• The day surgical unit (DSU) environment was not

particularly spacious in the ward and recovery area. Thismade it difficult to afford patients privacy, although staffdid their best by closing curtains and speakingquietly. Staff did, however, make sure there wereseparate days for male and female patients attendance.

• Nursing staff told us that, where an interpreter wasrequired, this was identified at preassessment andarrangements would be made in advance of the patientbeing admitted for their surgery.

• Nursing staff told us they would be made aware if apatient with learning disabilities was being admitted forsurgery. They described providing ‘normal’ care to theindividual, but took into account any specific needs,which would be identified in their ‘Health Passport’ orby carers and family. With respect to day surgical unitpatients staff told us the individuals carer couldaccompany them into the anaesthetic room and also inrecovery post-surgery.

• Patients who had additional needs associated withliving with dementia were identified to staff by the useof a small blue flower sign. Staff told us there was adementia team who assessed patients in order toensure that specific needs were addressed. Staff alsosaid as part of their observations they monitored patientfor signs of delirium, depression and dementia.

• A healthcare assistant gave an example of the actionstaff took to ensure a patient who was deaf receivedinformation in a suitable manner. This included carefulpositioning to facilitate lip reading and the provision of awhiteboard for writing more complex information on.

• A registrar told us that it was easy to transfer patients todifferent surgical specialties where the needs of thepatient indicated this.

• We heard information during the patient boardhandover, which alerted staff to patients who needed tobe supervised when mobilising. We heard too thatspecific needs of individuals were discussed in terms ofplanning for discharge home or for ongoing care.

• We observed that there was a range of cultural andmedical-related diets available for patients to choosefrom. For example, low fat, kosher, halal, diabetic, veganand African or Caribbean main courses.

Surgery

Surgery


• Information about the food services was visible on somewards we visited and we saw signage that indicated thatmenus could be translated into alternative languages ifrequired.

Learning from complaints and concerns• Clinical staff were aware of the complaints reporting and

investigation process, although there was a generalfeeling from staff that they did not get many complaints.

• A complaints procedure leaflet was available in areas,which provided information to patients about theprocess.

• We saw information about the Patient Advice andLiaison Service was available to patients. However, anewer member of nursing staff did not know what thePatient Advice and Liaison Service was.

• A patient on Coptcoat Ward said they had been giveninformation about complaints and added that theywould speak to the person in charge if they needed toexpress a concern.

• Complaints data was collected by the surgical divisionand we saw that, in the December 2014 data, there hadbeen five complaints and seven for November 2014, oneof the latter of which had been classified as‘high-severe’. Three of the responses to the Decembercomplaints had not been managed within the 25working days and indicated a 'red' status for patientexperience on the surgical directorate performancemetric. This indicated that the performance was lessthan expected.

• The surgical directorate performance metric alsoincluded information on complaints by month. Figuresfor January and February 2015 indicated there had beenfive complaints in each month. This was rated as a'green' status, indicating they were doing better on theoverall trend.

Are surgery services well-led?


Senior leaders understood their roles and responsibilitiesand were committed to overseeing the standards of serviceprovision in all surgical areas.

The senior leaders of the surgical divisions had a cleardirection of focus underpinned by the values of the trust.Work was in progress on developing the surgical

directorate strategic aims and principles, with a draftprepared for liver services. Work was required to cascade tostaff the strategic objectives to enable these to come tofruition.

Robust governance arrangements were in place to monitor,evaluate and report back to staff and upwards to the trustboard. The surgical directorates identified actual andpotential risks at a service and patient level but did notalways monitor and manage such risks or monitorprogress.

Staff reported positively on their leaders, theirapproachability and support. Staff felt valued, respectedand enjoyed working in the surgical areas. Patients andstaff were encouraged to contribute to the running of theservice, by feeding back on their experiences andexpressing ideas.

The surgical directorate encouraged innovation, learningand continuous development.

Vision and strategy for this service• There was some awareness of the trust’s vision by ward

and DSU staff, although staff could not always state thespecific terminology. Feedback to our questionsincluded the vision being about: “Continuingdevelopment, striving to improve and excellence.” Ahealthcare assistant said the vision was about,"Inspiring others, working together for the community,supporting one another and improvingcommunications." All the staff we spoke with in maintheatres did not have any awareness of the values orvision.

• There was a five year strategic plan in place for the trust,which identified surgical related areas of focus.

• We asked members of the senior medical and clinicalmanagerial team if there was an overarching surgicalstrategy. We were told about and provided with a copyof the ‘Liver Services at King’s College Hospital DraftStrategy Document 2014-2024’. This contained thebroad vision and objectives underpinned by the valuesand culture needed to meet these. On reviewing thedocument, we saw there was extensive informationwhich took account of risks, aims and expectations,along with timescales.

• We were told that each care group had a strategy, with acentral strategy team looking at elective surgery. At thetime of our visit there was no formal strategy in place fortrauma and orthopaedics and we were told, “A

Surgery

Surgery


fundamental decision is needed from the trust boardabout what it wants in respect to elective surgical work.”We were told there had been some development ofoptions, supported by data regarding the acute side. Itwas said there was a clear end point, whichencompassed the management of major traumapatients. We were told that an informed decision on thedirection of travel was awaited and a three point planwas being presented later in April this year to the trustboard. However, staff we spoke with did not have anyawareness of the work taking place to develop thestrategy and we did not see reference to the strategybeing discussed within the board agendas reviewedfor February, March or April 2015.

• We saw a copy of the South East London, Kent andMedway work plan for 2015/16. This included variousworkstreams, which included the Denmark Hill site, alead person responsible and timeframes. We sawupdates had been made on the 6 February 2015.

Governance, risk management and qualitymeasurement• The governance structure in the surgical division

included monthly risk and governance meetings,chaired by the governance lead and attended by thehead of nursing and senior managers. This fed into theDeteriorating Patient Group and Safer Care Forum andupwards to the serious incident committee. The latterwas chaired by the medical director. We reviewedminutes of risk and governance meetings andconcluded from these that there was a process in place,which enabled review of incidents, review of patientsafety reports and the risk register

• We were told the surgical divisions had a strong clinicalgovernance framework, which followed the LondonStrategic Clinical Networks Governance FrameworkToolkit (August 2014).

• Within the renal division, there was a rolling programmeof meetings on Mondays, which were multidisciplinaryand covered business issues and the patient experience.Feedback was said to be given to the respective caregroups. Performance meetings were also held, duringwhich the scorecards were reviewed with relevant leadsand reports were presented to the trust board.

• Medical staff reported receiving regular governancenewsletters and we were told that the nursing staff

tabulated green and yellow incidents for each unit, sothat ward areas and theatres received governancefeedback. We saw such incidents were discussed inminutes of meetings and communications to staff.

• We reviewed the surgical division and corporate riskregisters and saw that potential and actual risks hadbeen identified.

• We reviewed minutes from the surgical safetyimprovement group for March 2015 and saw referenceto the importance of auditing compliance with safetychecks across all surgical areas.

• Staff in the DSU reported their highest three risks asbeing related to unplanned admissions, patients turningup, but not having been booked in for a procedure onthe system and maintenance problems, which weredependent on the estates department.

• Divisional clinical effectiveness reports, led by therespective governance leads provided detailed updates.For example, regarding performance, areas forimprovement, audit and priorities of action. We saw thereport for the Critical Care, Theatres and DiagnosticsReport for 2104, updated January 2015, to confirm this.However, we noted that there was no information toindicate that there was any auditing of compliance withpatient safety checks, despite the risks of adverse eventsoccurring by not adhering to these.

Leadership of service• We observed and heard from members of the leadership

team who spoke with us, demonstrating a passion,commitment and enthusiasm for their roles andtowards the staff and services provided.

• Staff in all areas reported positively on their immediateleadership. For example, staff said they felt “valued,respected and listened to”. A member of ward staff theyenjoyed working at the hospital very much and that itwas “absolutely fantastic”. They said they felt very wellsupported by staff and the leadership and teamworkwas cited as a positive aspect.

• A newer member of staff explained how they had regularcommunication from the hospital prior to commencingtheir role. They said that because of this: “I felt I knewthem before I even got here.” They described the leadersas being very welcoming and supportive. In addition tothis, they said: "They are all very competent in their jobsand lead by example.”

• Matrons were said to have had their responsibilitiesreduced so they could be closer to the patient and

Surgery

Surgery


provide stronger leadership. There was an expectationthat every patient was seen by the ward manager andmatrons went to every area they were responsible forwhen on duty.

• Although some staff said they saw the head of nursing(HoN), they had not necessarily seen the chief executiveofficer (CEO). Staff in the DSU said the HoN sometimescame and spoke at the audit learning days that tookplace. Matrons and the general managers were said tobe “good” and leaders were said to be "open andapproachable". One staff member said, “I like this styleas it is more respectful and makes us willing to domore.”

Culture within the service• We observed that the culture in all areas we visited was

open and included active engagement across the teamand other members of the multidisciplinary workforce.Comments made by staff included having a “feeling offamily, team King's and working together”. In relation tothe culture and what worked well, comments included,“The people, some are phenomenally talented and theyare prepared to work hard,” and, “It’s all about thepatients.” Staff were said to be open and receptive whenthings were not quite so good and there was acommitment to care.

• Staff felt comfortable when it came to reportingincidents and near misses as well as raising concerns.Staff generally felt able to challenge colleagues ifneeded and to put forward ideas. A new member ofnursing staff said their opinion was valued regardingpatient care and this was not disregarded.

• Staff said they enjoyed working at the hospital. Onemember of the medical staff in the DSU said: “Althoughit was a major teaching hospital, it had the atmosphereof a district general hospital.” They added that it was“friendly and welcoming” and they were valued andrespected by staff in what was said to be a “cohesivedepartment”.

• Therapists reported having a good working relationshipwith nurses and medical staff and felt there was goodmultidisciplinary teamwork.

• We saw and heard from staff that there was a culture ofsharing information. Formal communications from theCEO, newsletters and emails provided methods ofcommunication to keep staff updated and informed.

• Staff found there were opportunities for learning on thejob and teaching was actively encouraged.

• The turnover rate of nursing staff in the directorate was15%, up to February 2015.

• Sickness rates within surgical nursing workforce rangedbetween the lowest level of 2.17% in November 2014 upto a maximum of 3% in December 2014. The overallfigure up to the end of February 2014 in the renal andsurgical directorate was 3%.

Public and staff engagement• Staff engagement took place as routine on ward and

surgical department areas, with 'huddle' meetings inDSU and theatres, which allowed staff to put forwardmatters, both positive and negative. Where staffmeetings took place these were said by staff to enablediscussion of issues and sharing of ideas. We saw in theDSU staff area a noticeboard covered in Post-it noteswhere staff had shared their thoughts about threepositive things about the unit.

• The NHS staff survey results for 2014 indicated anoverall score of 3.78, which was above (better than)average for staff engagement, compared with trusts of asimilar type.

• Patient engagement was monitored through thesurgical division ‘heat map’, a copy of which wasprovided to us for the period January to December2014. We saw from this respecting patient responses themajority of outcomes scored above the benchmark.There were, however, areas rated as 'red', particularly inAugust 2014 where questions relating to having theirquestions responded to by nurses and doctors andbeing involved as much as they wished to be indecisions about care fell below the benchmark.

Innovation, improvement and sustainability• The Denmark Hill location was very proud to provide us

with information of their achievements. This includedsetting up the first national training for trauma skillscourse in the country. The course teaches trauma teamskills, trauma networks and hands on clinical skills in amulti-disciplinary course. The course was the first inEurope to teach 'Resuscitative Endovascular BalloonOcclusion of the Aorta' (REBOA) on cadavers'(publication accepted) and was expected to form thebasis of the UK REBOA working group training course. Sofar, over 200 members of the trauma network hadcompleted the course, which takes place twice a year.

Surgery

Surgery


• The Denmark Hill location was said to be the only one inthe UK with a general surgical trauma model and,therefore, they met the design of the new curriculum intrauma surgery. All future trainees in trauma surgerywould be based in general surgery.

• The surgical team told us they had the UnitedKingdom's first SpR in trauma surgery, with 24 hours aday, seven day a week trauma registrar level cover onthe trauma team independent of the surgical registraron call.

• We were told a combined general surgery/orthopaedictrauma fellowship had been approved by the RoyalCollege of Surgeons of England and that this was thefirst fellowship ever in the UK to combine general andorthopaedic training in one post.

• An emergency theatre pathway project had developedfrom the emergency theatre audit in 2013, which hadrevealed poor data availability, due to a paper andwhiteboard based booking system with no standardisedquality control or data collection. An electronic booking

system was implemented in 2014, along with anelectronic emergency theatre board on the electronicpatient record. Data was produced from this regardingtheatre activity and access to the emergency team(CEPOD) during the year. Audit and re-auditing of bothappendectomy and damage control pathways showedimprovements. The appendectomy pathway had beenpresented as a best quality improvement project.

• There was recognition and acknowledgement within thesenior management team that capacity planningneeded to develop further, that a trauma ward wasrequired and the junior doctor’s rota required additionalsupport.

• A copy of the divisional clinical effectiveness report forcritical care, theatres and diagnostics outlined anumber of innovations. This included the new Safety inAnaesthesia and Learning from Incidents (SALI)newsletter. The report also described information thatwas going to be collected respecting enhancedperioperative care for high risk patients.

Surgery

Surgery








Information about the serviceCritical care at King's College Hospital (Denmark Hill site)was described by the trust as having 16 intensive care unit(ITU) neurology beds (Jack Steinberg Ward), 14 ITU medicalbeds (Frank Stansil Ward), 17 ITU surgical beds (ChristineBrown Ward), 15 ITU liver beds (liver intensive care unit -LITU), four high dependency unit (HDU) liver surgery beds(Todd Ward), ten HDU cardiac beds (Victoria and AlbertWard), four HDU renal beds (Fisk Ward ) and 11 HDUneurology beds (Kinnier Wilson Ward). The HDUs weremanaged within the divisional governance structures of thelead division.

Over 2,500 patients a year were admitted to the ITU areaswith increasing admissions in the last five months. Thehospital is also a tertiary service for transplants as well astrauma, so some of the patients admitted were for organtransplants, particularly liver, which made up 249 patientsin 2014/15. However, we found that the ITU beds weremore used as general ITU beds that mostly specialised inliver and neurology/neurosurgery in two units. We visitedall these areas, plus where level 2 patients were beingcared for in obstetrics.

We spoke with over 15 patients, families and friends, over90 members of staff, including: nurses, doctors, alliedhealth professionals (including pharmacists andtherapists), administrative/clerical/ancillary staff, iMobilestaff (who provided the critical care outreach service), theliver transplant coordinator team, as well as clinical and

managerial leads. We also checked over 25 patient recordsand 25 pieces of equipment, observed care, and reviewedhospital and stakeholder records such as policies,procedures and audits.

Criticalcare

Critical care


Summary of findingsAlthough the critical care service at the hospital hadpositive patient feedback, produced better than averageoutcomes for patients, were involved in innovativepractice and treated highly complex patients, due to itstransplant and trauma services, there were fundamentalareas of the service that required improvement.

Although there was work in place to build a new set ofcritical care units, current facilities were not adequate,with a lack of bed and storage space. There was a lack ofbed capacity and a lack of infection control facilities.Some of the HDUs did not always meet patient to nurseratio standards.

Medicines management was not appropriate in anumber of areas, particularly storage. There was a high,but improving rate of pressure ulcers. Patient recordswere not always complete, although there were alsoplans to improve this via a new electronic system.Mental Capacity Act 2005 awareness and recording wasnot always in place. There was multidisciplinaryworking, but it was not taking place across all the staffgroups. Governance arrangements were fragmented.

There was an innovative iMobile service (who providedthe outreach service), patient outcomes were betterthan peer services, incident reporting and learning wasin place, patient harms were mostly well managed,public engagement was proactive, and staffdevelopment was positive.

Are critical care services safe?


The critical care service did not meet basic safety standardsin some areas, particularly on some of the HDUs. The liverand renal HDUs did not always meet patient to nurse ratiostandards. There was a high number of acquired pressureulcers in the ITUs, although this was on a much improvedtrend. Infection control guidance was not always compliedwith, particularly regarding hand washing sinks, personalprotective equipment, colour coding and facilities.Equipment was stored inappropriately in a number ofareas. Medicines management was not always appropriate,particularly relating to intravenous fluids and storage.Patient record completion was not always complete inareas such as nursing assessments and signatures.

However, incident reporting and learning was mostly wellembedded, with improving audit results as a result ofchanges. Medical staffing levels were mostly appropriate.Safety thermometer results in areas other than pressureulcers were very positive. Management of deterioratingpatients was well established, with a clear process andactions. Plans in the event of a major incident wereappropriate.

Incidents• One surgical never event occurred in critical care in

November 2014 with regard to retention of a wirefollowing the insertion of a femoral vein line. No furthernever events have taken place since November 2014.The Trust told us that staff had been made aware of thisincident through teaching, procedures to prevent it inthe future were put in place. In addition to the standardline audit, a further audit was initiated to assesschanges in practice. The audit started to showimprovements with documentation completion overallimproving from 78.5% to 88.1% over a four monthperiod although sometimes the lack of recording wasdue to other areas of the hospital. Particular areas thatstill required improvement were documenting theassistant name (54.7% completion) and recordedwitnessing of the guide wire being removed (54.7%completion).

• There had been two reported serious incidents sinceFebruary 2014, categorised as one delayed diagnosis

Criticalcare

Critical care


and one suboptimal care of a deteriorating patient. Onewas where the medical registrar did not escalate adeteriorating patient and another where a patient wasnot well managed on non-invasive ventilation (NIV) priorto discharge, so they were readmitted and subsequentlydied. There had also been a necrotic pressure ulcer postsurgery in critical care. The deteriorating patientincident investigation showed there was no concernwith the treatment given, as the patient being intubatedhad an impossible airway to intubate. Nonetheless,signs were put up in bed spaces regarding sedation andairway procedures. The learning after the NIV dischargewas also appropriate as, although the root causereported it was due to known complications postprocedure, learning was identified in cardiology to setup a working group for discharge and to ensureconsultants reviewed a patient to prevent them beingdischarged too early.

• There had been a number of amber (moderate harm ornear miss incidents that warranted a root causeanalysis) reported in critical care. These included: a lineremoval causing a patient to have a haematoma whichon investigation was escalated to the medical team atthe time, reviewed by medic and pressure applied. Thetrust told us the patient was discharged to the wardbecause of the need of admitting a new levelthree patient and the patient was handed over to theward where the patient was managed and reviewed bythe iMobile team, the patient was treated with a unit ofblood on the ward. Another amber incident was where aprescription of penicillin (tazocin) was written althoughthe patient was allergic to it, the allergy status was nottransferred from the old to the new drug kardex and thejunior doctor did not challenge the consultants’instructions who was unaware of the allergy. There hadbeen a number of infection incidents where goggles hadnot been worn by staff although the trust told us theequipment was available on all occasions.

• On LITU, incidents included delays with cleaning and anumber of medicines safety incidents, so a risk reviewwith pharmacists had been completed. However, sinceiMobile had been introduced, there had been a reducedamount of incidents occurring across the hospital.

• Minutes from the risk and governance meetings showedthat there was a high amount of medicine incidents inthe directorate that included critical care, mostlyrelating to morphine. These minutes showed there was

confusion on signing of controlled drugs, so the servicearranged training and developed a new policy toaddress this. There had also been two systems for bloodtags in LITU so the service aligned them.

• In December 2014, there had been seven health andsafety incidents, but zero amber and above incidents inthe directorate.

• Staff at all levels in most ITUs were able to tell us how toreport an incident and told us they received feedbackboth on individual incidents they reported and onincidents that affected their unit with learning shared athandovers. Briefings were sent out by each unit, whichincluded highlights of learning from incidents eachmonth. Staff understood their responsibility under theDuty of Candour regulations and we saw examples ofthe correct process being followed. Drop in sessionswith governance managers took place regardingincident reports. The HDU senior staff said they hadmonthly meetings discussing incidents. Medical staffhad brief safety meetings before their handovers.Pharmacists were able to give examples of learning fromincidents, such as when there had been issues withmedicine infusions. Folders of incidents were kept onthe units. A risk nurse was in place for the ITUs whoattended a forum regarding root cause analysis intoincidents. A team day regarding risk was also held oncea year.

• However, we were concerned that staff in some of theHDUs and one ITU were not as aware of incidentlearning and did not receive feedback, particularly onFisk Ward.

• Staff told us mortality and morbidity meetings tookplace once a week and were informed by a deceasedpatient summary. The trust told us patient notes andother documents were also reviewed.

Safety Thermometer• There were 59 pressure ulcers reported since December

2013 (variable month to month) in critical care. Therewere five pressure ulcers and one deep vein thrombosis(DVT) on Kinnier Wilson Ward reported since October2014. Frank Stansil Ward had 22 pressure ulcers and zerofalls last quarter with 13 grade 3 and ten grade 1pressure ulcers in the last year – mostly nose and earpressure ulcers. Christine Brown Ward had 23 pressureulcers and zero falls. Nine were grade 1, 13 grade 2 and

Criticalcare

Critical care


one grade 3 pressure ulcers. These were mostly locatedon patient lips and nostrils due to nasogastric (NG)tubes. Jack Steinberg Ward reported 12 pressure ulcersand zero falls.

• The ITUs were trialling new full/total face masks forcontinuous positive airway pressure (CPAP) and new NGtube tape to reduce the amount of ear and nosepressure sores, but staff told us the main reason for theincrease of pressure ulcers was due to the amount ofpatients over winter who had a high length of stay.

• The trust told us that a flow chart was in place to guidestaff to when to use pressure relieving devices; howeverstaff raised concerns that pressure reliving mattressesmay not be used early enough and that there were notenough mattresses and cushions. Records showedcritical care units were adhering to best practice toreduce the amount of acquired pressure ulcers and toimprove pressure management of those patients whoalready had them, such as using gel padded devices.

• Senior nursing staff told us all patients with pressureulcers were reviewed by tissue viability nurses (TVNs)and discussed pressure area management at a SaferCare Forum. A pressure ulcer group also reviewed allpressure ulcers that had been acquired, to share anylearning. There had been a noticeable decline inacquired pressure ulcers since nurses stopped rotatingbetween units although it was not clear this was thereason for the decline. TVNs were available and we weretold they responded immediately when referrals weremade to their service. However, we were not told aboutTVNs on all units.

• There had been seven falls and nine urinary tractinfections (UTIs) in critical care since December 2013.Neither was currently concerning to staff as incidence ofthese was low. Staff told us that, when there was anincrease in falls, this was raised with staff to try andreduce them. However, the cause of this increase wasusually felt to be a high number of patients withdelirium and agitation.

• Safety thermometer results were displayed in all theunits we visited and discussed at unit meetings. Theseshowed improving results, with a competitive elementbetween the units to have the least pressure ulcers.However, some staff were not aware of the link betweenthe boards displayed and the Safety Thermometerinformation reported. Some band 5 and band 6 nursesdemonstrated a lack of awareness of their areas safetyperformance on the units.

• All patients had stockings and medicines to preventdeep vein thrombosis (DVTs) and we saw no omissionsin venous thromboembolism assessments.

Cleanliness, infection control and hygiene• We observed all but one HDU to be clean with

appropriately-sited hand gel dispensers andobservation of infection prevention and controlguidance, such as hand washing between patients,‘bare below the elbows’ and wearing personalprotective equipment, such as aprons and gloves.Appropriate signage was also displayed on doors orbarriers if a patient was infectious orimmunosuppressed. Equipment was mostly clean andhad been labelled to show they had been cleanedwithin the last 24 hours.

• Some side room doors were left open when patientswere infectious. Some clinical waste bins on Fisk Wardwere left overflowing and we observed a full sharps binon Victoria and Albert Ward.

• There was a lack of side room availability across allcritical care units although this was on the risk register.None of the side rooms were arranged to be negative(no air out) or positive (no air in) airflow which meantthey did not have the correct facility to differentiaterooms between immunosuppressed patients and thosethat were infectious although pressure was higher in thecorridors than cubicles and LITU had filtered air. Staffreported, and we found, patients having to be barriernursed in bays rather than side rooms, with screens inplace on Kinnier Wilson Ward. To mitigate the risk, ahierarchy was in place to prioritise those patients thatshould be moved into side rooms, with patients withdiarrhoea, tuberculosis, influenza, measles and chickenpox regarded as being high priority. In addition, deepcleans were conducted between each patient stay. Ifmore than one patient was infectious in the ward area,those with a similar infection were cohorted together sothey could be treated without being spread with otherpatients.

• There was a lack of bedside sinks in one ITU and twoHDUs as each bed space did not have a sink to handwash. On one HDU, hand washing sinks were not withinpatient bed spaces. We did observe some staff did notwash their hands in some of the HDUs. There was nohand washing facilities at the entrance door to Victoriaand Albert Ward, but hand gel was available.

Criticalcare

Critical care


• Hand hygiene across critical care was at 93.97%compliance, up from 83.82% in May 2014. On LITU, itwas 90.3% in April 2015 and averaged between 92% and95% in previous months. Only one staff member out of15 did not clean their hands in LITU according to a spotcheck audit in April 2015. The hand hygiene audit forKinnier Wilson Ward was 95% and 100% in the last twoweeks. Frank Stansil Ward’s last hand hygiene auditsvaried between 96.3% and 100%. Christine BrownWard’s were 95.5% overall. Jack Steinberg Ward’s were93.1% and 94.7% in the last two recorded months priorto the inspection.

• Critical care had a just better than national average ratefor patients who acquired methicillin-resistantstaphylococcus aureus (MRSA). Each critical care unithad an infection control scorecard which showed trendsand year round results for infections, hand hygiene,cleaning, infection prevention and control (IPC) trainingand documentation. Year to date LITU had zero MRSAs,three cytolethal distending toxins (CDTs), 27vancomycin-sensitive enterococcis (VREs), 15Enterobacteriaceae, 15 resistant non fermenters and tenother acquired infections. Intensive care national auditand research centre (ICNARC) data showed acquiredMRSA rates were better than the national average, Cdifficile incidence was around the national average.Sepsis was improving to better than the nationalaverage. There had been no infection outbreaks in anyof the critical care units. Senior staff were aware therehad been a trend of C difficile appearing, but reportedthat none were attributed to cross contaminationbetween patients, and told us they were mostly likely todo with the lack of side rooms. The same issue wasreported that caused the high amount ofcarbapenem-resistant Enterobacteriaceae (CRE)infections.

• For the other ITUs, ICNARC showed acquired MRSA wasbelow (better than) average after recent variableperformance. Acquired C. difficile had increased(worsened) with a recent slight decrease (improvement).Sepsis was below (better than) average.

• MRSA screening was 100% for elective patients and90.9% for emergency patients. Intravenous (IV) lineaudits were 100% compliant with guidance other thandocumentation completeness which was 91.2%.Antibiotic stewardship recording was 93% for clinicalindication, 87% for recording of the stop and review

date and 100% followed the guideline. Medirestcleaning (a healthcare support service) was 98.3%,nurses cleaning was 93.8%, commode cleanliness was100%.

• The trust WIRED training system showed compliancewith infection prevention and control (IPC) training was75% for nurses, and 51% for doctors across the criticalcare service. On the Victoria and Albert Ward, trainingrates were at 86% for aseptic non-touch technique(ANTT), and 73% for IPC. However the trust told us theWIRED system was not up to date and other figures theyhad showed IPC training at 100% for nurses.

• Continuous central venous catheter (CVC) audits wereundertaken in all of the ITUs on a monthly basisalthough we only reviewed those in three units. Resultsshowed that the last catheter-related bloodstreaminfection (CRBSI) was in November 2014 and there hadbeen a total of ten infections since April 2014 out of9,487 bed days, which was low.

• One HDU unit did not have a sluice, and other sluiceswere located far away from some patient beds meaningstaff had to carry commodes and dirty linen quite far forcleaning.

• There were infection control link nurses for each unit.Microbiology and infection control staff conductedclinical rounds daily, three by a consultant and two by aregistrar. However, staff told us microbiology did nothave routine cover for the HDUs and some staff told usthe IPC team was not very visible. However the Trusttold us microbiology cover was provided to all HDUs bythe microbiology consultant aligned with that specialtyarea.

• IPC meetings took place weekly and monthly andweekly meetings involved microbiology.

• Some staff reported they had not been trained regardingthe Ebola infection although the trust told us coremembers of staff had been trained that had thecompetency to care for patients with Ebola.

• We saw some blood stains, including on the bedsidelinen of a couple of patients, but they were on dialysis atthe time, which meant there was likely to be someblood drips at times.

• Confidential waste bags were in use and, although theywere not always secure, they were located away frompublic areas.

Criticalcare

Critical care


Environment and equipment• Most critical care areas had a lack of space and did not

conform to national standards. Particularly on LITU andTodd Ward, where the lack of space meant only one bedcould be transferred through the corridor at any onetime with a lack of space for staff either side of a bed inthe corridor. As patients were critically ill, we wereconcerned that, in the event of an emergency, if apatient was being transferred through the corridor atthe time, there would be a high risk that both staff andresuscitation equipment would not be able to pass apatient being transferred on the corridor, thus delayingpotentially life-saving treatment. However, no incidentof this kind had been reported by the time of ourinspection. Most of the units did not comply withnational guidance regarding bed space. To reduce theimpact, the units conducted declutter days to ensureequipment was not blocking space and equipment wasmanoeuvred to create space to rehabilitate patients.

• Emergency equipment, such as resuscitation trolleyswere available throughout the units and checks forthese were up to date apart from on Christine BrownWard and Jack Steinberg Ward, where around 10% ofthe checks had not been recorded. However, we wereconcerned there was only one resuscitation trolley on aHDU and this was placed at one end of the unit, whichwas a full length of a corridor away from the other side.The HDUs did not have their own resuscitation trolley,as these were shared with the rest of the general wardthey were on.

• Some oxygen cylinders were stored inappropriately ontheir sides in a room that was not secure on JackSteinberg Ward, and they were incorrectly stored on oneHDU where staff were unaware of whether they were fullor empty.

• We checked a range of equipment, of which a few itemswere out of date, two by over three years.

• IV fluid storage was inappropriate in both Victoria andAlbert Ward and Fisk Ward, where they were stored inopen areas, due to a lack of clinical rooms.

• We were concerned that mobile x-rays conducted in oneof the HDUs did not meet radiation protectionguidelines. Staff told us they were not aware of anyspecific precautions. Todd Ward had identified a riskregarding protection of staff and patients during x-rays,

but there were no plans to address this. However thetrust told us they had reviewed their practice and statedthat they were in line with radiation protectionguidelines.

• There was inappropriate storage of blood gas machineson Christine Brown Ward, as they were in the sluice.There were concerns regarding blood gas machinesbreaking down across the ITUs, however, they were ableto share blood gas machines in the event of oneneeding repair.

• There was an appropriate amount of ventilatorsavailable on the units and these were regularly serviced.They were standardised between the units, so nursesdid not have to be retrained if they were rotatedbetween the units.

• Although the risk register highlighted the lack of scopesas a concern, none of the staff told us this was aproblem.

• Staff reported having good access to technical supportwhen there were problems with equipment. However,this was not available seven days a week.

• LITU environment audits were conducted for nursing,cleaning and estate, which showed mostly above 90%compliance, although the most recent estate result was74.3%.

• LITU staff were concerned by the lack of rehabilitationequipment such as tilt tables and hoists statingaccessing them was “luck of the draw”. However thetrust told us that there was sufficient equipmentavailable which are shared between the units.

• A quality round took place on Kinnier Wilson Ward,which included a check of all the equipment andfacilities, such as the blood gas machine, resuscitationtrolley and oxygen cylinders. Our inspection showedthere were no concerns regarding equipment checks onthis ward.

• Hand rails were in place in bathrooms and all ligatureswere risk assessed, which were mostly graded as ‘lowrisk’ with some graded as ‘medium risk’.

Medicines• Most medicines were appropriately stored and

managed on the ITUs. Medicine fridges on the HDUswere checked and at the correct temperature, althoughone was not locked and one ITU fridge had no record oftemperature checks. Controlled medicines (those thatrequired security) on some of the HDUs wereinappropriately stored. Some medicines were stored

Criticalcare

Critical care


loose and were out of date by up to three months.Medicines were sometimes signed for by initials ratherthan full signatures. Three drugs fridges had the keys leftin their locks. Some non-controlled drugs were notlocked away and, therefore, were accessible tounauthorised persons.

• The controlled drugs policy was up to date.• There was a conflicting message regarding who should

create and retain the lists of authorised signatories formedicines. There was no list of authorised signatoriesavailable in the areas we visited and staff were notaware of who the accountable officer for controlleddrugs was.

• Nursing staff had medicine management training, whichincluded tests on drug calculations and IV fluids.However, medicines training was not always up to date.There was an attendance rate recorded of 27% formedical staff and 92% for nurses at refresher days as itwas not part of the trust's mandatory training and therewere no specific requirements in critical care for it.However, all staff had to pass a medicines assessmenttest before they were able to administer medicines. Noagency staff gave oral medicines unless they wereregularly employed by the trust and would still have topass the competency test.

• An audit showed that critical care met most controlleddrug standards. However, areas for improvement wereidentified on Christine Brown Ward in two areas, FrankStansil Ward in two areas, Jack Steinberg Ward in threeareas, LITU in all but one area and Todd Ward in fourareas.

• In December 2014, an antibiotic audit showed all unitswere 100% compliant with standards.

• IV fluids in most units were not stored appropriately in anumber of areas where rooms were not locked andtemperatures were not controlled.

• There had been a recent increase of heparin incidentson the ITUs, which most staff were aware of. In response,a medicines group was set up with link nurses, whichhad led to improvements and a reduction in theseincidents.

• There was a mix of paper and electronic prescribingcharts and there was inconsistent practice. This had ledto an incident where there was a prescribing duplicationerror.

• We observed that medicines to take home by thepatient were not formally handed over to staff and wereleft on a cupboard in an unlocked area.

• There was a dedicated pharmacist that covered allneurology services, including Kinnier Wilson Ward andthere were pharmacy teams for all critical care areas.

• A recent medicines management audit showed most ofChristine Brown Ward and Frank Stansil Ward werecompliant with guidance, but there were a number ofconcerns in Jack Steinberg Ward, including: a lack ofdocumented reasons for medicine omissions, nursesnot knowing where the medicines management policywas located, and inappropriate drug fridges.

• Allergies were clearly recorded as part of the medicinesadministration record and we reviewed only one recordwhere the medicines administration record did notinclude a patient's known allergy, although it had beenrecorded on the previous chart.

Records• A new critical care patient safety analysis document was

in place on the ITUs. This included assessments inpsychosocial needs, falls, restraint, and actions taken ifa safeguarding referral, Deprivation of LibertySafeguards, lasting power of attorney or best interestassessment was required with relevant guidance andflow charts incorporated as part of the document to aidstaff. However, staff said this still required “bedding in”.There had been no formal programme introducing thenew patient record templates before they were usedalthough it had been brought in a measured way. Thesedocuments were different depending on the HDU.Kinnier Wilson Ward had three separate assessmentbooklets, each differing in recording of assessments.These booklets included some, or all, of the followingassessment criteria: falls, bed rails, moving andhandling, nutrition and Waterlow risk assessment (forpressure sores), swallowing, mobility, breathing,communication, personal care, continence, blood,psychological, pain, social and sleep assessments.

• There was a mix of electronic and paper records in thecritical care units, whereas other wards were fullyelectronic. This meant records changed when patientstransferred to other units and this was causing someconcerns. However, basic information for stepping downpatients was electronic, such as discharge summaries.When we checked the paper records against theelectronic records for when patients stepped down,

Criticalcare

Critical care


there was very little missing information other thansome handovers that were not signed off and onecentral venous catheter (CVC) check had not beencompleted.

• Nursing records were often incomplete in all the HDUsand one of the ITUs, with gaps in recording, such as:comfort rounds, consultant review on admission andreviews of sedation. Some patient records had loose leafsections and some records were illegible. Discussionsbetween relatives and doctors were not alwaysrecorded in the notes. When we spoke with senior staff,no nursing assessments audit had been undertaken toascertain if these were being completed. They felt anyissues would be picked up and corrected through theSafety thermometer, when records were reviewed aspart of mortality and morbidity meetings and on qualityward rounds by matrons. Quality rounds reviewedvenous thromboembolism (VTE), pressure areas,catheters, falls risks, social interaction and the overallnursing documentation, but in a summary way withoutparticular checks, such as legibility, signatures andsome assessments.

• There was 80% compliance with ventilator-associatedpneumonia (VAP) care bundles.

• Electronic notes did not have comprehensive guidanceon how they should be completed. Abbreviations werebeing used, which were not clear or in line with trustpolicy.

• Information governance training was 70% on KinnierWilson Ward and 60% on Victoria and Albert Ward.Critical care mandatory training for health records was64% for medical staff and 88% for nurses. We observedsome receptionists not locking their computers whenthey were away from their desks.

• Most patient records were kept away from public areasand stored either in bedside drawers or behind thenurse’s station.

Safeguarding• According to WIRED, compliance with safeguarding

training on the ITUs was at 65% for level 2 adults (19%for administrative staff, 82% for nurses and 37% formedical staff), children level 2 safeguarding training was85% for medical staff, 89% for nurses, children level 3safeguarding training was 36% for nurses, and notrecorded for medical staff. On Victoria and Albert Wardsafeguarding adults training was 65%. The trust statedthat safeguarding training rates were higher as their

electronic training records system was not accurate.However, staff were aware of how to report asafeguarding concern via the electronic system and whothe safeguarding trust wide team was.

• Each unit had a social worker to refer to if there was asafeguarding concern. Matrons and managers were alsoalerted, so staff were kept informed.

• We saw appropriate examples of safeguarding referrals,but reviewed some patient records where a referral mayhave been needed where the assessment anddiscussion had not been recorded. However staff wereaware of the safeguarding concern and had recordedthe subsequent action electronically.

Mandatory training• Training rates provided to us by the trust via their WIRED

system showed, for critical care, that equality anddiversity was 71% for medical staff and 96% for nurses.Fire was 54% for medical staff and 64% for nurses.Health and safety was 61% for medical staff and 97% fornurses. Manual handling was 27% for medical staff and63% for nurses. Resuscitation was 54% for medical staffand 75% for nurses. However, when we checked thetraining matrixes for the ITUs, they were all at 85% orabove for their overall training rates. Lower rates wererecorded for the HDUs. A lot of staff were not up to datewith their training on Kinnier Wilson Ward, but they hadbeen booked in for sessions. We were informed thepractice development nurses (PDNs) monitored trainingrates and kept staff informed about what training theywere required to complete, or update. The trust told ustraining rates were higher at 85% or above astheir WIRED system was not accurate.

• All relevant staff told us they were trained in immediatelife support (ILS). However, on Victoria and Albert Ward,we were told 80% were ILS trained.

Assessing and responding to patient risk• Early warning scores (track and trigger system to

monitor and escalate patients whose condition maydeteriorate) were recorded on an electronic systemoutside of critical care. iMobile (who provided theoutreach service) were alerted and were able to monitorif patients were deteriorating to the level that theyneeded to review their treatment. All the staff we spokewith praised the iMobile service. They particularlysupported the HDUs for patients that were steppeddown from the ITUs or patients at high risk ofdeteriorating. Any patient potentially needing escalation

Criticalcare

Critical care


of care required a review by iMobile first. The iMobileservice included nurses, an intensive care consultantand registrar during the day and a registrar at night whowas advanced airway trained.

• We observed patients being escalated to iMobile andthe response was immediate. One patient required level3 care, so a consultant from critical care reviewed thepatient and admitted them.

• Out-of-hours access to liver transplant coordinatorswere available in case a patient required urgentassistance.

• Emergency resuscitation simulation training andscreening for dysphagia took place.

• All HDU staff were trained in an ALERT course (amulti-professional course to train staff in recognisingpatient deterioration and act appropriately in treatingthe acutely unwell), which aids staff in managing adeteriorating patient. Staff feedback from this waspositive.

• The hospital audited the ‘failure to rescue/deterioratingpatient’ process, which was where staff had failed toidentify or act on patients that were deteriorating. Itshowed a total of 180 patients had some omissionregarding failure to rescue between February and May2014. 16% cent were not recognised, 13.4% were notresponded to when a call out was made, 9.6% had norecord of deterioration and 8.3% had not beenescalated. However, these errors were reducing monthon month.

• ICNARC records showed iMobile reviewed nearly allpatients stepped down from the ITUs other than fromLITU although the trust told us they reviewed LITUpatients other than those post-transplant. There wasalso a ward round by one of the iMobile nurses once aweek on Kinnier Wilson Ward to review step downpatients. LITU staff were not able to explain why therewas no review after discharge other than the fact thatHDU wards were physically close to LITU, so anyconcerns could be followed up rapidly.

• HDUs had their own track and trigger sheets, which wasa step up in observations from general wards, such ashourly observations with individual checks on all theareas within critical care guidance, such as:responsiveness, movement, blood pressure, respirationand so on. When we checked these, they were mostlycomplete, although some observations were not doneas frequently as required.

Nursing staffing• Christine Brown Ward's establishment was 77.56 nurses

(75.44 were in post), 5.38 HCAS (seven in post) and it wasusing 12% of bank staff. Fisk Ward's establishment was26.23 nurses (22.61 in post), 7.24 healthcare assistants(seven in post) and using 17% bank staff. Frank StansilWard figures showed their establishment as one nurse(none in post), zero healthcare assistants (zero in post)and 3% bank usage. However, seven nurses had startedsince January 2015 and there actual staffing figureswere included within those reported by Jack SteinbergWard. Jack Steinberg Ward had an establishment of172.62 nurses (177.78 in post) eight healthcareassistants (10.77 in post) and using 8% bank staff.Kinnier Wilson Ward had an establishment of 23.11nurses (25.99 in post) 10.2 healthcare assistants (9.5 inpost) and using 29% bank staff. When we inspected,they had two vacancies. LITU had 22% bank staff. Thiswas slightly higher than the 20% guideline for theFaculty of Intensive Care Medicine standards and wasacknowledged as borderline by LITU. On-goingrecruitment was taking place, which included anadditional 20 nurses from the Philippines. Victoria andAlbert Ward had an establishment of 63.7 nurses (48.11in post), 13 healthcare assistants (9.45 in post) and wereusing 14% bank staff, which matched what we were toldby staff, particularly at night where there was a higherreliance on bank staff.

• The usage of agency nursing staff in critical care was3.2%. Vacancies were reported as 0% for technical staff,0% for additional clinical staff, 11.04% for administrativestaff, 16.36% for allied health professionals (AHPs),9.59% for scientific staff, 0.12% for medical staff, and11.17% for nurses. Senior managers estimated therewas around a 5% vacancy rate, with very little use ofagency staff, due to a six month recruitment drive toemploy nurses for Christine Brown Ward when itopened.

• Nurse staffing levels across all the ITUs and all but twoof the HDUs were within national guidance. All the ITUshad 1:1 nursing care for patients. The only patients thatever received 1:2 care were level 2 or below patients. Allbut the renal and liver HDUs had 1:2 care during the day.Records and rotas showed that one unit, which was notat this ratio, had an established ratio of 1:4/5 and theycared for dialysis and confused patients, but not allpatients were level 2. One HDU had a ratio of 1:3 atnight. One ITU was using a high level of agency staff and

Criticalcare

Critical care


one HDU had no supernumerary nurse, but the rest hadlow levels of agency and bank use. We saw one nurse ona HDU caring for a level 2 patient, two postoperativepatients and a patient with 1:1 support by a healthcareassistant (HCA).

• Supernumerary practice development nurses were inplace for each unit. Overseas nurses that were recentlyappointed were initially supernumerary and supervisedfor three weeks before they became part of theestablishment numbers. Other new recruits weresupernumerary for two weeks. Student nurses onplacement were also supernumerary.

• There was not always a supernumerary floating nurse,or healthcare assistant on each level 3 unit, whichmeant that sometimes staff felt stretched, particularlyduring breaks. There was also not always a band 7 nurseto manage the unit at night, though there was always aband 6 nurse and always one band 7 on shift acrosscritical care. If staffing levels were below requirement,taking into account the acuity of patients, they wereable to move staff to other units to fill any gaps.Sometimes the practice development nurse or matronhad to take on a clinical caseload when there was astaffing shortage. One practice development nurseestimated this happened around 30% of the time. LITUassessed that they did not always meet the requirementfor supernumerary nursing staff outside of the clinicalcoordinator at times, due to high patient acuity.

• Extra corporeal membrane oxygenation (ECMO) patientshad three nurses to two patients due to their acuity.

• Matron rounds took place informally, but nothing formalwas in place.

• Nursing staff had recently stopped rotating betweenunits to provide standardisation and consistency ofcare. This also allowed for the units to be more generic,so nurses did not lose their competency for caring forpatients with different conditions. However, there wasan acknowledged concern that this meant the unitscould become specialist.

