barking, havering and redbridge university hospitals nhs trust … · 2020. 4. 1. · and national...

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

Urgent and emergency services Requires improvement –––

Medical care (including older people’s care) Requires improvement –––

Outpatients and diagnostic imaging Requires improvement –––

Barking, Havering and Redbridge UniversityHospitals NHS Trust

KingKing GeorGeorggee HospitHospitalalQuality Report

Barley LaneGoodmayesIlfordEssex, IG3 8YBTel: 01708 435000Website: http://www.bhrhospitals.nhs.uk/

Date of inspection visit: 7 - 8 September 2016Date of publication: 07/03/2017

1 King George Hospital Quality Report 07/03/2017

Letter from the Chief Inspector of Hospitals

Barking, Havering and Redbridge University Hospitals NHS Trust provides acute services across three local authorities:Barking & Dagenham, Havering and Redbridge. Serving a population of around 750,000 and employing around 6,500staff and volunteers.

King George Hospital opened at its current site in Ilford in 1995 and provides acute and rehabilitation services forresidents across Redbridge, Barking & Dagenham, and Havering, as well as providing some services to patients fromSouth West Essex. The hospital has approximately 450 beds.

The trust was previously inspected in 2013, and due to concerns around the quality of patient care and the ability of theleadership team, the Trust Development Authority (TDA) recommended that the trust be placed in special measures.

We returned to inspect the trust in March 2015. A new executive team had been appointed, including a new Chair.Overall, we found that improvements had been made, however it was evident that more needed to be done to ensurethat the trust could deliver safe, quality care across all core services.

The trust has continued its improvement plan, working closely with stakeholders and external organisations. On thisoccasion we returned to inspect the trust in September and October 2016, to review the progress of the improvementsthat had been implemented, to apply ratings, and also to make recommendation on the status of special measures. Wecarried out a focused, unannounced inspection at King George Hospital of three core services – the EmergencyDepartment (ED), Medical Care (including older people's care) and Outpatients & Diagnostics (OPD).

This inspection subsequently found that some improvements had been made and ratings have been adjustedaccordingly. Overall, we have rated King George Hospital as requires improvement.

Our key findings were as follows:

Are services safe?

• The percentage of patients seen on arrival in the emergency department (ED) within 15 minutes between August2015 and August 2016 averaged 70%.

• There was a lack of evidence that learning and understanding of treating patients with suspected sepsis wasembedded within the ED.

• Patient records were not always kept secure.• There was a high dependency on locum doctors and lack of senior medical staff in the ED.• There were too few paediatric nurses in the ED.• There were breaches in the fire resisting compartmentation across the hospital site, which had been caused by

previous contractors drilling holes for data cables and services.• Medical staff were failing to meet trust targets for completion of mandatory training, across all topics.• Staff completion rates in basic life support were below the trust target, due to a lack of external training sessions.

There were low levels of resuscitation training in the ED.• There were poor levels of hand hygiene compliance observed in the ED and in OPD.• Although a comprehensive induction programme was in place for all new diagnostic imaging staff, some new staff

members did not know where to find the Local Rules.• The air handling unit in paediatrics and minor injuries had been out of service for at least three weeks prior to this

inspection.• There had been an improvement in the reporting of incidents and the sharing of lessons from these across the

hospital.• Staff were aware of their responsibilities with regards to duty of candour requirements, confirming there was an

expectation of openness when care and treatment did not go according to plan.

Summary of findings


• The dispensing and administration of medication had improved, with prescription charts being used correctly andprocesses being correctly followed and audited. Medication in the emergency and OPD were found to beappropriately stored.

• Nursing staff demonstrated an awareness of safeguarding procedures and how to recognise if someone was at risk orhad been exposed to abuse.

Are services effective?

• There was a backlog of National Institute for Health and Care Excellence (NICE) guidance that was awaitingconfirmation of compliance across the trust.

• Fluid charts were not always filled out and some patients did not like the food, or found it hard to eat.• Patient outcomes in care of the elderly were limited by the lack of consultant geriatricians to lead improvements

within the service.• In the Lung Cancer Audit 2015, the trust was below expected standards for three key indicators relating to process,

imaging and nursing measures.• The pathways for patients with cancer were not always correctly managed. There was poor communication with

tertiary centres, which caused delays with patients requiring tertiary treatment/diagnosis at other specialisthospitals.

• There was a lack of effective seven day working across the hospital.• The trust had updated all of their local policies since the last inspection, and these were regularly reviewed.• Nursing and medical staff completed a variety of local audits to monitor compliance and improvement.• Pain was assessed and well managed on the wards, with appropriate actions taken in response to pain triggers.