• Nursing staff undertook two handovers each day. Theseincluded a handover for the whole unit and aone-to-one handover between the nurses looking aftereach individual patient. Handover sheets werecomprehensive and there were full discussions about apatient's social and medical history, the treatment plan,and details regarding current observations.

• iMobile had a high workload from the HDUs, but staffingwas at establishment.

• None of the patients we spoke with reported that therewere delays in receiving support from nursing staff ifthey pressed their call bell, although a minority ofpatients felt there should be more staff.

• Some of the HDUs reported they struggled to recruitband 6 nurses.

Medical staffing• Medical cover for three of the ITUs was within national

guidance. A consultant was on site for each unit everyday and they were on either a four or three-day rota,with 12 hours on site and 12 hours on-call, which hadbeen introduced in March 2013. This was a tripling in thenumber of consultants from a few years ago. Eachconsultant was then on-call during the night andlocated so they could come into the unit within 30minutes. During the day, each unit had at least oneregistrar and two year 2 or more senior doctors with twofloating doctors who worked across the units attachedto iMobile and the emergency and trauma departments.At night, each unit had a registrar on site and there wereregistrars in cardiology, trauma and neurology availableas well as two advanced trainees covering critical careand the emergency department, iMobile and trauma.Job plans were also arranged so the consultants hadenough professional activities to be critical carecompetent, as required by national guidance.

• Critical care doctors were the primary clinicians forpatients on the units, so although they should still beseen by medical and/or surgical doctors, responsibilityfor care rested with critical care. There was also supportfrom the iMobile doctor and emergency department(ED) anaesthetist, who were both airway trained. Rotaswere arranged so consultants did not have additionalcommitments elsewhere in the hospital. It was rare for aconsultant to be called in on-call, which we were toldwas due to the junior doctors having suitableexperience as many of them were clinical fellows andconsultants were often on site until 10pm.

• LITU conducted an audit against the intensive caresociety standards which showed they had a 1:19 ratio ofconsultants to patients which is contrary to therecommended 1:8 to 1:15. They assessed this asappropriate for LITU but no rationale was given in theaudit although the trust stated that this was due to a

Criticalcare

Critical care


lack of emergency cases and patient turnover. However,there were no incidents related to this ratio and otherparts of their practice were within national guidancesuch as twice daily medical reviews.

• The HDUs sat within their own medical or surgicalspecialty, so they had no rotated anaesthetic support.Critical care doctors would only review patients on areactive basis. However, the units had dedicatedmedical or surgical doctors depending on whatspeciality they were, such as neurologists, renalconsultants and cardiologists/cardiac surgeons. Forinstance, Kinnier Wilson ward had a clinical fellow as itslead clinician and a junior doctor was on shift 24 hours aday, seven day a week. There was also input fromneurologists and neurosurgeon consultants.

• Medical rounds were appropriate, with a full review of apatient’s history, the medicines and treatment they werereceiving, as well as any social aspects that requiredhighlighting, such as informing next of kin. On the HDUs,different ward rounds took place. For example, onKinnier Wilson Ward, the clinical lead conducted around, but also neurology and neurosurgery conductedtheir own separate rounds.

• We observed part of a critical care handover and thisincluded a checklist, such as an introduction by all thedoctors, review of the unit's capacity, and discussion onany meetings that day. They also discussed eachpatient's situation, such as their social and medicalhistory, treatment plan, observations and ensured anyplans were within current guidelines.

• There was anaesthetic cover in obstetrics at night, butthey were often stretched if there was a caesarean andepidural occurring at the same time. However, 85% ofpatients were reviewed within 24 hours of admission bya consultant or registrar.

• Board rounds were scheduled daily, but did not alwaysoccur. However there were always safety briefings.

Major incident awareness and training• The major incident policy was up to date and had

appropriate action cards for critical care staff on how toact in the event of an emergency. Staff on LITU wereaware of where to locate it and could describe the unit’sresponsibilities.

• Emergency procedures were in place if a patientrequired an urgent procedure on the unit, such as alaparotomy.

Are critical care services effective?

Good –––

Critical care services achieved above average outcomes forpatients, particularly regarding mortality and the impact ofthe iMobile service. Most national and local guidance wasup to date and being followed. Pain relief was wellmanaged. Staff were mostly competent to care for patientsand had access to a range of development and trainingprogrammes. Seven-day services were mostly in place.

However, rehabilitation guidance had not been followed,despite showing positive outcomes. There was a lack ofsome therapists and AHP support, both directly and as partof multidisciplinary teams. The Mental Capacity Act 2005was not followed for some patients we reviewed with a lackof mental capacity assessments and some staff showed alack of understanding of the Act. Training rates for mentalcapacity were also well below the trust target.

Evidence-based care and treatment• All the policies and procedures we reviewed other than

the one on health and safety were up to date. LITU stafftold us they were currently updating policies relating togastrointestinal bleeds, acute liver failure and use oftherapeutic plasma exchange.

• The health and safety folder was out of date, withpolicies and procedures dated from 2010/11. However,staff told us the most up-to-date guidance was on thetrust intranet and the introduction folder to the criticalcare service was based on current national guidance.Mobile computers were available for staff to find up todate guidance while they were working. Staff told usthey were alerted if there were changes to protocols.

• The LITU performed an audit to assess whether it wasmeeting the Faculty of Intensive Care Medicinestandards. They assessed that they met 44 standardsout of 57 with the rest rated as amber such as criticalcare trained staff at 50%, rehabilitation of patients andlack of critical care trained pharmacist although therewas mitigation for each of these.

• iMobile measured themselves against the OperationalStandards and Competencies for Critical Care Outreachservices, which included measures for both the way

Criticalcare

Critical care


patients are escalated and the work iMobile didthemselves. There was use of track and trigger (earlywarning scores) in the appropriate manner, such aslevels of escalation and types of observation.

• The hospital achieved 73% on its self assessment of itscritical care services – 19 of the 26 weekday andweekend critical care standards were met againstLondon Quality Standards in 2013 with only four notmet in 2015.

• Only 2% of National Institute for Health and CareExcellence (NICE) guidance required action. Theseincluded updates relating to perioperative hypothermia,critical illness rehabilitation, neuropathic pain, and drugallergy. There were continuous audits and monitoring toensure the units were complying with nationalguidance.

• The service had poor rehabilitation guidancecompliance, with only 50% of patients having ashort-term goal and 8% a medium-term goal.Recommendations from their audit showed a need for arehabilitation ward round, a records tool, rehabilitationprescriptions on discharge, and goal attainment scaling(GAS) for tracking goal settings. Physiotherapists saidrehabilitation was not a priority and agreed that thehospital was not complying with guidelines. There wasno on site weekend cover to ensure patients wereassessed for their rehabilitation needs within 24 hours ofadmission, or that they were discharged with arehabilitation prescription, as required by NICEguidance although there was an out of hours serviceseven days a week. Out of hours cover was beingdiscussed with the therapies team. Only ‘at risk’ patientson LITU were given active therapy five days a week andthis was only for 30 minutes when Faculty of IntensiveCare Medicine standards require 45 minutes for allpatients requiring rehabilitation. However the trust toldus a new multidisciplinary advice and goals in intensivecare (MAGIC) document and new rehabilitation processhad been introduced since the audit which hadimproved rehabilitation goal setting.

• The National Confidential Enquiry into Patient Outcomeand Death (NCEPOD) showed compliance with theirstandards, at 80%. Still to complete were tracheostomycare gap analysis. However, the service hadimplemented recommendations from acute problems(26 of 29 done), caring to the end (16 of 24) perioperativecare (one of 11) and cardiac arrest procedures (eight of20).

• An audit in December 2014, for IV lines in the ITUsshowed compliance with dressings at 100%, date 100%,line needed 100%, documentation complete 75%, lessthan 72 hours 100%. These were consistent, orimproving, in the next three months withdocumentation at 95% and 86% in two of the units inMarch 2015. In LITU, IV line audits showed 100% inMarch 2015 in all areas, but date recorded, which was91.3%. This was fairly consistent with previous months.However, the IV line audit for Kinnier Wilson Wardshowed overall compliance was at 60%.

• The March 2015 VAP audit for the critical care unitsshowed a result of 86.8% compliance, with particularconcerns regarding: oral care/oropharyngeal suction,sedation hold, humidification, cuff pressure monitoringand in-line catheters. However, this result was worsethan the previous few months, where compliance wasabove 90%.

• Concerns were raised in an audit regarding parenteralnutrition. This showed there was a need for a formalparenteral assessment, and that staff required furthereducation on the parenteral nutrition guidelines as itshould start at five to seven days post admission whenstaff were commencing it at two days post admission.However, the trust told us new evidence suggestsguidance should be changed to allow parental nutritionon admission.

• There was a tracheostomy folder, which includedrelevant and up-to-date information for staff, such as:emergency care for blockages, environmentalchecklists, a suctioning guide, monitoring cuff pressureand decannulation.

• The matron-led quality round that we observed on LITUtook place weekly to ensure adherence to policies andprocedures. The latest round showed some issues withrecord keeping.

• Each ward had a noticeboard reminding staff aboutpolicies and procedures, such as: the management ofsepsis and delirium, guidance for inotropes, and how torefer to iMobile, among others.

• Pharmacists were using national guidance in their work,such as NICE and South London Cardiac and StrokeNetwork Group guidance.

Pain relief• Patients reported that they received pain relief when

they required it and that it was reviewed regularly.

Criticalcare

Critical care


• Pain scoring was in place and records showed thesescores were well managed.

Nutrition and hydration• Staff, including: nurses, housekeepers and healthcare

assistants were enabled to support patients to eat .• Enteral nutrition plans were nearly all complete, but

sometimes more detail was needed. These werecompleted electronically so the necessary protocols forthe patient could be calculated.

• We observed nasogastric (NG) tubes in place for somepatients and these were appropriately inserted.

• There was good nutrition compliance, but the servicereported there were issues with calorie intake bypatients, such as lack of prescribed nutrition support,and insufficient calories. Therefore, the service waslooking at high protein feeds, better records, and energybalances. Some nurses felt they observed patients beingmalnourished, but couldn’t do anything due to a lack ofexpertise. However, we found patients were monitoredfor their calorie and energy intake during our inspection.Food charts were also in place and were complete. Theywere compliant with the NHS London standard fordietician, speech and language and occupationaltherapist support.

• Food and drink on patient surveys was reported asbeing ‘adequate’ other than some concerns regardingtaste and texture.

• There was only one permanent dietician allocated tothe ITUs who conducted a daily round and was part ofthe allied health professions meeting. However, the restof the dietician service was reactive to any referrals. If anallocated dietician was on leave, the lead dietician hadto cover them, which meant they were very stretchedand could only review high risk patients. We were toldthis situation was due to cost pressures and thedivisional difference between therapies and critical care.

• The food we observed looked appetising and a stockwas always available in the kitchen if a patient washungry overnight. Drinks were placed within reach ofpatients.

Patient outcomes• The Intensive Care National Audit & Research Centre

(ICNARC) showed critical care services had a bettermortality rate than the national average, although aslightly worse than average rate for patients who wereless than 20% risk of mortality and much better thanaverage for patients with an above 20% risk of mortality.

• The ICNARC audit for Frank Stansil Ward, Jack SteinbergWard and Christine Brown Ward for July to September2014 (which was the latest published at the time of ourinspection) showed their data was mostly completeother than NHS number, length of stay (LOS) andoutcome. Physiology variables were mostly complete,other than arterial blood gases and blood lactate. Theservices were reducing the use of cardio-pulmonaryresuscitation (CPR) to just better than average.Ventilated admissions showed variable mortality ratesand better than average sepsis. Severe sepsisadmissions showed around average mortality.Pneumonia admissions showed variable mortality.Elective surgery admissions showed improving toaverage mortality, and average to below average sepsis.Emergency surgery admissions showed variablemortality and better than average sepsis. Traumaadmissions showed just better than average mortality.

• The service had worsening (more) early deaths afterbeing better than the national average and variablebetween better and worse than the national average forlate deaths. Mostly patients required respiratory,cardiovascular or gastroenterology organ support(machines supporting the patients organs to work) witha small amount of patients requiring renal, neurologicaland dermatological advanced level support. Mostpatients required between one and three of their organssupported, but there were small amounts of patientsrequiring four and above organs supported with highamounts of bed days. Post unit deaths were improvingto better than the national average at 6%. Most patientsstayed as independent as they were before admissionbut a minor amount had increased dependency. 8.4%of patients suffered a brain stem death and of these, justless than 10% of patients donated organs. The mortalityratio was 0.90 according to ICNARC and 0.84 accordingto the Acute Physiology and Chronic Health Evaluation(APACHE II) which was better than the national averageand showed the units were the best ITUs for the topthree admitting units in the country.

• ICNARC results for LITU from October to December 2014showed data completeness was 100% or near 100%apart from ethnicity, NHS number, neurological status,average length of stay (ALOS), and outcome. Physiologydetails were complete other than arterial blood gaseswith most others just below 100%. Cardio-pulmonaryresuscitation (CPR) rates were just better than thenational average. Ventilated admissions had a better

Criticalcare

Critical care


than national average mortality rate, and reducing rateof blood infections. Severe sepsis patients had a betterthan national average mortality rate and this wasimproving. Pneumonia patients had a better thannational average mortality rate and this was improving.Elective surgery patients had a better than nationalaverage mortality rate which was improving and werearound the national average for sepsis. Emergencysurgery patients had a mortality rate that was betterthan the national average and improving and sepsis wasaround the national average. Trauma patients had avariable mortality rate between better and worse thanthe national average but this was recently improving.The amount of early deaths were better than thenational average and late deaths had recently improvedto around the average. Patients requiredmostly respiratory, gastroenterology, renal and cardiacorgan support. Organ support was at advanced level inup to 40% of cases with high amounts of renal and liversupport. Admissions were roughly equally spreadbetween one and six organs supported. Post unit deathswere variable between better and worse than thenational average. A small amount of patients weredischarged with decreased dependency. Just below50% of patients that did not survive had treatmentwithdrawn before their death. There were no brain stemdeaths and no patients donated organs. Mortality wasaround 7.5%. The mortality ratio was 1.04 accordingto ICNARC and 1.20 according to APACHE II, which wasimproving, but slightly worse than average for similarunits. It was fifth out of nine on mortality and sixth in thenumber of admissions according to ICNARC, worst ofnine on mortality and eighth for the number ofadmissions according to APACHE II although the trusttold us the units compared to had differing case mixeswhich affected comparing their mortality rates.

• Critical care services had a better than average sepsisrate and had a better than average ‘unplannedreadmissions within 48 hours’ rate. When readmissionsdid occur, staff on the HDUs said ITUs took them within30 minutes of them being identified as needing care.

• The Donor Audit showed they had received 116donations (which was part of a rising trend), 73 kidneys,14 pancreas, 26 livers and eight hearts. In seven areasthe units performed better than average includingreferral to the Specialist Nurse in Organ Donation –SNOD. Three areas performed similar to average (stafftested to see whether death was neurological, and that

consent was given by the patient’s family), and twoareas required improvement measures (the patient’sfamily was approached for donation and the amount ofactual donors from each pathway was recorded). Thetrust told us they have investigated the areas ofrequiring improvement and said they had found noconcerns.

• There were good outcomes for most patients receivingextra corporeal life support (ECLS) or extra corporealmembrane oxygenation (ECMO), other than cardiacpatients, where the survival rate was average and had amortality rate of 0.76 . For all ECLS patients, the survivalrate was 49% and all liver patients it was 60%. Thepredicted survival rate was 34.5% for patients withECMO and less than 10% if patients had only standardcritical care intervention with an overall mortality rate of0.78.

• Patient rehabilitation outcomes were assessed usingnationally recognised quantified tools but we did notreceive audits for these.

• iMobile were involved in an international study on shortterm outcomes after rapid response. This showed 58%of patients had an improved outcome after involvementby iMobile with one unexpected death out of 63 referralsin the first 24 hours. After four weeks, 30% had a ceilingof care (patient treatment wishes/limits on care) with73% still alive and which 93% of deaths that occurredwere expected.

• iMobile conclusions from their audits showed that lessthan 10% of referrals to them were inappropriate. Therewere better resuscitation outcomes, patients wereidentified earlier as deteriorating, there was a reducedlength of stay, better quality of care and treatment wascost effective. However, there was no change inmortality rates, no change in cardiac arrest rates, a risein unplanned admissions, mortality in delayedadmissions and unexpected deaths and a worry thatgaps were appearing between the wards and the criticalcare team. However, SHMI showed intervention byiMobile reduced mortality by 12.3% and cardiac arrestswere also reduced by between four and 10 per month,depending on the statistical method used. There was nochange in readmissions.

• A pharmacy Clinical Interventions Audit showed 44% ofmedicine interventions resulted in a patient's length ofstay not increasing or improving.

Criticalcare

Critical care


Competent staff• In December 2014, WIRED showed that appraisals were

at 31.7% within critical care, but other figures receivedshowed they were at 4% for technical staff, 3% foradditional clinical staff, 9% for administrative staff, 14%for allied health professionals, 12% for scientist staff, 0%for medical staff, 7% for nursing staff. The trust reportedthat appraisals were actually at 70% in March 2015.However, all staff reported that they had received anannual appraisal and had had one-to-one meetingswith senior staff or supervision. We were told the figureswere reported as being so low, due to changing from apaper-based to an electronic system.

• Over 70% of nursing staff were critical care trained ontwo ITUs, but other units only had around 50% trainednursing staff, which was the minimum amount requiredunder national guidance. We were told that a number ofnew staff had been recruited within the two years priorto the inspection, but all were on courses to becomecritical care trained. Shifts were arranged so critical caretrained staff were always on shift and were balancedbetween trained and untrained staff. LITU were seekingalternative funding to ensure nurses were on trainingcourses. Courses were university recognised, but notaccredited, which was being discussed withKing’s Health Partners. Staff on the HDUs were specialitytrained, but the trust no longer provided a HDU specificcourse although there was access to a university course.The course they had included a cardiac element, whichnurses in critical care and other cardiac areasundertook. HDU staff felt competent to care for patientswith tracheostomies and weaning.

• Staff were complementary about the induction trainingthey received. There was a checklist for agency andbank staff to complete to ensure they were competenton a ward before they started working, which we sawwas being completed. This included training onventilators. This was also tailored to the unit worked on.The checklist was in depth. On Victoria and Albert Ward,it included areas regarding: respiratory care,haemodynamic assessment, neurology, liver,gastrointestinal tract, fluid management,catheterisation, hygiene/mobility/wound care,psychological care, practice development, peopledevelopment, team building/problem solving, and drugadministration. This was prioritised within a precepteesfirst two years to ensure the most important areas werelearnt within the first six months. An orientation

handbook was also given describing: relevant contacts,type of patient records used, reporting of incidents,security protocols, fire safety, IT, intranet, policies andprocedures and leave. There was a checklist thataccompanied this, which involved going through thehandbook areas in more depth, plus orientation thatinvolved being taken around the unit, meeting membersof staff, reading through policies and procedures and anintroduction to the various IT systems. These weresigned off by the staff member and mentor.

• There was access to development opportunitiesthroughout most of the critical care units, includingprogrammes for staff to progress grades, such as fromband 5 and 6 as well as leadership courses for seniorstaff. External studies, conferences and courses werealso available. Development days occurred once amonth for Kinnier Wilson Ward staff. Band 5 nurses wereasked to lead shifts under supervision as part of theirdevelopment. However, LITU and Jack Steinberg Wardstaff both reported that access to training programmeswas becoming more limited and funding for these wasbeing cut.

• All but some of the consultants for Jack Steinberg Wardwere either intensivists or critical care airway trained orwere in training, and some of the registrars at night andother doctors were not airway trained. We were told thatan intensivist was always available elsewhere if ananaesthetist on Jack Steinberg Ward needed them.Where there were shifts with doctors who were notairway trained, this was highlighted at handover.

• Junior doctors we spoke with were happy with thetraining and teaching they received in critical care. Weobserved that registrars were empowered to lead award round with consultant support.

• iMobile staff met the Operational Standards andCompetencies for Critical Care Outreach Services as thelead practitioners had a postgraduate qualification incritical care and they had at least three yearsexperience. All nurses either had, or were workingtowards, a clinical qualification. They also ran teachingsessions each month that included education andtraining in tracheostomy care.

• Each unit had practice development nurses allocated tothem. Practice development nurses were trained inteaching, but their teaching was not formally assessedon an on-going basis. We could find no evidence thatthey had a structured personal developmentprogramme although the trust told us there was one

Criticalcare

Critical care


which included peer assessments, learning objectivesand manage under performing staff. All nurses had twomentors. Mentors had their competencies assessed toNursing and Midwifery Council (NMC) standards.

• Band 6 staff did 90% clinical work, band 7 staff membersdid 80% clinical work and band 8 staff did 40% to 50%clinical work to stay competent, according to thepractice development nurses.

• There was appropriate training for speech and languagetherapists (SALTs) and other allied health professionals.

• A variety of teaching and courses were availablethroughout critical care services, which was specific tothe units. SALT teaching for nursing staff was in place.Weekly teaching sessions for LITU and the renal HDUwards were in place for CVC care, accountability, nursingdocumentation, and medicines management. Invites tonursing, medical and Allied Health Professionals weremade for these training sessions. A liver specialistcourse was also available for nurses in LITU. Trainingwas in place for dysphagia, tracheostomies andsimulation. Kinnier Wilson Ward had access to traumabrain injury specialist nurses. Critical care staff were dueto be trained in peripherally inserted central catheter(PICC) line insertion to reduce their dependency onradiology, and one nurse had already done this.Respiratory workshops were held with physiotherapistsevery three months. Competency-based transitioncourses were in place for staff that transferred from ageneral ward to critical care.

• Sixteen nurses and eight consultants were ECMOtrained. IV training was at 75.9% for nurses and 58.9%doctors. Most staff were ALS trained. Overall, training forequipment in LITU was 83.25%.

• Staff on Kinnier Wilson Ward felt underutilised, as theyfelt competent to take critical care patients, such aspatients on inotropes and continuous positive airwaypressure (CPAP) and biphasic positive airway pressure(BPAP), but the ward no longer cared for these patientgroups.

• Where staff were registered with the professionalregulator there were systems in place for registrationchecks to be carried out, and we saw evidence that theywere happening.

• Professional registration checks on staff were carriedout.

Multidisciplinary working• Internal multidisciplinary team working was described

as ‘strange’ by some staff. Although consultant wardrounds were conducted with a pharmacist on the ITUs,there were separate board rounds that did not include apharmacist, but did include therapists. There was oneband 7 and three band 6 speech and languagetherapists (SALT) allocated to the critical care beds, butoccupational therapists (OTs) were not allocated to theunits, so only reviewed patients that were referred andcould not attend all the board rounds, as they were atthe same time on each unit. However, we were told theycontributed to multidisciplinary team meetings. Staffsaid they could access pharmacists andphysiotherapists easily and that they were supportive.Pharmacists were not part of ward rounds on the HDUs,but did have daily face-to-face meetings with thenursing staff. There was one 0.5 whole time equivalent(WTE) band 7 pharmacist, and one band 6 pharmacist.There were also two band 5 pharmacists dedicated tothe liver intensive therapy unit (LITU) who attendedhandover.

• There was no dietician allocated to the overallmultidisciplinary team meetings for LITU, but this hadbeen escalated. However, we did observe goodmultidisciplinary team working when discussingindividual patients, such as a tracheostomy patientsbeing discussed with a SALT. SALTs undertooktracheostomy ward rounds once a week but there wasno dedicated SALT support for weaning patients.

• Therapists were on some ward rounds on HDUs.Pharmacy and microbiology conducted their own wardrounds on the HDUs, but the rest of the microbiologyteam's work was reactive. There was no lead OT forcritical care and three OTs in total for critical care. Therewere three physiotherapists, one band 7 and two band 6physiotherapists for each unit, which was atestablishment level.

• Critical care staff were involved in external meetingswith another trust regarding their ECMO service to sharegood practice and discuss patient options.

• There was a positive relationship between critical carestaff and transplant coordinators. Staff told us criticalcare patients were flagged if they required anemergency donor transplant. Recipient coordinatorswere involved in daily meetings to discuss post

Criticalcare

Critical care


transplant outcomes and LITU patients with a range ofspecialist consultants, including LITU and hepatologyconsultants, as well as social workers, pharmacists andsubstance misuse workers, but there were no therapists.

• LITU were developing their work with the critical careoperational delivery network and had a lead nurse forthis. HDU staff felt they had developed good links withthe ITUs.

• There were multidisciplinary team meetings within thecardiothoracic department that involved staff onVictoria and Albert Ward.

• Multidisciplinary team meetings took place weekly toreview all long stay patients, those requiringrehabilitation and patients with complex needs.

• The research team for critical care was cross specialtyand undertook a number of projects that included bothcritical care and other areas, such as a project on braininjuries with neurology staff.

Seven-day services• Seven-day working was in place, with nursing levels not

reduced and appropriate medical staff available atweekends. Pharmacists were also available seven daysa week on site. However, there was no SALT oroccupational therapists at weekends for critical care.

Access to information• Formal handover documentation was in place for

patients being stepped down. This was mostlycomplete, but was not always signed off.

Consent and Mental Capacity Act (includeDeprivation of Liberty Safeguards if appropriate)• There was varied awareness of the Mental Capacity Act

2005 and records regarding patients' mental capacitywas inconsistent. Some staff were aware of theirresponsibilities, but some nurses said they had not beeninvolved in a capacity assessment.

• WIRED showed training for consent was at 72% formedical staff. Mental Capacity Act 2005 training was at15% for medical staff and 65% for nurses. Victoria andAlbert Ward Mental Capacity Act 2005 training was at56%. Training courses had been booked for the MentalCapacity Act 2005 and Deprivation of Liberty Safeguards.However the trust told us training rates were higher at80% or above.

• Deprivation of Liberty Safeguards applications werebeing appropriately recorded, but Mental Capacity Act2005 assessments were not being conducted when

required. Referrals were made to external psychiatriststo carry out mental capacity assessments and we sawevidence that these had been requested for somepatients. Advocates were also being utilised duringmental capacity assessments.

• A restraints audit was conducted in November 2014 overa two-hour period across all the ITUs. This showed that11 out of 54 patients were restrained by staff. The auditdid not check the assessments for medicine-basedrestraint, but did check when physical restraints were inplace. This showed three of the four patients who hadbeen physically restrained had no mental capacityassessment. However, staff were aware that restraintshad to be prescribed. We observed patients with'mittens' on to prevent them removing wires and tubes,but no capacity assessment for these had beenrecorded. On one ward, they had a protocol for using'mittens' with an assessment, but no capacityassessment was part of this. When we reviewed apatient who had them, there was no entry in themedical notes, or daily review.

• Social workers and psychologists were available, butsenior staff felt they needed more of them.

• Consent forms, with accompanying informationbooklets were in place for those patients receivingtransplants, which included what information to sharewith the NHS Blood and Transplant service. The bookletfully explained how the patients’ information would beused.

Are critical care services caring?

Good –––

Most of the feedback we received, and our observations ofcare, showed that staff were kind, compassionate andcaring towards patients, family and their friends. This wasreflected in the surveys. Although it was not always easy toidentify staff, they introduced themselves and gave clearexplanations to patients, involving them in their care.Emotional support was available and had been assessed,although there were areas to improve.

Compassionate care• Patient, family and friends feedback was mostly

positive. One family told us they “could not praise staffenough”. The only negative feedback we received from a

Criticalcare

Critical care


minority of people was that the doctors could be “standoffish” and staff on the level 2 units were not alwaysfriendly. Patients told us they felt safe and they werebeing cared for in a calm environment.

• Almost all observations of care we made were positive,showing kind and compassionate care. We observednurses assisting patients to the bathroom and givingclear advice on when to use the call bell if there was aproblem. However, curtains were not always fully drawnwhen patients were being cared for and we observedone doctor speaking to a patient from the corridor intotheir side room without entering it, meaning theirconversation was overheard by other patients andvisitors.

• All the survey results we reviewed were positive,although there was a poor response rate. For JackSteinberg Ward, the results from December 2014 toFebruary 2015 showed there had been 29 responseswith the worst score of 4.1 out of five (five beingexcellent, one being poor) for the atmosphere of thewaiting room. Most responses were above 4.6 out of five.Particularly high scores were concern and caring bystaff, skill and competence of nurses and likelihood torecommend the unit all scoring 4.89 or above. Mostadditional comments were positive, but there weresome negative comments regarding poorcommunication with a next of kin, long waits forinformation, lack of lockers, lack of a quiet room, qualityof food and noisiness of cleaners. Action plans were putin place for these, including reminders aboutascertaining next of kin, a map for rest and café areas,review facilities for relatives, review provision of lockersand reminders to cleaners. The action plans showedwhere these were completed, with some provision inplace, while others needed further work. Staff told usthey received the feedback from these surveys frommanagement.

• In the LITU, they received 148 responses to their familysatisfaction survey in 2014. The lowest score was 4.2 outof 5 for the atmosphere of the waiting room with allother responses being 4.6 or above. Most additionalcomments were positive, with some negative commentsabout lack of information, waiting room facilities,refreshments, and toilet availability. A further survey wasconducted in February and March 2015 which had 13responses. This showed that most results either stayedthe same or improved while issues around theenvironment remained.

• For Frank Stansil Ward, they had 11 responses inFebruary and March 2015. The lowest score was theatmosphere of the waiting room at 3.9 out of five.However, all other responses were 4.4 or above andmost showed improvement from their previous survey.All the specific comments were positive other than thesize of the waiting area.

• Kinnier Wilson Ward had started trialling their ownfamily survey for a month. Responses had so far beenpositive. The NHS Friends and Family Test for this wardwas also above average, but this did not separate thelevel 2 unit from the rest of the ward.

• iMobile were capturing ad hoc feedback from patients,which was reported as part of their service evaluation.One comment was, “Care has been marvellous, wewould never have got this from our local hospital.” Inaddition, they conducted a patient, family and friendssurvey in 2015, which received 43 responses on a 88%response rate. Almost all the results were positive andnone of the specific comments received were negative.

• We saw a number of ‘thank you’ cards in all the units.• Boards on Fisk Ward showing patient details and

conditions were in public areas, which meant they didnot maintain a patient's privacy and confidentiality.

• We observed screens being used on units that weretight for space to maintain privacy and dignity.

Understanding and involvement of patients andthose close to them• Patients, families and friends overwhelmingly reported

that they felt involved in their care and were givenexplanations about their treatment. We also observedthis happen where a family queried a patient’s physicalposition and the rationale for this was explained in akind manner. One family member told us that staff had“communicated at every stage”. Staff said they involvedthe families in patient care if they wished, such aswashing and bathing. Any risks were explained.

• It was not easy for patients to identify staff. Thenoticeboards only displayed staff at matron level orabove. The uniforms between nurses, doctors and AlliedHealth Professionals did not easily distinguish betweenthem, with both nurses and doctors in blue and patientsreporting they could not clearly see name badges. Onlythe matron and team leaders wore different colours.However, we observed all staff introducing themselvesand patients told us staff identified themselves beforetalking to them.

Criticalcare

Critical care


• There was a lack of recording of whether patients wereinvolved in their care on Jack Steinberg Ward.

• The iMobile surveyed patients and their family andfriends about their involvement in their care and ifquestions were answered in an understandable way. Allcomments were positive.

• Patient diaries had not been started in Christine BrownWard, although staff wanted to introduce them. This wasdespite them having been started at the Princess RoyalUniversity Hospital.

Emotional support• The intensive care social work team conducted a report

between March 2014 and February 2015 on emotionalsupport for friends, family and patients. It reported therewas no lead for bereavement care, there was no policyregarding bereavement care in intensive care, there wasno training regarding bereavement support, staff felt theneed to be supported, and that there were concernsregarding bereaved children. However informationneeds were met and reflective practice would bebeneficial. It was also said there was regular teaching onteam days, there was bedside teaching, teachingsessions with junior doctors, support by the trust for alead role and good senior management meetings incritical care. Recommendations included having abereavement guideline, study day, informing familiesabout information and support, give staff supportregarding children, having a resource box on wards withinformation, pilot reflective practice groups, embed alead role within critical care at band eight with lead insafeguarding and development of a bereavementservice. There was also a suggestion of putting forwarda business case for a band seven role to cover six days.Research ideas included assessing a family’s needs.Since the audit, the trust told us a bereavement leadconsultant had been named, with lead nurses andmultidisciplinary training since January 2015.

• There was access to a chaplaincy service and weobserved staff signposting families and patients to themwhen they needed to.

• Counselling services were available and a bereavementclinic was due to be set up.

Are critical care services responsive?


Critical care services were not responsive to patient needs,although plans were in place to address this in thelong-term via a new critical care unit. Currently, there was alack of critical care beds, which affected LOS, and delayeddischarges. The environment was not fit for purpose, withinadequate storage space, rehabilitation space and visitorfacilities.

However, the service was mostly coping with the facilities ithad, with well conducted bed meetings and some flexibilityin bed capacity. Patients who required additional supportmostly had their needs addressed.

Service planning and delivery to meet the needs oflocal people• There was a lack of storage space in most units we

visited. Former bathrooms and sluices were being usedas storage areas in some of the ITUs. Staff had very fewlockers to store items in. Some items, such as hoists andchairs, were left in corridors. Some storage areas wereleft unlocked or had no door at all. There was a lack ofspace for rehabilitation of patients and a lack of chairs.The waiting area and relative’s rooms for friends andfamily of patients were very cramped and small. Thechairs were uncomfortable, but there were drink holdingfacilities in some of them. There was only one showerand toilet on Fisk Ward and these were at the end of theward corridor. Therefore, patients either had to mobiliseover a long distance, or had to be provided with acommode even if they were able to mobilise. There wasno procedure room in Fisk Ward. Jack Steinberg Wardhad a poor ward environment, with beds too close toeach other and a lack of patient facilities.

• A patient-led assessment of the clinical environment(PLACE) survey was conducted in two of the HDUs. InKinnier Wilson Ward and Victoria and Albert Ward, theenvironment passed. However, there were concernsregarding dustiness, facilities that required minorrepairs and lack of storage.

Criticalcare

Critical care


• There was a high amount of noise from the buildingwork for the new critical care units, which was effectingKinnier Wilson Ward and Jack Steinberg Ward inparticular although the trust told us the noise was notbreaching health and safety standards.

• There were call bells in all the ITUs and HDUs in eachbed space.

• Critical care admitted 45 cases for ECMO in two years,but only admitted two at a time onto LITU to ensuresafety.

• iMobile reviewed 518 patients a month on average,which mostly were referred by a nurse or junior doctorwith some high percentages by registrars, or as aproactive response by iMobile. In six months, they hadreviewed 2,686 patients. Most resulted in a full review, oradvice by iMobile, a critical care discharge review orother intervention. Most referrals were by the trauma,emergency and acute medicine directorate, with highreferrals also from surgery, neurosurgery and cardiology.Referrals mainly related to respiratory reasons, anescalated early warning score, hypoxia or hypertension.Around half of referrals were out of hours.

• A follow-up clinic was available for patients, family andfriends to attend after they were discharged from theITUs.

• Accommodation was arranged with the Salvation Armyproperty opposite the hospital if family and friendsrequired it. Staff estimated that this accommodationwas available around 80% of the time, when required.

Meeting people’s individual needs• The social work team for critical care produced a report

for March 2014 to February 2015. This showed that 68%of psychosocial assessments were being completed,with some parts of the form not used, such as:communication and preferences, safeguarding issuesnot acted upon, staff reporting the form was not fit forpractice, staff feeling uncomfortable asking questionsregarding patients' wills, staff reporting that a bettercommunication section was needed and betteroutcomes would be reported if the family were involvedin information gathering. A new critical care patientsafety document was introduced to reflect thesefindings, such as a family section to be completed.

• Patients' mental health status was recorded, including apsychosocial assessment. Referrals were made to the

psychiatric team and HDUs said they would ensurepatients had 1:1 care with a healthcare assistant.However, staff reported that they did not always getenough input from psychologists.

• Learning disability Health Passports were in place. Thelearning disability team were referred to if a patient wasidentified as requiring additional support for theirneeds. Doctors told us they would write things down if apatient was hearing impaired. However, we saw noevidence of ‘This is me’ documents or easy readdocuments.

• Visiting times were flexible outside of the advertisedhours, so friends and family could visit when wasconvenient for them.

• A trust wide specialist team of nurses in delirium was inplace, who conducted teaching in this area, althoughscreening for delirium was not 100%.

• A range of patient and family information was availablefor those who required support from the transplantteam. This included a liver transplant group called‘LISTEN’, which gave support to pre- and post-transplantpatients. Other information, such as financial/socialsupport, about the transplant process (including pre-and post-surgery) were also given to patients and theirfamilies once they were referred, to allow for a greaterunderstanding of the transplant process and treatmentoptions.

• An alcohol liaison team was in place and staff in criticalcare reported being well supported by them.

Access and flow• The ICNARC audit for Frank Stansil Ward, Jack Steinberg

Ward and Christine Brown Ward for July to September2014, (which was the latest published at the time of ourinspection) showed transfers in were higher than thenational average. There were no non-clinical transferswhich was just better than the national average. Mostadmissions into the hospital for critical care stays wereplanned surgical or transfers in, though just over aquarter were unplanned admissions. Most patients werelevel 2 or 3, but a small number were level 1. Patientlength of stay (LOS) showed over half had less than one,or one day stay, but nearly a quarter stayed over sevendays. Most patients were admitted to the hospital whohad a critical care stay were from home and were fullyindependent. Most admitted patients came to ITUhaving been admitted from theatres, other ITUs orwards. Ventilated admissions showed LOS had just

Criticalcare

Critical care


increased to worse than average. Severe sepsisadmissions showed variable LOS. Pneumoniaadmissions showed variable LOS. Elective surgeryadmissions showed variable LOS. Emergency surgeryadmissions showed worsening LOS. Trauma admissionsshowed worsening LOS.

• The wards above had improving early and out-of-hoursdischarges after recent spikes, though the spike was dueto using recovery beds as level 2 beds. They had a lowamount of out-of-hours discharges to ward. There wereworsening delayed discharges by mostly a day to twodays, although there were small amounts more thanthat. Most patients were discharged at level 1 or 2,though there was a high amount who were dischargedat level 0. The service had improved early and latereadmissions, but they were still worse than averageand the trust stated that this was due to the case mixthey received as a tertiary centre. The units were betterthan average for transfers out and non-clinical transfersout. Most patients were discharged to comparablecritical care, or they no longer required critical carestandard treatment. Most patients had delayeddischarges. Most discharges were to a ward, orHDU. 96.4% of patients were visited by iMobilepost-discharge. However, this was improving. Mostpatients were discharged home from hospital. LOSwas longer than the national average particularly forsurvivors. ICNARC showed occupied beds increasedfrom around 30 in March 2015 to around 42 in April 2015which the trust commented was due to an increase incapacity by 15 beds in April 2015.

• ICNARC for LITU from October to December 2014 (whichwas the latest published for this unit at the time of ourinspection) showed they were variable for patientsbeing transferred into the units. They had nonon-clinical transfers. They had a small amount of level1 care in the first 24 hours. Most admissions came frompatients who lived at home and were able to livewithout assistance though a small amount of patientswere in need of minor and major assistance. Mostadmissions came from the ED, theatres or wards.Ventilated admissions had average LOS. Severe sepsispatients had average LOS. Pneumonia patients hadaverage LOS. Elective surgery patients had a longer thanaverage LOS on an increasing trend. Emergency surgerypatients had better than average LOS on an improvingtrend. Trauma patients had variable LOS, but this wason a recent improving trend. However all of these were

on very small numbers of patients. Early discharge wasbetter than average and improving. Out-of-hoursdischarges were worse than average. Out-of-hoursdischarges to ward were variable, but now were worsethan average.

• There was better than average delayed discharges, withmost were delayed by less than a day. Unit survivorswere mostly discharged at level 0, but a high minority ofpatients were transferred at level 1 and 2. Early and latereadmissions were worse than average, though theywere improving. Most discharges were for comparablecritical care, or were due to the patient no longerrequiring critical care standard treatment. A smallamount of patients had delayed discharges. Mostdischarges were to a ward or HDU. No visits wereconducted by iMobile after discharge from the LITU.Most patients were discharged home rather than to anursing home or other place of residency. The LOS wasworse than average. Occupied beds were between 10and 16 but mostly between 13 and 15 although highoccupancy can be due to more than one patient using abed the same day due to a transfer out.

• In December 2014, the trust scorecard reported thatthere were 165 discharges, 155 level 1 bed days, 1,522total bed days. Four days was the median stay (longerthan the trust target), there was 104.4% bed occupancy,three readmissions (at 1.7% in July to September 2014,which had improved from six months prior to theinspection), 158 unplanned admissions, 153 delayeddischarges (93%), 46 single sex breaches, 11out-of-hours discharges (eight in Christine Brown Ward,which equates to 15% of discharges).

• In February 2015, a trust scorecard for the LITU showedthey had 45 admissions, 10 level 1 days, 106% bedoccupancy, a LOS of six days, 46 discharges/deaths, noout-of-hours discharges, four patients who receivedECMO, and 21 liver failure or liver disease patients.

• Senior staff were concerned about out-of-hoursdischarge rates, but assured us the patients were beingidentified for stepping down before the night, but mosttimes, nights were when ward beds became available.Staff told us most of these were tracheostomy patients,as there was no dedicated elective ward wheretracheostomy patients could be stepped down to. Theysaid this was also affecting the flow throughout thehospital.

• Critical care services were better than average for12-hour and 24-hour delayed discharges. However,

Criticalcare

Critical care


delayed discharges affected 85% of patients. Onepatient had their discharge delayed by 670 hours anddelays of over four hours occurred in 19% of cases. LITUdid not always meet the four-hour target to dischargeonce a decision to discharge had been made.

• They were above the national average for bedoccupancy (100% or just below against 85% average)with between 47 and 32 beds occupied at a time, mostlyaveraging between 40 and 46. Admissions had alsoincreased by 10% in 2014/15. These figures showedthere was a lack of critical care beds. There was a planto open a new 60-bed critical care unit (of four 15 bedpods) in 2016/17, which had been delayed nearly a year,due to site foundation issues. Senior staff expected onlyone or two of the existing units to close due to thecurrent lack of capacity and expected an increase in theneed for critical care beds. To mitigate this, in themeantime, an additional three beds could be opened inthe current ITUs and staff told us less acute level 3patients were sometimes stepped down to HDUs beds ifthere was a lack of capacity. The service had alsoopened the Christine Brown ITU in July 2014. Beforethis, there were HDU beds in different areas of thehospital, such as recovery. A plan had also beendiscussed to convert another ward into a critical careunit before the new build was finished. However, HDUstaff told us they had not been engaged in the plans forthe new critical care unit and were worried about theimpact this would have, due to the lack of space for theHDUs to expand unless they increased into the generalsurgical and medical ward spaces.

• Bed management meetings were held four times a day.We observed a bed management meeting, wherepatient flow was effectively managed, with anydeteriorating patients highlighted, as well as discharges.Individual patients were discussed so that theappropriate ward bed could be allocated for theircondition, including any current patients in outlyingwards. The meeting also displayed that constantconversations between specialties were undertakenbetween bed meetings, so each specialty was preparedfor any patients they were admitting. Bed managerswere also aware of which patients iMobile had reviewed,in case any patient needed to step up to a level 3 bed.The particular bed meeting that we attended showedthere was some flexibility in capacity, but it was limitedand there were some wards experiencing difficulties inkeeping patients flowing through.

• There were a small amount of elective surgeriescancelled due to lack of critical care beds, with the mostin February 2015 with 11 cancelled, whereas, in mostmonths since October 2014, only one or two had beencancelled. Senior managers felt most cancellations weredue to a lack of beds on Kinnier Wilson Ward and anupsurge in neurological trauma patients who requirelong LOS.

• ICNARC showed iMobile reviewed almost all of thepatients discharged from three of the level 3 units, butnone from LITU although the trust told us they reviewedall non transplant patients that were transferred fromLITU. Staff on the liver units told patients would bereviewed by an LITU doctor if necessary, but nothingformal was in place, nor was there a follow-up clinic.Staff in Todd Ward did not feel the lack of an iMobilereview meant there was any impact on care, such asreadmissions or poor patient outcomes. However, wesaw no plan to address this although the trust told usliver patients would be reviewed via various meetings.

• LITU tried to keep most patients as liver specialtypatients, but had around 10% of patients that werenon-liver speciality.

• Length of stay for a hepatectomy was two days. Auditsshowed iMobile had hospital reduced post critical carelength of stay by 7.3 days and prevented around fourcritical care admissions a month.

• We observed one patient on Kinnier Wilson HDU thathad been on ITU for a year before being stepped downand had been on the HDU a further 90 days althoughthe trust told us this should be sometimes expected dueto their case mix of patients.

• Level 1 patient breaches occurred on all critical careunits and these were declared.

Learning from complaints and concerns• December 2014 showed there were no complaints for

critical care and no unresolved complaints in LITU or theVictoria and Albert Ward. Very few complaints weremade about critical care units in the year prior to theinspection. Most were regarding the rest of the patients'pathway. There were some concerns regarding earlydischarges, but these related to the transition to theward, not the decision to discharge itself. The units mostrelied on patient surveys and comment cards forfeedback.

• Jack Steinberg Ward had evidence to show they wereencouraging complaints and they learned from them,

Criticalcare

Critical care


with staff reporting they received feedback if there wereany issues. One example was where the visiting policyfor patients with learning disabilities was reviewed andfound to be more flexible after a complaint. However,learning was not consistent elsewhere.

• Most complaints on critical care units were dealt withinformally. However staff were not always aware of theprocesses by which patients could complain, such asthrough Patient Advice and Liaison Service.

• Kinnier Wilson Ward had very few complaints, but hadintroduced a nurse in charge round where they talked topatients and their relatives to keep them updated afterfeedback from a complaint.

• Not all wards displayed a leaflet showing how peoplecould complain. However, we saw the leaflet containedall the information to complain, such as: how tocomplain informally and it listed the contact details forthe Patient Advice and Liaison Service, the complaintsdepartment, Parliamentary and Health ServiceOmbudsman and advocacy services. It also signposteda link to an online complaints form. However, the leafletdid not have any information in another language andmerely signposted people to Patient Advice and LiaisonService to get support.

Are critical care services well-led?


The ITUs were better led than the HDUs, although therewas still room for improvement in the ITUs. There was aclear vision and strategy in place within the ITUs we visited,as well as iMobile. The vision for the HDUs was very limited.The ITUs were led by a different directorate than the HDUsand LITU which meant leadership was fragmented andoften disorganised.

Public and staff engagement in the ITUs was well advancedand varied, but there was a lack of engagement with staff inthe HDUs. Risk and governance of all the units was mixedbetween the units and, although there were attempts toensure good communication, this was still fragmented attimes. Research and innovation was well established in theITUs but some staff were concerned it did not match itspeer trusts.

Vision and strategy for this service• All ITUs we visited had a ‘Big three’ or ‘Big four’, which

were three or four identified themes for the month forstaff to focus on, such as ensuring relatives filled inquestionnaires or being aware of heparin guidelines.

• There was a strategy to continue with the model of notrotating the nurses between the ITUs, to improve teambuilding and build staff competencies with the differenttypes of patients which staff told us was partly based ona model they reviewed in Melbourne, Australia. Therewas an awareness that this had the potential ofspecialisation of staff, but it would increase familiaritywith the units and ensure continuity of care. Most staffwe spoke with seemed to be on board with not rotating,but there were some that wanted the variety of rotating.

• The vision of iMobile was to present their model to otherhospitals, expand the model to other sites and developthe pathways between outreach and the highestreferring areas.

• Staff were aware of the values of the trust.• There was a clear vision and strategy to improve ITU

care at the hospital. Individual units had their ownshort-term goals. However, there was no vision withinthe HDUs other than trying to expand.

Governance, risk management and qualitymeasurement• There was a mix of governance arrangements for critical

care. Three of the ITUs were governed under the criticalcare, theatres and the diagnostics department.However, the LITU was governed within the liverspecialty, although there were some governancemeetings for the ITUs that included LITU. The HDUswere governed within their surgical or medical specialtyrather than within critical care. This may impact onleadership and governance issues that requirecross-divisional working. Some staff in critical care feltthe HDUs should be within their directorate and patientstreated by critical care doctors as their primary clinician.

• Critical care governance meetings took place monthly.These included: managers, consultants, matrons andpharmacists, but we saw no minutes that includedother allied health professionals or LITU attendance.They highlighted results of audits, serious incidentinvestigations, and overnight admissions. However,there was little recorded discussion of learning fromincidents.

Criticalcare

Critical care


• The critical care risk register did not show when eachrisk was added. It highlighted the capacity and facilityrisks we found, but only some of the safety risks, such aspatient records, awareness of the Mental Capacity Act2005, medicine management, and pressure ulcers werecaptured on the register.

• When we spoke with senior staff, there was some lack ofawareness of the concerns we found during ourinspection.

• Monthly risk meetings took place involving Victoria andAlbert Ward staff.

• Safety briefings occurred each morning and anoperational meeting occurred weekly to discuss safety,infections, capacity, and staffing which was attended byconsultants, divisional leads and nurses.

Leadership of service• Most staff told us they felt supported within the ITUs by

senior management, including the clinical director,divisional manager and head of nursing. If there was aconcern, division-level staff were responsive.

• We were concerned about the leadership on the HDUs.Some staff told us they reported concerns withinneurosciences division, but did not get feedback.

• Some staff on Fisk Ward felt concerns they were raisingwere either not being listened to, or not being actionedby their management team.

• Leadership within the ITUs was visible, with a matron oneach unit when there had previously been just one forall the ITUs. However, beyond the division, leadershipwas not always visible to frontline staff, despite ‘back tofloor Friday’ where senior staff came onto the wards.

• Senior management felt critical care was supported as aservice by the trust and research staff felt supported bysenior management.

Culture within the service• Staff, including domestics told us there was a good team

ethic in all the units. There was no reporting of bullyingor harassment by anyone we spoke with who wascurrently working on the units. There was peer supportand staff reported that it was a friendly environment towork in. The Jack Steinberg Ward received an award forteam of the month in January 2015. Staff reported thatthey understood each other’s social circumstances, sowere able to offer support when necessary. We wereconstantly told the units were better now than they hadbeen a few years ago. There was a good rapportbetween doctors and nurses.

• Sickness levels were 1.3% for technical staff, 2.9% foradditional clinical staff, 3.7% for administrative, 1.5% forAllied Health Professionals, 2.1% for scientists, 1.5% formedical staff, 3.1% for nurses. Kinnier Wilson Ward had ahigh amount of sickness, but this had drasticallyreduced recently. Senior staff acknowledged sicknesswas concerning at times, but there was good supportfrom occupational health with face-to-face meetingsand ‘return to work’ interviews.

• Turnover of staff was 16.4% for technical staff, 17.4% foradditional clinical, 11.0% for administrative, 17.9% forAllied Health Professionals, 11.1% for scientists, 44.5%for medical staff, 14.4% for nurses. Staff said they wereconcerned pay grades could be causing the highturnover and leading to staff resigning, but thenreturning as bank staff. Senior staff acknowledgedturnover meant the service did not expect to be fullyestablished across both its sites until September 2015.To reduce turnover, the service had a trainingprogramme in place to enable all staff to develop bymoving up to the next grade, but there were no figuresyet to show whether this was having an impact. Exitinterviews of staff leaving were taking place.

• Senior staff within the units said they felt supported bythe human resources department if there were anyconcerns regarding performance management.However, one staff member complained about thelength of time human resources took regardingcontracts and pay queries.

• Critical care units had a social night once a year, whichwas open to all staff on the units, including Allied HealthProfessionals and ancillary staff.

• There were sometimes tensions between critical caredoctors and other specialty doctors, particularlyregarding reviews of patients and when transferring theprimary clinician from critical care to a specialty doctor.We received reports and observed patients havingdelayed discharges, or transfers due to disagreementsabout which specialty would become the lead. Patientswere sometimes not reviewed by a specialty doctor.

• Staff feedback regarding iMobile was overwhelminglypositive and this matched the reports iMobile produced.

• Some staff felt they were thanked by management fortheir work but were not aware of a reward scheme eventhough the trust had one.

Criticalcare

Critical care


Public and staff engagement• Staff on the ITUs had been engaged in the planning of

the new critical care unit and plans for the new ITsystem. They had also been engaged in a project calledICARUS which focused on medical handover, wardrounds and inter-professionalcommunication. However, staff in the HDUs told us theyhad not been involved and LITU staff were concernedtheir unit would not be adjacent (near) to step downHDUs. There was a lack of staff involvement in day today business planning.

• There were a number of public engagement initiativesto promote feedback. Patients, friends and family hadbeen involved in a pathfinder group to plan the newcritical care unit as well as set other priorities, such asimproved communication, improved facilities and theuse of technology. Relatives’ questionnaires were beingcompleted and boxes for these were in waiting rooms,although they had a low response rate at times.Follow-up clinics were held with patients and theirfamily and friends, which included a feedback element.Patient forums were also held. The latest patient surveyresults were emailed to staff and were discussed at unitmeetings.

• Doctor’s meetings involved all grades of doctors fromjuniors to consultants. Consultants told us they feltengaged in the operation and vision of critical care atthe hospital.

• The ITUs had a staff newsletter, which includedinformation such as: any forthcoming changesforthcoming, bed occupancy, risk, safety and quality.

• A number of noticeboards were in staff rooms showingcurrent performance.

• Multidisciplinary board rounds had been arranged andwere attended by relevant staff includingphysiotherapists.

Innovation, improvement and sustainability• Critical care were treating patients with ECMO, which

they were not commissioned for, but this was stillconsidered an innovative practice, due to its specialty.

• Critical care had a research team that joined withemergency care, which had been involved in a numberof audits and trials to encourage and promoteinnovative practice, such as Vasopressin versusNoradrenaline as Initial therapy in Septic Shock(VANISH), Crash Three, Eurotherm and other medicinetrials. New ways of working had been rolled out after

being trialled by the research team, such as videofluoroscopy, and changes to the sepsis protocol.Medical staff told us pressure from other areas of thehospital was not affecting their work, as they were stillable to do 50% research, 50% clinical work. However,some staff told us they were under resourced inresearch compared to their peer trusts and some unitsfelt they did not get involved in research as much asthey would like, although there were link researchnurses. Nevertheless, doctors felt there was a goodresearch culture at the hospital.

• Cost improvement plans (CIPs) were in place, such asreducing the use of expensive medicines when therewere cheaper and as effective alternatives. Althoughsenior staff acknowledged there were financialpressures, they felt current CIPs would not compromisecare as they focused on reviewing the skills mix, andbetter procurement deals. There was no pressure toclose beds.

• There was a plan in place to bring in a new IT system forcritical care so patient notes could be fully electronicand that it would integrate with the current trustsystems, other national critical care systems andprimary care, so information could move between eachdivision. There was also a project to give patients Skypeaccess to increase nurse to patient time. These hadbeen approved and part funded by NHS England.Suppliers were currently being procured at the time ofour inspection.

• The service had developed using Optiflow as analternative form of oxygen therapy, which could bemanaged on the wards without the need for critical caretrained staff.

• iMobile were not just an outreach and rapid responseteam, but also followed up critical care discharges anddelivered critical care in ward beds. It was made up of amultidisciplinary team and was proactive as well asreactive, monitoring early warning scores electronicallywithout requiring a referral.

• Kinnier Wilson Ward had access to electronic prescribingand administration (ePMA) for examining critically illneurological patients and was involved in someresearch such as Transcranial Dopplers (tests of velocityof blood flow in the brain and trials in haemorrhages).

• Frank Stansil Ward had iPads on order to help aidcommunication with patients, their family and friends.

Criticalcare

Critical care


• The new critical care unit planned to have a simulationcentre for teaching staff, and to facilitate learning fromincidents.

• A variety of link nurses were in place at band 7, includingtrauma, pressure ulcers, nutrition, renal, records,

deterioration, IPC, neurology, safety and rehabilitation.Staff representatives for each unit were also arranged ateach band for involvement in service improvementprojects.

Criticalcare

Critical care








Information about the serviceKing's College Hospital Denmark Hill Site is part of theKing’s College Hospital NHS Foundation Trust. The hospitalis recognised internationally and nationally for its foetalmedicine and specialist gynaecology and maternityservices. Women’s services provide inpatient andoutpatient gynaecology services and all services relating topregnancy. They are part of the women and children’sdivision of the trust, which also provides services atPrincess Royal University Hospital.

Facilities at the Denmark Hill site include: the NightingaleBirth Centre (with a 10-room labour ward), a triage facility, afour-bed observation bay and two birthing rooms. Thecentre has two operating theatres, a recovery area with fivebeds, a two-bed high dependency unit and an additionalroom with two beds for ‘transitional’ care. William GilliatWard has 50 postnatal and antenatal beds. There is amaternity assessment unit open from 8am to 7pm.

Community midwifery services provide an initialassessment for pregnant women in the area, and deliverantenatal and postnatal care at locations in the area. Sixper cent of births are at home, supported by communitymidwives. There were about 5,400 births in 2014.

The hospital is a regional centre for a number ofspecialisms. The Harris Birthright Centre, a foetal medicineunit for the assessment and treatment of unborn babies,sees for more than 10,000 women each year. There are jointantenatal clinics for women with diabetes, hypertension orsickle cell, and clinics for women with mental health, liveror neurological conditions. Gynaecology specialisms

include urogynaecology, gynaendocrinology and infertilityand reproductive medicine. King’s College Hospitalundertakes diagnosis of gynae-oncological conditions andprovides a combined service with another trust.

The gynaecology unit provides both inpatient andoutpatient services and has about 3,000 visits to theoutpatients department each year (about half of which arefollow-up visits). Gynaecology surgery takes place in theday surgery unit and in main theatres. There is also anambulatory care unit where women can have proceduresunder local anaesthetic or attend for other day treatments.Gynaecology inpatients stay on Brunel Ward, which is alsoused for female surgical patients.

We inspected all maternity and gynaecology areas withinthe hospital and visited the community antenatal clinic anda community midwifery clinic. We spoke with 12 womenand received comments from people who contacted us totell us about their experiences. We spoke to over 60members of staff, including: maternity support workers,midwives, nurses, medical staff of all grades,administrators, senior managers, porters and domesticstaff. In addition, we held meetings with midwives, nurses,support workers, trainee doctors, consultants andadministrative staff to hear their views. We reviewedinformation provided by the trust, such as reports, minutesof meetings, audits and activity data.


Maternity and gynaecology


Summary of findingsMaternity inpatient care and treatment was not alwaysreceived in the right place and/or at the right time attimes of peak demand. These issues were long standing,and although the service had taken action to deal withthe flow of women through inpatient areas, they had notbeen resolved at the time of our inspection.

Midwifery, support and medical staff worked hard tokeep women safe. However, sickness levels amongmidwives had risen and consultant leave was notcovered, bringing additional pressures to maternity staff.

It was recognised by senior staff that medical cover atnight, which was provided across gynaecology andmaternity inpatient services, was insufficient toguarantee prompt review and treatment of patients.

There were a number of gynaecology and maternityservices offering innovative and ground-breakingservices. Care and treatment was evidenced-based andthe audit programme monitored adherence toguidelines and good practice standards. Actions wereidentified following audits and these were re-audited.

There were robust care pathways for pregnant womento access appropriate services.

The safety of maternity and gynaecology services wasenhanced because reporting of, and learning from,incidents was promoted. There was systematic,multidisciplinary review of incidents. Risks wererecorded and plans put in place to address, or mitigatethese risks. Nevertheless, some risks of which we wereinformed, such as challenges with medical andconsultant cover, were not on the risk register.

Senior management in women’s services hadsucceeded in establishing integrated clinicalgovernance structures, including risk management,across the newly merged trust, which now includedPrincess Royal University Hospital.

There were clear reporting routes to the trust-widecommittees and the board. There had been changes tothe delivery of gynaecology services at the Denmark Hillsite as a result of the merger, and senior management inmaternity services had spent time supporting and

developing maternity services at Princess RoyalUniversity Hospital. Following the structuralreorganisation, the aim of the women’s service was toachieve stability and the delivery of high quality care.




Are maternity and gynaecology servicessafe?


Inpatient maternity services had high bed occupancy levelsat times of peak demand. The challenges of caring forwomen at these times were exacerbated by the high acuityof some women using the service and the physical capacityof the unit. Midwifery staffing levels had improved andthere had been a review of the workforce to optimise theirdeployment, but at the time of our inspection leaders ofthe maternity services and front-line staff reported thatmidwives and support staff were under stress. Women werenot always reviewed in a timely way by medical andconsultant staff and there were sometimes delays toplanned caesarean section procedures. The service reliedon the commitment and hard work of midwifery, supportand medical staff to provide safe care.

The safety of maternity and gynaecology services wasenhanced because reporting of, and learning from,incidents was promoted. Medical staff took part in thereview of incidents and the investigation of seriousincidents, but they did not routinely report incidents andthis meant that concerns were not always recorded andreviewed.

All areas we visited were visibly clean and there wereregular audits of infection control policies. However, thetriage area was not suitable for its purpose. Equipmentchecks were not always recorded and these discrepancieshad not been noticed. The processes for managingmedicines safely and for checking equipment incommunity midwifery services were not robust.

There were well-developed care pathways in maternityservices for women identified as being ‘at risk’ because ofmedical conditions or vulnerability.

Arrangements for assessing and responding to patient riskin gynaecology services were generally good, althoughvenous thromboembolism (VTE) assessments needed to beimproved.

Incidents• Maternity and gynaecology services promoted the

reporting of, and learning from, incidents. Midwives,nurses and support staff told us they were encouraged

to record any incident that might affect the care ofwomen and their babies. Staff we spoke with said therewas an expectation of openness, and the divisional riskmanagement policy stated that incident reportingwould not lead to disciplinary action unless there werebreaches of professional conduct.

• A high percentage of staff at King’s College Hospital NHSFoundation Trust reported incidents. In the 2014national staff survey, 98% of staff (compared to thenational average of 90%) said they had reported errors,near misses or incidents witnessed in the month prior tothe survey. We saw that 475 maternity incidents hadbeen reported between September 2014 and January2015. Serious incidents were discussed weekly at amultidisciplinary meeting in maternity and gynaecologyservices and were allocated for investigation.

• In maternity services, the weekly meeting was chaired inrotation by the consultant obstetricians. There was areview of incidents, with serious incidents allocated forinvestigation. These included incidents that had notbeen reported at the time of the event, but that hadcome to light as a result of a case review or the provisionof additional information. We saw an example of theinvestigation of ‘red’ rated serious incidents in maternityservices, undertaken by senior medical and/ormidwifery staff, supported by the trust risk manager,with a full root cause analysis. There were four red ratedincidents from September 2014 to January 2015. Thetrust serious incident committee reviewed andmonitored recommendations and actions arising fromthese investigations. A further 19 incidents werecategorised as amber, investigated by the senior staffand discussed at divisional meetings. Amber incidentsincluded cases of no harm, such as when a midwife didnot follow the birth plan of a high risk woman. Themajority of incidents were categorised as ‘green’ andwere low or no harm. These were allocated for localreview by managers for trend analysis.

• The 'Duty of Candour' was integrated into the responseto incidents. The trust had appointed a ‘CandourGuardian’ to lead on the trust-wide work.

• Medical and consultant staff in maternity services didnot routinely report incidents on the electronicreporting system. The incidents we reviewed sometimesindicated that a midwife had reported an incident at therequest of a consultant. We did not see reports of




incidents that medical staff told us affected thetreatment of women, for example, the difficulty inproviding timely treatment when a consultant was onleave.

• There were multidisciplinary perinatal morbidity andmortality meetings with paediatric services.

• A group debriefing was offered to staff present after aserious incident. There was no systematic approach,however, to ensure that staff were offered a debrief.Midwives gave us examples of when they hadapproached their matron or supervisor of midwives todiscuss something that had caused them anxiety, butsaid this was not automatically offered. Senior staff toldus supervisors of midwives were expected to offersupport in these circumstances, but agreed there wasscope for improvement to ensure a consistentapproach. We were told that the debrief for medical staffwas part of the investigation process of seriousincidents.

• There were 490 gynaecology incidents reportedbetween August and the end of 2014.

• There had been one ‘Never Event’ for gynaecology (aNever Event is a serious, largely preventable patientsafety incident that should not occur if the availablepreventative measures had been implemented). Awoman had passed a retained foreign object postprocedure. A full investigation was carried out, duringwhich the instrument concerned was withdrawn fromuse. The manufacturer was informed, the Surgical CountPolicy was amended, and all staff were informed of theneed to include all disposable instruments, includingdetachable pieces in the count in future. Action planswere in place for each of the root cause analyses (RCAs)we reviewed. The action plans included: details of theobjective, actions required, start date, due date, personresponsible, as well as an update on progress made.

Safety Thermometer• The NHS Safety Thermometer is a local improvement

tool for identifying harm free care. The hospital used avariant of this called the ‘ward accreditation scheme’,which assessed environmental standards,hospital-acquired infections and other standards.However, this tool had not been adapted to maternityservices, and was, therefore, of limited value for staff or

patients viewing the results. Expected and actualstaffing were displayed. During our inspection staffingwas mostly in line with expectations, with one supportworker short on the labour ward.

• Brunel Ward, the gynaecology ward, had scored bronzein the previous period and was working to improve onthis. Information was on display about hand hygiene95% (on target). There had been one pressure ulcer, andno falls. Expected and actual staffing levels were ondisplay. There was one healthcare assistant (HCA) shortat the time of our inspection. The 95% target for venousthromboembolism (VTE) assessments was not beingmet – the rate was 90%.

Cleanliness, infection control and hygiene• All divisions had put controls in place to address the

risk, identified on the trust risk register, that infectioncontrol policies had not been consistently implementedat the Denmark Hill site. Standards of environmentalcleanliness had been set and there were regularinfection protection and control audits. An infectioncontrol scorecard was maintained for maternity servicesand for the gynaecology ward.

• All areas we visited were visibly clean. There was gel atthe entrances to the wards and receptionists reinforcedits use. We observed staff regularly washing their handsand using hand gel between women. The hospital’s'bare below the elbow' policy was adhered to, and therewas ready access to personal protective equipment,such as gloves and aprons. Cleaning schedules were ondisplay in the ward and other areas where women weretreated. There had been no reported cases of MRSA orMSSA bacteraemia on the inpatient wards in 2014/15.

• Midwifery staff were aware of cleaning and infectioncontrol procedures for birthing pools.

Environment and equipment• We were told there was adequate equipment on the

labour ward and saw new cardiotocography (CTG)machines were in each labour room. The medicalassessment unit was well-equipped, and had a scanner.Community midwives were able to access equipmentand there was a storeroom for homebirth equipment.However, community midwives who might be called toa homebirth did not all have the neonatal resuscitationbag, which was only available with emergencyequipment. The postnatal ward had used the‘productive ward’ programme to identify improvementsto the way stock was ordered and stored.




• The processes for checking equipment and stock werenot robust in inpatient areas or in the communitymidwifery centre we inspected. For example, althoughwe found the equipment to be in working order on aresuscitation trolley in the antenatal/postnatal ward,checks were not recorded every day, as instructed. Thefollowing number of checks had been recorded in 2015:in January there were 18, in February there were 17, inMarch there were 23. On the labour ward checks wereeven less frequent, with checks recorded 26 times in thefirst three months of 2015. Community midwiferyequipment was only checked about every two months,and the checks were not clearly recorded for each pieceof equipment.

• Brunel Ward (the gynaecology ward) was accessed by anarrow staircase or lift. The doors were not wide enoughto take a bed. A trolley had been purchased to avoidwaiting for porters where an urgent transfer needed. Itwas recognised that the transfer of patients in the eventof fire was a risk. A plan had been agreed with the fireofficer to restrict the number of patients with mobilityproblems on that ward.

• At one end of the inpatient ward was new ambulatorycare unit for women attending for procedures underlocal anaesthetic or day treatments such as rehydrationfor women with pregnancy sickness. There was awaiting area, treatment room and recovery area withfour couches.

• The gynaecology clinics and the one-stop and rapidaccess services for women with early pregnancyconcerns or with pelvic pain was co-located in theGolden Jubilee Wing. There was a large waiting areawith treatment rooms and ultrasound scanningfacilities.

• We observed that some lifts were out of order duringour inspection, with people waiting in the lobby for 10minutes or more, and, on one occasion, we were in apublic lift that was being used by staff to transfer soiledlinen. These lifts were also used to take babies to theneonatal ward for their medication. Portering staff toldus the problems with transfers between floors werefrequent as there was only one lift that was for use bystaff alone that was large enough for a trolley.

Medicines• We saw that medication was stored appropriately in

inpatient areas. Medicine administration was recordedand signed for, with two signatures for controlled drugs.

• Medicines in the community midwifery offices were notstored appropriately. Fridge temperatures were notregularly checked and medicines stored there were notchecked to see if they were in date. A drug in the on-callbag did not have a ‘use by’ date. Stock drugs were notroutinely checked, but they were checked whendispensed.

• Midwifery and gynaecology ward staff recorded errors inmedication administration on the incident reportingsystem and these were analysed for trends. Pharmacistssupported services in the management of medicines.Microbiology supported services in the appropriate useof antibiotics and in understanding the pattern ofinfections in maternity services.

• Managers were responsible for making sure midwiveswere up to date with training in medicationadministration. Midwives competency for administeringdrugs was assessed and support provided for those whowere not successful.

Records• We reviewed a small number of patient notes on the

gynaecology and maternity wards. These had beencompleted with relevant clinical information and signedand dated in accordance with guidelines. Recordkeeping was part of mandatory training. Three-quartersof midwifery staff had competed the training.

• A standardised clinical record-keeping tool had recentlybeen developed, which would be used by supervisors ofmidwives to undertake regular audits. Informationcollected about record keeping at other audits wasdisseminated to staff to remind them of the importanceof consistent recording for the audit programme.

• Administrative staff on the wards obtained the mainpatients records from the medical records department,and we heard from administrative staff that this systemworked well. They entered information on the electronicpatient record system.

• All pregnant women receiving services carried their ownhand-held notes.

• A rolling audit was carried on out on compliance withHAS1 paperwork for the termination of pregnancyrequired by the Department of Health, and compliancewas 100%. Records were in line with the Abortion Act1967.




Safeguarding• Managers and staff in maternity demonstrated

understanding of what was important to promotewomen’s safety and protect them from abuse and toprotect unborn and newborn babies.

• Community midwives assessed vulnerability of womenearly in antenatal care. Safeguarding alerts were madeon the maternity system. There was a safeguardingmidwife at the hospital, who was available for advice,who was part of the trust safeguarding team. There wasa named doctor for safeguarding.

• Mothers who missed antenatal appointments werefollowed up and an alert was put on the maternity ITsystem. An audit of reasons for non-attendance wasplanned.

• Midwives and medical staff were required to attend level3 safeguarding children training updates. Eighty-eightper cent of midwives and 68% of medical staff hadcompleted this level. Nearly all (93%) of midwifery staffand 80% of medical staff had completed level 2safeguarding children, 90% of midwifery and 17% ofmedical staff had competed level 2 safeguarding adults.

Security• There was a receptionist on the labour ward at all times.• Access to each area of the maternity and gynaecology

wards were restricted by use of swipe cards. A memberof staff released the door once it had been confirmedwho was entering the ward.

• There was a draft abduction policy. The service hadtried a system for tagging babies, but found thisunsatisfactory. They were now exploring the use ofanother tagging system.

• Some community midwives we spoke with were notaware of the lone worker policy. Some staff hadpersonal alarm devices, but these were not consistentlyallocated or used. The service was in the process ofpiloting new devices, which would be allocated to allcommunity staff, but it was not clear that it would bemandatory to use them.

Mandatory training• The recently-appointed practice development midwife

had taken on the overview of training for midwives andwas in the process of setting up systems to monitor theuptake of training. There were four days of mandatorytraining a year. Ninety per cent of midwifery staff hadcompleted resuscitation training, 86% moving andhandling and 75% infection control. Other mandatory

training included risk management, bereavement andskills and drills for obstetric emergencies. Medical staffhad lower rates of attendance, with 60% completinginfection control and 50% resuscitation training.

• Completion of mandatory and statutory training wasmostly above the trust’s target for all staff groups ingynaecology services. Staff we spoke with said they hadcompleted mandatory training.

Assessing and responding to patient risk• Women were assessed in the medical assessment unit

or in triage before they were admitted to the wards.• There had been action to improve assessment of risks to

women and their babies. For example, there had beenimprovements in the identification of rhesus negativewomen to increase the number of women who receivedimmunoglobulin.

• Staff said they had been trained in the modified earlyobstetric warning score (MEOWS) to recognise womenwho were becoming unwell. Recent audits on the use ofthe MEOWS on both wards had found improvements inthe completion and scoring of the MEOWS, which were89% and 87% respectively. Babies were monitored usingcardiotocography (CTG)when this was necessary.

• There had been training and other initiatives to improvethe interpretation of ECG and the introduction of thenew machines, linked to a central consult, was expectedto improve consistency. Senior staff were able to reviewall traces and to easily access medical history to aiddecision making. Nevertheless, we observed (and staffreported) that, at times of high demand, it waschallenging to provide timely review of women and theirbabies. For example, frequent monitoring of high-riskwomen having an induction of labour.

• There had been audits of the records in the highdependency unit (HDU) and new documentationintroduced to improve recording. A repeat audit wasplanned to assess the effectiveness of this.

• Observations of women in recovery were recorded onthe trust-wide recovery chart.

• Midwives on HDU valued the availability out of hours ofthe iMobile team, who provided the critical careoutreach service. The midwife on the HDU, who wascaring for two women and their babies on her own atthe time of our unannounced inspection at theweekend, said if a woman deteriorated, she wouldcontact the team. Figures from the iMobile team




indicated they had been called seven times in fivemonths to the labour ward. The team identified anintensive care bed and facilitated the transfer of womenwhen this was necessary.

• There were arrangements for monitoring thedeteriorating conditions of women on the gynaecologyward.

• Adapted World Health Organisation surgicalsafety checklists were used for gynaecological andobstetric procedures and their use audited. The trusthad introduced an improvement plan to increaseadherence to the checklist, which includedobservational audits of its use. We did not see a recentaudit of the use of the checklist for gynaecological orobstetric surgery. We were told the consultantanaesthetist, obstetrician and trainee doctor discussedeach case before the caesarean section list, but the fullteam pre-list brief and post-list debrief, part ofrecommended practice of the 'five steps to safersurgery’ did not take place. Theatre staff told us therewas not time for reflection or discussion after lists aboutwhat went well and what could be improved. It was notclear whether the theatre staff, who worked for anotherdivision, or the maternity staff were responsible forreporting incidents, such as the late starts of the electivecaesarean section lists.

• There was a blue code alert, which was specific toobstetric emergencies and facilitated a promptresponse from all those involved in emergencies,including porters who collected blood.

Midwifery staffing• The establishment staffing level for midwives was 1:26,

lower than the England average. Nevertheless, we weretold of, and observed, pressures on the labour ward andthe postnatal/antenatal ward because of high demand,the high proportion of women with medical and socialneeds, and the limited physical capacity of the wards.Bed occupancy rates at the trust were consistentlyhigher than the England average. The establishmentstaffing levels for support workers were not being met,with only half the posts filled, and there was regular useof agency staff. Agency midwives filled shifts that werevacant because of leave or sickness. Sickness rates were11% on the labour ward and 18% on the postnatal/antenatal ward at the time of our inspection. Onaverage, four agency staff were used every 24 hours onthe labour ward to compensate for sickness or

vacancies. There were additional pressures onpermanent staff because agency midwives were notable to complete computerised records and agencysupport workers were unfamiliar with the system forordering and distributing supplies.

• Some midwives said they reported incidents of staffingshortages, but other people said this was so usual theydid not submit reports.

• One-to-one care of labouring women was prioritisedand this was nearly always provided. At times of staffshortages, managers were available for advice.Community midwives were called in to support thelabour ward and there were also occasions when stafffrom the antenatal/postnatal ward went to the labourward to assist.

• Because of lack of capacity on the labour ward, therehad been at least one birth in antenatal beds everymonth in the year up to January 2015, and sometimesthis had been a weekly occurrence. Midwives from thelabour ward were expected to come and assist, but wewere told that, on some occasions, there was noadditional staff and two midwives in the antenatal areashared the care of 20 women so that the third midwifewas able to provide one-to-one care to the woman inlabour.

• Midwives and medical staff reported concerns about thesupport given to other women who might be at risk.This included women with medical conditions, or a highrisk pregnancy admitted to an antenatal bed andhigh-risk women having induction of labour. On one dayof our inspection, a midwife was looking after twowomen in the four-bed bay and was also running triage.Women in the HDU with complex needs, some of whomwere postnatal and had their babies with them, werebeing cared for by one midwife. Out of hours, a midwifecared for women recovering from an emergencycaesarean section and their babies.

• The postnatal/antenatal ward was very busy, and weobserved midwives and maternity support workersasking women to wait until they had finished anothertask before they responded to their request. In additionto concerns about the pressure of caring for womenwho might be at risk, members of staff felt that the carewas not responsive, and women did not always receivethe attention they needed, for example in support withbreastfeeding.

• Midwifery staff told us that they had sometimes beenunable to take a break in a 12-hour shift. This had been




recognised by management and steps were being takento make sure every midwife had a break during her shift.Midwives said things had improved recently. However,staff attributed the high levels of sickness in recentmonths to the stress of the non-stop pressure of work atbusy times.

• The service had taken steps to mitigate the risk ofinsufficient midwives to care for women appropriately.Additional staff had been recruited, including additionalsenior midwifery staff to monitor demand and providesupport to the labour ward and the ward coordinator. Award coordinator said this had made a “massivedifference” to her ability to manage demand. She alsosaid she could always get support out of hours whenshe needed it.

• The director of midwifery had undertaken a workforcereview in 2014, which had been released in March 2015.The plans included redeployment of staff, such asstaffing the birth rooms with community midwives tofree more midwives to staff the labour ward.

• There had been a decision to cap bookings from outsidethe local catchment area, in particular from the LondonBorough of Croydon, and we were told of cases whenreferrals had been refused. Guidelines were in place tofacilitate early transfer home from the labour ward,when possible. However, less than 6% of mothers weredischarged home from the Nightingale Birth Centre in2014.

Gynaecology staffing• The average percentage of nursing bank staff in the

second half of 2014 had been16%. Staff told us thatmost bank staff worked regularly on the ward, and noagency staff were used. Staff said there was sufficientadministrative support on the ward. The level ofvacancies had fallen in recent months.

• Core nursing staff on the ward had roles as championsfor particular areas. For example, for IV drugs orinfection control and these nurse champions wereresponsible for auditing these.

• Nursing staffing in the termination unit was satisfactoryand stable.

Medical and theatre staffing• There was 94 hours of consultant cover for maternity

services at the Denmark Hill site. Consultants werepresent on the maternity unit from 7am to 9pm everyday and were on call from their homes at night. Traineedoctors and midwives told us consultants came in when

they were needed. However, the room used byconsultants to sleep overnight had been converted forother use and there was no other space at the hospitalprovided for them.

• During our inspection, we observed that there weresenior, middle grade and junior specialist traineemedical staff on duty on the maternity unit during theday shift seven days a week. There was a junior traineecovering both obstetrics and gynaecology at night. Thesenior trainee doctor also covered both services and wewere told they were usually dealing with gynaecologypatients. If the on-call gynaecologist attended thehospital, the senior trainee might be released for dutieson the maternity unit, but we were told this washappening less frequently during the last year becausethey were often at Princess Royal University Hospital.This limited the availability of doctors at night in forwomen in labour, on triage or in the HDU who requiredmedical review. The junior trainee doctors we spokewith said they had access to consultants for advice andsupport when this was necessary, but there wereinevitably delays to medical review at times at night.

• When women went to triage after hours, there weresometimes waits of up to two hours to be reviewed by adoctor. We were told that, occasionally, women (forexample, those who were past their due dates), wenthome rather than wait. Women were only admitted tothe wards after they had been assessed on thematernity assessment unit or triage.

• There was no cover for consultant leave, so theremaining consultant covered both labour ward and thedaily elective list. Senior trainee medical staffsometimes covered the theatre list, but a consultantmight also be needed for an emergency caesareansection. There were nine obstetricians and threeobstetrician/gynaecologists working at the hospital, sothere was frequently one consultant down because ofleave or study days.

• Obstetric theatres were staffed by main theatres. Therewas only one recovery nurse allocated to the maternityunit during weekdays, who might have to care for up tofive women. A support worker provided care to thebabies.

• There were ten general consultant gynaecologists, threeconsultants in urogynaecology and three working in theassisted conception unit. These were supported byclinical nurse specialists and trainee medical staff. Two




consultants shared the work in the termination clinic.There was back-up consultant cover in place should thesurgeon be absent, to ensure that late gestation womencould always be accommodated.

• Specialist physiotherapists worked in gynaecologyclinics and on the ward, seeing patients on referral fromconsultants.

• Registrars and more junior doctors covered bothobstetrics and gynaecology. Some consultants coveredobstetrics and gynaecology, but others specialised inone or the other.

Are maternity and gynaecology serviceseffective?

Good –––

Women’s care and treatment was planned and delivered inline with current evidence-based guidance, standards andlegislation. There were arrangements in place to audit thecare and treatment provided and to identify improvementsto practice. Women had a choice of pain relief as required,but there were sometimes delays to requests for anepidural.

There were opportunities for professional development formidwives and nurses in women’s services. Trainee doctorswere well supported. Multidisciplinary team working wasgood.

Some newly qualified midwifery staff had not receivedappropriate training for them to carry out their roleeffectively. This had been identified and action taken toaddress this shortfall. Three quarters of midwives had notreceived an appraisal in the last year.

Evidence-based care and treatment• Women’s services at King’s College Hospital NHS

Foundation Trust had a strong record of initiating andparticipating in research, and in producingevidenced-based clinical management publications.

• There were audit programmes in place in maternity andgynaecology services, which was informed by changesin national guidance, patterns of incidents, researchprojects and clinical outcome data. Some of the auditswere conducted across the two sites, others werehospital specific. There was a guidelines reviewcommittee, which met monthly to review and ratify

guidelines with reference to the National Institute forHealth and Care Excellence (NICE), the Royal College ofObstetricians and Gynaecologists (RCOG) and internalexpertise. The committee approved tools to auditcompliance with the approved guidelines.

• The hospital was a regional centre for foetal medicineand complex gynaecological services. These serviceshad been assessed as compliant being with, orexceeding the standards of care expected of specialisedservices and were involved in the most recentdevelopments of evidenced-based treatment.

• The specialised unit for foetal medicine offered anenhanced antenatal screening programme. There wasroutine screening for indicators of risk, such as the useof a doppler (an ultrasound device) to measure bloodflow between the placenta and the foetus, withfollow-up scans and other tests when this was indicated.A 36-week scan looking at foetal growth was beingtrialled to identify ‘at risk’ foetuses. There had been areduction in the number of stillbirths over the threeyears prior to the inspection, and the hospital was nolonger an outlier for this indicator.

• The trust was not following RCOG guidelines onantenatal tests for low-risk women and they were doingsome tests that were considered unnecessary. Thisincreased the midwives’ workload. The trust had madea decision to delay the implementation of recent NICEguidance on blood sugar testing and glucose tolerancetests at early stages of pregnancy, until the service hadbeen reorganised because of the demands this wouldplace on the service (a high percentage of women usingthe service were diabetic).

• It was not clear that midwives understood how torespond to the test to identify jaundice, because wewere told they routinely sent any jaundiced baby to theemergency department (ED). This was not in line withguidance on postnatal care.

• The trust contributed data to the National NeonatalAudit Programme (NNAP) and to the Mothers andBabies: Reducing Risk through Audits and ConfidentialEnquiries in the UK (MBRRACE-UK).

• Recent gap analysis of NICE quality standards formaternity included postnatal care and caesareansection. We saw examples of maternity audits that hadbeen carried out across the trust, such as neonatal andfoetal outcomes of hypertensive pregnancies.Some audits were hospital specific, such as outpatient




induction of labour. The audits identified areas of goodpractice and areas for improvement, and there werefurther audits to check whether improvements hadbeen implemented.

• There were no nationally required audits forgynaecology. However, the hospital contributed to theBritish Society of Urogynaecology (BSUG) auditdatabase and to the British Society of GynaecologicalEndoscopy, as well as national and London cancernetworks.

• Some gynaecology audits were carried out trust-wide,for example, gynaecology Rapid Access Referrals andcancer outcomes, and the diagnosis and managementof tubal ectopic pregnancies. We saw audits todemonstrate evidence-based practice, such ascompliance with NICE guidance, and with localguidelines and action following this. For example, keyimprovements from the tubal ectopic pregnancy auditwere to reduce the number of out-of-hours operations,and to ensure a second opinion was sought, in line withthe guidelines, for all women who had pregnancy at anunknown location (where a pregnancy cannot be seenwithin the womb on an ultrasound scan).

• Other audits were site specific, such as early pregnancyoutcomes in women with hyperemesis gravidarum, anda rolling audit of the completion of HSA1 forms (formsfor recording information about abortions in Englandand Wales) to show compliance with the Abortion Act1967. Audit results were presented to relevant staff andchanges to policy and practice were made asappropriate.

• The hospital had formally asked for a derogation fromimplementing NICE guidance CG154, ‘Ectopic pregnancyand miscarriage: Diagnosis and initial management inearly pregnancy of ectopic pregnancy and miscarriage,’NICE CG 171, ‘Urinary incontinence: The management ofurinary incontinence in women,’ and NICE CG122,‘Ovarian cancer: The recognition and initialmanagement of ovarian cancer.’ NICE Quality Standardsgaps and baseline assessment tools had to be approvedby the divisional quality governance committee. Theyhad evidence-based derogation documentation andregular audits of practice to ensure practice was inwomen’s best interests.

Pain relief• Staff told us that they were able to obtain pain relief or

other medication for women. All the women we spoke

with told us that they had received pain relief theywanted. However, there were times when requests foran epidural were delayed when anaesthetists wereattending an emergency in theatre.

Nutrition and hydration• There was a programme to improve breastfeeding

support, as part of UNICEF’s Baby Friendly Initiativeaccreditation scheme’. Breastfeeding rates were goodcompared to the national average, with 80% of womenbreastfeeding on discharge. The service had set agoal of 85%.

• Women on the postnatal wards and gynaecology wardssaid they were satisfied with their meals. A kitchen onthe maternity unit provided meals for women,and snacks were available from the fridge out of hours.

Patient outcomes• The caesarean section rate was close to the national

average in spite of the service seeing a high number ofhigh risk women for whom caesarean section wasindicated. The goal of reducing the caesarean sectionrate to 26% or lower had been met in three months in2014; the figure was 27.6% for the year. Processes hadbeen put in place to reduce unnecessary procedures.There was senior medical review when possible beforethe decision to go to theatre was made, and cases ofcaesarean sections were reviewed the followingmorning by the multidisciplinary team. Midwivesdiscussed vaginal births after caesarean sections (VBAC)with women, including those with medical conditions,when this was appropriate. There had beenimprovements to the management of induction oflabour, and follow up audits continued toidentify further action. There was a weeklymultidisciplinary review of CTGs to improve staff skills ininterpretation.

• Trust maternity services had been identified as anoutlier in 2012 and in 2014 in the CQC maternity outlieranalysis for puerperal sepsis and other puerperalinfections within 42 days of delivery. The trust hadundertaken a 12-month surveillance process, whichincluded a clinical review and a coding audit of cases.They reported to CQC that the population of womenthey served were at higher risk of puerperal infectionsthan the average population. They had also identifiedaction to lessen the risk of infections. A multidisciplinaryclinical audit of best practice in infection control had




been conducted on the maternity wards in March 2015,covering hand hygiene, the number of vaginalexaminations and the use of indwelling catheters. Thishad identified areas for improvement, for example,improved hand hygiene standards among medical staff,who had a compliance rate of less than 50%.

• The trust was within expected limits for maternal andneonatal readmissions.

• A centrally produced obstetrics dashboard reported onactivity and clinical outcomes for the maternitydepartment. A locally produced maternity birth reportgave additional detail.

• There was a programme to increase the percentage ofwomen having a normal birth (without any medicalintervention) to meet the service goal of 40%. The rate in2014 was 38%. The percentage of home births was6%, higher than the national average of 2.3%. Furtherwork was needed to increase understanding amongsome midwifery staff of how to facilitate normal birth atthe Nightingale Birth Centre.

• Maternity services had identified that women were notalways being assessed and managed appropriately forthe risk of VTE. A trust nurse had provided additionaltraining for midwifery staff, and the postnatal seniormidwife was reviewing a further set of incidents with apharmacist to identify underlying causes.

• There was a management performance scorecard forgynaecology, which covered key clinical effectivenessmeasures. The average length of stay on the ward waslower than the target, as was the readmission ratewithin 30 days of treatment. Emergency gynaecologycare performance was good.

• Women we spoke to who had had treatment forgynaecological conditions at the hospital said they feltwell informed and were pleased with the outcome. Theurogynaecology service is world–renowned and all thewomen’s services were backed by a strong researchbase to support developments in healthcare.

• The clinic organisation and outpatient care for thetermination of pregnancy was effective in supportingwomen with serious medical conditions because therewas access to other specialists, if necessary. Disposal offoetal tissue was in line with national guidance.