There was a dedicated hospital pain team.• The majority of staff received annual appraisals on their performance, which identified further training needs and set

achievable goals.• There was evidence of effective multidisciplinary working within wards and across departments. All members of staff

felt valued and respected.• Patients attending OPD received care and treatment that was evidence based.

Are services caring?

• Patients were cared for in a caring and compassionate manner by staff throughout their stay. Most medical wardsperformed in line with the national average in the NHS Friends and Family Test (FFT).

• Patients’ privacy and dignity was maintained throughout their hospital stay.• Psychological support for patients was easily accessible and timely. Patients were routinely assessed for anxiety and

depression on admission.• The chaplaincy team offered comprehensive spiritual support to all patients, regardless of religious affiliation.• Some patients and relatives felt that more could be done to involve them in their care, especially surrounding

discharge.

Are services responsive?

• The ED failed to meet the four hour national indicator for treating or admitting patients.• There was no viewing room in the ED where people could see their deceased relatives.• The trust was consistently failing to meet national indicators relating to 62-day cancer treatment. This issue had been

added to the corporate risk register and actions had been undertaken to improve performance.• The trust was not meeting 18-week national indicators for non-urgent referral to treatment (RTT) times.• The percentage of patients who did not attend (DNA) their appointment was above the England average.• 13% of appointments were cancelled by the hospital. This was higher than the England average of 7.2%.• NHS England suspended endoscopy screening invitations to the trust for eight weeks from July 2016. There was a risk

of delayed diagnosis of bowel cancer due to inability to provide a full screening service to the local population.

Summary of findings


• Staff across the hospital told us that they could not always discharge patients promptly due to capacity issues withinthe hospital or community provisions had not been put into place.

• Patient information leaflets were not standardly available in languages other than English. Although face-to-face andtelephone translation services were available, many staff were not familiar with how to access these.

• The Patient Advice and Liaison Service (PALS) did not always respond to complaints in a timely manner.• Diagnostic waiting time indicators were met by the trust every month between May and August 2016, meaning over

99% of patients waited less than six weeks for a diagnostic test.• There had been an 88% reduction in the overall backlog of patients waiting over 52 weeks since May 2016.The

hospital was using a range of private providers to assist in clearing the backlog of appointments where there weremost demand for services.

• Ward-based pharmacists helped to facilitate discharges in areas where they were available. There was also apharmacy discharge team who worked 11am to 4pm weekdays.

• Walk-in patients were streamed effectively in the ED, including back to their own GP.• People living with dementia received tailored care and treatment. Care of the elderly wards had been designed to be

dementia friendly and the hospital used the butterfly scheme to help identify those living with dementia who mayrequire extra help. Patients living with dementia were nursed according to a specially designed care pathway andwere offered 1:1 nursing care from healthcare assistants with enhanced training. A specialist dementia team anddementia link nurses were available for support and advice. There were also dementia champion nurses in the ED.

• Support for people with learning disabilities was available. There was a lead nurse available for support and advice.• There was a frail and older person’s advice and liaison team which worked closely with the ED.• The environment of children’s ED was child friendly and well laid out.

Are services well led?

• The trust had developed a clinical vision and strategy and communicated this to staff of all levels across the hospital.• There was a system of governance and risk management meetings at both departmental and divisional levels across

core services, however this had not yet developed effectively in some areas at the time of inspection. An externalorganisation had worked with the trust on ensuring their governance structures were more robust.

• Quality improvement and research projects took place that drove innovation and improved the patient experience.Regular audits were undertaken, overseen by a committee. The hospital facilitated a number of forums and listeningevents to engage patients in the development of the service.

• Most nursing and medical staff thought that their line managers and the senior team were supportive andapproachable. The chief executive and divisional leads held regular meetings to facilitate staff engagement. However,some comments we received from staff reflected that they were not always happy with the management orleadership.

• The trust could not evidence how they maintained records to ensure they knew their locum staff had up to datetraining in sepsis management

• Many staff with whom we spoke were unclear about the future direction of the ED and the impact on job security.• Monthly nurse staff meetings in the ED had become less frequent due to pressures of work.

We saw several areas of outstanding practice including:

• The hospital provided tailored care to those patients living with dementia. The environment in which they were caredfor was well considered and the staff were trained to deliver compassionate and thoughtful care to these individuals.Measures had been implemented to make their stay in hospital easier and reduce any emotional distress.

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

Importantly, the trust must:

• Ensure all patients attending the ED are seen more quickly by a clinician.