Competent staff• There was an induction programme for new midwives

and a year’s preceptorship programme, supported by a

midwifery practice facilitator. However, a review of thetraining found that training in key skills such as:suturing, cannulation, medicines management andintravenous fluids had not been delivered to all newlyqualified midwives over the last two years. An audit oftraining needs had been undertaken and it wasexpected that all staff would be competent in theseskills by the end of 2015.

• Student midwives and newly qualified staff weresupported by a mentor, but staff told us there was aninconsistent approach to mentoring.

• Midwifery support workers said they had good supportfrom their tutor, who promoted training opportunitiesfor them. They were trained to take on tasks such as theobservation of mothers and babies and to providebreastfeeding support. There was limited opportunity,however, for further development, except for supportworkers who wished to train as a midwife.

• Appraisal rates for midwives were low, with only onequarter of midwives recorded as receiving an appraisalin the last year. Senior midwives found it difficult to givetime to this task.

• Midwives said they were encouraged to take updevelopment opportunities. For example, the midwifeoverseeing the audit programme told us of theencouragement she had received from management todevelop her skills and attend conferences. Othermidwives gave examples of training they had attended,such as recognising the rapidly deteriorating womanand an FGM study day.

• Trainee doctors told us they were well supported andhad the study days they needed. There were goodopportunities for training on the job. There had been avisit from the deanery recently and their report hadbeen complimentary about the support for trainees.

• Nursing and support staff in gynaecology services hadthe training they needed to carry out their roles safelyand effectively. Staff told us there were effectiveinduction programmes for new staff. Nursing staff onBrunel Ward, which had recently moved to its currentlocation, and now had a different case mix, had receivedtraining in caring for other surgical cases as not all thepatients on this ward were gynaecology patients.

• Clinical audit training and audit facilitation wasavailable through a central trust team.




Multidisciplinary working• Many staff members, including the porter on the unit,

praised the communication and teamwork of midwiferyand support staff on the inpatient wards. Medical andmidwifery staff worked well together and respectedeach others’ skills and knowledge.

• There were team handovers on the labour ward twicedaily. We observed the evening handover at 7.15pm,which was attended by 15 staff: medical staff, thecoordinator from the previous shift and the doctor andmidwives coming on duty. The labour ward coordinatorwent through each woman individually describing thecurrent state and the plan. They then discussed thewomen on the antenatal/postnatal ward who maycause concern. The information was relevant and thestaff attentive.

• Neonatal handover was conducted separately.Paediatric staff came to the labour ward to discuss thebabies on the postnatal ward and to provideinformation about access to neonatal intensive carecots when this was needed. Staff reported goodrelations between frontline staff, but it was not clearthat there was effective communication to resolveissues, such as transitional care for newborn babies.

• A multidisciplinary meeting was held every other weekon the maternity unit.

• Women we spoke with in gynaecology services reportedgood multidisciplinary working both internally andexternally. Physiotherapists and consultants workedclosely with patients in urodynamics.

• There was prompt identification of women at risk andan effective care pathway, with rapid access to testing.Women could also access appointments at specialistclinics and they had access to appropriate specialists.The hospital provided specialist care for pregnantwomen with a variety of medical conditions, includingpregnancy-related hypertension, diabetes, sickle celland cholestasis (a liver disorder), and non-pregnancyrelated conditions, such as neurological diseases. Therewas close working between obstetricians andconsultants in the hospital specialisms such asneurology, liver disease and sickle cell. Some of theseclinics were supported by specialist midwives. Therewas a strong history of close working with psychiatristsin the neighbouring mental health trust, with access totwo perinatal psychiatrists. There was a designatedjunior specialist trainee doctor post for perinatalpsychiatry on call.

Seven-day services• Consultants worked seven days a week until 9pm.

On-site medical cover out of hours was not always easyto access.

• There was access to scanners, interventional radiology,pharmacy and the outreach services seven days a week.

• There were two dedicated obstetric theatres that werefully staffed, Monday to Friday. There were fouremergency theatre teams to cover trauma, generalsurgery (which might include gynaecology emergencies)and the two obstetric theatres. If a second emergencyteam was needed for obstetrics, a support worker mighthave to act as the circulating nurse.

• The early pregnancy unit was open on weekdaymornings. Women not seen that day were given anappointment for the following day. All women withgynaecology or early pregnancy concerns could reportto the hospital in an emergency through the ED.

• Weekend cover for the gynaecology ward was on the riskregister and recruitment was under way to improvejunior medical staffing.

Access to information• Midwives said, and we saw from looking at records, that

information from community and clinic antenatalappointments were available to them so that theyunderstood the needs of the women using the service.Information was also stored electronically. The women’smedical and obstetric history was availableelectronically when there were concerns about theprogress of labour.

• Postnatal booking for local women were routinely madewith community midwifery services following the birthand it was very rare for the first postnatal visit to bemissed. If the woman came from outside the local area,their local community midwifery team was sentinformation about their admission via fax.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards• Arrangements were in place to seek consent for surgery

and other procedures. We saw that consent forms hadbeen appropriately signed in the notes we reviewed.Women told us they had understood the risks of surgicaland medical treatment and we saw leaflets explainingthe risks and benefits of particular procedures.

• The trust had set procedures for assessing a patient’scapacity, whether they came into hospital as anemergency or for planned surgery. We were told that




doctors were responsible for assessing a patient’scapacity. The staff we spoke with talked confidentlyabout mental capacity assessments within the remit oftheir role.

• Midwives had access to advice from specialist midwiveswhen they had concerns that pregnant women mightnot have capacity to make specific decisions.

Are maternity and gynaecology servicescaring?

Good –––

Women said staff were caring and that they had been giveninformation about the choices available to them. Weobserved woman-centred care and saw staff respondingrespectfully to requests for support, even when they werebusy.

Specialist staff offered sensitive management of loss forwomen suffering miscarriages or stillbirth.

A clinic offered counselling, as required, to women withcomplex medical needs seeking termination of pregnancy.

Specialist staff offered to meet women who hadmiscarriages or stillbirth.

Compassionate care• The women we spoke with reported that they received a

good quality care and kindness from staff. We observedwoman-centred care and saw staff respondingrespectfully to requests for support, even when theywere busy.

• A woman on the postnatal ward who had attended thehypertension clinic said the care she had received was“exceptional”. She saw a specialist midwife, receivedregular monitoring and scans and was given a phonenumber to call at any time if she had concerns. Anotherwoman had been admitted early because ofhypertension. She praised the clinic staff and thekindness of ward staff.

• Women using maternity services at the trust reportedsimilar experiences to women using other trusts in thenational survey of women’s experiences of maternityservices 2013. Most women said they were treated withkindness and understanding and that they hadconfidence and trust in the staff caring for them duringlabour and birth.

Understanding and involvement of patients andthose close to them• Three women we spoke with who were receiving

antenatal care from community midwives said they feltthey had been offered choices about the birth. Two ofthe three were from outside the catchment area and feltlucky to be booked at King’s College Hospital (theDenmark Hill site). A woman we spoke with on thepostnatal ward said she had received continuity of careduring her pregnancy from two midwives (on thecaseloading team) and had planned to have a homebirth. She had decided to come to the maternity unitduring labour and her midwife had accompanied her.She said she could not have had better care and thatstaff on the maternity unit had also been very helpfuland kind.

• Women on the postnatal ward were pleased that theirpartners were able to stay with them overnight.

Emotional support• A bereavement midwife contacted all women who had a

stillbirth, or pregnancy loss above 14 weeks, and metthose who wanted a meeting. This midwife wasavailable during Monday to Friday, 8am to 4pm, butthere was limited flexibility for a prompt appointment tosee women who suffered a loss out of hours.

• Because of the demands for space on the maternity unitand ward, there was no designated room for bereavedparents. However, we observed staff taking steps toenable a woman who had a stillbirth to have time withher baby. Women who had had a previous pregnancyloss were also seen by a bereavement midwife. A planwas put in place and the women were then supportedby their community midwives. Midwifery staff valued thesupport of the bereavement midwife and mandatorytraining on pregnancy loss had been introduced for staff.Midwives gave information about agencies that providecounselling support for women and their families.

• A clinic offered counselling, as required, to women withcomplex medical needs seeking termination ofpregnancy.

• There was support for people of Muslim and Christianfaiths available from a chaplaincy team who could alsocontact community faith leaders and the humanistassociation. The chaplains were assisted by a group ofvolunteer ward visitors.




Are maternity and gynaecology servicesresponsive?


Maternity services had taken action to address theproblems with capacity, but there were blockages at timesof peak demand, which resulted in women sometimes notreceiving care in the right place. Some facilities did notprovide privacy for women using them.

There were clear pathways for access to appropriateservices for pregnant women.

Gynaecology services were responsive to women’s needs,particularly through one-stop and rapid access clinics.There were some delays in referral-to-treatment and somecancelled surgery, but the proportion of cancellations wasrelatively low. There was evidence of learning fromcomplaints.

Service planning and delivery to meet the needs oflocal people• There was high demand for maternity services at the

Denmark Hill site from within the local catchment area,from women referred for specialist care, and fromwomen outside the area who want to have their baby atthe hospital. Because of the problems with capacity, thedivision had a goal of reducing the number of births to5,200 a year.

• The risk of insufficient space to provide adequate careand treatment to women using inpatient maternityservices had been identified in 2012. Steps had beentaken to mitigate the risk by reorganising theNightingale Birth Centre, with a five-bed recovery areaand a two-bed ‘transitional’ care room for postnatalwomen, or for women who required additionalobservation. Dividers had been installed in two labourrooms to ‘double up’ women not in established labourat busy times. Senior management told us of plans toaccess additional space, but there had been noagreement at trust board-level at the time of ourinspection.

• Women going to the triage area had to walk through thelabour ward. The second triage room was used to storesupplies, had no windows, and there was not enoughroom for a bed or trolley.

• The medial assessment unit was small, there was noprivacy and it was difficult for staff to have confidentialdiscussions with women. The two labour rooms thatwere divided by a screen at times of high demand werealso inappropriate for confidential conversations.

• The waiting area in the labour ward was small and wasat the entrance to the ward so did not provide privacy orcomfort.

• There were plans to reorganise community midwiferyservices to provide a more efficient service. The needs ofthe local population were well understood, and therewere services to meet particular needs, such as sicklecell services.

• Many gynaecology procedures could be done withoutan overnight stay in hospital, so more women now cameto the day surgery unit for procedures under generalanaesthetic. An ambulatory care service enabledwomen to have minor procedures under localanaesthetic, such as a hysteroscopy or surgicalmanagement of miscarriage. The ambulatory servicealso treated women with hyperemesis gravidarum(excessive vomiting in pregnancy).

• There was an integrated care pathway for termination ofpregnancy. The clinic provided advice, including oncontraception and sexual health, nurse consultationand counselling where women wanted this. Women sawa doctor for final consultation and consent. There werefour clinical sessions and one operating list a week.Emergency referrals were seen within two weeks. Thisservice was for women in Southwark, Lambeth orLewisham, but the unit was also developing as a tertiarycentre for women with medical conditions that hadassociated high risk factors. The unit was not availableto teenagers. All terminations over 14 weeks were doneas day surgeries.

• Plans had been developed to improve referral time forwomen to be seen by a senior doctor, particularly whenpresenting as an emergency.

Access and flow• Women were referred to maternity services by their GP,

or could self-refer. About half the bookings for localwomen were centralised at the antenatal clinic, close tothe hospital. This enabled midwives to book highnumbers of women, and to make sure blood resultswere sent to the women. However, the




service recognised that this did not provide continuity ofcare; women will have a named team and midwife forbooking following the reorganisation of the communitymidwifery services.

• The hospital did not meet the target of booking 90% ofpregnant women before 13 weeks of pregnancy, but wasin line with similar services in London. Over threequarters of women were seen within the recommendedtime period and this rose to over 80% when it wasadjusted for women who were later attenders.

• The maternity assessment unit was open from 8am to7pm on weekdays and it provided a flexible service forwomen who were referred by their community midwifeor GP, or who came to the hospital themselves forassessment. Women whose babies were being cared forin the neonatal unit were able to go to the unit forpostnatal checks.

• When the maternity assessment unit was closed,women who needed assessment came to triage.

• Low-risk women who were past their dates andassessed as requiring induction were able to go homefollowing treatment and returned when they werefurther on in labour. Women who required induction formedical reasons were admitted to the four-bed bay.

• At times of peak demand, staff were often unable tomaintain the flow of women through inpatient areas.Women in labour might be referred to the antenatalarea if there was no bed on the labour ward and it wassometimes impossible to move women from the labourward to the postnatal ward because it was full. Therewas medical presence to facilitate the discharge ofwomen and their babies, but if the woman or babyrequired additional care, discharge was not possible.Beds in the four-bed bay were often used by antenatalwomen with medical needs, in addition to womenhaving induction of labour. On one of the days of ourinspection, the two ’transitional’ beds were being usedby an antenatal woman with medical needs and awoman waiting to be discharged after the birth of herbaby. We were told ‘gridlock’ occurred frequently, whichsometimes resulted in women giving birth on theantenatal ward, or planned caesarean sections beingcancelled. Staff found it difficult to provide responsivecare in these circumstances.

• Midwives did not provide 'transitional care' for babieson the postnatal ward who needed antibiotics or othertreatment. A support worker accompanied the motherto the special care baby unit (SCBU) to receive this care.

On the day of our inspection, there were four babies onthe postnatal ward who required this treatment fourtimes a day. The support worker told us it wastime-consuming to take the babies to SCUBU, wait forthem to be treated, and return to the ward. When therewas one or more lifts out of order, even more time wastaken. The support worker was unable to carry out othertasks at these times and this meant other staff had aheavier workload, particularly at the evening meal time.We asked about plans for developing a transitional carefacility, where babies could be provided with treatmentby midwives, but were told there had been no formaldiscussions about this possibility between the maternityservice and the children’s service. Midwives currentlyhad no time to provide the care, and most wouldrequire additional training in order to do so.

• We observed that midwives and support workers on thepostnatal ward were very busy and found it difficult toprovide responsive care. They were often carrying outessential tasks, such as monitoring women and theirbabies, and had to ask women who requestedassistance, for example with breastfeeding, to wait.

• There was not always a cot available on the neonatalunit for babies who needed it, and the ward coordinatorhad to arrange for a transfer to another hospital. Thiswas sometimes outside London.

• Maternity services had taken steps to understand theflow of women and to take steps to alleviate theblockages, for example, by discharging women directlyfrom the labour ward. The variety and complexity of theneeds of the women, however, made it difficult to findstraightforward solutions. Until more capacity becameavailable, the service focused on the mitigation of riskand the implementation of the extreme workforcepolicy.

• The extreme workload management policy describedthe escalation of concerns and the action to take whenthere was a shortage of beds, to make sure the safety ofwomen and babies was maintained. There was amidwifery manager on call out of hours, who wasexpected to come into the hospital within 60 minutes ofa 'red' alert. The unit had closed twice in 2014 in linewith the policy. The unit had no beds available on oneoccasion in February 2015, but had not been able toclose as there were no other maternity units able to takewomen.




• Some women told us waiting times for gynaecologyappointments were long. In discussion with staff welearned that the waiting times were mainly fornurse-led, or physiotherapy clinics where the wait wastwo months or more.

• The inpatient gynaecology ward had moved to a smallerspace last summer and there were fewer beds. Complexplanned gynaecology cases and emergencygynaecology patients were on this ward because mostplanned gynaecology surgery had been transferred toPrincess Royal University Hospital. This was intended toprevent cancellation of planned surgery at the DenmarkHill site because of bed capacity. Staff reported thatthere were still not enough theatre slots or beds foremergency surgery for ectopic pregnancies orgynaecological emergencies. If there was no bed andwomen were not stable, they had to wait in the ED. Staffwere encouraged to report shortage of beds as anadverse incident.

• Ninety-two per cent of patients were treated within the18-week target. However, there were delays for patientsrequiring complex urogynaecology surgery because ofthe shortage of beds and theatre slots on this site.

• The early pregnancy unit (EPU) was open daily in themornings as a walk-in service. Women were assessedand scanned by doctors. This was a busy clinic and ifthere was not time for a woman to be seen and scannedshe would be offered an appointment next day.However, priority was given to any woman appearingseriously unwell.

• One-stop gynaecology clinics operated from 9am to4pm, Monday to Friday and on Saturday mornings.

• Reductions in gynaecology operating lists at both theDenmark Hill site and Princess Royal University Hospitalhad led to some cancellations of surgery. There hadbeen 176 cancellations between October 2014 andMarch 2014. Over half the cancellations had been madeon the day.

• We saw from the risk register that there had been aconcern that some day surgery patients had not beenoffered follow-up appointments. Staff told us a newsystem had been put in place as a failsafe, which wouldbe reviewed in three months time.

Meeting people’s individual needs• Early in pregnancy, women and their partners were

invited to talk to a midwife about maternity services andbirth options, including: the advantages and

disadvantages of home birth, the midwifery-led suiteand the main delivery suite. Books and toys wereprovided in the antenatal waiting area for youngchildren to use while their mothers waited forappointments.

• There was a discussion group held at a communitycentre, which was also run in Spanish, for womenwanting a homebirth. There were antenatal classes runfor women over 24 weeks into their pregnancies.

• There was information on display for women and newmothers on a wide range of topics including caesareansection and breastfeeding. There was a good selectionof information leaflets in English in gynaecology clinics.Staff said they could refer people to websites forinformation in other languages.

• There was a robust system to ensure continuing accessto appropriate services, which included following uptest results and women who did not attendappointments. All community teams had a namedconsultant, whom they could ask for advice if they hadconcerns, and midwives told us they received a promptresponse. There was an efficient appointment systemfor referral to obstetric clinics. Women told us they hadno problems getting an appointment at the communitymidwifery clinics or the specialist clinics.

• There were specialist clinics for a variety of medicalneeds and access to specialist midwives working withyoung people, women with mental health needs,women living with HIV, or women who had experiencedfemale genital mutilation.

• Research posters on the walls of the gynaecology clinicsgave short, informative summaries of research.Opportunities to participate in research were on anoticeboard.

• We were told that women who used the service whowere unable to speak English fluently could access aninterpreter service if required. An interpreter could bebooked to attend antenatal appointments if necessaryand a telephone service was also available.

Learning from complaints and concerns• There was information on display about the complaints

process. People we spoke with knew how to raiseconcerns or make a complaint. There were leafletsabout the Patient Advice and Liaison Service.

• Learning from complaints was integrated with clinicalgovernance. Staff were aware of the complaints process




and were involved if a complaint related to their ownactions. Forty-one complaints about maternity serviceshad been received in 2014. About half of these wereresponded to within the target timescale.

• There were 18 complaints about gynaecology in theyear. The main themes had been about staff attitude,delays to treatment and communication. We sawevidence of action taken in response to somecomplaints. For example, to minimise the admission ofgynaecology patients to non-specialist wards andadditional training for junior doctors on monitoring andescalating early warning scores, using Situation,Background, Assessment, Recommendation (SBAR)when a patient was becoming more unwell.

Are maternity and gynaecology serviceswell-led?


There was a clear governance structure in the women’s andchildren’s division and staff were proud to work at King’sCollege Hospital NHS Foundation Trust. However, somestaff felt that trust management were no longer responsiveto frontline staff.

There were a number of services that offered innovativeand ground-breaking services. There were clearly definedaccountability arrangements and staff felt well-supportedby their line manager.

Maternity services faced a period of change and wasimplementing the strategy for improving services in thecontext of insufficient capacity to meet demand and themerger with Princess Royal University Hospital.Gynaecology had also faced a period of change. Followingthe structural reorganisation, the aim was to achievestability and deliver high quality care.

Vision and strategy for this service• Women’s services staff were proud of the pioneering

work of the trust. Senior management worked withcommissioning groups to plan services for the localpopulation and meet NHS London Quality Standards,while operating as a regional centre.

• The strategy for maternity services to improve equity ofaccess, provide continuity of care and increase normalbirths was being implemented in the context of

insufficient capacity to meet demand. Midwiferymanagement was also addressing the challenges of themerger with Princess Royal University Hospital, with thealignment of management and clinical governancestructures. After a year of change, management werelooking forward to a period of stability in which toconsolidate the clinical governance arrangements, tostrengthen accountability and to finalise changes to theworkforce.

• The gynaecology services were being reconfigured toprovide greater equity between the two hospitals in thetrust, including the transfer of almost all plannedsurgery from the Denmark Hill site to Princess RoyalUniversity Hospital. These plans were being phasedgradually, with the expectation of improvements toservices to patients.

Governance, risk management and qualitymeasurement• There was a systematic approach to risk management

and clinical governance in the women’s and childrendivision, with clear reporting lines to trust committeesand the board.

• The Maternity Service Clinical Governance and RiskManagement Strategy described the roles andaccountabilities of committees and meetings. A jointmaternity clinical governance meeting was heldmonthly and reviewed the reports from the maternityrisk committee, the incident review meetings and thematernity dashboard meeting. The director of nursingand midwifery was the lead executive at board level.

• There was close working between the obstetric clinicallead for risk, the governance midwife, the director ofnursing and midwifery, and the trust risk manager forwomen’s services in reviewing incidents and identifyingrisk. The risk registers for maternity and gynaecologywere dynamic documents, with risks identified fromincident reports, and we noted that, if local actionfollowing an incident was not considered sufficientbecause there were wider system issues, the risk wasadded to the risk register. Each risk on the register wasdefined, and scored, with controls in place, a risk ownerand date for review.

• Staff in women’s services were aware of the riskmanagement process and the key risks to the service,and felt they were involved in their management. The




culture of openness was evident in the high number ofincidents and near misses recorded by staff and by thenumber of staff willing to talk openly to the inspectionteam.

• The maternity dashboard set challenging goals, whichrecognised risks (for example, the number of births notto exceed 5,200 a year (433 a month) and set highstandards (caesarean section rate of 26% andbreastfeeding rates on discharge of 85%).

• There was work in women’s services and in the trust toimprove clinical effectiveness. The King’s CollegeHospital Clinical Guidelines System (KCGS) wasavailable to staff.

• There was a maternity team section on the trustintranet, which provided information to staff aboutguidelines, audits and meetings, which we viewedduring the inspection. The page included a link to therecent NICE publication on midwifery staffing, acalendar of audit meeting dates and venues, andinformation about conferences. The audit page storedpresentations made at audit meetings. The maternitydashboard was available and updated monthly. Therewas a quarterly clinical effectiveness managementinformation report.

• The Department of Health (DH) requires every providerundertaking termination of pregnancy to submitdemographic data following every terminationprocedure performed. These contribute to a nationalreport on the termination of pregnancy (HSA4forms).There was a clear process for signing forms andsending them electronically to DH. The assessmentprocess for terminations requires two doctors signatureson HSA1 forms.These were audited yearly andperformance in all areas was 100%.

Leadership of service• Women’s services had clearly defined accountability

structures, which were replicated across the two sites.Matrons were allocated to inpatient and communityservices and additional senior midwives had beenappointed, who were expected to take an active role inunderstanding the stresses of the service and to makesure newly qualified staff were adequately supported.

• The merger with Princess Royal University Hospital hadinvolved considerable work for the division’s seniormanagement team. The clinical director had spent threedays a week during much of 2014 at Princess RoyalUniversity Hospital working with the obstetric

consultant group. Her clinical duties had been covered,but medical staff at the Denmark Hill site commentedon the impact on her absence. Moving electivegynaecology from the Denmark Hill site to the PrincessRoyal University Hospital site resulted in losinggynaecology beds as well as increasing the workloadpressure on consultants and leading to revising their jobplans.

• The management team had developed anorganisational development paper and an associatedaction plan for midwifery. There had been a culturalreview to understand the stress on staff and uneasecaused by the merger. The service was working withhuman resources to develop the skills and knowledge ofline managers and to improve accountability.

• Some medical and midwifery staff expressed theopinion that the leadership of the trust was becomingmore autocratic and was no longer responsive to theviews of frontline staff. Gynaecology consultants whohad been affected by the restructure of their servicereported that they did not have ready access to themedical director to express their concerns. Somemidwives were concerned that the trust, which hadallowed flexible working hours for staff with caringresponsibilities, was no longer “family friendly” and thismight have an impact on retention of staff. There wasanxiety about proposed changes to the communityservices, although midwives said there had beenmeetings to inform them of proposals and they hadbeen asked to express preference for their deploymentin the reconfigured service.

• Midwifery and nursing staff in women’s servicesreported that they felt well supported by their linemanagers.

Culture within the service• Staff were proud to work at the hospital and were

committed to providing a good service. Many membersof staff commented on good teamwork, respect for eachother and shared values. However, there were concernsabout the pressure of work in maternity services and theimpact this would have on staff, and potentially onwomen using the service.

• We found processes for supporting staff were notconsistent. For example, the foetal medical unit sawmany women who were screened for foetal abnormality.However, in addition to the pressures of staffing on thisextremely busy unit, there was no external supervision




for the midwives who had responsibility for arrangingtermination of pregnancies. There also was noconsistent approach to debriefing maternity staff afteran adverse event.

• There were regular meetings on the labour ward and ofthe central antenatal community midwife team. Otherareas met less often and we were told it was oftendifficult to attend meetings because the wards were sobusy. There was a feedback folder in the staff room ifstaff could not attend. Feedback from women, bothpositive and negative, was given to staff.

Public engagement• The trust used its own system for gathering comments

and suggestions, such as, ‘How are we doing?’ forms,which women, visitors and staff could complete online,or they could fill in comment cards in the hospital.

• The response rate to the to the NHS Friends and FamilyTest for women using maternity services for the sixmonths to March 2015 was low compared to otherservices in the hospital and to the national average. Theresponse rate ranged from 7% to 17% for women inlabour and was usually less than 10% for antenatal andpostnatal care. The women who responded weregenerally positive about care, but there were somecomments about how busy the antenatal/postnatalward was.

• Friends and family data for the gynaecology ward had amoderate response rate of 28%. Eighty-four per cent ofresponders were ‘likely’, or ‘extremely likely’ torecommend the service based on the care they receivedat the time of our inspection. Responses had fluctuatedthroughout the year.

Innovation, improvement and sustainability• There were a number of services that offered innovative

and ground-breaking services.• The foetal medicine unit provided interventions, such as

foetal blood transfusions, fetoscopic insertions ofendotracheal balloons and laser separation proceduresof placental circulations for complicated monochorionictwin pregnancies.

• The enhanced scanning programme included combinedscreening for chromosomal abnormalities at 12 weeks,with women given the results on the same day. A36-week scan looking at foetal growth was being trialledto identify at risk foetuses.

• Specialised services, such as the hypertensionpregnancy service, provided a regular review of womenbefore and after the birth of the baby.

• The gynaecology and urogynaecology services offered aone-stop service with diagnostics carried out by aspecialist doctor. The hospital was a regional trainingunit for this service and the unit was recognised as agold standard unit by the British Society ofUrogynaecology (BSUG).

• The urogynaecology and early pregnancy units and theHarris Birthright Research Centre for Foetal Medicinewere active in research and often lead on changes topractice, such as in the expectant management ofectopic pregnancy and recommendations on hormonereplacement therapy.

• The hospital offered ambulatory care for hyperemesisgravidarum, which meant women did not have to stay inhospital.







Responsive Good –––



Information about the serviceKing’s College Hospital NHS Foundation Trust provides ahost of secondary and tertiary services for neonates,children and young people. The 35-cot neonatal intensivecare unit provides level 3 surgical and medical care forbabies born from 23 weeks gestation often with complexconditions. Referrals are received both locally andnationally and it is the regional centre for neonatal surgery.In addition to the neonatal intensive care unit, the trustalso hosts an eight-bed paediatric intensive care unit(Thomas Cook Children’s Critical Care Centre), which isequipped and staffed to provide level 3 intensive caresupport and is supported by an eight-bed paediatric highdependency unit.

Lion ward is a 10-bed children's ward, which provides carefor children with neurosurgical conditions. Rays ofSunshine Ward is a 15-bed ward, which specialises inproviding care to children with complex hepatic,gastrointestinal and nutritional disorders and diseases.Princess Elizabeth Ward is an 11-bed surgical unit and Toniand Guy Ward is a 15-bed children's ward providing care tochildren with a range of general and specialist medicalconditions, including cystic fibrosis and sickle cell disease.

Over 2013/2014, the trust hosted 9,209 inpatient spells,with 51% of cases being emergency unplannedadmissions, 33% being day case admissions and 16%being elective admissions. The children's service is anational hub providing a highly specialised service tochildren with liver problems.

During the inspection, we spoke with 16 parents and theirchildren, as well as over 40 members of staff, including:nurses, student nurses, matrons, play specialists, teachers,clinical nurse specialists, doctors, consultants and supportstaff. We observed care and treatment being provided andalso carried out an unannounced inspection of the serviceon 28 April 2015 when we visited Toni and Guy Ward andthe paediatric short stay assessment unit.

Servicesforchildrenandyoungpeople

Services for children and young people


Summary of findingsNursing staff levels were seen to be in line with nationalstandards in the majority of clinical areas, except for theneonatal intensive care unit where nursing levels weresuch that one-to-one care could not always be providedin line with national standards.

Continued increased capacity within the neonatalintensive care unit meant that the number ofconsultants and junior doctors employed was notsufficient to meet the needs of the unit. The existingmodel of medical cover was not sustainable in the longterm, as there was a reliance on the good will of a smallnumber of doctors to work additional hours.

The environment in which children and neonates werecared for was, in the main, appropriate. However, theincreased capacity of the neonatal intensive care unitmeant that space between cot spaces was sometimescramped, which meant that access to cots wassometimes restricted or limited.

The uptake of mandatory training in some professionswas far below the trust standard. Staff demonstrated anopen and transparent culture about incident reporting.A culture of optimising patient safety was apparentamongst nursing and medical staff alike. Staffunderstood their roles and responsibilities in reportingincidents and described how they learnt from incidents.

Patients were safeguarded from the risk of abuse. Staffwere well versed in the trust’s local safeguardingpolicies and could describe national best practiceguidance. Staff adopted a truly holistic approach toassessing, planning and delivering care. Staff developedand advocated the use of innovative and pioneeringapproaches to care, especially for those children withcomplex liver conditions and those who requiredsurgery as neonates. Additionally, the service hostednational specialist multidisciplinary bariatric services forchildren with obesity issues.

Clinical teams worked collaboratively to enhance theprovision of care to children. The service led on a rangeof national medical and surgical initiatives and workedin conjunction with a range of third party peers to driveforward advancements in paediatric surgery andmedicine. Paediatric mortality rates were seen to be in

line, or better than peer averages across a range ofspecialties. The service participated in a range of localand national audits, including clinical audits and othermonitoring activities, such as reviews of services,benchmarking, peer review and service accreditation.Accurate and up-to-date information abouteffectiveness was shared internally and externally andwas understood by staff. Information from local andnational audit programmes was used to improve careand treatment and people’s outcomes, but some workwas required regarding the management of patientswith asthma and diabetes. When people were due tomove between services their needs were assessed early,with the involvement of all necessary staff, teams andservices. People’s discharges or transition plans tookaccount of their individual needs, circumstances,ongoing care arrangements and expected outcomes.

Staff acknowledged that the demands on the servicewere increasing year-on-year and that capacity hadproven to be difficult to manage during peak times. Thiswas especially pertinent to the neonatal intensive careunit (NICU), whose activity had been seen to beincreasing annually. The organisation recognised theneed to extend children's services over the coming yearsto ensure that it could continue to meet the needs of thepopulation it served. Plans had commenced to build anew children's hospital on the Denmark Hill site andlocal initiatives had commenced, including the openingof a paediatric short stay unit to help alleviate capacityproblems in the short term.

Staff were aware of the trust vision and values. Staff hadbeen provided with information on trust developmentsthat had been cascaded down from their line managers.The service had a child health specific strategy, whichwas aligned to the trust-wide strategy. The strategy wasdriven by quality and safety and took into account therequirement for the service to be fiscally responsible.There were governance arrangements in place, forwhich a range of healthcare professionals assumedownership. Further work was being undertaken tostrengthen the governance relating to children whoreceived care or treatment outside the auspices of childhealth services. There was evidence that risks weremanaged and escalated accordingly.




Nursing staff reported good management support fromtheir line managers. Changes to the management teamwithin the NICU was said to have a had a positive impacton the service. Innovation and long-term sustainabilitywere seen as key priorities for the leaders of the service.Participation in national and international research wasa driving motivation for clinical staff in order that thewellbeing and clinical outcomes of children could beenhanced.

Are services for children and youngpeople safe?


Nursing staff levels were seen to be in line with nationalstandards in the majority of clinical areas except for theNICU, where nursing levels were such that one-to-one carecould not always be provided in line with nationalstandards.

Continued increased capacity within the neonatal intensivecare unit meant that the number of consultants and juniordoctors employed was not sufficient to meet the needs ofthe unit. The existing model of medical cover was notsustainable in the long term, as there was a reliance on thegood will of a small number of doctors to work additionalhours.

The environment in which children and neonates wascared for was, in the main, provided in appropriateenvironments. The increased capacity of the NICU meantthat space between cot spaces was sometimes cramped,which meant that access to cots was sometimes restrictedor limited.

The uptake of mandatory training in some professions wasfar below the trust standard. Staff demonstrated an openand transparent culture about incident reporting. A cultureof optimising patient safety was apparent amongst nursingand medical staff alike. Staff understood their roles andresponsibilities in reporting incidents and described howthey learnt from incidents.

Patients were safeguarded from the risk of abuse; staff werewell versed in the trust’s local safeguarding policies andcould describe national best practice guidance.

Incidents• No never events had been reported by the hospital for

the children’s and young people's service in the periodFebruary 2014 to January 2015.

• Learning from incidents was disseminated to staffthrough the ‘Child Health Safety’ newsletter. Thenewsletter included trends from incidents, as well asdescribing the lessons that had been learnt and actionsthat staff should consider to help reduce the risk topatients. For example, the Spring 2015 newsletter listedmedication incidents as the most common form of




incident report across both sites within the child healthdivision. There was considerable focus on the reductionof incidents, which had resulted in patients receivingmedication dosages which were ten times therecommend amount. Nursing staff were aware of thenewsletter and were aware of the recommendationsthat had been made as a result of the incidents that hadoccurred over the previous year.

• Nursing and support staff on the wards and withinpaediatric intensive care said they had beenencouraged to report incidents by members of thesenior nursing team.

• Regular incident trend reports used red, amber, yellowand green indicators. Those that were yellow or greenwere investigated by the ward managers. The incidentsthat were marked with red or amber were passed to theclinical governance and risk management team forinvestigation and would be investigated by a consultantand a senior nursing staff member. We saw a breakdownof incidents by category and date that allowed trends tobe identified and action taken to address any concernsin a timely manner.

• Between September 2014 and December 2014 a total of449 incidents had been reported which were attributedto incidents occurring within the children's division atthe Denmark Hill site. There were 211 incidents thatwere graded as having caused no harm, four havingcaused moderate harm or illness, 50 caused minorinjury or illness and 183 were ungraded. One incidentresulted in the death of a patient. We spoke with staffand considered a range of documents, whichdemonstrated that a significant number of learningpoints had occurred as a result of the patient’s death,including the enhancement of communication betweenparents and clinical and nursing staff. Staff had beenprovided with opportunities to discuss the incident andto review the management of the child, in order thatlessons could be learnt, so as to reduce the likelihood ofanother incident happening again in the future.

• Incidents that had been rated as ‘amber’ or ‘red’ werediscussed at the local child health divisional quality andgovernance committee, which was attended by thesenior divisional team. Root causes were considered,actions generated and named allied healthprofessionals assigned to incidents to aid in consistencyin ensuring that actions were resolved against timelines.

• There were arrangements in place for ensuring thatmortality and morbidity meetings took place on a

regular basis. In addition to local mortality reviewmeetings, members of the surgical team alsoparticipated in a review programme, which includedrepresentation of surgeons from two neighbouringtrusts in order that clinical outcomes could beconsidered and learning shared across the three truststo help enhance patient care and clinical outcomes.Additionally, the neonatal intensive care team also heldmortality monitoring committees every two months andsurgical neonatal mortality and morbidity meetingsevery six months, which included representation fromthe neonatal medical team, the surgical team, the foetalmedicine team and anaesthetic teams. Every perinataldeath was reported to the Maternal, Newborn and InfantClinical Outcome Review Programme (MNI-CORP).

• Consultants and nursing staff were well versed in theconcept of their responsibilities regarding the Duty ofCandour. There were local arrangements in place forensuring that patients and their carers were keptinformed of incidents and were provided with thenecessary support as well as being kept informed of anyinvestigations and their outcomes.

Cleanliness, infection control and hygiene• All the ward areas were visibly clean. Appropriate

colour-coded equipment was used for the respectiveareas.

• There were arrangements in place for ensuring that toysand play equipment was appropriately decontaminatedbetween uses.

• Hand wash basins were available on the entrance toeach of the clinical areas, including the paediatric andneonatal intensive care units. We observed visitors usingthese facilities and staff were observed to challengevisitors when they did not wash their hands on arrival tothe clinical area.

• We observed staff complying with the trust's policies forinfection prevention and control. This included wearingpersonal protective equipment, such as aprons andgloves, following the ‘bare below the elbows’ policy andfrequently decontaminating hands both before andafter patient contacts.

• An infection control scorecard dated September 2014indicated that there had been no reported cases ofMRSA bacteraemia within the child health division (April-September 2014). During this same period, there had




been a total of 59 hospital-acquired alert organismconfirmations within the child health directorate, ofwhich five were MRSA colonisation cases and one was aC. difficile case.

• The infection control scorecard reported 76.1%compliance against the Hand Hygiene Audit. This wasworse than the trust target of 95%, although theperformance trend was noted to be improving.

• The service reported 97.2% MRSA screening for the trusttarget, which was for 100% of cases to be screened inline with trust policy.

• Sixty-eight per cent of nursing and midwifery staff and47% of medical and dental staff working within thewomen's and children's directorate had completedtraining in infection control. This was below the truststandard of 80%.

• Where outbreaks of hospital-acquired infections hadtaken place, there was evidence that staff had learntfrom these incidents and had taken action to reduce therisk of similar incidents happening again in the future.

• The child health directorate had an establishedantimicrobial stewardship programme, which wassupported by a multidisciplinary team.

• The neonatal team had taken a range of actions toensure that the risk of pseudomonas infection(gram-negative rod bacteria commonly found in soil,ground water, plants and animals) to babies wasreduced. This included ensuring that babies were onlybathed in bottled, sterile water and ensuring that in linewater filters were attached to the taps. Additionally, staffreported that the issue formed a standing agenda itemwith the infection control meetings and routine testingof the water supply also having taken place.

Environment and equipment• Each of the clinical areas where children were inpatients

were locked, preventing unauthorised access. Parents/carers and visitors were able to gain access to theclinical areas by using a buzzer system, which wasmonitored by nursing staff. We saw that members of thenursing or administrative team greeted each visitor asthey entered each of the clinical areas.

• The trust had a child abduction policy, which had beenrehearsed prior to our inspection to ensure that staffwere appraised of the action to take in the event of achild abduction incident.

• Members of the clinical team raised some concernsregarding the temperature of the Thomas Cook

Children’s Critical Care Centre. The issue was listed as arisk on the divisional risk register as the cold conditionson the unit had impacted on the welfare of somepatients. There were arrangements in place for ensuringthat when the environment became too cold and allincidents associated with the cold temperatures werereported as incidents. While there were processes inplace for mitigating the impact of the cold environmenton the newborn, and while there was evidence that theissue had been discussed at the local governance groupand escalated internally, there was little evidence todemonstrate that robust action was being taken toresolve the issue in the long term.

• The department had a range of equipment that wascleaned and checked regularly and was sent for routinemaintenance. Staff were aware of who to contact oralert if they identified faulty equipment orenvironmental issues that needed attention.

• We checked resuscitation trolleys on the NICU, PICU,Toni and Guy Ward, Princess Elizabeth Ward and thepaediatric short stay unit and found that they had beenregularly checked by staff and were ready for use.

• On the neonatal intensive care unit there were limitedfacilities available to enable staff to nurse infants inindividual cubicles if there were concerns aboutinfectious diseases. Staff were, however, able todescribe the actions they would take in the event thatthey were required to barrier nurse an infant. Thisincluded nursing babies in incubators and increasingnursing levels so that babies were cared for on aone-to-one basis.

• Staff working on the neonatal and special care unitreported that, during periods when there was increasedoccupancy within the unit, space between cots andincubators was reduced and so conditions becamecramped. Staff considered that this posed a potentialrisk to the welfare of babies, especially in the event of anemergency situation. We noted that the conditionswithin the neonatal intensive care rooms was cramped,due to the high usage of multiple medical devicesincluding ventilators, as well as a presence of chairs forvisitors and family members.

Medicines• It was noted that a risk relating to the management of

medicines on the Thomas Cook Children’s Critical CareCentre was rated as having a severity risk of 25 (whichwas high). The risks related to an increased frequency of




medicine administration errors (including incorrectdose calculations and shortfalls in the second checkingprocess amongst nurses). We found that changes topractice had been made including the increase insupervision of junior nursing staff and improvedcommunication amongst staff to share outcomes fromprevious incidents. However, what was not apparentwas whether changes to systems and processes hadbeen considered to reduce systemic failings.Discussions with the consultant pharmacist provided uswith some assurance that action was being taken toaddress the risk of overdose of injectable medicinesacross all child health wards (the Rule of One project).

• Staff were observed to be preparing intravenousmedications in line with the local trust policy. Staffreported that they received daily advice and supportfrom a pharmacist who we observed to be screeningdrug charts for inaccuracies and prescribing errors so asto reduce the possible risk of harm to patients throughdrug errors.

• There were processes for ensuring medications werekept securely. Medication fridges were routinelychecked to ensure they were operating correctly in orderthat medicines were stored in in line with manufacturerrecommendations.

• We reviewed four drug charts, patient details wereappropriately recorded, the allergy status of the patientwas documented, medications had been prescribed byregistered medical practitioners and each chart wasfound to be legible.

• Staff had access to policies and supporting information,including intravenous drug preparation guidance,British National Formulary (BNF) for Children andpharmacist support.

Records• An electronic patient system ran alongside paper

records and allowed staff to quickly access patients'previous medical history without delay. This wasespecially important for patients who had complexmedical histories, including those with cystic fibrosis,liver disorders and cancer.

• We randomly checked ten observation records andcase-tracked five patients’ records, which includedreviewing electronic records for completeness and to

ensure that patient-specific treatment plans had beenrecorded. Records were found to be contemporaneousand staff were able to accurately describe the individualtreatment plans for patients.

• We saw that the observation records had included adetailed bedside paediatric early warning score (BPEWS)chart, which had been kept up to date.

• Seventy per cent of administrative staff, 39% of medicaland dental staff, and 74% of nursing staff had completedmandatory training in health record keeping. This wasbelow the trust standard of 80%.

Safeguarding• Ninety-three per cent of nursing staff and 74% of

medical staff had completed child safeguarding (level 2)training; the trust target was 80%.

• Eighty-eight per cent of nursing staff had completedchild safeguarding (level 3) training. These figures werebetter the trust standard of 80%. However, only 60% ofmedical and dental staff working within the women'sand children's directorate had completed the same levelof training.

• Staff could describe the referral process for alleged orsuspected child abuse and knew the names of the leadstaff member for safeguarding. While there was noformal clinical safeguarding supervision available forstaff, staff said they were well supported by thesafeguarding team and could access them for adviceand support on an ‘as required’ basis.

• A policy relating to safeguarding children and youngpeople was readily available and accessible and hadlast been reviewed in August 2014, making reference tonational guidance and best practice processes. Staffwere able to locate the policy with ease using the trustintranet system.

• Staff working on the NICU were able to describe thearrangements they had in place for being informed ofsafeguarding concerns, which were likely to have impacton babies who were scheduled to be admitted to theunit. There was close working relations between thenames of midwife for safeguarding and the nursing andmedical staff working on the NICU.

Mandatory training• Eighty-two per cent of nursing staff had completed their

mandatory training in clinical moving and handling. Thiswas above the trust standard of 80%.




• Eighty-seven per cent of nursing staff and 42% ofmedical staff had completed resuscitation training. Thetrust target was 80%.

• Thirty per cent of nursing staff and 9% of medical staffhad completed their mandatory training relating to theMental Capacity Act 2005.

Assessing and responding to patient risk• The service used a bedside paediatric early warning

scoring (BPEWS) system to help them to recognise thedeteriorating patient. BPEWS charts were in use, whichgave staff directions for escalation. There were BPEWSmonitoring charts for different age groups, namely ageszero to three months, three to 12 months, one to fiveyears, five to 12 years and from 12 years upwards. Wesaw that the BPEW recording charts were found to becompleted on admission and then at plannedfrequencies during the patient’s stay.

• We looked at completed charts and saw that repeatobservations had been taken within the necessary timeframe. Audit data provided by the trust demonstratedthat there had been consistent improvements in thecompleteness of the BPEW scoring chart with the mostrecent results demonstrating that 97% of charts hadbeen completed correctly.

• Staff explained how they used the BPEWS chart andhow they matched the score to care recommendations.Staff had knowledge of the appropriate action to betaken if a patient’s BPEWS was elevated. There wasdocumentary evidence of when patients had triggeredthe BPEWS escalation protocol. Staff reported thatmedical staff responded within set timescales, whichensured that patients were assessed in a timely manner.

• Nursing staff were able to describe the process forescalating emergency issues, such as violence,absconders, safeguarding, Child and Adolescent MentalHealth Services (CAMHS) issues, non-accidental injury(NAI) and bed management issues. The flowchartprovided emergency numbers for staff to page or phonethe relevant team, such as: consultants, resuscitationteam, security and safeguarding leads.

• Paediatric site practitioners were available to reviewpatients out of hours, especially when nursing staff wereconcerned about the clinical condition of patients. Wespoke with two site practitioners who were both awareof two patients who were acutely unwell on Toni and

Guy Ward at the time of our inspection. Thisdemonstrated that staff were communicating thecondition of acutely unwell patients to the relevantindividuals within the hospital.

Nursing staffing• Nursing staff turnover within the women's and children's

directorate was reported as being at 12.5% betweenApril 2013 and March 2014. Data demonstrated thatnursing staff turnover was at 3.4% between July 2014and September 2014.

• The overall nursing vacancy rate for women's andchildren's services was reported as being at 1.82%.

• Sickness rates within the women's and children's ratewas seen to be increasing between July and September2014, and was at 3.83% in July 2014, 4.35% in August2014 and 4.6% in September 2014.

• The NICU was reported as having insufficient numbersof substantive nursing staff to meet the demands of theunit. Cot occupancy had been seen to be increasingover the previous three years and was reported asconsistently operating above it's funded capacity.Nursing staff deficits had triggered the seniormanagement team to submit a business case in order toincrease funding to recruit additional nursing staff andto reduce the over-reliance on agency staff. At the timeof the inspection, the service was not able to meet thenurse-to-patient ratio for babies who required intensivecare treatment. Current ratio's allowed for anurse-to-patient ratio of 1:2 as compared to the nationalstandard of 1:1 care – as per the British Association ofPerinatal Medicine (BAPM) standards. In addition to thereliance on agency staff to support the neonatalintensive care unit, the sickness rate amongst staffwithin the unit was reported as being above 5% for2014/15, with many nursing staff telling us that they feltadditional pressure and increased stress levels as aresult of the increased demand on the service.

• The Thomas Cook Children’s Critical Care Centrereported that there were sufficient numbers of nursingstaff available to meet the nurse-to-patient ratio as setby the Paediatric Intensive Care Society (PICS). Datafrom the Paediatric Intensive Care Audit Network(October 2014) demonstrated that the overall nursingestablishment for the Thomas Cook Children’s CriticalCare Centre was below that of the national standards,with five whole time equivalent (WTE) nurses per bedspace employed. This fell below the national standard




of 7.01 WTE nurses per funded bed space. While thebudgeted establishment was below the minimumrecommended paediatric intensive care standard, staffreported that bank and agency staff could be accessedto support the unit.

• There were systems in place for ensuring that theclinical needs of patients were assessed and staffinglevels adjusted accordingly. Paediatric Site Practitionerswere responsible for assessing staffing levels out ofhours and for ensuring that wards were suitably staffedwith appropriately skilled individuals.

Medical staffing• Child Health employed a total of 108 medical staff, 57 of

whom were employed at consultant level. Sixty-threeper cent of doctors were employed at specialist registrar(year 1-6) level, which was higher than the nationalaverage of 51%. Two per cent of doctors were employedas foundation year 1 or 2 trainees. This was below thenational average of 7%.

• The NICU was supported by eight WTE consultantneonatologists who provided cover to the unit 24 hoursper day. A business case had been submitted to theexecutive team to increase the number of consultantsavailable to support the NICU. This was in response tothe recognition that the unit was consistently runningabove it's funded capacity.

• Doctors for a range of specialties were available 24hours a day. There was general medical and paediatricintensive care consultant cover seven days a week,including a consultant on call at night. There was coverfrom junior and middle grade (specialist trainee) doctorson the wards day and night.

• Handovers on the neonatal intensive care unit tookplace daily between the day and night medical teams.We noted that, while the majority of cases were handedover at the cot side as part of a formal ward-round basis,due to the number of babies within the unit, somebabies were not formally handed over. This wasespecially applicable to those babies who were clinicallystable, were well known to the medical staff and hadgenerally been inpatients for a long period of time.

• Consultants led on a range of ward rounds on thevarious wards. We noted that specialty doctors,including those from the respiratory team conductedregular, twice daily ward rounds.

Major incident awareness and training• Senior nursing and clinical staff reported that they had

received major incident awareness training. Senior staffwere aware of the location of the major incident planand were well versed in it's contents.

Are services for children and youngpeople effective?

Good –––

Staff adopted a holistic approach to assessing, planningand delivering care. Staff developed and advocated the useof innovative and pioneering approaches to care, especiallyfor those children with complex liver conditions and thosewho required surgery as neonates. Additionally, the servicehosted a national specialist multidisciplinary bariatricservice to children with obesity issues.

Clinical teams worked collaboratively to enhance theprovision of care to children. The service led on a range ofnational medical and surgical initiatives and worked inconjunction with a range of third party peers to driveforward advancements in paediatric surgery and medicine.

Paediatric mortality rates were seen to be in line with, orbetter than, peer averages across a range of specialties.

The service participated in a range of local and nationalaudits, including clinical audits and other monitoringactivities, such as reviews of services, benchmarking, peerreview and service accreditation. Accurate and up-to-dateinformation about effectiveness was shared internally andexternally and was understood by staff. Information fromlocal and national audit programmes was used to improvecare and treatment and people’s outcomes. Performanceagainst a range of national audits was seen to be in linewith, or better than, national averages although some workwas required regarding the management of asthmapatients and those with diabetes.

When people were due to move between services, theirneeds were assessed early, with the involvement of allnecessary staff, teams and services.

Evidence-based care and treatment• The trust’s hospital protocols were based on the

National Institute for Health and Care Excellence (NICE)and the Royal College of Paediatrics and Child Health




(RCPCH) guidelines. Local policies were written in linewith this. Staff knew where to find policies and localguidelines, which were available on the intranet. Therewere systems in place for ensuring that policies werereviewed following changes to national guidance.

• Consultants and nursing staff from a range of specialtieswere engaged in the development of national andinternational treatment guidelines as well as engagingin international research programmes.

• There were a range of clinical pathways and protocolsfor the management and care of various medical andsurgical conditions which had been developed inconjunction with healthcare professionals from a rangeof specialties.

• Nursing staff confirmed clinical governance informationand changes to policies and procedures and guidancehad been cascaded down by the matron and wardmanager via emails, special meetings and discussion atteam meetings, which were held monthly.

Pain relief• We observed that a variety of tools were used to assess

pain, depending on the age of the child and their abilityto understand information. The pain assessment chartwas embedded in the BPEWS chart. For a younger child,we noted that a pain assessment tool using ‘smileyfaces’ had been used. The child had been asked tochoose a face that best described their own pain. In thecase of a child living with a learning disability, a Face,Legs, Activity, Cry, Consolability (FLACC) behavioural toolwas used.

• Condition-specific guidance was available to staff tohelp them to manage cases, for example, thosepresenting to the hospital in sickle-cell crises.

• We saw that the special care baby unit (SCBU) and NICUused kangaroo care (a technique where the baby is heldskin-to-skin with the parent) as a means of helping tostabilise neonates. We observed that parents wereencouraged to engage in skin-to-skin care as frequentlyas the condition of the baby permitted.

• Advanced pain management services were availablethrough a dedicated pain management team. Thepaediatric site practitioners had undertaken additionaltraining to enable them to provide second and third

stage pain management services out of hours, aconsultant anaesthetist was available 24 hours per dayto assist with patients who presented in severe pain orwho required additional intervention.

Nutrition and hydration• Patient records included an assessment of each

patient’s nutritional requirements. The service used theadapted Screening Tool for the Assessment ofMalnutrition in Paediatrics (STAMP) to assess nutritionalrisk for all patients.

• Patients with poor food and hydration intake wereobserved closely. The care pathway observation chartincluded a section for nurses to monitor the food andfluid intake of these patients. This ensured patients’nutritional and hydration needs had been monitoredand maintained.

• Parents and children commented that there werechoices in the menu offered each day and that the foodprovided was ‘good’. The menu card was given topatients to select their menu in the morning and hotmeals were served twice a day. Sandwiches and snackboxes were available throughout the day.

• We saw that children had drinks readily available bytheir bedsides.

• Specialist paediatric dieticians were available tosupport the wider multidisciplinary team.

• A multidisciplinary bariatric clinic which providednational services to obese children had beenestablished. At the time of inspection, eight patients hadbeen operated on, in line with strict selection criteria.National bariatric symposiums had been facilitated bythe service.

• There were policies in place to support staff to ensurethat patients were starved preoperatively, in line withnational recommendations. Three parents told us thatthey had not received any preoperative informationregarding the starving times for their child. On twooccasions, parents had not sufficiently starved theirchildren and so the children were delayed in going totheatre. Staff were well versed in the requirements andacknowledged that further work was required to ensurethat the local policy was communicated to parents andcarers to educate them so as to reduce the likelihood ofdelays in future cases.

• A joint working collaboration had been establishedbetween King’s College Hospital NHS Foundation Trustand South London and Maudsley NHS Foundation Trust




to establish a child and adolescent eating disorderservice, which was hosted at The Maudsley Hospital,London. Changes to treatment pathways, including theintroduction of family therapy and integrated outpatientand inpatient therapies was seen to lead to medicalstabilisation and more cost-effective care in the longterm.

Patient outcomes• The service participated in a range of national audit

programmes in order that benchmarking andmeasuring of clinical effectiveness could take place.Audits participated in included the Childhood EpilepsyAudit, the British Thoracic Society Paediatric AsthmaAudit, the National Paediatric Diabetes Audit (NPDA),Mothers and Babies: Reducing Risk through Audits andConfidential Enquiries in the UK (MBRRACE-UK) and theNational Neonatal Audit Programme (NNAP).

• Summary Hospital-level Mortality Indicators (SHMIs)across a range of specialties were seen to be betterwhen compared to peer services for neonatology,paediatric gastroenterology and paediatrictransplantation services.

National Paediatric Diabetes Audit• The glycosylated haemoglobin (HbA1c) measurement is

recognised as being the best indicator for long-termdiabetes control. Because red blood cells in the humanbody survive for eight to 12 weeks before renewal,measuring glycated haemoglobin (or HbA1c) can beused to reflect average blood glucose levels over thatduration, providing a useful longer-term gauge of bloodglucose control. Data from the 2013 NPDAdemonstrated that King's College Hospital (the DenmarkHill site) paediatric diabetes service performed worsethan the national average with regards to Hba1c ratiosbeing below 58mmol/mol, in that 11.6% of the hospitalcase mix had a Hba1c below this level. This comparedwith a national case mix mean of 17.1% and a regionalcaseload mix of 17.6%.

British Thoracic Society Paediatric Asthma Audit• Performance against the national clinical audit for

paediatric asthma was varied. A higher proportion ofpatients could expect to receive a chest X-ray andantibiotics when compared nationally (78% of childrenhad a chest X-ray versus 26% nationally and 50% ofchildren received antibiotics versus 26% nationally).Ninety-three point eight per cent of children who were

administered steroids to help manage their conditionhad received a dose prior to admission versus 18.6%nationally. The service had acknowledged that furtherwork was necessary to ensure that patients weremanaged appropriately and in line with nationalstandards. A local audit had subsequently beencommissioned.

• It was reported that no children received informationleaflets, peak flow meters or a store of steroids prior todischarge. This compared negatively against nationalperformance, where 47% of children were giveninformation, 4% were given a peak flow meter and 11%were given a store of steroids. Further, the number ofchildren who had their technique for using an inhalerdevice assessed prior to discharge was reported as 59%locally versus a national average of 44%.

National Neonatal Audit Programme (NNAP)• Performance against the NNAP (2013) was positive . The

NICU performed better in each of the five key indicators,including: recording of temperature within one hour(97% versus 93% nationally), administration ofantenatal steroids (87% locally versus 85% nationally),the number of eligible babies screened for retinopathyof prematurity (RoP) – 100% locally versus 95%nationally, the number of babies discharged homereceiving some or all of their mother’s breast milk (52%locally versus 35% nationally) and the number ofparents who received a consultation from a seniormember of the team within 24 hours of admission to theunit (94% versus 84% nationally).

Paediatric Intensive Care Society Audit Network(PICANet)• Risk adjusted standard morality rates for the paediatric

intensive care unit (PICU) over the previous three yearshad consistently been better than expected (2011 – 0.86,2012 – 0.96 and 2013 – 0.83).

• Emergency readmission rates within 48 hours ofdischarge was better than the national average with areadmission rate of 0.8% versus 1.8% nationally.

Competent staff• Staff reported that they had attended induction on

starting employment and had attended mandatorytraining, including basic life support. All nursing staffworking on the special care baby unit had completedtheir newborn life support training.




• There were arrangements in place for ensuring thatnewly qualified nurses were orientated across both ofthe hospitals (King’s College Hospital and Princess RoyalUniversity Hospital). Newly qualified nurses were alsosupported by way of undertaking a preceptorshipprogramme, as well as receiving support from a practiceeducator. However, some junior nursing staff reportedthat their individual preceptorship programme had notbeen as effective as it could have been, due to theinfrequency with which they were worked with theirpreceptors. The ward managers that we spoke withacknowledged that further work was required toenhance the preceptorship programme, so that newlyqualified staff were sufficiently supported.

• There were systems in place for monitoring training fornew staff, through the training department. Practicedevelopment nurses worked in a range of specialitiesand oversaw newly qualified nurses and those goingthrough their induction period to ensure appropriatetraining had been arranged for them. This includedmandatory training, mentorship training andcompetency assessments, such as for theadministration of oral and intravenous medication.

Multidisciplinary working• Overall, staff reported good multidisciplinary working

across the children’s division, with other services withinthe trust and with external organisations, such as localauthorities and general practitioners, who had madereferrals. There were good shared care arrangementswith surgeons, and other services, such as theatres,orthopaedics and psychiatry.

• We found that the pathway for emergency patientsrequiring treatment from the maxillofacial surgical teamwas disjointed and poor communication existedbetween the surgical team and the paediatric sitepractitioner team. For example, we found two caseswhere beds were required for patients, and for whomboth parents reported that the admission process hadbeen convoluted and had led to some delays.

• Several multidisciplinary team meetings were heldmonthly, including serious case reviews, a safeguardingsteering group meeting and a weekly psychosocialmeeting. The care and treatment of each patient wasdiscussed and different views were listened to beforemaking decisions in the best interests of the child.

• While multidisciplinary working existed within the NICU,with multiple specialties providing input into the clinical

care and support of complex cases, we found theorganisation of such working to be disjointed. A range ofweekly meetings took place with varying specialtiesattending the meetings, where decisions were madeabout treatment plans. However, it was noted that at notime, complex case meetings were held, where allspecialties were in attendance at the same time. Therewas, therefore, a risk of some disjointed working anddelays in decisions being made regarding treatmentplans.

• The arrangements for the transitioning of patients withchronic health conditions, especially for those with liverconditions was exceptionally robust. The service wasleading on national and international transitional careprogrammes and research to enhance the transitionprogramme for adolescents undergoing livertransplantation, in order to improve mortality ratesamongst 20 to 30 year olds. The service had a liveradolescent strategy, which was supported by clinicalnurse specialists, paediatric and adult hepatologists,clinical psychiatrists, specialist social workers, livertransplant surgeons and sexual health consultants.Specialist adolescent liver outpatient clinics operatedtwice a month to support this age group. Eighty-eightper cent of patients reported that their overallexperience of the transitional care service was "verygood" or "excellent". Due to the success of theadolescent service, it was noted that the age of referralto the clinic had progressively reduced between 2008and 2013 from a median age of 17.4 years to 16.1 years,meaning that more patients were being offeredadditional support over a longer period of time.

• Play specialists were available each day and provided aservice to children accessing clinical services ininpatients, outpatients, PSSU and paediatric intensivecare. Staff reported that some infants on the SCBUwould have benefited from input from play specialists,especially for those infants who had been on the unit forsome months.

Seven-day services• There was a 24 hour consultant-led service, with

medical and nursing cover for each of the clinical areas.There was support from diagnostic services, including:radiology, physiotherapy and speech and languageservices.




Consent• Parents on the wards confirmed that their consent had

been sought prior to treatment of their child. Theydescribed how the procedures had been explained tothem by both doctors and nurses. They felt they hadbeen given very clear information and were wellinformed before they signed the consent form forsurgery and treatment.

• Staff were able to describe the legislative requirementsregarding consent and confirmed that policies andprocedures were available to ensure that informedconsent was obtained from the appropriate individual.Staff were able to describe the concept of Gillickcompetencies and the arrangements for seekingconsent from children and young people where theyhad been assessed as being competent to makedecisions regarding their care and treatment.

• Although the uptake for training of the Mental CapacityAct 2005 and Deprivation of Liberty Safeguards was lowacross the directorate, staff were able to describe thearrangements that were in place should the legislationneed to be applied. Staff reported that the leastrestrictive form of deprivation would be used anddecisions were made in conjunction with the widerfamily unit, specialist social workers, clinicians andnurse specialists.

Are services for children and youngpeople caring?

Good –––

Parents were complimentary about the medical andnursing staff and they felt their child was in safe hands.Parents felt involved in the care of their child andparticipated in the decisions regarding their child’streatment.

There was good staff interaction with patients and parents.Both children and parents were treated with compassion,dignity and respect, although some additional work wasrequired to ensure that patients who accessed the diabetesservice had their views heard and were respected andunderstood by all members of the team.

Compassionate care• Response rates against the service's ‘How are we doing’

survey were seen to be consistently better than the trustbenchmark of 86%.

• Performance against a range of Commissioning forQuality and Innovation (CQUIN) payment frameworkmeasures regarding patient experience consistentlyexceeded benchmarks:

• Throughout our inspection, we witnessed good staffinteraction with patients and parents. We observedgood, friendly and appropriate communication bynursing and medical staff with parents and their child.We observed how the nurses assisted parents andchildren during recovery from a surgical operation.

• Parents were all complimentary about the care and thestaff who cared for their child. Both children and parentswere treated with compassion, dignity and respect.

• One parent commented, “Very good service, althoughthe ward can be a little noisy at night. The staff offeredme a tour and have been very supportive”. Anotherparent said, “I received information before we arrived forour surgery. The staff have been very informative. Theyhave been compassionate and have demonstrated ahigh level of understanding about how we, as a family,are feeling. We are all extremely anxious and both thedoctors and nurses have moved mountains to reassureus."

1. Ninety per cent of responders stated that that theywere able to find someone on the hospital staff to talkabout their worries or fears.

2. Over 92% said that when they had importantquestions they got answers that they couldunderstand.

3. Response rates regarding questions at night, nurseresponse time to call bells and support on dischargewas consistently above, or better than, the trustbenchmark.

• Parents were all complimentary about the care and thestaff who cared for their child. Both children and parentswere treated with compassion, dignity and respect.

Understanding and involvement of patients andthose close to them• Parents felt well informed before they signed the

consent form for surgery and other treatment. They feltinvolved in the care and in the decisions regarding theirchild’s treatment. One parent said, “I was able to meet




with the surgeon on two occasions before signing theconsent form. I was given sufficient information in orderthat I could make an informed decision. As a family, wehave all been involved in planning the care for ourchild."

• Patient and parent satisfaction survey questionnaireswere available and the results were published on thedashboard, together with the action taken to improvethe service.

• Within the NPDA experience survey for children andyoung people (2013/2014), 100% of patients reportedthat they either ‘agreed’ or ‘strongly agreed’ that theyreceived useful information from members of theclinical team. While the majority of patients either‘agreed’ or ‘strongly agreed’ that clinical appointmentswere well organised and gave them sufficient time todiscuss everything that they would like to discuss, 8.3%of patients disagreed. This was worse than the nationalaverage of 3%.

• Parents reported they were given appropriateinformation and the proposed treatment was explainedto them by both doctors and nurses.

Emotional support

• A range of healthcare specialists were available toprovide emotional support to the family and to thechild. Bereavement nurse specialists, clinicalpsychologists and psychiatry services were available tofamilies who were grieving the loss of a child or sibling.

• Psychological support could be offered to patients withcomplex health needs. The paediatric bariatric servicereferred all patients to a psychologist whose role it wasto help support the adolescent in the lead up to, andfollowing, their surgery in order to enhance recoveryand to adjust to physical body changes, as well as tosupport the emotional wellbeing of the individual.

• While 88.6% of patients in the NPDA patient experiencesurvey ‘agreed’ or ‘strongly agreed’ that they felt heard,respected and understood by all members of the team,11.4% disagreed. This was worse than the nationalaverage of 3.2%.

Are services for children and youngpeople responsive?

Good –––

Staff acknowledged that the demands on the service wereincreasing year on year and that capacity had proven to bedifficult to manage during peak times. This was especiallypertinent to the NICU whose activity had been seen to beincreasing annually. The organisation recognised the needto extend children's services over the coming years toensure that it could continue to meet the needs of thepopulation it served.

People’s discharge or transition plans took account of theirindividual needs, circumstances, ongoing carearrangements and expected outcomes.

Service planning and delivery to meet the needs oflocal people• Paediatric site practitioners had been employed to

oversee the day-to-day operation of the service, havinginput into the admissions and discharges of eachclinical area. Also, the site practitioners were available toassess the clinical condition of patients about whomstaff were concerned and were also available to providesecond line pain management services out of hours.

• Daily unit meetings took place, allowing the nurse incharge from each clinical area to discuss their bedoccupancy, upcoming discharges, elective andemergency admissions.

• We noted that young people up to the age of 18 werecared for within the children’s and young people’sservice and saw evidence that their transition into adultservices was managed effectively. This was especiallynoted for young people with complex liver disorders,where an extensive transitional care service had beendeveloped to help support young people’s move fromthe paediatric liver service to the adult team.

• The service employed a range of clinical nursespecialists to ensure that patients with specific healthconditions and their families received expert care andsupport. These included those for liver disease, sicklecell disease and respiratory conditions.

Access and flow• The total number of cot days within the NICU and SCBU

was seen to have peaked in 2010 when 12,499 days were




reported. While there had been a marginal decrease incot days through the following two years, cot days werenoted to have slowly increased and were reported as12,253 cot days in 2013. While there had been adecrease in the number of special care cot days (from areduction of 6,927 in 2010 to 6,155 in 2013), there hadbeen an increase in the number of cot days for babiesrequiring high dependency or intensive care support(5,572 in 2010 and 6,098 in 2013). It was widely acceptedby the senior management team and those workingwithin the NICU that it did not have a sufficient numberof cots to ensure that it could meet the needs of thelocal and regional population. Staff reported that poordischarge planning had impacted on the ability of somebabies to be repatriated to local neonatal units toenable their care to be continued. Further, the acuityand complex clinical conditions of some babies had ledto significant increases in their length of stay. Whilethere was some action being taken, including improvingthe working relationships between the NICU and thepaediatric intensive and high dependency care teams tofacilitate the transfer of babies to more age-appropriateenvironments, the increased occupancy in the PICU andHDU had meant that transfers could not always takeplace. There was also concern amongst the clinical staffthat the skill set of ward-based nursing staff meant thatthey were anxious to transfer babies to the children'sward for continued care.

• Staff reported that the occupancy on the neonatal unitconsistently fluctuated and at times was reported tohave peaked at 40 babies. The week prior to ourinspection we found this to be the case. During theinspection, occupancy of the unit fluctuated between 34and 36 babies. Nursing staff reported that, while bestpractice was for there to be a cot available at all times,in order that an emergency admission could beaccepted, this was often not the case. Nursing staff saidthat the service adopted a more responsive approach tomanaging emergencies instead of it being proactive,and that this was attributed to an overall lack ofcapacity within the unit. Data provided by the trustdemonstrated that cot availability on the NICU at theDenmark Hill site was a continuous problem. Dailyreports to the ‘Emergency Bed Service’ betweenSeptember 2014 and January 2015 demonstrated that

cots were only available on 12 out of a possible 153days. This meant that 36 mothers were transferredoutside of the South East Neonatal Network and 16transferred within the network, during that time period.

• Occupancy difficulties within the NICU were listed as arisk on the divisional risk register and had a residualseverity risk score of 16. In order to enhance thedischarge process of babies, a nurse had beenappointed to work as a special care dischargecoordinator, as well as establishing a more robust inreach service, which intended to help facilitate the earlydischarge of infants, while dedicated nursing staff wereavailable to support parents in the lead up to, andsubsequent discharge from, the unit.

• The paediatric surgical team had access to onededicated theatre, which some surgeons felt wasinsufficient to meet the growing demands of the service.There were, however, arrangements in place forensuring that the surgical team had access to theemergency theatre and were able to discuss withcolleagues on a daily basis any surgical cases, whichshould be prioritised in order that the needs of the mostcritically-ill patient be put first.

• As a means of trying to resolve ongoing capacity issueswithin the children's service and to help enhance thepathways for children, a paediatric short stay unit wasopened in July 2014 and was designed to treat patientswho required inpatient care of less than 48 hours. Wesaw evidence that the introduction of the paediatricshort stay unit had led to a reduction in the cancellationof elective surgical cases and also an increase in thenumber of specialty patients being able to be admittedto Toni and Guy Ward as a result of improved bedmanagement. Inpatient cancellations was seen to havepeaked at 12 in November 2014, but had since revertedto zero for January and February 2015. Overall, surgicalcancellations had reduced from 54 prior to the openingof the paediatric short stay unit (PSSU) to 34 (37%reduction) following its inception. Further, there hadbeen a marked reduction in the number of paediatricmedical outliers admitted to non-medical wards afterthe opening of the PSSU.

• The outpatient ‘did not attend’ (DNA) rate was seen tobe worsening month on month and was significantlyabove the trust target of 8% (as of February 2015 theDNA rate was reported as being at 16.6%).




• The scorecard for the service, which was provided to uslacked any data regarding emergency readmission ratesand diagnostic waits of more than four weeks.

Meeting people's individual needs• There were information leaflets available for many

medical conditions, including child-friendly leaflets ondiabetes, asthma and sickle cell anaemia.

• The menus included cultural dishes reflecting the localcommunity.

• Activity facilities were provided with toys, colouringbooks and games to entertain children on the ward.Play activity specialists covered the ward to assistinpatients.

• Children were given educational support five days aweek. The teacher gave a choice of subjects for thechildren to choose, depending on their age group. Allactivities were documented in accordance witheducation guidelines. The education team were able toprovide specialist support to children living withlearning and complex physical disabilities. This includedthe use of pictorial and electronic communication tools.

• The wards operated flexible visiting times to enableparents to visit or to stay with their child at all times.

• Translation services were available to those patientsand families for whom English was not their firstlanguage.

• The liver team raised concerns that there was limitedbed capacity to provide care and support to adolescentsin an appropriate environment.

• Parents whose children were receiving long-term carewere provided with accommodation local to thehospital.

• Children who required support for mental healthconditions were routinely nursed on a one-to-one basis.Staff told us that, while the service did not employspecialist mental health nurses, shifts could be coveredwith bank and agency staff.

• While the service employed a range of clinical nursespecialists, there was some concerns raised that, due tothe complexities of some children’s conditions and theincreased workload of the specialist team, somepatients may not always have sufficient time to speakwith the nurse specialists at length.

• The clinical nurse specialists provided a range ofoutreach clinics in other hospitals in order that patientswere not required to travel to the Denmark Hill site forclinic appointments.

• Information leaflets for parents was also on display onthe noticeboard in the children’s wards, Thomas CookChildren’s Critical Care Centre and the NICU.

Learning from complaints and concerns• Information was available for patients to access on how

to make a complaint and how to access the PatientAdvice and Liaison Service. A dedicated member of staffwithin each of the clinical areas, including the matron,reviewed all formal complaints received and concernswere raised with the Patient Advice and Liaison Service.All concerns raised were investigated and there was acentralised recording tool to identify any trendsemerging. Learning from complaints was disseminatedto the whole team to improve the patient experiencewithin the department.

• Information was readily available for patients whowished to make a complaint, but who may have neededsupport to do so.

• Complaint levels within the child health directoratewere seen to be generally low. Staff reported that theyalways tried to resolve issues in the first instance byspeaking with family members. In response to a recentserious incident, staff had produced a new leaflet, whichwas aimed at supporting parents to escalate theirconcerns to senior members of the clinical and nursingteam if they felt they were not being heard by membersof the team and were concerned about the clinicalcondition of their child.

Are services for children and youngpeople well-led?

Good –––

Staff were aware of the trust vision and values. Staff hadbeen provided with information on trust developmentsthat had been cascaded down from their line managers.The service had a child health specific strategy, which wasaligned to the trust-wide strategy. The strategy was drivenby quality and safety and took into account therequirement for the service to be fiscally responsible.

There were governance arrangements in place for which arange of healthcare professionals assumed ownership.Further, work was being undertaken to strengthen the




governance relating to children who received care ortreatment outside the auspices of child health services.There was evidence that risks were managed and escalatedaccordingly.

Nursing staff reported good management support fromtheir line managers. Changes to the management teamwithin the NICU was said to have a had a positive impact onthe service.

Innovation and long-term sustainability were seen as keypriorities for the leaders of the service. Participation innational and international research was a drivingmotivation for clinical staff in order that the wellbeing andclinical outcomes of children could be enhanced.

Vision and strategy for the service• There was a service-level clinical strategy for child

health, which was aligned to the trust strategy. Thestrategic vision included both short and long-termpriorities for the next one to two years and three to fiveyears respectively and included developmentsregarding the environment, finance, service provisionand governance arrangements.

Governance, risk management and qualitymeasurement• Governance arrangements at the King’s College Hospital

(Denmark Hill site) were underpinned by a documentedrisk management process, which senior staff were wellversed in and they reported that its overall effectivenesswas good. There was engagement from a range ofhealthcare professionals regarding the clinicalgovernance and risk management process.

• Regular child health divisional quality and governancemeetings, chaired by the clinical director were held andattended by a range of health professionals, includingnursing staff and the divisional quality and risk lead.

• Standing agenda items at the divisional governancemeeting included a review of actions from previousmeetings, reviews of the divisional risk register, reviewsof recent incidents, consideration given to recent safetyalerts and infection control issues. Patient experience,clinical effectiveness and self assessment against thetrust risk management strategy were also considered.

• It was evident that some issues, which had impacted onthe clinical effectiveness of the service, including theescalation of the deteriorating child, had been escalatedto the divisional risk register and there was evidencethat action was being taken to address the issues.

• While the service had introduced a child healthscorecard in order that the quality of the serviceprovided could be monitored, we found that aproportion of metrics contained no information. It was,therefore, not possible to take complete assurance fromthe scorecard that all components of qualitymeasurement were being effectively undertaken.

• Participation in a host of national and local auditsmeant that the service could measure their clinicaleffectiveness and performance against a range of peersand national outcomes. Presentations and assurance tothe board meant that there was transparency within theservice and there was evidence that whereimprovements were required, action plans weredeveloped and further assurances offered tocommissioners and patient groups alike.

• The senior team acknowledged that further work wasnecessary to ensure that the governance arrangementsfor all children who received care and treatment atKing’s College Hospital NHS Foundation Trust wasstrengthened. The introduction of a child health boardhad received executive approval and while it was yet tobe formally established, it had been designed to ensurethat the skills and training of all staff who provide careand treatment was sufficient and that clinical areaswere appropriate to meet the needs of children.

Leadership and culture of the service• Leadership of the service was by way of a triumvirate

with a clinical director, head of nursing and generalmanager. It was noted that the operationalmanagement of the service was provided by way of thegeneral manager's deputy, who was well versed in theoperational strategy and vision of the service. Theclinical director had delegated responsibility to specialtyleads and the head of nursing had delegated someresponsibility to her deputies. Development of thematrons and ward managers was seen as a key priorityand empowerment of the role of the paediatric sitepractitioner was seen as key to ensuring the service waswell-led.

• The leadership of the neonatal intensive care servicehad undergone change in recent months and wasreported by staff to have been a positive change. Therehad been significant shortfalls identified by the newteam regarding the management of the NICU. We foundthat the shortfalls had been identified and were beingresolved, including the lack of nursing, medical and




therapy support staff to support the growing service.Additionally, the ongoing capacity issues caused bypoor discharge planning had been identified and newroles had been created as a means to resolve the issues.Morale within the NICU was reported to be improvingamong both the medical and nursing staff since therehad been a change in medical and nursing leadership.

• Staff were highly complimentary about the frontlinemanagement team. Junior doctors felt the consultantswere very approachable and supportive.

• Ward managers and matrons reported that havingsupernumerary status allowed them the time to developtheir workforce and to address quality and patientsafety issues. The head of nursing was an advocate ofensuring that the ward managers were visible to theirstaff and, therefore, promoted the concept of themanagement team undertaking regular clinical shifts.

• The staff that we spoke too were extremely proud towork for King’s College Hospital NHS Foundation Trustand felt that the care they provided was excellent.

• There was an open culture amongst the staff group.Staff felt confident to report incidents and concerns inthe majority of clinical settings, although it was notedthat the culture within the NICU was one in whichpersonal issues that impacted on the workforce wouldtry to be resolved among staff, as compared to sharingthose concerns with the management team. Again, thishad been identified by the management team and workwas being undertaken to ensure that personaldifferences were resolved in a professional and timelymanner.

Public and staff engagement• Specialty services invited feedback from a range of

service user groups and families in order that servicescould be developed and reconfigured to ensure theymet the needs of the population. The liver servicehosted annual functions, which allowed patients tomeet with each other in order to allow peerrelationships to develop as well as to allow staff to seekfeedback from patients.

• Patient feedback was widely disseminated across eachof the clinical settings and included initiatives including

‘You said, we did’ noticeboards, as an example. As ofApril 2015, the service was said to be introducing a newsystem to seek feedback from children aged eight yearsand above.

Innovation, improvement and sustainability• The introduction of the paediatric short stay unit was

seen to have enhanced the patient pathway for thosewho required treatment for acute illnesses, as well asimpacting positively on those patients who requiredrapid, open access to the children's wards. Engagementwith local general practitioners (GPs) had led to themproviding positive feedback about making referrals tothe acute medical team at the hospitals. There hadbeen a significant reduction in the number of patientswho presented to the ED who were seen for ‘treat andtransfer’. There had been two reported treat and transfercases up to April 2015, as compared to 43 during thesame period the previous year.

• The adolescent liver transition service was seen as agold standard service. Year-on-year, increases in thenumber of referrals to the service, as well as a reductionin the age of referral, meant that young people werereceiving support and advice at a much earlier stageand for longer durations. We reviewed information,which indicated that drug compliance had improved asa result of the initiative, as well as increases in patientexperience.

• While only a small service, the paediatric bariatricservice was seen as providing a holistic,multidisciplinary-led service to children across thecountry. The lead clinician had identified theimportance of maintaining their specialist surgical skillsand assisted with adult surgical cases. There wasengagement with the adult surgical team for each of thepaediatric cases, so as to ensure the service remainedsafe.

• As a result of a five-year paediatric and mental healthjoint working collaboration programme relating to themanagement of children with eating disorders, the localclinical team had presented nationally as well asadvising government officials on the structure andtreatment pathways for those with eating disorders.





Effective Requires improvement –––





Information about the serviceKing’s College Hospital NHS Foundation Trust providesintegrated end of life care across King's College Hospital(the Denmark Hill site) and Princess Royal UniversityHospital. End of life care was not seen as the soleresponsibility of the specialist palliative care team (SPCT).End of life care at King's College Hospital (Denmark Hill site)consisted of an SPCT who worked in partnership with thelocal voluntary sector provider, St Christopher's Hospice,providing support to patients with complex symptoms atthe end of life. A practice development nurse (PDN) andclinical nurse specialists (CNS) support the generalist staffin the delivery of end of life care, as well as training andeducation of nursing and medical staff.

The SPCT was led by the lead palliative care consultant anda nursing matron. The team consisted of social workers, aservice manager and team administrator. In addition, thebereavement office staff provided bereavement supportafter death and the chaplaincy team provided multi-faithsupport.

The core SPCT were available five days per week, Mondayto Friday, 9am to 5pm. At weekends and bank holidays,specialist registrars (StRs) provide a first on-call visiting anda telephone advice service via the King’s Health Partnership(KHP), King’s College Hospital NHS Foundation Trust andGuy’s and St Thomas’ Hospital, supported by the on-callconsultant.

During the inspection, we visited a variety of wards acrossthe trust, including: Lonsdale Ward, Howard Ward, OliverWard, Annie Zunz Ward, Mary Ray Ward, Donne Ward, Todd

Ward, Katherine Monk Ward, Lister Ward, Davidson Ward,Fisk Ward and Cheere Ward, the emergency department(ED), the neurological intensive therapy unit (NITU), thechemotherapy day unit, Bereavement Centre, the mortuaryand the Macmillan Information and Support Centre.

We spoke with palliative care medical consultants,registrars and junior ward doctors, clinical nurse specialists,registered nurses, a practice development nurse (PDN),bereavement staff, ward matrons, head and assistantheads of nursing, porters, mortuary staff, Specialist Nurse inOrgan Donation (SNOD) and the hospital chaplain in orderto assess how end of life care was delivered.

We reviewed documents relating to the end of life careprovided by the trust and the medical records of tenpatients receiving end of life care. We observed the careprovided by medical and nursing staff on the wards andspoke with four patients receiving end of life care and fourfamily members of patients receiving end of life care.

We received comments from our public listening event andfrom people who contacted us separately to tell us abouttheir experiences. We reviewed performance informationheld about the trust.

Endoflifecare

End of life care


Summary of findingsCurrent trust policy around syringe drivers wasinconsistent across the sites and did not protectpatients from adverse incidents. The cover for theconcealment trolley was in poor repair and was aninfection control risk. We saw little evidence of thedocumentation of preferred place of care/preferredplace of death or the wishes and preferences of patientsand their families. Although there was a unified do notattempt cardio-pulmonary resuscitation (DNA CPR)policy, orders were not consistently completed inaccordance with the policy. There were also nostandardised processes for completing mental capacityassessments.

Staff at King's College Hospital (the Denmark Hill site)provided compassionate end of life care to patients. Thespecialist palliative care team (SPCT) providedface-to-face support, seven days a week, with apalliative care consultant providing out-of-hours cover.There was strong clinical leadership of the SPCT andchaplaincy team resulting in well-developed, strong andmotivated teams. Bereavement support was availablefrom the social workers, chaplaincy and bereavementoffice staff, who were able to provide support for carersand their families following the death of their relative.The teams worked well together to ensure that end oflife policies were based on individual need and that allpeople were fully involved in every part of the end of lifepathway. However, we did not see any evidence of along-term vision around end of life care across the trust.

Relatives of patients receiving end of life care wereprovided with open visiting hours and were also offered‘keepsakes’ from the deceased patient. There wasexcellent spiritual/religious awareness by staff acrossthe hospital and facilities were in place to support thedifferent cultures and religions of the local population.

End of life care was embedded in all the clinical areasand staff we spoke with were passionate about end oflife care and the need to ensure that the wishes andpreferences of their patients and families were met asthey entered the last stage of their life.

There was a multidisciplinary team approach tofacilitate the rapid discharge of patients to their

preferred place of care or preferred place of death.Patients were cared for with dignity and respect andreceived compassionate care. Medicines were providedin line with guidelines for end of life care.

Endoflifecare

End of life care


Are end of life care services safe?


A syringe driver was used in the wards to deliver consistentinfusions of medication to support end of life patients withcomplex symptoms. Patients being discharged with asyringe driver in place required the specialist palliative careteam (SPCT) to connect a different syringe driver fordischarge. However, nursing staff on the wards had notbeen trained in the use of the syringes used on dischargeand, as a consequence, clinical issues had developed,including blocked pumps, resulting in pain medication notbeing delivered to patients. The current trust policy aroundsyringe drivers used with end of life care patients did notafford optimum protection against the risk of adverseincidents.

An X-ray trolley was being used as the hospitalsconcealment trolley because the actual trolley was beingrepaired. The cover for the concealment trolley was in poorrepair and was an infection control risk. Medical staff werenot based on the chemotherapy day unit. This could be anissue if medical support was required by patientsimmediately and doctors unavailable.

The mortuary provided data about incidents withsummaries of actions taken to mitigate the risk ofreccurrence. A total of 59 incidents had been reported inthe last 15 months. Of these, three were classed as seriousincidents.

Incidents• All the staff we spoke with told us they were encouraged

to report incidents using the electronic reportingsystem. A senior nursing staff on Todd Ward told us thatfeedback from incidents was given at the staff meetingsthat took place monthly. Minutes of the most recentstaff meeting showed that areas discussed includedincident reporting.

• Incidents that related to end of life care were discussedat the palliative care governance meeting. To monitoradverse incidents, the SPCT had set up a ‘governanceaction tracker’. We reviewed the action tracker forJanuary/February 2015 and noted that seven incidentswere logged for both the Denmark Hill site and PrincessRoyal University Hospital sites. There were clear

descriptions of the incidents recorded and the actionstaken following the incidents. The majority of incidentswere around medication errors. By monitoring theincidents related to end of life care, the SPCT were ableto monitor themes and influence training and policy toimprove the quality of end of life care across the trust.Learning from incidents was shared through regularstaff meetings, the daily bulletin to staff, emails fromconsultants and the setting up of a web page. Wardmeetings were held monthly and minutes from themeeting were available on the ward. On Lonsdale Ward,one nurse told us that the feedback received regardingincidents was good.

• The mortuary provided data about incidents acrossboth sites reported from 1 January 2014, withsummaries of action taken to mitigate the risk ofreccurrence. Fifty-nine incidents had been reported inthe past year and of these, three were classed as seriousincidents (red), five as moderate (amber) and all the restwere low risk incidents. We reviewed how the red riskswere managed and noted that the appropriateprocedures were followed, including a root causeanalysis and discussion with families. We noted that oneof the red risks was due to be discussed at the April 2015serious untoward incident meeting by the palliative careconsultant. We were shown by the mortuary staff thatsystems had been introduced in the mortuary toprevent similar incidents happening in the future.

• The chemotherapy outpatients senior nurse told us thatadverse incidents were recorded in the electronicreporting system, as well as informing the unit managerand lead chemotherapy nurse. In the 12 months prior tothe inspection, incidents had included medication notprescribed on time and chemotherapy drugs omittedfrom the prescription, thus delaying patient treatments.Incidents reported also included blood spillages,extravasations and medication errors.

Cleanliness, infection control and hygiene• The wards, mortuary and viewing areas we visited were

clean, bright and well maintained. In all clinical areas,the surfaces and floors were covered in easy-to-cleanmaterials allowing hygiene to be maintainedthroughout the working day.

• Ward and departmental staff wore clean uniforms andobserved the trust’s ‘bare below the elbows’ policy.Personal protective equipment (PPE) was available foruse by staff in all clinical areas. In the mortuary, we

Endoflifecare

End of life care


observed adequate supplies of PPE for use by visitingundertakers and porters. However, the cover for theconcealment trolley was in poor repair and was aninfection control risk.

• Draft guidance was available for staff to follow to reducethe risk of infection when providing care for people afterdeath in the trust’s ‘Care of the Body After Death – LastOffices Policy 2015’. The approved policy was due to beintroduced across all areas in the hospital soon. Thepolicy included the wearing of gloves, aprons and theuse of body bags. A red dot was placed on the deathcertificate to highlight to all staff that may come intocontact with the deceased person that they had had aninfection. However, we noted that in the incidents,which had occurred in the mortuary, mortuary staff didnot always learn on time that a deceased patient hadhad an infection.

Environment and equipment• People reaching the end of their life were nursed on the

main wards in the hospital. The bereavement policysuggests that whenever possible, patients were to becared for in side rooms on wards in order to offer quietand private surroundings for the patient and theirfamilies. We observed this in practice when we visitedthe wards.

• A syringe driver was used to deliver consistent infusionsof medication to support end of life patients withcomplex symptoms. Patients to be discharged with asyringe driver in place required the SPCT to change it toanother type of syringe driver prior to discharge. Asenior nurse on Donne Ward told us that they did notdischarge patients home at the weekend, because theydid not have access to the SPCT to change the syringedrivers.

• Staff told us that acutely-ill patients were sometimesadmitted with a particular syringe driver in situ. Nursingstaff on the wards had not been trained in the use ofthese syringe drivers. As a consequence, clinical issueshad developed, including blocked pumps resulting inpain medication not being delivered to patients. Wewere told by the SPCT that staff in the ED were trained todisconnect the syringe driver. However, during theinspection, we spoke to two patients who had beenadmitted to the wards with the particular syringe driverin place, which later resulted in poor pain managementbecause the syringe driver had become blocked.

• The use of two types of syringe drivers across the trustincreased the risk of potentially harmful errors andincidents. We therefore noted that the current trustpolicy around syringe drivers used with end of life carepatients did not afford optimum protection against therisk of adverse incidents.

• Syringe drivers were available across the trust, onrequest from the equipment library. On Katherine MonkWard a nurse told us that the syringe drivers wereroutinely cleaned by ward staff and a date was put onthem stating when they were due for annualmaintenance. The monitoring requirements for thesyringe drivers were on the electronic prescribingsystem in the patients’ electronic records.

• Pressure-relieving equipment, including mattresses,was available for patients requiring them. We saw thesemattresses in use on Katherine Monk Ward where anend of life patient was being nursed on an air mattress.

• The mortuary was secured to prevent inadvertent orinappropriate admission to the area. CCTV was evidentin four areas in the mortuary. Freezers were lockable toreduce the risk of unauthorised access and the potentialfor cross infection.

• Equipment was maintained by the estates department.However, we saw that an x-ray trolley was being used asthe hospitals concealment trolley as the actual trolleywas being repaired. Staff told us the trolley had beenaway for a week and they were unsure when it would bereturned.

• The mortuary was due to be refurbished, but weobserved chalk being used to write people’s names onthe fridge doors. This was a risk with this that namescould be wiped off easily.

Medicines• The SPCT had introduced the ‘Management of the Dying

Patient – Clinical Guidelines for the Control ofSymptoms’, which set out the management of patientswho had been recognised as dying. The guidelines gavegood, easy to follow instructions, including: signscommonly seen in the last few days of life, commonsymptoms and essential components of care.

• Clear guidelines set out the drug management ofsymptoms in the dying patient and included reducingmedication to a minimum, the route of administration,‘as required’ medication and the medication necessaryto support the management of the five symptomsexperienced by patients at end of life: pain, nausea and

Endoflifecare

End of life care


vomiting, breathlessness, agitation and respiratorysecretions. Symptom control algorithms had beenagreed and implemented to support the managementof dying patients.

• Medical teams were asked to contact the SPCT if patientsymptoms persisted, or the patient had a complexmedical condition, such as Parkinson’s Disease, ordiabetes. We saw that a second set of guidance hadbeen developed to support patients with end stagerenal failure. On Lonsdale Ward the foundation year 2(FY2) doctor told us that they were happy to prescribeend of life anticipatory drugs, but they would not start asyringe driver unless they had senior guidance.

• The trust undertook an audit of the NICE clinicalguideline CG140, ‘Opioids in palliative care: safe andeffective prescribing of strong opioids for pain inpalliative care of adults’. Specific challenges identifiedincluded leadership, generalists versus specialist andmonitoring outcomes. The King’s Opioid Safety Group(KOSG) meeting was developed to provide leadership.The terms of reference clearly set out the purpose of thecommittee, which included: monitoring adverseincidents and any action plan developed, reviewing thepain and palliative care register, reviewing safety alertsand cascading via the risk management department.The responsibilities of the KOSG also included reviewingserious complaints and approving local guidelines.

• We reviewed the minutes of March 2015 KOSG meeting.We noted that adverse incidents were discussed and anew KOSG action tracker was set up. Safety alerts werein place, which included discussions around highstrength opioids that must not remain on the wards andneeded to be returned to pharmacy within seven days.Patient information was discussed as to whether therewas a need to improve these. The trust had respondedproactively by establishing this group to provideleadership in the management of opioids in order toimprove patient safety. This was demonstrated by thenew ‘opioid patch monitoring chart’, approved by thegroup in February 2015. This chart was secured in thepatient’s paper prescription chart. We noted a posteralerting staff around the prescribing of oral opioids sentout by the group.

• We were told by staff on the wards we visited thatmedication for end of life care was available on the wardand was easily accessible. We observed that locks were

installed on all store rooms, cupboards and fridgescontaining medicines and intravenous fluids on thewards we visited. Keys for cupboards were held bynursing staff.

• Medicine administration records were completedaccurately in the patient records we looked at.

• On Todd Ward and Lonsdale Ward, as well as the liverITU, we were shown that controlled drugs were handledappropriately and stored securely, demonstratingcompliance with relevant legislation. Controlled drugswere regularly checked by staff working on the wards wevisited. We checked the contents of the CD cupboardagainst the controlled drug register on two wards andfound they were correct.

• On Mary Ray Ward, we reviewed a patient’s electronicpatient record (EPR). We saw evidence of good teamwork with the SPCT for the control of pain anddiscussions with the patient and the family.

Records• The EPR allowed staff to identify patients at the end of

their lives, which then initiated an assessment of thepatients’ individual needs and facilitated thedevelopment of individualised care plans. However,during the inspection we noted that there was still amixture of paper and EPR across the critical wards,which introduced a level of risk as information/instructions could be missed.

• The palliative care consultant told us that allface-to-face and telephone activity outside of coreworking hours was recorded using a standardisedcontact sheet across KHP and Lewisham Hospital. Thisimproved patient safety by passing clinical informationbetween teams, along with a permanent record of theconversation, which could be placed in the patient’srecords to ensure continuity of care between careproviders. At the end of an evening or weekend,handover sheets around the care delivered wereemailed to the handover consultant.

• The chaplaincy service used a database to enterminimal data about their consultations. This includedthe patient’s name, date of birth, episode of care andany particular requirements. This allowed thechaplaincy to deliver streamlined care if the patient wasreadmitted to the hospital over a period of time.

• In the chemotherapy day unit, several forms ofdocumentation were completed by the nursing staff.

Endoflifecare

End of life care


These included: a nursing update on the EPR, thecompletion of paper notes that included a safetyquestionnaire and the e-prescribing chemotherapysystem.

• We reviewed the EPRs of ten patients receiving end oflife care. These demonstrated the SPCT had supportedand provided evidence-based advice, for example, oncomplex symptom control and support for the patientsand families as they traverse the care pathway. Thisspecialist input by the SPCT ensured that a high level ofexpertise was used to ensure the best possible care wasdelivered to end of life care patients so that people hada positive experience of healthcare.

• The end of life policy stated that patients at the end oflife were assessed by the medical and nursing teams sothat individualised care plans could be developed tomeet the patient’s needs. In the EPR records wereviewed, we observed documentation was pooraround the wishes and preferences of the patient.

• Patients receiving end of life care were placed on the‘generic medical pathway’. However, within the renaldatabase, we observed the storage of patients’demographics, symptom control needs, quality of lifemeasurement and patients’ preferences.

• The hospital had recently introduced an electronicversion of the do not attempt cardio-pulmonaryresuscitation (DNA CPR) orders. The resuscitation officertold us that, as part of the admissions process, a box inthe EPR was completed with the status of the patient.This would be completed on admission or during theward round (by a consultant within 24 hours). Atreatment escalation plan was being piloted that wouldspecify the ceiling of care. On Oliver Ward, the seniornurse told us that DNA CPR orders were monitored twicedaily during multidisciplinary handover rounds. Aregistrar showed us the electronic process, including themaking of an electronic treatment escalation plan. Thedoctor demonstrated a high level of understanding ofthe principles, especially best interests and the role offamily.

• A daily DNA CPR list was distributed to the resuscitationteam, critical care outreach team and the clinical sitemanagers, which identified the patients across thehospital that had a DNA CPR order. The resuscitationofficer told us that this had improved the managementof deteriorating patients.

• The DNA CPR policy had been developed separatelyfrom the resuscitation policy by the SPCT. In March 2015,

a snapshot audit was undertaken of 30 patients. Out ofthe 12 patients who had a DNA CPR in place, only threehad explanatory forms completed on EPR. Six had paperDNA CPR orders, with only two completed correctly. Ofthe 12 orders, six had recorded discussions with thepatient and six with the family. The conclusion was thatthere was current confusion with a mix of paper andelectronic records. Furthermore, there were threepatients who were not for DNA CPR, however, there wereno electronic or paper DNA CPR forms, whichrepresented a clinical risk.

• We looked at a sample of 12 DNA CPR forms across anumber of wards and found the same issues as theaudit throughout the hospital. We found a mixture ofpaper and electronic DNA CPR orders. On Mary RayWard, we reviewed two EPRs and found old style DNACPR forms, which were raised on the 4 April 2015. Thechange from paper orders to electronic began on 1 April2015, so there seemed to be a lack of clarity as to howDNA CPR orders should be completed. We reviewed athird order written on EPR, but there was no explanationon how the decision was made.

Safeguarding• We reviewed the training records on Annie Zunz Ward

and noted that 24 of 33 staff had completed theirsafeguarding training.

Mandatory training• We reviewed the end of life training programme, which

was last updated on 6 April 2015. An end of lifee-training module was developed in 2012, withmandatory training for nurses introduced in 2013. Thetrust had set an 80% compliance target, however, acrossthe trust they were achieving 60%. The wards that wereachieving above the 80% target included Cheere Ward(94.4%), Fisk Ward (95.65%), Dawson Ward (100%), AnnieZunz Ward (90%) and the liver ITU (92.59%). Wards thatwere not reaching the 80% target included Donne Ward(66.67%), Lonsdale Ward (58.33%) and Oliver Ward(65.79%).

• We noted that other staff across the trust, where end oflife training was not mandatory had also completed thetraining module. These included a variety of healthcareprofessionals, including: managers, consultants, helper/assistants, trainee practitioners, occupationaltherapists, physiotherapists, healthcare scientists,

Endoflifecare

End of life care


clinical psychologists and social workers. Thishighlighted that staff were interested in ensuring thatgood end of life care was delivered by all healthcareprofessionals to all relevant patients.

• The mandatory training records of the SPCT were up todate. We saw the team had completed their training inline with trust policy.

• Minutes of the most recent staff meeting showed thatareas discussed included mandatory training.

Assessing and responding to patient risk• Patients that were recognised as deteriorating or dying

were commenced on the end of life care plan. We weretold by staff that this would be commenced afterdiscussion with the consultant, the multi-professionalteam, as well as patients and relatives. An end of lifecare identification order was raised by the ward, whichalerted the SPCT and they visited the ward the followingday to review the care plan with the nursing staff.

• The trust had a project to develop ‘Treatment EscalationPlans’ (TEPs). The plans would help to ensure consistentconsideration of treatment and care needs and supportthe timely decisions on the 'ceiling of care' andresuscitation status for patients who were movingtowards the end of their life. The aim of the 'ceiling ofcare' is to provide guidance to admitting staff who donot know the patient, so that there is continuity with thepatients’ previously expressed wishes, and/orlimitations to their treatment are clear.These plans weredrawn up with the involvement of the patients andfamily. The TEPs were launched in February 2015 onOliver Ward and RD Lawrence Ward and providedmedical and nursing teams with clear guidance on thetreatment management of patients who weredeteriorating in order to prevent inappropriate care/treatment being delivered.

• The trust used the early warning score (EWS) system formonitoring acutely-ill patients, to alert staff ofdeterioration in their condition. The tool allowed staff tomonitor patient functions, such as their heart rate,blood pressure, temperature and oxygen levels. OnTwining Ward, the sister told us that patients wereobserved every four to six hours, but if there was anincrease in the score (five and above) the patient would

be reviewed. A senior nurse told us that, as patientsapproached the end of their life, they were reviewedhourly and a senior nurse reviewed the patient at thebeginning and end of the shift.

• The senior nurse on RD Lawrence Ward told us that, onadmission, risk assessments were completed for eachpatient to ensure their needs were identified and theoptimum care was delivered. Risk assessments wereincluded on moving and handling, pressure area andnutrition.

• The ward manager on the chemotherapy day unit toldus that there was no medical support on the unit, whichcan be an issue if medical support was requiredimmediately and doctors were unavailable. We weretold that, on some occasions, there was only one doctorcovering the three haematology specialties and,therefore, the unit had to call the inpatient registrar orconsultant.

• Where the progression of a patient’s illness was clear,the amount of intervention was reduced to a minimum.Care was based on ensuring the person remained ascomfortable as possible at all times. When patients wereidentified as being at the end of their lives, monitoringwas modified to ensure an emphasis on comfort. Stafftold us that any changes to the frequency of monitoringwere discussed with patients and their families toensure they understood the plan of care. This wasconfirmed on Annie Zunz Ward, where we observednursing reviews taking place ever four hours in the last48 hours of the patient’s life, which included: mouthcare, comfort and positioning.

• On Davidson Ward, the ward manager told us that‘huddles’ took place at 10.30am each morning todiscuss any issues related to patients. A weekly meetingtook place with occupational therapists (OTs),physiotherapists and social workers to discuss thepatient’s management. If patient incidents hadoccurred, the nursing staff were encouraged to reflectthese within the ‘huddle’.

Nursing staffing• There were palliative care ‘link’ nurses on a number of

the wards we visited including Oliver Ward, DavidsonWard and the Jack Steinberg Ward (ICU). However, wewere unable to establish the exact number of palliativecare link nurses across the wards. The Specialist Nursein Organ Donation (SNOD) told us organ donation linknurses worked across the wards.

Endoflifecare

End of life care


• The SPCT consisted of four clinical nurse specialists (3.6WTE) and one WTE practice development nurse. Thenursing team was managed by a 0.2 WTE matron.

• Nursing staff on the wards told us there was enoughstaff on duty to ensure the needs of patients at the endof their lives were met. Staff said patients who were veryclose to the end of life would have a dedicated memberof staff with them whenever possible. On DavidsonWard, a nurse told us that staffing levels were shortsome days, which made delivering appropriate levels ofcare difficult.

• On the chemotherapy day unit, there was a vacancy fora band 6 nurse. The unit had two long-term agencynurses who supported the service.

Medical staffing• The hospital was well established, with five consultants

in palliative medicine (3.4 WTE), two of whom wereemployed full-time, delivering hospital-based care andoutpatient clinics. The consultants work plans were amixture of clinical and academic sessions.

• The consultants were supported by two specialistregistrars and a FY2 junior doctor who was shared withoncology. The registrars supported the delivery of aseven-day, face-to-face service and were part of theKing’s Health Partnership.

• Specialist palliative care consultants provided Mondayto Friday, face-to-face reviews and provided specialistadvice out of hours. Two of the palliative careconsultants were assistant medical directors and playeda senior role in the running of the trust.

Duty of Candour• The senior nurse on the chemotherapy day unit told us

that, when mistakes were made, the patient wasinformed immediately and details of the incident wereput in writing to the patient. We were told that, after theinvestigation, feedback was given to the patient.However, we were unable to see evidence of this duringthe inspection.

Major incident awareness and training• We looked at the mortuary’s storage contingency plans.

The mortuary had the capacity to store 64 deceasedpatients. We noted that, when four fridge spaces wereleft, the contingency plans were put into play, withmortuary staff or clinical site managers organising extrastorage spaces at a local undertaker’s premises. Thepolicy also stated that, in extenuating circumstances,

there could be a need for the trust to hire a refrigeratedcontainer. However, we noted that this plan had notbeen followed in January 2015 when the mortuary hadreached capacity. We were told that staff involvedinformed mortuary staff that they were unaware of thestorage contingency plans. This incident was reviewedat the local risk meeting. No deceased patient remainswere disturbed, so it was rated as an ‘amber’ incident.

Are end of life care services effective?


The do not attempt cardio-pulmonary resuscitation (DNACPR) policy had been developed separately from theresuscitation policy by the SPCT. A snapshot audit of 30patients in March 2015 concluded that there was confusionwith a mix of paper and electronic records. The audit foundthat, although three patients had DNA CPR orders, therewere no electronic or paper forms for these patients, whichrepresented a clinical risk. There also seemed to be a lackof clarity as to how DNA CPR orders should be completed.

We found no documented evidence that mental capacityassessments and best interest decisions wereappropriately undertaken and discussions with the patientand family had take place. However, we were told that if aprocedure needed to be done and the patient could notconsent, a best interest decision would be made with theinvolvement of the family where possible.

Limited advanced care planning (ACP) was undertakenacross the hospital. The only ACP undertaken was theProactive Elderly Advance Care Planning (PEACE) planningtool. This was for patients being discharged to a nursinghome who did not have mental capacity and wasdeveloped in conjunction with the family to establish carein the patient’s best interests. The trust was also overdependent on the SPCT for the delivery of good end of lifecare.

The hospital had access to an electronic palliative carecoordination system (EPaCCS), which was called‘Coordinate My Care’. This system alerted healthcareprofessionals across care providers of the wishes andpreferences of the end of life patient. The SPCT had accessto this system but the ED team did not.

Endoflifecare

End of life care


There had been ten mortuary incidents reported in the 15months prior to our inspection relating to poor porteringpractices, which suggested that further training wasrequired in the working practices of the mortuary.

The trust had responded to concerns regarding theLiverpool Care Pathway (LCP) and informed staff of thereplacement guidance to ensure patients were treatedsafely and in line with national guidance. The SPCT practicedevelopment nurse (PDN) visited the wards daily tosupport the nurses and doctors with documentation.

Use of national guidelines• King's College Hospital (Denmark Hill site) had

responded to the National Recommendations of theLiverpool Care Pathway (LCP) review, ‘More Care, LessPathway’ (2013) by removing the LCP from the trust.From 12 November 2013, the hospital agreed to stopusing the LCP to support the care of the dying patient.On Oliver Ward, the ward sister confirmed that the trustwas not continuing to use the LCP. This showed that thetrust had responded to concerns regarding the LCP andinformed staff of the replacement guidance to ensurepatients were treated safely and in line with nationalguidance. A nurse on Davidson Ward told us, “When theLCP was withdrawn there was not a lot of support withwhat to do, but the SPCT was always helpful.”

• To maintain standards and ensure consistent care forpatients approaching the end of their life, staff wereasked to continue to regularly assess the needs of allpatients and clearly identify patients who appeared tobe dying. The decision to place patients on end of lifetreatment was a multi-professional one led by theconsultant in charge. On Oliver Ward, the sister andjunior doctor told us that placing a patient on the end oflife care plan was a multidisciplinary decision madeafter the patient had received active treatments.

• The SPCT PDN told us that they reviewed patients whowere flagged as requiring end of life care. Since theremoval of the LCP, an end of life notification order wascompleted by the wards. We reviewed data submittedand saw that a snapshot audit took place between the16 and 22 March 2015. Nine notifications were receivedby the SPCT and this suggested that ward teams werealerting the SPCT when the decision was made that apatient was dying. Depending on whether the patientwas regarded as routine, urgent or an emergency, theSPCT PDN or matron visited the wards and reviewed thepatient with ward staff around the five priorities of care.

• Through the clinical effectiveness group, the SPCTmonitored compliance to the NICE guidelines (QS13 andCG140). Gaps in compliance with standards were placedon an action plan and were monitored through thegroup.

• After communicating to the patient and family that theirrelative was dying, an individualised end of life care planwas developed that included regular assessments andthe management of symptoms. On Mary Ray Ward, wesaw evidence of good individualised care, including:symptom control, anticipatory medication, a review ofinterventions and discussions with the family. A King’sCollege Hospital web page (KWIKI) was set up to guidestaff, covering the key areas of an individualised end oflife care plan, ongoing care and care after death.

• The SPCT PDN told us that they visited the wards dailyto support the nurses and doctors with documentation.We were told there were no standard care plans for endof life care, however, this was work in progress. One staffmember told us, “We need to be careful we don’tdevelop another LCP.” Nursing notes we reviewedconfirmed that there was no standardised personalisedend of life care plans. Nevertheless, we saw that carewas delivered and recorded.

• A ‘Care of the dying: questions and prompts for allprofessionals’ leaflet and an ‘end of life careidentification’ order were introduced to the workforce inAugust 2013 in preparation for the removal of the LCP.These listed a number of core principles, which were feltto be crucial to good care in the last few days of lifeincorporating a number of the NICE quality standard 13(‘End of life care for adults’) statements. The flowchartwas a checklist, which aimed to support healthcareworkers as an aid to the memory.

• The end of life care policy was published on the 1January 2015 after being approved by the End of LifeStrategy Group and ratified by the King’s CollegeHospital executive/board of directors. The policy, whichsets out the trust’s response to the withdrawal of theLCP and the systems in place to support identificationand care for people that are dying and their families.This policy compliments ‘The management of the dyingpatient: clinical guidelines for control of symptoms’(September 2014), the Bereavement Policy (2007) andthe Do Not Attempt Cardio-Pulmonary ResuscitationPolicy (2014).

Endoflifecare

End of life care


• The advanced renal care programme had goodprocesses in place to identify and support the palliativecare needs of patients with end stage renal disease whowere not suitable for renal replacement therapy.

• The hospital took part in the National Care of the DyingAudit of Hospitals (NCDAH) round four, in 2014. Theinformation gathered offered insight into the clinicalpractices at that time and areas that would benefit fromimprovement strategies as well as aspects of care theclinical teams were delivering well. The audithighlighted three areas where the organisational keyperformance indicators (KPIs) were not achieved.

• In order to address the organisational KPIs not achievedand to improve compliance in two clinical KPIs, aNCDAH detailed action plan was developed (dated 23September 2014) around the key findings. We sawevidence during the inspection that the action plan wasin the process of being actioned. We observed that atrust board executive for end of life care had beenappointed and this was the chief nurse.

• The SPCT completed a scorecard each month thatcovered the key performance indicators set by the trust.We reviewed the data submitted in December 2014 andFebruary 2015. The data confirmed that, in December2014, 216 referrals were received and of these, 179patients were reviewed by the SPCT. Sixty-eight patientshad a cancer diagnosis (38%) and 109 patients did not(60.9%). In February 2015, 204 referrals were made andof these, 174 referrals were reviewed. Of the referrals, 64patients had a cancer diagnosis (36.7%) and 114patients had a non-cancer diagnosis (65.5%). Across theyear, a palliative care consultant told us that 65% oftheir patients had a non-cancer diagnosis and 34% hada cancer diagnosis. This demonstrated that the SPCTactively supported a high number of non-cancerpatients. This was above the national average of 28% ofpatients with non-cancer diagnosis who were supportedby an SPCT.

• Although there was no electronic system that flagged upif a palliative care or end of life patient had beenadmitted, the introduction of an end of life careidentification order raised by the ward staff, highlightedto the SPCT, patients who might require specialist SPCTinput. When an order was received, the SPCT reviewedthe patient with the ward staff the following day. On

Lonsdale Ward, two FY2 doctors confirmed that theysent an electronic identification order when it wasexpected that the patient could die after they had beenidentified by a senior doctor.

• A palliative care consultant told us that the onlyadvanced care planning undertaken was the PEACEdocument.

Pain relief• Effective pain control was an integral part of the delivery

of effective end of life care. On RD Lawrence Ward, asenior nurse told us that pain would be reviewed as partof the “essential care review”. This highlighted how oftena patient’s pain needs would need to be reviewed.

• On Annie Zunz Ward, we reviewed an EPR and foundthat anticipatory medicines were prescribed andappropriately used. In the Quality Sampling Audit(October 2014 to December 2014), it was found that 11out of 15 patients had their anticipatory medicationappropriately prescribed.

• The SPCT were involved in advising and reviewing themedication of patients approaching the end of life. OnDonne Ward, a nurse told us that the SPCT were“excellent” and came quickly to support complexsymptom management including advice on themedication required to manage pain effectively as wellas advising the medical and nursing teams around themedication that the patient no longer required. We weretold by staff on the wards we visited that all patientswho needed a continuous subcutaneous infusion ofopioid analgesia or sedation, received one promptly.

• On RD Lawrence Ward a senior nurse told us that, forpatients suffering from dementia and learningdisabilities, their pain would be assessed by clinicalobservations, including: facial, vocal, behavioural andphysical signs.

Nutrition and hydration• In the ‘Management of the Dying Patient’ guidance and

in the end of life care policy, multi-professional teamswere encouraged to pay specific attention to thepatient’s nutritional and fluid requirements. Theguidance said that, “Oral fluid and nutrition must alwaysbe offered provided this was not causing any harm ordistress to the patient.” In the daily care plan review,staff were encouraged to maintain basic, excellent care,

Endoflifecare

End of life care


which included encouragement and support andensured the patient’s and family’s views and preferencesaround nutrition and hydration at the end of life wereexplored and addressed.

• On Lonsdale Ward, a FY2 doctor told us they prescribedintravenous fluids to support the hydration of patientsas they approached the end of their lives. On Annie ZunzWard, we reviewed a patient’s EPR and noted repeatedassessments of their hydration and nutritional needs.

• On RD Lawrence Ward, the senior nurse told us that, onadmission, the patient underwent risk assessments,which included a malnutrition universal screening tool(MUST) assessment. This tool identifies patients who areat risk of poor nutrition, dehydration and who haveswallowing difficulties. Patients identified as high riskwere referred to the dietician, who developed a foodplan. The ward staff developed a food record chart thatwas completed daily.

• On Twining Ward and RD Lawrence Ward, we observedthat the coloured (red) tray scheme was being used toindicate patients who needed additional help at mealtimes. Meal times were protected, which meant staffensured people could eat uninterrupted except forurgent clinical care. We were told that staff encouragedrelatives to support family members who were receivingend of life care. On reviewing the quality samplingconducted in the trust between October 2014 andDecember 2015, the 15 cases audited found that sevenout of 15 had a review of their nutritional needsassessed, of which, only two were conducted by a seniorclinician. Only five cases had their hydration needsassessed, of which, only three were conducted by asenior clinician. This suggested that further work wasrequired to become compliant to trust policy.

• To improve patient’s quality of life, a mouth care policywas in place across the trust. This was available on theKWIKI page. The senior nurse on Katherine Monk Wardtold us mouth care was regularly performed on patientswho were entering the final stages of their life. Weobserved this taking place and it included using softchildren’s tooth brushes to clean their teeth, Vaseline orlip salve to soften the lips and gauze swabs with waterto hydrate the mouth. In the quality sampling audit(October to December 2014), it was found that mouthcare was being undertaken in eight out of 15 patientsand four did not require it. This suggested that threepatients were not receiving mouth care.

Patient outcomes• The SPCT had introduced ‘quality sampling’ to monitor

the quality of care delivered to end of life patientsagainst the five priorities of care. This samplingsupported the development of a training and educationprogramme. The sampling took place at the beginningof each month and the first five deaths, each month,were audited.

• The ‘quality sampling’ included assessing if a seniordoctor responsible for the patient care identified thatthe patient was dying, the diagnosis that the patient wasat the end of their life was communicated and the risksand benefits of nutrition/hydration. The audit wasundertaken by two palliative care doctors. Fifteendeaths were audited between October and December2014. Areas where it was felt compliance needed to beimproved across the five priorities includeddocumentation that the patient was dying (seven out of15 had no senior documentation), communicated to thepatient that they were at end of life (only two out of 15cases discussed this) and there was no information inany of the 15 cases given to patients or their familiesaround organ donation. Recommendations from theaudit were: ongoing education via the road shows, wardend of life champions, updating the ward teams aboutthe results of the audit and more education of juniordoctors. These would ensure all patients were receivingconsistent, safe care no matter where they werereceiving their care across the wards.

Competent staff• The palliative care PDN facilitated trust-wide

programmes, such as preceptorship study days, allnursing and midwifery induction, clinical supportworkers training, transforming end of life care studydays and the ward road show schedules. We reviewedthe palliative and end of life care educational plan,which showed that training days at the Denmark Hill siteand Princess Royal University Hospital had beenscheduled in for 2015/16.

• Transforming end of life care courses were planned aspart of the KHP. We observed that the next study dayswere at King’s College Hospital (Denmark Hill site) on 11and 12 May 2015. Ward road shows had been planned,with training being delivered on Katherine Monk Wardon 25 May 2015 and Lonsdale Ward on 1 June 2015.

• The SPCT were actively involved in the training andteaching of medical and nursing staff. In February 2015,

Endoflifecare

End of life care


we noted that 13 hours were allocated to the training ofdoctors, 35 hours for teaching doctors and 13 hours forteaching nurses. A total of 61 hours of the team’s time inFebruary 2015 was allocated to training and teaching.

• We were shown the medical training records thatdemonstrated that junior doctors had regular trainingwith the palliative care consultants, with FY2 doctorsreceiving opioid prescribing training.

• One of the palliative care consultants supportedundergraduate training, including loss and grief. Thisdemonstrated the commitment of the team to improvethe quality of care delivered on the wards.

• We reviewed the SPCT operational policy 2014/15 andthis demonstrated that all team members hadundertaken national advanced communication skillstraining, which gave the team the necessary skills tocommunicate appropriately in difficult situations theymay come across.

• The SPCT had two social workers who worked within thepalliative care multidisciplinary team. The socialworkers supported the psychosocial needs of patients/families and provided integrated bereavement followups. A psychosocial worker was based in critical care tosupport the complex needs of patients and theirfamilies receiving intensive care.

• On the chemotherapy day unit, the senior nurse told usthat all staff were trained in the N59 Care of the Patienthaving Cytotoxic Chemotherapy course. However, theunit had no training posts and, therefore, successionplanning did not take place.

• Palliative care link nurses were on some of the wards wevisited. The palliative care matron told us that that therewas no structured education programme for link nurses,however, the team recognised there was a need forconsistency. Feedback to the link nurses was throughthe End of Life Care Quality and Implementation Group,where, through training and education, they were ableto cascade the latest information down to all staffgroups within the ward to support the delivery of goodend of life care. However, attendance at the End of LifeCare Quality and Implementation Group had been poor,with no one attending the group in March 2015. Thepalliative consultant told us that a new way to providefeedback was being discussed.

• The portering manager told us that they had receivedtraining to support the movement of deceased patientsto the mortuary. The training included access to themortuary, use of the hoist, fridge spaces paperwork and

use of PPE. However, when we reviewed the mortuaryincidents, there had been ten incidents reported in thelast 15 months related to poor portering practices,which suggested that further training was required inthe working practices of the mortuary.

• The chaplain was a ‘SAGE & THYME’ trainer (‘SAGE &THYME’ is a mnemonic which guides healthcareprofessional/care workers into and out of aconversation with someone who is distressed orconcerned).

• The chaplain told us that this involved training nursesand midwifes to give them the necessary skills tomanage difficult situations. Other training provided bythe chaplain included talks on ‘Spirituality and religion’,which we were told had been recently given to a groupof healthcare assistants (HCA).

• The CNSs in the SPCT were line managed by thepalliative care matron. One CNS who told us thatappraisals were undertaken and were up to date. Thisensured that staff were adequately supported todevelop their skills to support the delivery of highquality care.

• All palliative care CNSs had completed the trainingnecessary to enable them to practice at level 2psychological support for patients and carers.

• Minutes of the most recent staff meeting showed thatareas discussed included staff appraisals.

Multidisciplinary team working• The SPCT undertook morning meetings, where there

was handover and update on any issues that haddeveloped overnight with any of the patients. The teamalso discussed all referrals and hospice notificationsreceived the day before. A clinician triaged the requestsreceived and decided on the urgency of the request. Allrequests were allocated a key worker. We observed thehandover during the inspection.

• Weekly multidisciplinary team meetings included: aninpatient multidisciplinary team review (on Tuesdayevenings), a death/bereavement weekly review (onThursday mornings) and a discharge weekly review (onFriday mornings). During the inpatient multidisciplinaryteam meeting, we observed discussions taking placearound all new referrals, complex patients and thosewho had been on the caseload for three weeks. Weobserved that all discussions were minuted in the teamsspecialty database and that Patient Content Stores(PCS) and attendance sheets were completed.

Endoflifecare

End of life care


• We were told that the SPCT attended the thoracic,hepatopancreatic, biliary oncology, colorectal,neuro-oncology and the haemato-oncologymultidisciplinary teams. The SPCT supported jointclinics with their medical colleagues, including: weeklypalliative care/lung cancer clinics, monthly neurology/respiratory palliative care clinics and complex neurologyclinics every three months.

• The team leader in the Jack Steinberg Ward (ICU) told usthat multidisciplinary meetings took place with familymembers. The meeting included: consultants, nursingstaff caring for the patients, psychosocial workers andthe SNOD. Discussions around the management of thepatients took place with any concerns raised andwhether the needs of the family were meet. For relativeswho wished to discuss organ donation, the SNODdiscussed the options. Relatives of patients who werebrain stem dead were given a leaflet called‘Understanding brain stem death: A guide for relatives,’which allowed families to review the information givenand make the most appropriate decision.

• The SNOD told us that, after families had had aconversation around organ donation, they were giventime to make a decision. If the family could make animmediate decision, the process was slowed down. If adecision could not be made, no further pressure wasplaced on the family and the process was stopped.

• A SPCT CNS told us that close working relationshipswere in place with other clinical nurse specialists acrossthe hospital, including cancer and non-cancerspecialists. The SPCT CNS was able to describe the jointwork undertaken to support the complex symptommanagement at the end of a patient’s life.

Seven- day services• The SPC core team provided a Monday-Friday, 9am to

5pm service. At weekends and bank holidays, specialistregistrars (StRs) provided a first on-call visiting andtelephone advice service to the KHP acute hospitals(King’s College Hospital and Guy’s and St Thomas’Hospital), supported by the consultant on-call.

• Out of hours (after 5pm and before 9am), a consultantprovided telephone cover for health professionalsacross the local cancer centre. Monday to Friday, theconsultant was first on-call for telephone advice. Theconsultant rota comprised all specialist palliativemedicine consultants working across Guy’s Hospital,King’s College Hospital, St Thomas’ Hospital and

University Hospital Lewisham. On Mary Ray Ward, wereviewed an end of life EPR and observed good, valuedinput from the SPCT. We saw evidence of face-to-face,out-of-hours support and telephone support from theSPCT.

• The NHS Blood and Transplant organ donation service,led by the SNODs, were available across the hospital,Monday to Friday, 9am to 5pm. Outside these times anon-call service was provided.

• The chaplaincy service was available Monday to Friday,9am to 5pm. Outside these hours, the chaplaincyprovided an on-call service.

Access to information• The hospital used ‘Coordinate my Care’, (London

electronic palliative care coordination system (EPaCCS),which would alert healthcare professionals across careproviders of the wishes and preferences of the end of lifepatient. However, the ED team had no access to this. Wewere told by the SPCT this was being reviewed atpresent.

Mental Capacity Act, Consenting and Deprivationof Liberty Safeguarding• The trust had a Mental Capacity Act 2005 policy, which

included guidelines about patients with advancedecisions to refuse treatment. A nurse on Todd Wardtold us they were aware of the existence of the MentalCapacity Act 2005 and when it would be used. However,they were less clear of the Mental Capacity Act 2005process. The nurse felt they were a ‘patient advocate’and would speak to the matron or the ward manager ifsomething was being done to the patient without theirconsent.

• The senior nurse on Todd Ward told us that manypatients on the wards were confused. We were told thatMental Capacity Act 2005 assessments were undertakenby the doctors. However, we saw no evidence of thisduring the inspection. If a procedure needed to be doneand the patient could not consent, a best interestdecision would be made with the involvement of thefamily where possible.

• Mental capacity assessments and best interest decisionswere not always appropriately undertaken ordocumented and discussions with the patient andfamily did not always take place.

• On Annie Zunz Ward we reviewed the training records.We noted that five out of 10 staff had completed MentalCapacity Act 2005 training.

Endoflifecare

End of life care


Are end of life care services caring?

Good –––

Staff at King's College Hospital (the Denmark Hill site)provided compassionate end of life care to patients. Thepalliative care PDN performed patient reviews in asensitive, caring and professional manner, engaging wellwith the patient. The patient’s complex symptom controlneeds were being met and the supportive needs of boththe patient and relative were being addressed. The trust’shomeless team got involved if patients were homeless.

The SNOD told us that families whose relative donatedorgans would receive a phone call after the retrieval to letthe families know the process has been completed.Families would be invited to receive the St JohnAmbulance’s award.

In the ED, the breaking of bad news was led by a consultantand a senior nurse.

On the Jack Steinberg Ward (ICU), the team leader told usthat the psychosocial workers play a crucial role insupporting families whose relatives were extremely unwell.The psychosocial worker attended the meetings withfamilies where bad news was broken.

The SPCT conducted a patient satisfaction survey forpatients who had been treated by the SPCT during theiradmission to hospital as well as a bereaved carer survey.Staff demonstrated a positive and proactive attitudetowards caring for dying people.

Compassionate Care• During the inspection, we were able to observe several

end of life care patients being reviewed by the palliativecare PDN. The PDN performed the reviews in a sensitive,caring and professional manner, engaging well with thepatient. During a holistic assessment on Howard Ward,the PDN went through the patient’s pain management,medication prescribed, if the patient felt sick and if thepatient had any emotional needs.

• We observed that staff demonstrated a positive andproactive attitude towards caring for dying people. Theydescribed how important end of life care was and how

their work impacted on the overall service. On DavidsonWard a nurse told us that the ward was ‘open andhonest’ and was committed to providing good patientcare.

• A family member told us that the SPCT “pull[ed] thingstogether”. We observed the SPCT CNS responding to thepatient in a holistic manner. We observed that thepatient’s complex symptom control needs were beingmet and the supportive needs of both the patient andrelative were being addressed with the involvement ofthe trust’s homeless team, when necessary. The familymember told us that they were able to stay overnight onthe ward to support their relative.

• We observed, from the palliative care dashboard, that inDecember 2014, the team had 615 hours of contact withpatients, relatives and hospital staff. Of this, 267.3 hourswere spent with patients and 107.6 hours with families.This increased in February 2015 to 656 hours of contact,with 311.7 hours of contact with patients and 119.8hours with families. This demonstrated the patient andfamily focus of the SPCT.

• The SNOD told us that, after families had had aconversation around organ donation, families weregiven time to make a decision. If a family could notmake an immediate decision, the process was sloweddown. If a final decision could not be made by thefamily, no further pressure was placed on them and theprocess was stopped.

• One patient and their relative on Lonsdale Ward told usthat they were very happy with the care they receivedand that prompt pain relief was offered. The nurseslistened to them and call bells were always answeredpromptly. However, they were unhappy that they hadbeen moved three times since being admitted to thehospital.

• Several patients also told us that, after leaving the ED,they were moved around the wards. Two patients toldus they were on their third ward since being admitted.Relatives told us that handovers and informationsharing from the ED to the wards and between thewards were poor.

• The SNOD told us that families whose relatives donatedorgans would receive a phone call after the retrieval tolet the families know the process has been completed.Families were then contacted two to three weeks laterand given an update on how the recipients were doing.This was repeated a year after the retrieval to give thefamilies an update on the recipient. Families were

Endoflifecare

End of life care


invited to receive the St Johns Ambulance award. Thiswas offered by invitation to all families whose loved onedonated an organ in the UK and was givenposthumously to the donor, accepted on their behalf bya relative at a regional ceremony.

• The chaplain told us that they visited the wards tosupport patients and relatives when requested. Thiscould include bedside rituals, bible readings orproviding a listening ear. We spoke to a chaplaincyvolunteer who told us that they visited the elderly carewards on Tuesday afternoons to spend time listening topatients and greeting them.

• In the ED, the assistant head of nursing told us that thebreaking of bad news was led by a consultant and asenior nurse. Consultants were available between 8amand 2am daily. Nursing staff had not received training inbreaking bad news, but could be involved in theconsultations as part of the development. This wasconfirmed by a junior doctor who told us that they neverbroke bad news themselves, but that they were oftenpresent when senior doctors did.

• In the chemotherapy day unit, the senior nurse told usthat, when patients received chemotherapy thatrequired the removal of any of their clothing, thecurtains could be drawn to maintain the patient’sdignity and respect.

• The SPCT conducted a patient satisfaction survey forpatients who had been treated by the SPCT during theiradmission to hospital. This was part of the KHP. Thesurvey takes place annually and was sent to patientswho met the selection criteria to ensure no distress wascaused to those completing the survey. We reviewed the2014 survey, which had a response rate of 21%.Feedback from the survey was that the quality of careprovided was very high, especially in relation toinformation and support while in hospital, with only tworespondents stating that the team were unhelpful.

• A bereavement carer’s survey was also undertaken. Wereviewed the findings from the 2014 survey and saw thatthe comments were positive, apart from raisingconcerns around a delay in death certificates, the lack offacilities when families needed privacy and the fact thatthe bereavement office did not have seven-day opening.We saw that the SPCT were addressing the issues raisedand had placed these on the team’s action plan.

• The mortuary APT told us that patients that arrived atthe mortuary were prepared by the nursing staff in themajority of cases as stated in the ‘Care of the Body After

Death – Last Offices Policy 2015’. We were told that anaudit was being undertaken at the time of theinspection to monitor compliance. We were able toreview the audits from the three months prior to theinspection and saw that, in the majority of cases,deceased patients were being cared for in a respectfulway. We were told that the audit would remain in placeuntil the new ‘last offices’ policy, which was in the draftstage at the time of the inspection, was ratified.Mortuary staff were feeding the audit findings back tothe SPCT matron.

Understanding and involvement of patients andthose close to them• We observed the palliative care consultant undertake a

holistic patient assessment and plan of care onKatherine Monk Ward. The patient had no familypresent. The consultant discussed the plan of care withthe patient followed by a discussion with the staff nurseand junior doctor who prescribed the medication on theEPR immediately.

• On the Jack Steinberg Ward (ICU) the team leader toldus that families were always informed of decisions andwere included in decision making, as appropriate. Thisinvolvement started when the patient was admitted. Inthe liver ITU, we reviewed the EPR of a patient receivingend of life care. We found good documentation with lotsof entries regarding decisions with relatives from boththe medical and nursing teams.

• We reviewed 10 EPRs, and noted that patients referredto the SPCT were kept actively involved in their own careand relatives were kept involved in the management ofthe patient with the patient’s consent. On Twining Ward,we were told that, when a patient’s conditiondeteriorated, a discussion took place with the family. Ifthe patient wished to go home, a team discussion thentook place and all efforts were made to get the patienthome to their preferred place of death.

• The ward manager on Twining Ward told us that theyliked to include families as much as possible in caringfor their relative, but only as much as they wanted to beinvolved. Areas where relatives supported their relativesincluded mouth care and making sure the patients weresupported to lie comfortably. Relatives were alsosometimes asked by staff to support their relatives atmeal times.

Endoflifecare

End of life care


• The trust‘s bereavement policy states that familiesshould be given the opportunity to help in the care afterdeath. On the wards we visited, ward managers told usthat, while some families wished to be involved in careafter death, not many families did.

• The SNOD told us that three to four months after adonation has taken place, the family were sent aquestionnaire regarding their experience. We were toldthat feedback was good. However, we were unable toreview the questionnaire during the inspection.

Emotional support• All the palliative care CNSs had completed the training

necessary to enable them to provide level 2psychological support to patients and carers. One CNStold us that they all received monthly one-to-oneclinical supervision from a trained level 4 supervisor.

• The SPCT had two social workers that were level 3practitioners who were able to support the psychosocialneeds of patients/families and carers, providing anintegrated bereavement follow up and assessing andcoordinating the ongoing needs of patients/families andcarers to ensure their needs were met. On the JackSteinberg Ward (ICU) the team leader told us that thepsychosocial workers played a crucial role in supportingfamilies whose relatives were extremely unwell. Thepsychosocial worker attended the meetings withfamilies, where bad news was broken and attended themultidisciplinary team meetings to ensure that theywere equipped to provide the necessary supportrequired to facilitate the needs of the patients andfamilies before and after death.

• The team leader on ICU told us that, if a young parentwas critically ill, the team would contact the paediatricpsychosocial worker to support their children throughthe distressing situation. We were told that a book wasavailable, which tells the story of a dying parent in achild-friendly way.

• If a young parent died suddenly in the ED, a paediatricnurse was called to support their children. The ‘redthread’ (for children and young people from ages 13 to19) team would be called in to support the children andorganise counselling if necessary.

• Support to families whose relatives became organdonors was available through the SNOD. As informationcame to light that a patient could die, or activetreatment could be stopped in the next few days, the

SNOD would become actively involved in their care andsupport the family by being a point of contact forquestions and concerns which could arise through theprocess.

• Bereavement Centre staff undertook interviews withfamilies after the deaths of their relatives. Staff told usthat, after meeting the families, they were the point ofcontact if they need to speak to anyone in the next yearfollowing the death. Staff told us that if they had anyconcerns about the welfare of relatives they wouldcontact the family’s GP, where support could beaccessed.

• On the chemotherapy day unit, the ward manager toldus that systems were in place to support patients duringtheir palliative chemotherapy. If patients requiredsupport, mechanisms in place, including a referral beingmade to the cancer and haematology councillor, or avisit organised to a Macmillan information centre. Thecancer and haematology nurse specialists were alsoavailable to offer emotional support.

• The chaplain was available to provide spiritual andreligious support when asked by the patient/familiesand medical and nursing staff. On the ICU, a nurse toldus that they would call the chaplaincy, when requested,to support families.

Are end of life care services responsive?


Patients approaching the end of their life were given theopportunity to be nursed in a side room if one wasavailable. Open visiting hours for families whose relativeswere receiving end of life care was available on the wardswe visited. Information leaflets for families whose relativeswere receiving end of life care were available.

The Bereavement Centre contained a quiet room, whichmeant that interviews of the bereaved relatives took placewith the upmost privacy. The hospital had amulti-denominational Christian chapel, which was opened7am to 10pm daily. A multi-faith room called The Sanctuarywas available for people of all faiths, or none. A Hindushrine was being developed with support from one of thehospital consultants. A Muslim prayer room was available,with two carpeted prayer rooms and washing facilities.

Endoflifecare

End of life care


Memorial services called ‘A time to remember’ took place inthe chapel. Relatives from all faiths or no faith were invited.The SPCT aimed to see the majority of patients on thesame day as the referral. For urgent referrals, a target of100% was set and this was continuously achieved.

Complaints were reviewed by the End of Life StrategyGroup. Following complaints being investigated, actionswere in place to mitigate the same incidents happeningagain, including more staff training and the attendance ofthe ward manager at the End of Life Strategy Group.

Service planning and delivery to meet the needs oflocal people• As part of the end of life care policy, patients

approaching the end of their life were given theopportunity to be nursed in a side room if one wasavailable. However, patients that had infections tookpriority over an end of life patient.

• If a patient was nursed in a bay on the ward, privacy wasmaintained by keeping the curtains drawn, if requested,by the patient or family. The team leader on the JackSteinberg ICU told us that there were only two siderooms available to support end of life patients and itwas, therefore, not always possible to nurse end of lifepatients in a side room. Patients that may be in the lastdays of life would be found a room on a ward where theenvironment will be more appropriate as the noise inICU could be an issue.

• On Katherine Monk Ward, we observed a patientreceiving end of life care. The patient was being nursedin a single room. Curtains were around the inside of thedoor to protect the patient’s dignity and privacy. OnMary Ray Ward, we were told by the matron thatpatients receiving end of life care were nursed in a singleroom. However, no ‘Z’ beds or reclining chairs wereavailable on the ward. Some staff we spoke to told usthat ‘Z’ beds were available from paediatric wards,however, other staff were not aware of this. A palliativecare consultant told us that ‘Z’ beds were available fromthe Macmillian information centre. However, noward-based staff told us about this.

• We found little evidence of family rooms on the wards.However, staff would use the day room or nursing/doctor’s room to provide a quiet place for relatives. TheSPCT had recognised the shortage of quiet places forfamilies and had conducted a facilities audit. A list ofavailable spaces had been placed in the ‘end of lifefolders’ we saw on the wards, so staff could signpost

relatives to the nearest quiet room. In the minutes of theEnd of Life strategy Group, there was reference to afacilities leaflet, which was in the process of beingdeveloped. Although the trust had recognised the lackof quiet areas for families, we saw no evidence of howthe trust planned to take this forward.

• On all the wards we visited, staff spoke of the need foropening visiting hours for families whose relatives werereceiving end of life care. On Mary Ray Ward, TwiningWard and the liver ITU, staff confirmed that open visitinghours were available on the wards. The ward manageron Mary Ray Ward told us that tea and toast wasavailable to relatives.

• The SPCT told us that only a one car parking permit wasavailable for families whose relatives were receiving endof life care. We saw that, in the End of Life StrategyGroup meeting in March 2015, this was being reviewed.

• In the ED, we were shown Room 10, which could beused to care for seriously-ill patients and those whowere dying, so that they could be cared for in privacy.Double doors allowed the patient to be taken to the lastoffices room after their death. We were also shown therelatives room, which was next to the last offices room.The senior nurse told us that, if a death had occurred,other relatives were asked to wait in the waiting roomwhile the grieving family used the relative’s room. Thefamily could then be moved into the last offices room tospend time with the deceased patient.

• On Fisk Ward, relatives wishing to stay overnight withtheir relatives had the option of staying and having a ‘Z’bed or reclining chair to spend the night on. However,we were told that the environment was not good, ascubicles were small and the air conditioning was notworking.

• The SPCT CNS reviewed patients depending on theirneeds, offering them support and reviewing their careneeds. Patient contacts ranged from 15 to 60 minutesdepending on the need of the patient and their families,with many end of life patients requiring more than onecontact in a day. Palliative care medicine consultantsreviewed complex cases and spoke to medical teamsand carers.

Meeting people’s individual needs• On the Jack Steinberg ICU, the team leader told us that

visiting hours on the unit were between 1.30pm and 7.30pm daily. However, the team leader told us that, in

Endoflifecare

End of life care


exceptional circumstances, such as patients receivingend of life care and those in the last 24 hours of life,relatives were able to stay with their loved ones day andnight.

• Information leaflets for families whose relatives werereceiving end of life care were available and they weregiven out by SPCT CNSs when ward reviews took place.The information leaflet ‘Coping with dying’ coveredareas such as the patients reduced need for food anddrink, withdrawing from the world and changes inbreathing. The CNS told us that the leaflet had just beenintroduced and that, at present, the SPCT gave out theleaflet with a brief overview of the information andmade themselves available for any questions relativesmay wish to ask. A second leaflet given out was called‘The Palliative Care Team – information for patients andrelatives’, which described what palliative care is, themembers of the team and their contact numbers.

• The advanced renal team provided clinics locally and, ifthe patient became too frail, home visits could bearranged. Links with the hospice and primary carethrough the ‘Coordinate My Care’ system ensured thatpatients and their families were supported and theirwishes and preferences were met.

• We noted that the trust had a lone working policy andstaff had identification badges with pull pins, whichalerted the police in an emergency.

• For patients and relatives of patients affected by cancer,the Macmillan information centre, which was openedMonday to Friday, 10am to 4pm (except Bank Holidays),offered emotional, financial and practical support andinformation. The centre was able to direct patients/carers to local and national support services andsignpost them to self help and support groups. Thecentre provided support in a quiet and calmenvironment, with a full range of patient supportinformation both online and in paper format. Staff toldus that feedback was good around the service theyprovided, however, we were unable to see evidence ofthis during the inspection.

• The SNOD told us that families whose relatives wereclassed as brain stem dead and had consented todonate their relative’s organs, said goodbye in the ITUprior to their relative going to theatre. Care after deathtook place in theatre. For patients that were non-heartbeating donors, their families escorted them to thetheatre anaesthetic room, where the life support

machine was turned off. The family stayed with theirrelative as their life came to an end. The team leadertold us that cultural needs were guided by the familyand any faith leaders.

• In the ED, after a death has occurred, relatives weregiven a bereavement leaflet and the number of thenurse in charge as they left the hospital. Thedepartment’s clerk contacted the bereavement office,who in turn contacted the relatives the following day.

• The Bereavement Centre carried out the administrationof a deceased patient’s documents including theMedical Certificate of Cause of Death (MCCD) and theirbelongings, as well as providing practical advice andsignposting relatives to registering the death andplanning a funeral. The centre contained a quiet room,which meant that interviews of the bereaved relativestook place with the upmost privacy.

• The SPCT had a bereavement multidisciplinary team,where patients who died were discussed and anyconcerns around their families were highlighted andactions put in place to support the families. Contactwith the family was made two to three weeks after thedeath of their relative, followed by a bereavement lettereight weeks later offering follow-up bereavementsupport, including the need to discuss feelings or theneed to have questions answered. Families were offeredimmediate support and future support as well.

• The Bereavement Centre staff told us that systems werein place for the quick release of deceased patients, ifrequired, for religious reasons. Out of hours, the sitepractitioner was able to release the MCCD. We were toldthat the MCCD was available for relatives ideally withinthe next 24 hours, or the next working day, if the deathhappened over the weekend, except for those patientswho were referred to the coroner. However, we were toldthis did not always happen and there had been delaysin releasing the MCCD. We reviewed the actions from theEnd of Life Strategy Group meeting (March 2015) andsaw that actions had been put in place to prevent delaysin this process. No audit information was available tosee how long, on average, the MCCD took to be released.

• The team leader in the Jack Steinberg ICU told us thatrelatives could stay on the unit after a patient died tohelp with the after care of the deceased patient.However, we were told that this rarely happened.Relatives were offered a lock of hair as a ‘keepsake’ if the

Endoflifecare

End of life care


requested it. On leaving the unit, a bereavement leafletwas given to the relatives and the necessary phonenumbers to call if a family member wished to talk to amember of the multidisciplinary team.

• We visited the mortuary and observed the viewing suitewhere families came to spend time with their relativesafter their death. Appointments could be organisedthrough the bereavement office or mortuary and wasavailable Monday to Friday throughout the day. Theviewing suites were decorated in neutral colours, withno religious symbols in place, however, staff were ableto show us symbols of different cultures and religionsthat they had. We were told that the viewing area wasdue to be refurbished.

• The anatomical pathology technologist (APT) told usthat effective systems were in place to log patients intothe mortuary. We were walked through the process andwere shown the ledger type book that contained therequired information. We observed that the book wascompleted appropriately and neatly and was completedin a respectful way. Confidentiality was maintained at alltimes.

• Mortuary staff told us that they were unable to providean area for religious washings.

• Staff in the bereavement office told us that, if anappointment was required to view a relative in theviewing suite, they could arrange this. A convenient timefor the viewing was organised with the family. When thefamily arrived in the hospital bereavement office, staffescorted the family to the viewing suite and ensured theenvironment and the deceased patient was ready forviewing.

• Patients who died where it was unknown whether theyhad family or friends, required bereavement staff tosearch for any relatives with the help of the localcouncil. In such circumstances, the hospital arrangedthe funeral, with support from the chaplaincy.

• Next to the chapel a multi-faith room called TheSanctuary was available for people of all faiths or none.The room was open until 10pm each night, but accesscould be given at other times, if requested. The chaplaintold us that a Hindu shrine was being developed withsupport from one of the hospital consultants. Twoweeks ago prior to the inspection, a Buddhist chantingtook place in The Sanctuary.

• The hospital had a multi-denominational Christianchapel, which was opened 7am to 10pm daily, but can

be opened at other times, by request. The chapel couldaccommodate patients in beds for services. Thechaplain told us that all inpatients attending the chapelmust have an escort with them.

• Memorial books were available in the chapel. Therewere separate books for adults, children, haematologypatients, staff and volunteers.

• The trust did not have a separate religious or spiritualpolicy, but the remit fell within other policies, forexample, the bereavement policy. Chaplaincy staff toldus they followed national guidelines for chaplaincy.

• A Muslim prayer room was available, with two carpetedprayer rooms with washing facilities. Friday prayers wereled by two medical consultants. The chaplain told usthat plans were being drawn up to upgrade the prayerroom. Prayer mats and a Quran were also available.

• Sacred texts were available through the chaplaincy, ifrequired, on the wards. These included sacred texts forthe Jewish, Buddhist, Hindu, Muslim, Sikh and Christianfaiths.

• Memorial services called ‘A time to remember’ tookplace in the chapel. Relatives from all faiths or no faithwere invited. The service for children took place on thefirst Saturday in December and the adult service tookplace on the first Saturday in November.

• The chaplaincy was served by 7.3 WTE (11 people)chaplains representing the Christian faiths. An imamvisited the hospital one afternoon a week and twoMuslim volunteers were available. A Jewish visitorvisited the hospital on a Thursday. The chaplain told usthat a Buddhist volunteer was interested in supportingthe hospital.

• Chaplains were available 24 hours a day and easilycontactable through the hospital switchboard forout-of-hours visits. Staff could contact the chaplains bytelephone or in person to refer patients or ask them tovisit.

• The chaplaincy had 23 regular volunteers who visitedthe wards. Volunteers identified and offered initialpastoral support to end of life care patients. However, ifmore complex needs were expressed they would referthe patient to the chaplaincy.

• A range of services took place in the chapel daily,including lunchtime prayers for the Christiancommunity (Tuesday) and Roman Catholic mass(Friday). Written information about chaplaincy serviceswas available in leaflet form for patients and relatives toaccess and on the KWIKI page for staff to access.

Endoflifecare

End of life care


• The chaplain told us they were involved in thedevelopment of the end of life care, the bereavementand the ‘Care of the Body After Death – Last OfficesPolicy 2015’. The chaplain attended the Tuesdaypalliative care multidisciplinary team meeting where allpatients on the end of life care pathway were discussed.If any areas of concern were highlighted, the chaplainvisited the patient.

• Chaplains were involved in delivering regular training tostaff at induction training where they signposted staff toall the materials available and explained to staff aboutthe individualised spiritual care assessment. We sawthat spiritual guidelines were evident in thebereavement policy to inform staff of the importance ofthese to an individual.

• The chaplaincy provided services tailored to patients’individual needs. For example, they had conductedblessings and contract funerals of deceased patientswho had no relatives.

• Access to information had been addressed with theintroduction of the ‘Coping with dying’ leaflet. However,the facilities leaflet was still in development. Spiritualcare guidance was in place with one other policy indevelopment.

• In the bereavement policy, guidance was available forward staff to provide care in accordance with people’sreligious and cultural preferences. The guidance gaveinformation on care of the dying, post mortems, organdonation and funerals for patients of different faiths. Inthe chapel, we were shown a calendar, which had all thereligious festivals and important days highlighted. Allstaff told us they had access to specialist advice fromthe chaplaincy where clarification was needed.

Access and flow• We were told that systems were in place to facilitate the

fast-tracked discharge of patients to their preferredplace of care or preferred place of death, although, mostof these were not documented. The SPCT facilitated95% of the fast-tracked discharges. The SPCT CNSexplained that a multi-professional approach was inplace, which could involve a discharge liaison nurse,physiotherapist and an occupational therapist to ensurethat patients were discharged in a timely manner, withall the necessary support and equipment in place. Wewere told that ordering a hospital bed could take 24hours and oxygen could be secured within four hours.We were told that Lambeth and Southwark local

authorities ensured that equipment was in place thefollowing day after discharge. However, we were unableto substantiate this during the inspection. The trust didnot audit the responsiveness of the fast-tracked process.

• We were told that two-thirds of patients were local.However, with multiple clinical commissioning groupsto engage with, the process was not standardised.

• The team’s standards stipulated that routine referralsshould be seen within 2 working days, urgent oneswithin 1 (often the same day) and emergencies within 4hours on the day of referral. For February 2015, thepalliative care scorecard showed that the team hadachieved 92.3% against a target of 90% for routinereferrals, and 93.9% for urgent referrals against a targetof 97%.

• It had received 1,100 requests in 2014/15; 53% of thesepatients had a cancer diagnosis and 47% a non-cancerdiagnosis. The team told us that recently they hadreceived 15 referrals in one day; however, many referralswere received too late.

• The SPC team completed a scorecard each month thatcovered the key performance indicators set by the trust.The data submitted in December 2014 and February2015 confirmed that in December 2014 179 of 216referrals received had been reviewed by the SPC team.Sixty-eight of those patients had cancer (38%) and 109had not had a cancer diagnosis (60.9%.). In February2015, 174 of 204 referrals had been reviewed. Sixty-fourof these patients had a cancer diagnosis (31%) and 114patients had a non-cancer diagnosis (65%).

• The trust did not audit the percentage of patients thatachieve their preferred place of care/preferred place ofdeath. Patients were discharged to their home, hospiceor nursing home. We were told that two thirds ofpatients were local, but with multiple clinicalcommissioning groups to engage with, the process wasnot standardised. A palliative care consultant told usthat there were delays in securing nursing home places,which could be lengthy. An outsource team came to thetrust to support families in nursing home choices.

• We reviewed the quality sampling data provided andfound that, between September 2014 and February2015, out of 30 patients, 12 had no preferred place ofcare/preferred place of death written in their notes, 13were too ill and five had had their preferred place of

Endoflifecare

End of life care


care/death documented. This demonstrated thatward-based teams needed to improve the way in whichthe asking and recording of the wishes and preferencesof the patients was done.

• As part of the ‘Care of the Body After Death – Last OfficesPolicy 2015’, deceased patients were expected to betransferred to the mortuary within a four-hour window.Staff on the wards we visited told us that deceasedpatients left within this timeframe. However, we wereunable to review this during the inspection, as the wardsdo not audit this.

• The SPCT aimed to see the majority of referrals on theday of referral. Referrals to the SPCT could be byself-referral or by referral by professional groups, viaEPR. Referrals to the team were classified as ‘routine,urgent or emergency’. A senior clinician would triage allthe requests daily to ensure all were appropriate andthe urgency of the requests were acted on in anappropriate timeframe. The team standards stipulatedthat routine referrals were seen within one working day,that urgent referrals were seen within a day of referral,often the same day, and emergencies were seen on theday of referral. We reviewed the palliative care scorecardand saw that, for February 2015, a target of 90% was setfor routine referrals. The team were achieving 92.3%. Forurgent referrals, a target of 97% was set, but the teamwere achieving slightly below this at 93.9%. For urgentreferrals a target of 100% was set and this wascontinuously achieved.

• To support the transfer of patients from the hospital tothe community teams, the SPCT CNSs and the dischargeliaison nurse were able to describe the communicationflows and systems that were in place, including theengagement with the district nursing team, GPs and thecommunity palliative care team to ensure that thecommunity teams were well placed to delivercontinuous end of life care. If specialist palliative carewas required at home, the SPCT CNS made a referral tothe community palliative care team.

• We noted that documentation was in place to supportthe discharge of patients, including a standarddischarge summary and gold discharge summary. Thisensured that streamline care was communicated acrosscare providers.

• Minutes of the most recent staff meeting showed thatareas discussed included discharge planning.

Learning from complaints and concerns• Any complaints around the delivery of end of life care

were reviewed by the End of Life Strategy Group. Wewere told by a palliative care consultant that, in the lastyear, only one complaint had been made about theSPCT. The process undertaken when the complaint wasmade demonstrated that systems were in place torespond to complaints in a timely manner. We saw agood governance structure and learning fromcomplaints.

• Ward-based complaints about end of life care were alsodiscussed at the End of Life Strategy Group. In theminutes of the March 2015 meeting, the grouprecognised that the discussion about complaints hadslipped. Four complaints had been submitted acrossthe hospital about end of life care in the last threemonths. We reviewed the complaints and saw thatactions were in place to mitigate the same incidentshappening again, including more staff training and theattendance of the ward manager at the End of LifeStrategy Group.

• Bereavement centre staff undertook interviews withfamilies after the death of their relatives. Staff told usthat, when meeting families, if any issues arose aroundthe care of their relatives, the staff will contact themedical team involved and try and resolve the issue forthe family.

• We reviewed the clinical effectiveness programme andsaw that an audit was undertaken to ensure thatpatients that received palliative care were codedproperly to ensure that any complaints about their carecould be monitored appropriately. The audit tested thatthe palliative care code (z51) was being usedappropriately. Slight discrepancies were highlighted, butgenerally patients were being coded correctly.

• Minutes of the most recent staff meeting showed thatareas discussed included complaints.

Are end of life care services well-led?


The ‘End of life Strategy Group’ took place every twomonths, chaired by the director of nursing, with attendeesfrom palliative care and consultants from elderly care andITU. The director of nursing was appointed as the

Endoflifecare

End of life care


nominated board lead for the development of end of lifecare and provided representation at trust board-level forcare of the dying. However, we did not see any evidence ofa long-term vision around end of life care across the trust.

Monthly palliative care service development meetings tookplace, which fed into the integrated bi-monthly ‘PalliativeCare Governance Group’, which discussed areas including:adverse incidents, risk register and patient satisfactionfeedback. The SPCT were visible, responsive and wereactive in policy development and audit. Outside the trust,the team were involved in regional and national groups.

The chaplaincy service was led by the hospital chaplain.The lead chaplain was an integral member of the End ofLife Strategy Group, the Pan London Clinical StrategicNetwork for end of life care and chaired the organ donationcommittee.

Two members of the palliative care team led on theimplementation of the ‘Schwartz Rounds’ (SchwartzRounds are meetings which provide an opportunity for stafffrom all disciplines, across the organization, to reflect onthe emotional aspects of their work), which had beenestablished for staff. The partnership working with theKing’s Health Partners to provide access to face-to-face,seven-day specialist palliative care was established. Thetrust had participated in all four rounds of the NCDAH,which allowed scrutiny of the trust’s end of life care strategyand encouraged improvements in the care delivered.

The SPCT were actively involved in undergraduate andpostgraduate education and the training of generalist staffacross the trust.

Vision and strategy for this service• We did not see any evidence of a long-term vision

around end of life care across the trust. However, wewere able to review the 2014/15 action plan, which setout the work of the SPCT. This covered areas, such as:the introduction of a system for the identification ofdying patients, the development and implementation ofa treatment escalation plan, quality sampling of thetrust’s deaths, a bereavement survey and a review of thefacilities for families. During the inspection, we wereable to observe the above workstreams in place atvarying levels of completion.

• The End of Life Strategy Group had set out a draftproposal around their work plan for 2015/16. Theworkstreams the group were proposing to cover

included the development of a five-year strategy for endof life care in Lambeth and Southwark, a review of thecommissioning intentions for 2016/17, support for localcare networks and the setting of local priorities, as wellas establishing systems to oversee and measureprogress. Local priorities were due to be set by May 2015and were reviewed in September 2015.

• We reviewed an action plan in response to the NCDAH,2014 .This set out the key areas the trust could improvearound the delivery of end of life care in 2014/15. Theaction plan covered the areas where the organisationaland clinical KPIs were not compliant. A workprogramme to achieve compliance was in place, whichwe were able to review. We noted that areas ofnon-compliance had been addressed and actions werebeing taken illustrating that teams involved wereaddressing areas for improvement in a timely, cohesivemanner. We were told by the palliative care consultantthat feedback to the ward-based medical teams was viathe “grand rounds”, where issues could be flagged andawareness raised. We reviewed the ‘grand round’timetable and saw that palliative care was due to bediscussed in June 2015.

• A palliative care consultant told us that the trust’sresponse to the independent review of the LiverpoolCare Pathway (LCP): ‘More Care, Less Pathway’ (2013)and ‘One chance to get it right’ (2014) was to withdrawthe LCP from the trust and to introduce the ‘Fivepriorities of care’ when caring for patients as theyapproached the end of their life. The introduction of‘quality sampling’ had been used to monitor theimplementation of the ‘Five priorities of care’ across allthe wards.

Governance, risk management and qualitymeasurement• An ‘End of life Strategy Group’ took place every two

months chaired by the director of nursing, withattendees from palliative care and consultants fromelderly care and ITU. Agenda items discussed includedmonitoring performance, such as complaints, abereaved carers survey, a bereavement and DNA CPRpolicy, spiritual care, mortuary services, education andtraining and a review of the action tracker. The wideagenda covered by the group demonstrated theimportance of all areas in care of the dying patients.

• An end of life care ‘Quality and Implementation Group’was established to discuss end of life care with other

Endoflifecare

End of life care


divisions across the hospital and to be a forum for thefeedback to end of life champions. We were told by thepalliative care consultant that attendance at themeetings was poor and that was confirmed in theminutes of the March 2015 ‘End of Life Strategy Group’,where discussions took place on the best way to feedback on issues relating to end of life care. Suggestionshad been made to re-launch the group as a workshopfour times a year.

• We were told by a palliative care consultant thatseparate monthly service development meetings tookplace at the Denmark Hill site and the Princess RoyalUniversity Hospital. These groups fed into the integratedbimonthly ‘Palliative Care Governance Group’, whichdiscussed areas, including: adverse incidents, riskregister, patient satisfaction feedback, clinicaleffectiveness, which included team audits, qualitysampling feedback, research and infection controlupdates.

• We saw that the SPCT multidisciplinary team undertooka variety of roles, which included: continuously updatingits clinical governance programme, regularly reviewingand updating guidelines, protocols and patientpathways for all key service areas, ensuring regularappraisals, continuous professional development andcompliance, with mandatory training for all staff andmaking regular external clinical supervision available.The team considered reports on patient experience,clinical effectiveness and risk management and ensuredappropriate action plans were developed andimplemented. We noted that the SPCT was effective inthose roles and responsibilities, as we were able toreview action plans, palliative care meetings minutesand training records.

• The director of nursing had been appointed as thenominated board lead for the development of end of lifecare and provided representation at trust board-level forcare of the dying. This appointment was made as part ofthe NCDAH 2014 action plan.

• The specialist palliative care team had a risk register. InMarch 2015, four risks associated with the Denmark Hillsite were on the register, one of which was rated as a‘major’ risk. The prescribing and administration ofopioids to end of life care patients had been highlightedas a risk for 11 months. To mitigate this risk, a trust

Opioids Safety Group was established in October 2014and objectives set were due to be completed byDecember 2015. The risk register was reviewed at thePalliative Care Clinical Governance Group.

Leadership of service• There was good leadership of the SPCT, led by the

palliative care consultants and the nursing matrons.However, the cross-site integration of the teams was stilla work in progress. We observed that the SPCT werevisible, responsive and were active in policy and audit.Outside the trust, the team were involved in regionaland national groups, including London Cancer AlliancePalliative Care Group, Clinical Research Network SouthLondon and The National Association for SpecialistPalliative Care Social Workers.

• The chaplaincy service was well-led by the hospitalchaplain. We observed that the chaplaincy team werevisible, responsive and were involved in policy andauditing. The lead chaplain was an integral member ofthe End of Life Strategy Group, the Pan London ClinicalStrategic Network for end of life care and chaired theorgan donation committee. They were also involved inother groups, including the patient issues committeeand the Volunteer’s Steering Group. This highlighted thetrust recognition that religious/spiritual input was anessential part in the delivery of end of life care and thedevelopment of its policy.

• King's College London University, King's College Hospital(Denmark Hill site), Guy's and St Thomas' Hospital andSouth London and Maudsley NHS Foundation Trustswere part of King's Health Partners. King's HealthPartners had a five-year plan (2014/19) in place, whichsets out how they will work together. The aim is to focuson seven key clinical areas – cancer, cardiac, childhealth, dental, diabetes/obesity, mental health/neurosciences and transplantation/regenerativemedicine and will drive better understanding andimproved treatments in these fields through researchand education. King’s Health Partners provide aseven-day, face-to-face on-call service for palliative carepatients, across the trusts. This represented goodpartnership working across care providers ensuring thatpatient’s complex needs were met during the weekendand evenings up until 10pm.

• Two members of the palliative care team led on theimplementation of the ‘Schwartz Rounds’, which hadbeen established for staff to regularly come together to

Endoflifecare

End of life care


discuss the non-clinical aspect of caring for patients,including: psychological, emotional and socialchallenges associated with their work and help staffdeliver compassionate care. Schwartz Rounds had beenrunning since October 2013 and, as a result, the end oflife strategy group members secured funding, these willcontinue in 2015.The group were in the process ofidentifying people to become facilitators and supportthe Schwartz Rounds.

• The SNOD told us that the organ donation committeetook place every three months. A palliative careconsultant was a member of the group with thechaplain being the chair. The SNOD told us that datawas reviewed and discussed and the action plan wasupdated.

Culture within the service• SPCT members we spoke with were passionate about

supporting both families and staff in end of life care.This was confirmed when we spoke to staff on DavidsonWard. One nurse told us that SPCT staff were excellent inhelping with “discharge and complex symptom control”and another nurse told us how helpful and supportivethe SPCT CNSs were.

• All staff we spoke with demonstrated a positive andproactive attitude towards caring for dying people. Theydescribed how important end of life care was and howtheir work impacted on the overall service. On DavidsonWard, a nurse told us that the ward was “open andhonest and was committed to good patient care”. Stafffelt they could speak out and felt “listened to”. This wasconfirmed on Lonsdale Ward when a nurse told us thatthere was “an open culture on the ward where everyonefelt they could speak out and would be listened to”.

• SPCT staff told us that they felt supported in their rolesand told us how approachable there managers were. OnDavidson Ward, a nurse told us they felt well supportedby the line manager and the matron. They were alwaysaround and were “very approachable”. In thebereavement office, staff told us they felt supported bytheir line manager and appraisals were undertaken.

• The chaplain we spoke to told us that everyone tried todo their best around end of life care. They said,“Patient’s safety and quality were a priority here as it’s avery human place. People want to get it right.”

• Mortuary staff told us that they had lots of contact withnon-mortuary staff and contributed to the developmentof the end of life policies, including the ‘Care of the Body

After Death – Last Offices Policy 2015’ that was beingdeveloped. Chaplains, porters and undertakers werefrequent visitors to the mortuary and were able to seewhere their work fitted into the provision of end of lifecare services.

• Staff spoke positively about the service they providedfor patients. Quality and patient experience was seen asa priority and everyone’s responsibility and this wasevident in the SPCT in their patient-centred approach tocare.

• Across the wards we visited we saw that the SPCT wasintegrated well with nursing and medical staff and therewas obvious respect between specialties anddisciplines. On Fisk Ward, a nurse told us that the SPCTwas “very supportive” and this was also expressed by aFY2 doctor we spoke to on Lonsdale Ward.

Public and staff engagement• To ensure public and patient representation was

established and maintained within the trust, alayperson was appointed as part of the board tochampion end of life care.

• Staff awareness of the SPCT was raised by the annual‘Dying Matters’ at King’s College Hospital, a stall at theKing’s College Hospital. Open day and road showsacross the trust to raise awareness around the care ofthe dying amongst staff. A palliative care consultant toldus that public awareness around end of life care wasundertaken by St Christopher’s Hospice.

• The chaplaincy organised an annual remembranceservice for adults, children, staff and haematologypatients. A book of remembrance was available in thechapel where the name of the deceased could beplaced. Remembrance services took place in Novemberand December each year. Bereaved relatives wereinvited to the services via a card that was handed outwhen the family attended the bereavement office aftertheir relative had died.

Innovation, learning and improvement• We were told the trust implements end of life care

planning using the 'Coordinate my Care' system. Thisenabled the trust to share the care plan electronicallyinternally and with external care providers in Southwark,Lambeth, Lewisham and Greenwich, Bexley andBromley Cluster.

Endoflifecare

End of life care


• The SPCT were actively involved in service improvementprojects and undertook audits to monitor the quality ofend of life care across the trust. Audits undertakenincluded diabetes at end of life, palliative care on-callrota and acute palliative care treatment.

• Innovative work undertaken included the partnershipworking with the KHP to provide access to face-to-face,seven-day specialist palliative care (only 21% of trustsdeliver this nationally). The trust had participated in allfour rounds of the NCDAH, which allows scrutiny of thetrust’s end of life care strategy and encouragedimprovements in the care delivered.

• The palliative care team members were heavily involvedin contributing to the MSc in palliative care, wereactively involved in module teaching, including:palliative care in multiple sclerosis, ethics and palliativecare and palliative care for patients with renal disease.

• The improvement in end of life care in 2014/15 was via alocally agreed Commissioning for Quality andInnovation (CQUIN) payment framework. The CQUINwas for the turnaround time of the end of life care

patient’s discharge letters. A target has been set of 92%for the letters to be completed within 24 hours. TheSPCT had performed above that set target, with theteam achieving 96.9%.

• The palliative care matron told us that the hospital hadundertaken a pilot around the use of amber carebundles (assessment management best practiceengagement recovery uncertain), which were used tosupport patients that were assessed as being acutelyunwell and deteriorating, with limited reversibility andwhere recovery was uncertain. The end of life strategymeeting in October 2014 made the decision to no longeruse the amber care bundles. However, wards thatwished to continue using the amber care bundles wouldbe supported. During the inspection, staff on TwiningWard told us they continued to use the amber carebundles.

• The SPCT submitted data to the National Minimum DataSet, which allowed the team to benchmark their servicenationally and could be used as a service improvementtool.

Endoflifecare

End of life care


Safe Good –––

Effective Not sufficient evidence to rate –––





Information about the serviceKing's College Hospital, Denmark Hill site provided 735,148outpatient appointments in 2014/15. A number of differentspecialties are covered by the outpatient department,including: liver, renal, breast, fracture and orthopaedic,dental, dermatology, ear, nose and throat, ophthalmology,general medicine, cardiology, oncology, diabetic medicine,endocrinology, gastroenterology, general surgery and otherclinics. The outpatients and diagnostic imagingdepartment is open on Monday to Friday from 9am to 5pm.

As part of the inspection, we visited the outpatients anddiagnostic imaging department and spoke with 28members of staff, including: nurses, healthcare assistants,receptionists, the head of operations, departmentalmanagers and medical staff. We spoke with 45 patients andrelatives attending the hospital for a variety of outpatientsand diagnostic imaging procedures. Additionally, we visitedbreast radiology, X-ray and imaging departments,including: nuclear medicine, magnetic resonance imaging(MRI) and computerised tomography (CT) scanning. Wealso visited the outpatient booking office.

Before the inspection, we reviewed information about thetrust’s performance sent to us by the trust, informationfrom clinical commissioning groups (CCG) and otherstakeholders and information from the listening event. Weobserved interactions between patients and staff andinspected the environment where services were provided.

Phlebotomy and pathology services were providedprivately at the hospital by an independent contractor andwere, therefore, not visited during this inspection.

Summary of findingsPatients received a caring service, as staff treated themwith compassion, kindness and respect. Positivefeedback had been received by the trust from patientsusing the outpatients and diagnostic and imagingdepartments. The service was delivered by trained andcompetent staff who had been provided with aninduction as well as mandatory and additional trainingspecific for their roles.

The leadership, governance and culture with theoutpatient and diagnostic imaging services promotedthe delivery of person-centred care. Staff weresupported by their local and divisional managers. Riskswere identified and addressed at local level or escalatedto divisional or board-level if necessary. The trustpromoted a good working culture. However, someclinical staff we spoke with did not feel supported bytheir line managers.

Many patients complained about the waiting times inthe outpatient clinics. They said they had littleinformation about the waiting times and staff were notalways open with them about it. There was nosystematic template of clinic schedules for the hospital.Different clinics used different templates and sometemplates allowed for the over booking of clinics andmultiple bookings of appointments under one time slot.

Outpatient services were not organised in a manner thatresponded promptly to ensure patients’ needs weremet. Some patients experienced long delays in waiting


Outpatients and diagnostic imaging


times to their first outpatient appointment. The bookingteam were taking action to address waiting times andmonitored patients who did not attend forappointments.

The liver clinic environment presented challenges forstaff and patients, particularly in relation to the spacerequired for patients to sit comfortably while waiting fortheir appointments. Seating areas were cramped and,throughout our inspection, we saw patients standing inareas of the clinic, who were unable to find a seat.Access for patients and visitors with mobility issues waschallenging, due to tight spaces in corridors and seatingareas in some areas of the clinic.

Are outpatient and diagnostic imagingservices safe?

Good –––

There were systems in place, supported by adequateresources to enable the department to provide goodquality for care to patients attending for appointments. Wespoke with staff of all grades and disciplines across theoutpatient areas and were told that the majority felt thedepartment was adequately staffed to meet patients’needs.

We found that the environment was safe and the requiredsafety checks were being completed and recorded. Thedepartment was clean and well maintained. Equipmentwas readily available and staff were trained to use it safely.There were no hand gel dispensers at the main entrancesof some clinics however they were available in all clinicsand other areas of the clinics we visited. Although theclinics were busy, nursing staff provided good and safe careto patients. Treatment records were informative andshowed a clear pathway of the care and treatment patientsreceived at the hospital.

Incidents• During the last year there had been eight serious

incidents reported between February 2014 to January2015 and two Never Events reported between the sameperiods. We were told that all incidents wereinvestigated, including the Never Events, and we weregiven evidence of that including action plans andlearning from incidents.

• The Never Events were discussed at the departmentallevels and action taken to ensure that the incident isnever repeated. We were told by the Head ofOphthalmology that all the never events werethoroughly investigated and lessons learnt were sharedwith all staff concerned. However there was no closerworking relation with the other trust location; forexample the never events at the ophthalmologydepartment at this hospital was not shared with theophthalmology department at the Princess RoyalUniversity Hospital.

• Nursing managers told us they received regular reportsof incidents and this enabled them to identify themesand trends and take corrective actions accordingly.




• Incidents were reported as per trust policy via the Datixelectronic incident reporting system. They werereviewed at the clinical risk meeting and clinicalgovernance meetings in the medical directorate, andalso at departmental-level. Incidents were alsodocumented in the annual clinical governance report.Nursing staff informed us they were encouraged toreport incidents, which occurred in their working area.All of the staff we spoke with were confident to reportincidents via Datix.

• We were given examples of incidents that had beenreported by various outpatient clinics and diagnosticand imaging departments. For some of these, staff wereable to inform us of changes that had happened as aresult of their report. Although staff understoodincidents were monitored, some of them felt they didnot consistently receive feedback on the outcomes andaction taken as a result of their report. We were shownthe evidence of learning as a result of the incident thatwas reported and investigated by the department.

• In the ophthalmology department, there was a checklistdeveloped to prevent surgeons from using incorrectdata on the Medisoft system (Medisoft is the softwaresystem that is used for assessments, investigations andophthalmic procedures) and inserting an incorrectimplant into a patient’s eyes. This action took place as aresult of learning from Never Events. There was evidencethat the trust learnt from incidents and that action planswere developed to address any issues identified.

• We saw a breakdown of incidents by category and datethat allowed trends to be identified and action taken toaddress any concerns in a timely manner.

• All staff we spoke with in the diagnostic imagingdepartment understood their responsibilities when itcame to raising concerns and recording safety incidentsand near-misses. Staff felt confident that they coulddiscuss incidents with their direct line manager and thattheir concerns were listened to and acted on. Seniormanagers met regularly to discuss compliments,complaints, concerns and incidents. Themes fromincidents were discussed at the senior manager’smeetings and minutes of the meetings confirmed thiswas the case.

• We were given an example of an incident regarding apatient being given the wrong testing equipment at thesexual health clinic and staff described the action thathad been taken as a result. We saw that changes to

practice had been made and that this had beendiscussed during team meetings to ensure that maleand female testing kits were appropriately markedduring storage. We saw that actions had beencompleted within the given timescale.

• Safety alerts were received by managers and cascadedto all staff, displayed in the staff office and discussed atteam meetings. Minutes of staff meetings confirmed thatsafety alerts were being discussed and it was a standingagenda of the meeting.

Duty of Candour• Information regarding Duty of Candour had been

cascaded from the divisional managers to all staffteams. Staff told us information had also been madeavailable on the trust intranet regarding Duty ofCandour and the responsibilities for being open andtransparent with patients. One member of staff wespoke with demonstrated they were aware of thisinformation and how to access it.

• We saw evidence of Duty of Candour in action when theconsultant in the ophthalmology department gave usthe example of letters being sent to patients offeringapology and inviting them for a meeting to discuss theincident. This was one thing the department did whendealing with the Never Event incident.

Cleanliness, infection control and hygiene• The overwhelming majority of staff we observed in the

outpatient clinics and diagnostic imaging departmentwere complying with the trust policies and guidance onthe use of personal protective equipment (PPE) andwere seen to be 'bare below the elbows'. We observedstaff in the outpatient clinics undertaking hand washingwhen attending to patients and in-between patients.Staff working in the outpatient clinics had a goodunderstanding of their responsibilities in relation tocleaning and infection prevention and control.

• The clinic areas and imaging department were visiblyclean and tidy. We saw staff cleaning the areas betweenuse by patients using appropriate wipes, thus reducingthe risk of cross-infection or cross-contaminationbetween patients. Within the imaging department, stafftook active measures to ensure that infection controlissues were appropriately dealt with.

• Toilet facilities were located throughout the outpatientand diagnostic imaging departments and these wereclearly signposted. We looked at a sample of these and




saw they were regularly cleaned, with records showingwhen they were last cleaned. Clinical areas weremonitored for cleanliness by the facilities team.Housekeeping staff could be called to carry outadditional cleaning, where staff felt it was necessary.

• Nursing staff were responsible for cleaning clinicalequipment. We saw that there were checklists in placein each clinic room and observed that these had beencompleted to provide assurance that equipment androoms had been cleaned. The equipment that we sawwas in good repair and we noted that green labels wereplaced on the equipment that had been cleaned.

Environment and equipment• We found that the outpatient and diagnostic imaging

department had resuscitation equipment, withappropriate signage directing staff to its location. Allresuscitation equipment was checked during ourinspection and found to contain an automated externaldefibrillator, suction equipment, and oxygen along withthe appropriate emergency drugs and medical supplies.Other equipment was visibly clean, regularly checkedand ready for use.

• The main outpatient department was located in theGolden Jubilee Wing of the hospital and it is divided intovarious numbered suites for ease of access and patientconvenience.

• From observation in the outpatient clinic, we noted thatthere was adequate equipment. Staff told us that therewas not a problem with the quantity or quality ofequipment that was needed at the clinic.

• Equipment was maintained, checked regularly andgiven a portable appliance test (PAT) in line with thetrust’s policy. Labels on equipment stated when theequipment was last checked. All equipment we saw hadbeen checked within the last year.

• Within the imaging department, we looked at thetreatment rooms and found that they complied with thesafety guidance on radiology. Personal protectiveequipment, such as goggles and tabards were availablethe machines were locked when not in use and accessto the room was restricted when treatment was takingplace. Local rules drawn up by the radiation protectionadvisor was in place and a laser protection supervisorwas appointed by the department.

Medicines• Staff we spoke with were aware of medicines

management policies for reference purposes. Medicinesadministration records we checked were completedappropriately. There was a medicines informationleaflet for patients. We saw medication audits had beenundertaken with minutes seen of staff meetings toaddress any issues that arose from the audits.

• Medicines were stored in locked cupboards in theoutpatients department. Nursing staff ordered allmedicines through the hospital pharmacy.

• We found that controlled drugs and fridge temperatureswere regularly checked by staff working in theoutpatients and diagnostic imaging department. Thenurse in charge carried the keys to the controlled drugscupboard at all times. Two nurses checked controlleddrugs taken from the locked medicines cupboards foradministration. A lockable medicines fridge was inplace, and daily temperature checks were recorded bystaff. Temperature records that we looked at werecompleted and contained minimum and maximumtemperatures to alert staff when they were not withinthe required range. We also found evidence in thedermatology outpatients department of prompt andappropriate action that had been taken when a fridgehad been found to be outside of the recommendedtemperature range.

• Prescription pads were stored in a locked cabinet. Whenclinicians wrote patient prescriptions, the clinic kept alog which identified the patient, the doctor prescribingand the serial number of the prescription sheet used.This ensured the safe use of prescription pads.

• There were standard operating procedures in place atthe sexual health clinic for vaccinations and vaccinationreactions.

• Medications and contrast media required duringdiagnostic imaging procedures were administeredappropriately using approved patient group directions(PGDs). The use of PGDs enables the registered healthprofessionals other than doctors to supply and/oradminister medicines to patients. PGD was a writteninstruction for the supply and/or administration of anamed, licensed medicine for a defined clinicalcondition by specific healthcare professionals toimprove patient care by enabling healthcareprofessionals to administer medication withoutindividual prescriptions.




Records• All nursing and diagnostic imaging records were

electronic and stored on the hospital’s computersystem, which were accessible to clinical staff usingindividually issued secure passwords.

• Information governance training was mandatory for allstaff to ensure compliance with the Data Protection Act1998. The mandatory training records we saw showedthat all staff had completed Data Protection Act 1998training.

• The records management policy stated that anybreaches of data protection would be discussed at thesenior manager’s meeting and actions taken to remindstaff of the importance of data protection. We were notprovided with evidence to demonstrate that there hadbeen any breaches of data protection in the 12 monthsprior to the inspection.

• Staff we spoke with could not recall an occasion wheremedical records had not been available for a clinic, orwhen a patient could not be seen because their recordswere not available, because all records were heldelectronically with a secure backup in the event ofsystem failure.

• All patients attending the outpatient appointment forconsultation, radiological examination, or treatmentwere risk assessed in areas of mental capacity beforeundergoing their treatment or other invasiveprocedures.

Safeguarding• Staff we spoke with were aware of their responsibilities

and understood their role in protecting children andvulnerable adults. They demonstrated knowledge andunderstanding of safeguarding and of the trust’s processfor reporting concerns. The trust had a whistleblowingand safeguarding policy that was known to staff workingin the outpatient and diagnostic imaging department.They told us that they would feel happy using this policyto raise concerns if they felt it was necessary.

• There was a safeguarding lead at the hospital and theoutpatient and diagnostic imaging staff wereencouraged to contact the safeguarding lead if they hadany concerns about patients. Staff assured us they knewwho the trust’s safeguarding lead was and how tocontact them. We were told that the trust wasrepresented at both adult and children’s safeguardingstrategy meetings at the local council.

• Staff in the outpatient and diagnostic imagingdepartment had completed mandatory safeguardingtraining to level 2, and child protection level 2 training.They were able to talk to us about the insight andknowledge gained from this training. An outpatientnurse was able to give us an example of when staff inthe department had followed the trust safeguardingpolicy and made an appropriate referral.

• In the sexual health outpatient clinic, we were shownhow all safeguarding referrals were identified,monitored and updated. Staff described how eachreferral was recorded and reviewed at monthly meetingsand how the lead clinician managed these patientsaround the service.

• We were told the hospital had a robust system formonitoring female genital mutilation (FGM). The systeminvolved monitoring and providing support to patientsexperiencing or under threat of experiencing this abuse.We saw examples of information given to patients whenreferring them to other services within the hospital. Forexample, for corrective surgery. Records confirmed thatall cases of FGM were recorded and discussed with thesafeguarding lead.

Mandatory training• Corporate induction training was provided for all staff

and was compulsory for all staff to attend. There wasalso a service specific induction. This was specific to thedepartment where staff worked and their role. We sawrecords held within the outpatients and diagnosticimaging department, which showed the inductionrecords for new staff were comprehensive and up todate. All of the staff we spoke with confirmed that theyhad received their mandatory training in line with thetrust’s policy.

• Staff told us they were given time to undertakemandatory training, which was offered in a format oftwo days’ worth of face-to-face training, augmentedwith e-learning. Some staff told us that accessinge-learning had practical difficulties, as it was located onthe rust intranet, which meant access through somecomputers in some departments was not alwayspossible.

• The completion of mandatory training varied betweendifferent departments and clinics, with an average




completion ranging between 70% to 90%. Staff knewhow their training was monitored and confirmed thatmanagers reminded them when training was overdueand needed to be completed.

• We saw examples of staff training records showingcompleted training. We also saw examples of themonitoring that showed staff had undertaken allmandatory training, such as health and safety, infectionprevention and control, moving and handling,safeguarding and basic life support.

• Staff we spoke with were positive about the trainingprovided and were confident they would be supportedto attend additional training if they requested it.

Assessing and responding to patient risk• The hospital had systems and processes in place for

responding to patient risk. Staff were noted to beavailable in all the waiting areas of the clinics so thatthey would notice patients who appeared to be unwelland needed assistance. Staff we spoke withdemonstrated knowledge and understanding of patientrisk, particularly for people living with dementia orlearning disability, and elderly or frail patients with morethan one medical condition.

• There were clear procedures in place for the care ofpatients who became unwell. Staff we spoke with toldus about emergency procedures and escalation processfor unwell patients. However, they stated these had notbeen used often, as the department did not often haveacutely-unwell patients.

• In the diagnostic imaging department, staff we spokewith knew who their radiation protection adviser andradiation protection supervisor were for their clinicalarea. Staff explained how they would report anyconcerns about safety to their line manager. We sawlocal rules and copies of the Ionising Radiation (MedicalExposure) Regulations 2000 (IRMER 2000) in place.

• There were emergency assistance call bells in all patientareas, including consultation rooms, treatment roomsand the x-ray suite. Staff we spoke with told us when thecall bells were used they were answered immediately.Staff we spoke with were aware of their role in a medicalemergency. Staff provided an example of a patient whohad become acutely unwell during a clinic appointmentwhere a cardio-respiratory resuscitation (CPR) team hadbeen called to assist the patient.

Nursing staffing• The outpatient clinics were staffed by registered nurses

and health care assistants. Each clinic was run byregistered nurses and was supported by health careassistants.

• The outpatients and diagnostic imaging departmentused a staffing contingency plan to assess daily whetherthey had sufficient numbers of nursing staff in thedepartment. The plan included a staff escalationprotocol, which instructed staff on procedures to followwhen staffing levels fell below the level required to runthe department safely.

• All of the staff that we spoke with felt that there wereenough staff of a suitable skill mix to manage theworkload. Where areas required a trained nurse to beavailable for clinics, for example breast clinics, theywould be provided.

• Nursing staff told us that, although they were busy, theythought they provided good and safe patient care.

Medical staffing• Medical staffing was provided by the relevant specialty

running the clinics in the outpatient department.Medical staff were of mixed grades, from consultants tojunior doctors. There was always a consultant tooversee the clinics, and junior doctors felt supported bythe consultants.

• Doctors we spoke with thought they had a goodrelationship with outpatient nursing and clerical staff.They said they felt well supported and could discussissues with them.

• Trust policy stated that medical staff must give six weeksnotice of any leave in order that clinics could beadjusted in a timely manner. However, records showedthat the outpatient department was not compliant withthis policy. We were told that where the policy was notmet, staff escalated this to divisional or deputydivisional managers to be challenged, investigated andapproved.

• Consultants and registrars provided cover for each otherat times of annual leave or sickness whenever possible.All medical staff we spoke with confirmed thatcancellation of a clinic was a last resort.




Major incident awareness and training• The trust had a business continuity management plan,

which had been approved by the management team.The plan established a strategic and operationalframework to ensure the hospital was resilient to adisruption, interruption or loss of services.

• The hospital major incident plan covered majorincidents, such as: winter pressures, fire safety, loss ofelectricity, loss of the frontline system for patientinformation, loss of information technology systemsand internet access, loss of staffing, and loss of thewater supply.

• Staff we spoke with were aware of the hospital’s majorincident plan, such as winter pressures and fire safetyincidents, and they understood what actions to take inthe event of an incident such as a fire. Most staff wespoke with had attended major incident awarenesstraining within the last three years and were able todescribe the outpatient department’s role in the eventof a major incident.

Are outpatient and diagnostic imagingservices effective?

Not sufficient evidence to rate –––

Evidence-based assessments, care and treatment wasdelivered in line with National Institute for Health and CareExcellence (NICE) guidelines, by appropriately trained andqualified staff. Radiation guidelines, local rules andnational diagnostic reference levels (DRLs) were availablefor staff references. There was an assigned radiologyprotection adviser and an radiology protection supervisor.

A multidisciplinary team approach was evident across allthe services provided by the outpatients and diagnosticimaging department. We observed a shared responsibilityfor care and treatment delivery. Patients were providedwith sufficient information about their treatments and hadthe opportunity to discuss any concerns. Staff working inthe clinic told us their managers encouraged theirprofessional development and supported them tocomplete training. However, completion of training had notalways been possible, due to staff shortages that made itvery difficult to undertake study leave. Appraisals wereundertaken annually, but staff had no other form of formalsupervision on a regular basis.

The diagnostic imaging service manager monitored theradiology turnaround times for reports, which were sharedwith all staff during staff meetings. The diagnostic imagingdepartment had effective systems in place for monitoringradiation levels administered for diagnostic treatments,interventions and patient outcomes.

Evidence-based care and treatment• National Institute for Health and Care Excellence (NICE)

guidance and the trust’s treatment protocols andguidelines were available on the trust’s intranet. Stafftold us that guidance was easily accessible and wasclear and comprehensive. We saw that the outpatientsand diagnostic imaging department was operating toNICE guidance standards and local protocols andprocedures. Staff we spoke with were aware of how thisguidance had an impact on the care they delivered.

• We noted that NICE guidelines were in use in mostclinics. Staff we spoke with described how they ensuredthat the care they provided was in line with best practiceand national guidance. Adherence with NICE guidelineswas monitored by the relevant directorates’ clinicalgovernance committees.

• There were clear standard operating procedures (SOPs)for the imaging department, as required under IRMER2000 regulations. These addressed patient identificationand responsibilities of individual members of staff, andalso set training requirements for staff working at theimaging department.

• We were told by the diagnostic imaging lead that theradiation protection monitoring at the hospital wassatisfactory and in line with IRMER 2000 requirements.We saw evidence through audits which showed thatradiation exposure monitoring was up to date. Therewas no IRMER 2000 report submitted to the Care QualityCommission (CQC) in the last year.

Pain relief• The imaging department had a stock of pain relief and

local anaesthetic medication for use when invasiveprocedures were being carried out. We saw that painrelief was discussed with patients during theirconsultation or treatment and analgesia was prescribedas necessary and dispensed by the hospital pharmacy.

• Patients at the outpatients department had access topain relief when it was needed. Clinical staff reportedthat patients’ pain was assessed and monitored toensure they received the appropriate amount of pain




relief when in clinic. Staff told us that they could giveparacetamol to patients if they were in pain, but allother analgesics had to be prescribed before beingadministered to patients.

• Staff in the pain clinic told us that prescribed pain reliefwas monitored for efficacy and, where necessary, theychanged to meet patients’ needs. This was discussedwith patients as part of their ongoing management ofpain.

Patient outcomes• National guidelines for radiological reporting and the

clinic’s own quality standards for radiology practicewere followed regarding radiology activity andreporting. This included all images being qualitychecked by radiographers before the patient left thedepartment.

Competent staff• Patients who attended outpatient clinics and the

diagnostic and imaging department were very positiveabout the clinical staff and the care and treatment theyhad been given.

• In the diagnostic imaging department, there wereprotocols, policies and procedures in place for the useof equipment and these served as a reference manualfor staff. All staff had undergone local training in the useof all equipment in the diagnostic imaging department.We were shown a record of training completed by staffas part of their professional development.

• We spoke with a selection of staff in all departments,who told us they had participated in the annual trustappraisal system. The neurology clinic manager told usthey had attained a 90% appraisal rate of staff. However,there was no data or record to corroborate this figure.While some staff said they had formal supervisionmeetings with their managers, others said they did not.All staff we spoke with told us they were well supportedby colleagues and by their managers.

• We were shown how individual managers recorded andaccessed information regarding line managementresponsibilities for staff appraisals. Staff in the cardiacclinic told us how they took responsibility for initiatingthe appraisal process and showed us using the intranetonline system. They reported that they found thishelpful in ensuring that the appraisal process was fullyinclusive and not just a task that had to be completed.

• Staff were provided with training relevant to theirspecialty, such as general surgery, orthopaedics andcardiology. Staff told us they were trained in the care ofpatients living with dementia or who had a learningdisability. We saw evidence of this through themandatory training data submitted by the trust.

• We spoke with staff throughout the outpatients anddiagnostic imaging departments, who told us therewere many development opportunities available forthem and that the trust supported staff to broaden theircompetencies. We spoke with healthcare assistants,ward managers, link nurses, and nursing staff, whodescribed how the intranet published courses availableand contained good information for them to access. Thepractice development nurse told us how they attendedstudy days every three months, which ensured theywere updated and remained current. We spoke with arange of link nurses, including the dignity champion andthe diabetes lead. They described a culture ofdeveloping individuals and sharing best practice.

• We were told that the diagnostic imaging departmenthad a departmental induction programme forradiologists, radiographers and other staff working inthe department that included orientation on thedepartment’s equipment. We were told that each newstaff member was assigned a mentor. A member of stafftold us that a colleague would go through the controlswith them when a piece of equipment was new to them.However, they said that this was not recorded formally.We reviewed more recent induction and training recordsand these were found to be up to date.

Multidisciplinary working• There was evidence of multidisciplinary working in the

outpatients department. We were told about a numberof examples of where joint clinics were provided, forexample: the breast clinic, the dermatology clinic, theophthalmology clinic, the older person’s clinic and theoncology clinics.

• Many clinics had multidisciplinary meetings, particularlythe cancer related specialties, where the team agreedand planned the care for patients and decided whichclinician would be seeing the patient in the clinic toexplain the plan to them. We saw, for example, that amember of staff from the outpatient’s clinic and breastradiology team attended the breast caremultidisciplinary team meeting.




• Specialist nurses ran clinics for some specialties, suchas: a pain clinic, a breast clinic, a heart failure clinic anda diabetic clinic, among others. We spoke with some ofthe specialist nurses, who described how their clinicsfitted into patient treatment pathways. Nursing staff andhealthcare assistants we spoke with in clinics, such asorthopaedic and gynaecology clinics told us thatteamwork and multidisciplinary working were effectiveand professional.

• We saw that patients were regularly referred tocommunity-based services, such as community nursingservices and GP services.

Seven-day services• The outpatient department service ran from Monday to

Friday, from 8.30am to 5.30pm. We were told there weremostly no evening or weekend clinics, but the fractureand orthopaedic clinic provided Sunday services from8:30am to 1pm.

• The diagnostic and imaging department offeredseven-day services for inpatients and those whoattended the ED.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards• We saw evidence from staff training records that clinical

staff had completed training on the Mental Capacity Act2005 and Deprivation of Liberty Safeguards. Staff wespoke with confirmed they had completed training andundertaken regular updates. However, we noted thattheir knowledge of Mental Capacity Act 2005 andDeprivation of Liberty Safeguards was variable, withsome staff demonstrating clear knowledge of the actand its implications and others not being as clear.

• Patients we spoke with said that they completedconsent forms before their treatment, when this hadbeen appropriate. We were told that clinicians asked forconsent before commencing any examination andexplained the procedure that was to take place. Staffundertaking procedures were aware of the need toobtain patients’ consent and completed appropriateconsent documentation.

Are outpatient and diagnostic imagingservices caring?

Good –––

We saw that caring and compassionate care was deliveredby all staff working at outpatients and diagnostic imagingdepartment. We observed, throughout the outpatientsdepartment, that staff treated patients, relatives andvisitors in a respectful manner. Staff offered assistancewithout waiting to be asked.

Clinical room doors were kept closed, and staff knockedbefore entering clinic rooms to maintain patients’ privacy.Patients and relatives commented positively about the careprovided to them by the staff from all the clinics visited.Staff ensured that patients understood what theirappointment and treatment involved.

Patients told us they felt involved in their care andtreatment, and they thought that staff supported them inmaking difficult decisions. Patients told us they were givensufficient information about their care and treatment andwere fully involved in making decisions about their careand treatment. All the patients we spoke with told us thestaff were caring and polite. Patients we spoke with weresatisfied with the services provided and stated that doctorsand nurses had time to discuss with them their care andtreatment plan.

The liver clinic was cramped, which meant there was noprivacy for patients. We could hear the conversations takingplace between patients and staff. We observed patientshaving their vital signs taken on the corridor of the clinic.

Compassionate care• We observed most staff interactions with patients as

being friendly and welcoming. We observed someinstances where patients that attended the clinicregularly had built relationships with the staff thatworked there. We saw examples of caring interactionsby healthcare assistants. For example, friendly greetingsgetting down to a patient level to interact with them andmaintaining eye contact.




• We saw that staff always knocked and waited forpermission before entering clinic rooms. We also sawthat clinic rooms had signage instructing people toknock and wait for an answer before entering, tomaintain people’s dignity.

• One patient explained how the consultant hadexplained in detail their treatment options and ensuredthey had all the information they required. We observeda nurse explaining paperwork to a patient attendingtheir first appointment, following a diagnosis of theirillness. Everything was explained very calmly and theyalso ensured the patient and their partner had thecorrect phone numbers should they need to ring formore information. They were told to contact the clinic if“they were worried about anything at all”.

• People we spoke with told us they felt listened to andwere given sufficient information about their treatment.Patients’ confidentiality was respected. Patients andstaff told us there were always rooms available to speakto people privately and confidentially.

• Notices were displayed for patients informing them thatchaperones were available and offering them the rightto have treatment and consultation from the same sexstaff. An example of this was in the cardiac clinic, whereinformation was displayed explaining that patientswould be required to remove their clothing to the waist.One patient told us, “It is really good that they tell youwhat to expect before you have the test; it puts you atmore ease.”

• Throughout the two days we visited the outpatientdepartment, we observed nursing, healthcare andreceptionist staff interacting in a positive and caringmanner with patients. We saw that enquiries made atthe reception desks were responded to in a polite andhelpful manner. We saw patients being redirected toother clinic locations with a clear and reassuringapproach.

• We spoke with reception staff at the imagingdepartment, who demonstrated a clear understandingof their role. We observed patients being treated withcourtesy and dignity by reception staff, who signpostedthem to other waiting areas when required. Receptionstaff told us that, when patients arrived forappointments, their name, date of birth, address, andtelephone number were checked with them at this desk.

• The liver clinic was cramped, which meant there was noprivacy for patients. We could hear the conversationstaking place between patients and staff. We observedpatients having their vital signs taken on the corridor ofthe clinic.

• Patients we spoke with were positive about theoutpatient services and told us they were satisfied withthe treatment they received. Patients made positivecomments about nursing staff, healthcare assistants,receptionists and doctors.

Understanding and involvement of patients andthose close to them• Patients we spoke with told us they felt involved and

informed about their care. They told us they were givensufficient information to help them make any decisionsthey needed to make. We were told that treatmentoptions were clearly explained.

• We also observed the doctors behaving in a friendly andrespectful manner towards the patients in their care.One patient told us, “The doctor is particularly good;they took time to understand my problem."

Emotional support• Staff explained how they tried to provide support to

patients who were given distressing news. One nurseexplained how they ensured they were with the patientwhen the consultant spoke with the person. They wouldalso make sure they stayed with the person afterwardsto ensure there was no delayed reaction.

• Patients and relatives we spoke with confirmed thatthey had been supported when they were given badnews about their condition. Staff explained how theyensured patients were in a suitably private area or roombefore breaking bad news to them. We were told that itwas always possible to locate a suitable room for thesediscussions. Nurses were always available to help andsupport patients with information when they were inclinic.

• The chaplaincy team told us that they made occasionalvisits to the outpatient areas and would always attend, ifrequested, in order to offer spiritual support.

• Information was displayed in the various waiting areasabout any support services that might be appropriate.This included helpline numbers and support networksfor specific illnesses.

• Staff were observed to be sensitive to the needs ofpatients who were anxious and distressed about their




procedure at the imaging department. Staff were notedto allay patients’ fears and anxieties about the proposedprocedure, and they explained the procedure andstayed with the patient to provide support andreassurance.

• Patients we spoke with were positive about the clinicsand the staff they saw. They told us they were satisfiedwith the professional approach of the staff.

Are outpatient and diagnostic imagingservices responsive?


The outpatient service was not responsive to patients’individual needs. Overall, not all patients were seen withinthe national waiting time target for waiting to be seen in aclinic. In some clinics, we observed consistent delays inpatients being seen at their appointed time throughout thetwo days we were onsite at the hospital. Delays in clinicswere not always explained to patients. The informationboard displaying waiting times was not prominentlydisplayed where all patients would see it and, occasionally,the waiting times stated on the board were not correct, norwere they a true reflection of the waiting times.

We noticed that some clinics were overcrowded and staffwere struggling to cope with the patient numbers. The trustwas aware of concerns in this area and said, “Somedepartments are getting very busy and running to fullcapacity, which is starting to cause some issues aroundcapacity and waiting areas, this has been escalated to therelevant departments/teams.” This demonstrated that thetrust understood the challenges and identified risks withinthe outpatient department.

The outpatients and diagnostic imaging department wasmonitoring developments that impacted on care delivery,such as developing policy to monitor and reducenon-attendance at hospital appointments, longer waitingtimes, delivering on their referral-to-treatment (RTT)commitment and complaint responsiveness. In general,resources and facilities were good and met the needs ofpatients attending the department.

Service planning and delivery to meet the needs oflocal people• Patients told us they were allocated enough time with

the doctors when they attended their appointments,and that their appointments were not rushed. Doctorswere well informed about patients’ medical history, andpatients’ medical records were available to doctors.

• We found that patient waiting times varied in differentclinics, from a few minutes to over an hour and weobserved consistent delays in patients not being seen attheir appointed time in some clinics. Information aboutwaiting times was not always updated to reflect the truewaiting times. Even though waiting times for patients tobe seen in some clinics were long, we observed goodpatient flow in the main waiting areas of most clinics.

• Some reception and nursing staff told us they wouldinform patients if clinics were running late. However,several patients we spoke with expressed frustration atthe lack of information about waiting times. We weretold by some staff at the outpatient clinics that therewas no monitoring of clinics that were running late.Most of the staff we spoke with could not provide uswith audits or monitoring data that had taken place toidentify the frequency of late clinics and the length oftime patients waited after their allocated appointmenttime to be seen by a doctor or nurse. We also noted thatthere was no action plans in place to address theseissues at the clinic level.

• We were told by the management team that an increasein staffing had been agreed for the diagnostic imagingdepartment. This was identified due to some changes inthe running of the department and additional staff wererecruited to the team.

• We were told CT scans were done in-house, withinpatient scans reported on the same day. Outpatientsreported within 7 days, with 84% reported within threedays. The CT scans team currently worked seven daysper week, due to an increase in demand for the service.

Access and flow• Hospital Episode Statistics (HES) for July 2013 to June

2014 showed that 735,148 outpatient appointmentswere made. We noted that 79% of patients attendedeither their first, or follow-up appointments. The datashowed that the hospital's ratio of follow-up to newappointments was better than the England average. Out




of the total appointments made, 3% had been cancelledby patients and 7% by the hospital. The hospital’s‘cancelled appointments’ of 7% was higher than theEngland average at 6%.

• Staff gave patients reminders of appointments by textand voicemail. Voicemail reminders were sent five daysprior to an appointment, which was followed up by atext reminder the day before the appointment.

• The data also showed that 10% of patients did notattend their appointments, which was higher (worse)than the England average of 7%, and the trust averageof 9%. We were told by trust managers that thehospital's 'did not attend' rate was continuouslymonitored to enable changes and adaptations to bemade to minimise waste of resources. For example,texting and phone calls had been used to remindpatients of their appointment date and time. Measuringthe non-attendance rate was important, becausenon-attendances meant that resources were not beingused well and can have negative impact on patientsreceiving services at the hospital. The trust managerswere not able to tell us what difference had theseinitiatives made to the 'did not attend' rate.

• We were provided with a referral-to-treatment (RTT)report from April 2013 to November 2014, which showedthe trust operational standards were that 95% of onnon-admitted patients should start consultant-ledtreatment within 18 weeks of referral and 92% ofincomplete pathways should start consultant-ledtreatment within 18 weeks of referral. The worstperforming RTT by specialties were in the cardiothoracicsurgery and neurosurgery specialty, which were 72%and 74% respectively, for incomplete pathways. For thenon-admitted pathway, the neurology and neurosurgeryclinics were the worst performing, at 83% and 87%respectively.

• The trust RTT for non-admitted patients (incompletepathways) was 96%, which was higher (worse) than thenational average of 94% for patients starting treatmentwithin 18 weeks of referral from April 2013 to November2014.

• Cancer waiting times were similar to the Englandaverage for all the three measures at the trust level for2013/14. The percentage of people seen by specialistswithin two weeks of an urgent GP referral for all cancerswas 95%, and the percentage of people waiting lessthan 31 days from diagnosis to first definitive treatment

for all cancers was 98%. The percentage of peoplewaiting less than 62 days from urgent GP referral to firstdefinitive treatment for all cancers was 86%, all thesewere within the England average.

• The trust performed worse on the percentage ofdiagnostic patients waiting more than six weeks forappointments. The score was 5% compared with thenational average of 2%.

• The clinical investigations department had a dedicatedporter to assist patients in getting to and from thedepartment. This portering service enabled inpatientsto be brought to the department at an appropriate timeto improve the efficiency and smooth running of thedepartment.

• Paper referrals from general practitioners (GPs),consultants and the emergency department weremanaged by the Outpatients Administration Centre(OPAC) located at the Denmark Hill site. Choose andbook referrals were managed by a separate team alsolocated at this site. Choose and book referrals weredirectly bookable by patients who could access andbook appointment slots by phone or online. They couldalso be booked indirectly by OPAC staff. If choose andbook referrals could not be managed within 18 weektimescales, the system would alert staff, who would goto the referrer and obtain a paper referral that could bemanaged outside of the choose and book system.

• Once referrals were received, clerks then booked thepatient onto the system before sending the referral tothe relevant consultant for triage. Managers told us thatthe expectation was that consultants would triagereferrals within 48 hours. However, this was not alwayshappening. The manager of OPAC was working on aservice-level agreement, which was at draft stage at thetime of our inspection. They hoped that, oncecompleted and agreed by specialties, this documentwould have clear protocols and key performanceindicators (KPIs) around the timeframes for triagingreferrals.

• During triage, referrals would be rated for urgency andthen forwarded to the OPAC team to make theappointment. Two-week wait appointments were madewithin two weeks, urgent appointments were madewithin one to four weeks, and routine appointmentswere made within eighteen weeks. Central booking staffthen booked appointments using the urgency scale. Wewere told that the team used the same criteria across allspecialties, and would escalate to divisional leads if they




could not make appointments within the agreedtimescale. Staff did not have an escalation policy.Therefore, the OPAC manager had included theescalation of two 18-week breaches in the service levelagreement (SLA) draft that they were working on at thetime of our inspection.

• Where booking staff had escalated patients who theywere unable to book within the timescales required,divisional managers would steer staff on how to managethese bookings. We were told that this would beaddressed by providing extra clinics, convertingfollow-up appointment slots into new appointments,double booking clinic spots or by agreeing breaches inthe RTT.

• One issue raised by staff as a potential reason for18-week breaches was the cancellation of clinics. Cliniccancellations were managed by a separate team at theDenmark Hill site. Trust protocol dictated that clinicsshould be cancelled with at last six weeks’ notice. Stafftold us that this was not always adhered to, but that ifthey received requests for clinics to be cancelled withinthe six week notice period without a valid reason thesewould be sent back to the requester who would need tofind additional resources to run the clinic as planned.

• Clinic staff told us that, in order to manage cliniccancellations, each specialty held ‘firebreak clinics‘every five to six weeks. These were clinics that were keptempty in order to move cancelled clinics into the freeappointment slots. Staff told us that, if they still wereunable to re-book patients within the 18-week targetthey would refer this back to divisional leads who wereasked to arrange customised clinics.

• Clinic preparation staff prepared patient health recordsfor clinics. These staff worked for separate divisions andmanaged clinic lists for their specialties.

• Once staff members received clinic lists they wouldrequest health records from the medical records library.Once they had received health records they wouldattach outcome sheets to the record and ensure thatthey contained patient ID labels. Following clinics,health records would be returned to them where theywould use the completed outcome sheets to book anyfollow-up clinic appointments required.

• The medical records department was a closed library.This meant that only staff with required swipe cardscould access the facility. Staff in the library would pull

medical records for clinics, and inform clinic preparationstaff where health records were not in the library. Whenthis was the case clinic preparation staff would locateand collect the relevant health records.

• The hospital used mainly electronic records, however, insome clinics, like liver and orthopaedic, some notes arepaper-based records. Staff told us that, where healthrecords could not be found in time for clinics, atemporary set of health records would be created. Thisset would contain patient labels and copies of last clinicletters, referrals and relevant diagnostic results. Wheretemporary notes had been used library staff wouldmarry these with the main health records.

• Calls coming into the call centre were recorded. Therecordings were used during staff training and tomonitor calls following patient complaints. The callcentre monitored the number of calls coming into theservice, which was broken down by call type andspecialty. They also monitored the length of time it tookfor calls to be answered, the length of time calls took,and the number of people who ended the call before itwas answered. On Monday 13 April 2015, calls took onaverage 180 seconds to be answered. We were told thatMondays were the busiest day for the call centre.

• One issue raised with us during focus groups wasaround patients who had two patient ID numbers, whichcould confuse clinic bookings. OPAC staff told us thatthis happened when some patients transferring fromthe Princess Royal University Hospital had a numberprefixed with an ‘N’. The IT system at the trust would notaccept this, so the patient needed to be inputted intothe system as a new patient. This had caused someconfusion. Staff also told us that two ID numbers couldoccur through user error and when patients hadchanged their name without informing the trust.

Meeting people’s individual needs• We noticed that some clinics were overcrowded and

staff were struggling to cope with the patient numbers.The trust was aware of concerns in this area and said:“Some departments are getting very busy and runningto full capacity, which is starting to cause some issuesaround capacity and waiting areas. This has beenescalated to the relevant departments/teams.” Thisdemonstrated that the trust understood the challengesand identified risks within the outpatient department.

• Staff ensured that patients who were distressed orconfused by the outpatient environment were treated




appropriately. Patients with a learning disability or adiagnosis of dementia were moved to the front of theclinic list. The outpatient staff liaised, where needed,with ambulance transport staff to ensure that thisprocess ran smoothly. This was evident in the elderly/over 65 one-stop clinic, where the clinic staffcoordinated transport for patients attending the clinic.

• In response to the increased needs of patientspresenting at the sexual health clinic, the staff describedhow they screened each patient with a briefquestionnaire. This assisted them to identify thosepatients who may be at risk due to their lifestyle. Thishad enabled them to provide additional services tomeet the needs of these patients by engaging adedicated alcohol adviser and a domestic violencecounsellor to attend drop-in sessions. They reportedthat this had been well received by patients and theyintended to continue the initiative.

• Appointment booking systems did not consider thevariable needs of patients. This was particularly evidentin the most clinics, including: dental, ophthalmology,breast, renal and liver clinics, where patients mightrequire a longer appointment. This also contributed toappointments overrunning. We also noted that theclinic scheduling template allowed over booking ofclinics. In one time slot, four patients (two new and twofollow-up patients) were booked on that same time slot.These caused delays and the overcrowding of clinics.

• We were told that translation services could be accessedthrough Language Line Solutions for people whose firstlanguage was not English. However, there were noposters or written information available to informpeople of this service.

• The radiology waiting area catered for patients referredfrom inpatient wards and outpatient clinics and thosereferred directly by their GPs. The radiology departmentoperated seven-day services. The only dissatisfactionexpressed by patients we spoke with was about longwaits in the department.

• We noted that the environment within the receptionarea of some outpatient clinics allowed for confidentialconversations. However, in other clinics, likeorthopaedic, cardiac, respiratory and liver outpatientclinics, the waiting areas were small and easily filled up.We saw patients either standing in the clinic or on thecorridors waiting for their appointment.

Learning from complaints and concerns• Complaints were handled in line with the trust policy.

Initial complaints would be dealt with by the outpatientmatron, but if the matron was not able to deal with theirconcerns satisfactorily, they would be directed to thePatient Advice and Liaison Service. Staff explained thecomplaints procedure to us. However, complaintinformation was not readily available. We also foundthat Patient Advice and Liaison Service information wasnot on display in all the outpatient clinic areas of thehospital.

• We were given an example of a complaint regarding apatient being given the wrong testing equipment at thesexual health clinic and staff described the action thathad been taken as a result. We saw that changes topractice had been made and that this had beendiscussed during team meetings to ensure that maleand female testing kits were appropriately markedduring storage. We saw that actions had beencompleted within the given timescale.

• We reviewed five complaints received and action plans.The trust responded to the complaint and an actionplan was implemented and completed. Action from thecomplaint was that the outcome of the investigationwas to be shared at team meetings. However, we did notsee evidence of any lessons learned being shared withstaff.

• Complaints were discussed at departmental-level andalso at Directorate Clinical Governance Group meetings.However, there was no evidence to show that lessonslearned were consistently shared with staff. Most of thestaff we spoke with could not recall when actions fromcomplaints were shared with them.

Are outpatient and diagnostic imagingservices well-led?

Good –––

The leadership, governance and culture ensured thedelivery of person-centred care. Staff were supported bytheir local and divisional managers. Most risks wereidentified and addressed at local level or escalated todivisional level if necessary.

Staff felt their line managers were approachable,supportive and open to receiving ideas or concerns. Most




staff knew and understood the vision of the hospital andwere able to demonstrate how this was implemented inpractice. Staff enjoyed their work and felt that it made adifference to how patients felt about the hospital.

Clinical staff in all the outpatients and diagnostic imagingareas stated their managers were visible and provided clearleadership. There was an open culture amongst staff andmanagers. Staff said they felt empowered to express theiropinions and felt they were listened to by themanagement.

All staff had been involved in some aspects of the serviceimprovement plans and nursing staff reported beingencouraged to find innovative ways to improve the service.Never events were discussed at the departmental level andaction taken to ensure that all the never events were neverrepeated. We were told by the Head of Ophthalmologydepartment that all incidents including never events werethoroughly investigated using the root cause analysis andlessons learnt were shared with all staff concerned at thedepartment.

There was limited close working relations with otherhospitals within the trust. For example, the two neverevents at the ophthalmology department were not sharedwith the ophthalmology department at the Princess RoyalUniversity Hospital.

Vision and strategy for this service• Senior managers told us what their vision for their

service areas was. Most of the staff spoken with wereaware of ‘King’s Values’ and ‘Team King's’, which soughtto ensure that everybody at the trust was valuedequally. There were shared objectives and strategies inplace to achieve an improved service provision acrossall the trust’s sites.

• Staff were confident about the vision and values of theorganisation and one member of staff told us,“Everything we do is based on the values of the trust.”Another member of staff said, “Sometimes informationfrom the top of the organisation gets missed as it comesdown to floor level, however, the staff engagement wasgood.”

• Staff showed a good understanding of the values andvision of the trust and felt able to raise concerns.

Governance, risk management and qualitymeasurement• The diagnostic imaging department had risk

assessments in place to protect patients and staffduring care and treatment. For example, there was a riskassessment for staff who were pregnant and a checklistto risk assess children and pregnant patients who usedthe service.

• We saw separate local risk registers for differentdivisions and directorates that included the outpatientsdepartment, diagnostic imaging department etc. theseenabled the Corporate Governance Group tounderstand the most significant risks and approveaction to mitigate those risks.

• Risks were identified and addressed at the local leveland escalated to the management when necessary,however this was not consistent across the trust andsome departments of the hospital did not talk to eachother across the various sites of the trust locations andat the trust wide level. Some departments did not havea close working relation nor cooperation with theircounterpart at the Princess Royal University Hospital; forexample never events in ophthalmology at this hospitalwas not shared with the ophthalmology department atthe Princess Royal University Hospital.

• We were told the hospital had a risk register andmanagers were responsible for updating the registerwith their department’s risks. Managers told us theywere aware of the risks in their departments and weremonitoring and managing those risks. We were providedwith service-specific risks data associated with theoutpatients and diagnostic imaging department. Thesedemonstrate the monitoring of risks by the trust.

• Governance meetings were held monthly, which wereattended by managers throughout the outpatients anddiagnostic and imaging departments. There were alsospecialty governance meetings held for each division,but not for the whole outpatient and diagnostic imagingdepartment. The outcomes from these meetings wereshared with staff during staff meetings and monthlybulletins.

• There were regular team meetings to discuss issues,concerns and complaints across divisions anddepartments, however, some staff told us they were notgiven feedback from these meetings about incidentsand lessons learnt by their line managers.




Leadership of service• There were clear lines of accountability and

responsibility within the outpatients and diagnosticimaging department. Staff in all areas stated that theywere well supported by their managers, that theirmanagers were visible and provided clear leadership.

• Staff told us the hospital management team wereaccessible and visited their departments frequently.Supervisors and team leaders in the outpatients anddiagnostic imaging department stated the mainchallenges to delivering care were maintaining anappropriate skills mix and the recruitment of suitablyqualified staff.

• The staff who we spoke with told us that the director ofnursing was always helpful and supportive as was thehead of nursing for outpatient services. Staff said thatthey could approach their line manager and seniormanagers with any concerns or ideas. Theseconversations helped us to judge that theorganisational leadership had created an open andcollaborative approach across the trust. The trust had aprogram of ‘Ward to Board – Go See Visits’, where boardmembers visited clinical areas to interact with staff.

• We found competent staff managing each of the clinicalareas visited. Staff told us that they had confidence inthe people managing them and that leadership withinthe outpatients and diagnostic imaging department wasgood.

• Senior staff were visible to them, although theyappreciated that it was a big trust and, therefore,understood why they did not seem them often.

Culture within the service• Staff told us that as the clinic sizes increased, space

became a premium and that there was a culture withinthe organisation to try and find additional space byremoving staff facilities. We were told that, on thecardiac clinic, the rest room facilities for staff had beendecommissioned and was now utilised as an additionalconsulting room and this had caused considerableupset amongst the 26 members of staff. They said thatthey worked hard, often over their hours toaccommodate an additional workload and wereunhappy that the trust did not appear to value them byproviding basic comfort facilities.

• There was a positive culture amongst staff. Staff werecommitted and proud of their work. Quality and patientexperience was seen as a priority and to be everyone’s

responsibility. Radiologists and imaging staff felt wellsupported and there were good opportunities forprofessional development. Most staff supported eachother and there was good team working within thedepartments.

• All the staff we spoke with at the outpatients anddiagnostic imaging department told us thecommunication between different professionals wasgood and that it helped to promote a positive culturewithin the department. A consultant we spoke with toldus they thought the communication between thedifferent professionals was “excellent” and that it helpedpromote a “very positive working environment”. Clinicalstaff we spoke with told us they felt able to raiseconcerns and discuss issues with the managers of thedepartment. All staff we spoke with were professional,open and honest, and were positive about working atthe hospital. Staff acted in a professional manner; theywere polite, honest and respectful.

Public and staff engagement• The trust newsletter, ‘@King's’, for staff and the public,

included information on changes taking place at thetrust-wide level, such as how complaints weremanaged, information available to patients as well assignificant events occurring and new innovation withinthe trust. For example, there was information regardingthis inspection in the @King's magazine. Informationwas also provided regarding specific departmentalchanges.

• Staff we spoke with said they felt engaged with the trustand could share ideas or concerns within their peergroup and with their managers. Staff were given trustmessages directly via email, as well as through bulletinsand on screen savers. Staff we spoke with said they feltwell informed of developments and issues within thehospital and the wider trust in general.

Innovation, improvement and sustainability• A trust dashboard for outpatients was available to aid

managers and clinicians in making improvements to theservice.

• Senior managers told us there were plans in place todeliver on the trust RTT target, complaintsresponsiveness, deliver improvement on cancer patientexperience and quality of the patient experience in theoutpatient and diagnostic imaging departments. Theytold us they were confident that the improvements




could be delivered. However, these improvement planshad not been fully implemented at the time of ourinspection and not all staff were aware of these planseither.

• We were concerned about the delays in waiting timesthroughout the outpatients department. A senior nursetold us that one of the main challenges in the servicewere regular delays for patients’ waiting times and theoverbooking of clinics. However, there was nosystematic action taken at the directorate level toaddress the situation.

• We were told by staff during the focus group meetingsand this was corroborated during the onsite inspection

by clinical staff that, due to the merger with PrincessRoyal University Hospital and Orpington Hospital, thetrust inherited a shortage of staff across the nursingworkforce and there had been few opportunities toimplement innovative activities. Clinical staff were moreconcerned about maintaining the service and keepingpatients safe.

• The imaging and diagnostics department were workingon succession planning due to the merger and numberof vacancies across all the trust sites.




Outstanding practice

We found the following areas of practice to beoutstanding:

• Trauma nurse co-ordinators tracked pathways andprogress of trauma patients by visiting them daily onthe wards. This role also included networking withother trusts and co-ordinating repatriation in advance

• The ED had an established youth worker drop inscheme operated by a London based organisation,which was effective in supporting vulnerable youngpeople. Staff could refer young people to the service,although engagement was voluntary. The service alsosupported young people to access specialist servicessuch as housing support and social workers

• The iMobile outreach service was innovative and therewas evidence that it was producing positive outcomesboth for patients and the critical care service as awhole.

• The pioneering specialist services in neurosciences,liver and haematology.

• The surgical directorate had set up the first nationaltraining for trauma skills course in the country.Training included the first multi-disciplinary freshfrozen damage control trauma training

• There were well-established pathways for pregnantwomen, which provided appropriate antenatal care,including access to specialist clinics for women withmedical need.

• The foetal medicine unit provided interventions suchas foetal blood transfusions, fetoscopic insertions ofendotracheal balloons and laser separationprocedures of placental circulations for complicatedmonochorionic twin pregnancies.

• The enhanced scanning programme includedcombined screening for chromosomal abnormalitiesat 12 weeks, with women given the results on thesame day.

• The gynaecology and urogynaecology services offereda one-stop service with diagnostics carried out by aspecialist doctor. The hospital was a regional trainingunit for this service and the unit was recognised as agold standard unit by BCUG.

• For children with complex liver conditions and thosewho required surgery as neonates, staff developed andadvocated the use of innovative and pioneeringapproaches to care.

Areas for improvement

Action the hospital MUST take to improve

• Review its facilities within critical care so that it meetsboth patient needs, and complies with buildingregulations. This includes bed spacing and storagefacilities, particularly for IV fluids and blood gasmachines.

• Ensure the trust complies with the Mental Capacity Act2005 in regard to mental capacity assessments,particularly in the use of restraint, and that staff aretrained and aware of their responsibilities.

• Ensure that the 'Five steps to safer surgery' checklistwas always fully completed for each surgical patient.

• Re-configure the Liver outpatient clinic in order toavoid overcrowding.

• Ensure patients referral to treatment times do notexceed national targets.

• Improve patient waiting times in all outpatients’clinics.

• Review the capacity of the maternity unit so thatwomen and their babies are receiving appropriate careat the right place at the right time.

• Implement a permanent solution to the periodicflooding following heavy rain of the renal dialysis unitand endoscopy suite areas.

• Ensure that current trust policy around syringe driversaffords optimum protection for patients against therisk of adverse incidents.

• Ensure the cover for the concealment trolley fordeceased patients is in good repair and notan infection control risk.

Action the hospital SHOULD take to improve

• Fully complete controlled drug registers in the ED.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


• Complete safeguarding flowcharts for childrenattending the ED.

• Improve the number of senior ED medical staff trainedin safeguarding children training at level 3 to meetIntercollegiate Committee for Standards for Childrenand Young People in Emergency Care Settingsrecommendations.

• Identify and mitigate risks to patients attending the ED,such as the development of pressure sores, falls andpoor nutrition.

• Improve the uptake of training on the Mental CapacityAct 2005 and Deprivation of Liberty Safeguarding forstaff working in the ED, medical care, surgery andchildren and young people services.

• Review staff understanding of the Mental Capacity Actin critical care and end of life care, to ensure theirpractice and documentation reflects the legislation.

• Develop guidelines for admission to the children’sCDU.

• Review the area used for the children’s CDU to ensurethe environment fulfils the criteria for a ward area.

• Review the practice of undertaking adult consultationsin the children’s ED.

• Improve patient flow and waiting times in the ED,including their arrangements for making decisions toadmit patients.

• Take action to improve the percentage of ED patientsseen, treated and discharged within four hours.

• Consider ways of improving the documentation ofpatient 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 iseffectively rotated.

• Ensure it continues to review its critical care bedcapacity so that it can meet its expected admissions.

• Review its patient record documentation to ensure it isfully completed and information between wards isseamless.

• Review its use of the Waterlow assessment to ensurethose patients that need pressure relieving support,receive it.

• Review the nursing, consultant and juniordoctor levels on the neonatal intensive care unit.

• Review the space between cot spaces on the neonatalintensive care unit as they were sometimes restrictedor limited.

• Provide clear and up to date information onoutpatient clinic waiting times.

• Monitor the availability of case notes/medical recordsfor outpatients and act to resolve issues in a timelyfashion.

• Review medical cover for gynaecology and obstetrics.• Stop overbooking outpatient clinics including the liver

OPD 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 andtheir families is documented.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activity

Diagnostic and screening procedures

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 15 HSCA (RA) Regulations 2014 Premises andequipment

All premises and equipment used by the provider werenot:

- suitable for the purpose which they are being used

- properly used

- properly maintained

because;

1. The bed spacing and storage facilities, particularly forIV fluids and blood gas machines within critical care, didnot meet patient needs or complied with buildingregulations.

2. The Liver outpatient clinic was overcrowded withpatients.

3. The space capacity of the maternity unit wasinadequate, which meant that women and their babieswere not always receiving appropriate care at the rightplace and at the right time.

4. There was periodic flooding following heavy rain to therenal dialysis unit and endoscopy suite areas.

5. The current trust policy around syringe drivers usedwith end of life care patients did not afford optimumprotection against the risk of adverse incidents.

6. The cover for the concealment trolley for deceasedpatients was not in good repair and was also an infectioncontrol risk.

Regulation 15 (1) (c) (d) (e)

Regulated activity

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices



Surgical procedures


Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Systems and processes were not established or operatedeffectively to ensure the provider was able to assess,monitor and mitigate risks relating to the health, safetyand welfare of service users and others who may be atrisk which arise from the carrying on of the regulationactivity because;

1. The 'Five steps to safer surgery' checklist was notalways fully completed for each surgical patient.

Regulation 17 (1) (b)

Regulated activity


Surgical procedures


Regulation 14 HSCA (RA) Regulations 2014 Meetingnutritional and hydration needs

The nutritional and hydration needs of patients was notalways met because;

1. The hospital did not comply with national guidanceregarding critical care patients’ access to a dietician.

Regulation 14 (2) (a) (ii) (b)

Regulated activity



Regulation 11 HSCA (RA) Regulations 2014 Need forconsent

The provider was not complying with regulation 11 (1)and (3) as the provider was not always acting inaccordance with the Mental Capacity Act 2005 as peoplewho use the service did not always have their capacityassessed before physical restraint was applied.

Regulated activity

Regulation

Regulation

Regulation






Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

The provider was not complying with regulation 12 (1)and (2)(c) as persons providing the care and treatment toservice users did not always have the qualifications,competence and skills to do so safely as they were notalways aware of their responsibilities under theMental Capacity Act 2005 and training rates for staff inthe Mental Capacity Act 2005 were well below the trusttarget of 90%.




King's College Hospital Denmark Hill Site - Care Quality ...

Documents

Transcript of King's College Hospital Denmark Hill Site - Care Quality ...