Summary of findings


• Take action to improve levels of resuscitation training.• Ensure there is oversight of all training done by locums.• Take action to improve the response to patients with suspected sepsis.• Take action to address the poor levels of hand hygiene compliance in ED.

In addition the trust should:

• Endeavour to recruit full time medical staff in an effort to reduce reliance on agency staff.• Increase paediatric nursing capacity.• Ensure there is a sufficient number of nurses and doctors with adult and paediatric life support training in line with

RCEM guidance on duty.• Improve documentation of falls.• Document skin inspection at care rounds.• Document nutrition and hydration intake.• Review arrangements for the consistent sharing of complaints and ensure that learning is always conveyed to staff.• Make repairs to the departmental air cooling system.• Ensure that all policies are up to date.• Improve appraisal rates for nursing and medical staff.• Ensure that consent is clearly recorded on patient records.• Regularise play specialist provision in paediatric ED.• Ensure that patient records are stored securely.• Ensure staff and public are kept informed about future plans for the ED at King George hospital.• Continue plan to repair breaches in the fire compartmentation as detailed on the corporate risk register.• Continue to monitor hand hygiene and infection control across all medical wards and follow action plans detailed on

the current corporate and divisional risk registers.• Monitor both nursing and medical staffing levels. Follow actions detailed on corporate and divisional risk registers

relating to this.• Monitor and improve mandatory training compliance rates for medical staff. Improve completion rates for basic life

support for nursing and medical staff.• Continue to work to improve endoscopy availability and service, as detailed on the corporate risk register.• Make patient information leaflets readily available to those whose first language is not English.• Increase staff awareness of the availability of interpretation services.• Ensure leaflets detailing how to make a formal complaint are available across all wards and departments.• Ensure there are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient

appointments and ensure patients have timely and appropriate follow up.• Ensure there are appropriate processes and monitoring arrangements in place to improve the 31 and 62 day cancer

waiting time indicator in line with national standards.• Ensure there is improved access for beds to clinical areas in diagnostic imaging.• Address the risks associated with non-compliance in IR(ME)R and IRR99 regulations.• Ensure the 18 week waiting time indicator is met in the OPD.• Ensure the 52 week waiting time indicator is consistently met in the OPD.• Ensure the OPD 62 day cancer waiting time is consistently above 85%.• Ensure percentage of patients with an urgent cancer GP referral are seen by a specialist within two weeks consistently

meets the England average• Ensure the number of patients that ‘did not attend’ (DNA) appointments are consistent with the England average.• Ensure the number of hospital cancelled outpatient appointments reduce and are consistent with the England

average.• Ensure diagnostic and imaging staff mandatory training meets the trust target of 85% compliance.

Summary of findings


• Develop a departmental strategy in diagnostic imaging looking at capacity and demand and capital equipmentneeds.

• Improve staffing in radiology for sonographers.

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

Requires improvement ––– Lack of resuscitation training was rated as high onthe corporate risk register and compliance rates forresuscitation training were low for both doctors andnurses.No paediatric staff grade nurse had in-dateadvanced paediatric life support training.Whilst the trust told us it confirmed all training doneby locum staff on their induction checklist, it wasunable to supply CQC with a record of all trainingdone by locum staff, including resuscitation, sepsisand safeguarding training.There was poor recognition of and response topatients with suspected sepsis.There were poor levels of hand hygiene compliance.The air handling unit in paediatrics and minorinjuries had been out of order for at least threeweeks prior to our inspection. This made it difficultto regulate safe temperatures within which to storedrugs.There was a 59% vacancy rate amongst medical staffand the lack of senior medical staff was rated as highon the corporate risk register. This resulted in a highdependency on the use of locum staff, who whilstfully qualified as doctors may not have worked in anemergency department previously.In addition, there was a shortage of paediatricnurses which was also rated as high on the corporaterisk register.The ED failure to comply with the four hour standardwas rated as extreme on the corporate risk register.Ambulance turnaround time did not meet thenational handover indicator for 64% of the timebetween June 2015 and May 2016.However, staff told us that they were encouraged torecord incidents and said there was good sharing oflearning from incidents through e-mail, meetingsand training days.Junior doctors felt well supported by senior doctors.Walk-in patients were effectively streamed and somewere redirected back to their GP.

Summaryoffindings

Summary of findings


Staff were compassionate towards patients andthere was a frail and older persons advice andliaison team as well as dementia champion nurses inthe ED.There was a designated observation ward which wasused to assess the community support needs ofvulnerable patients before being discharged.Patients told us they felt staff informed them of whatwas going on and staff told us they knew who thedepartmental leadership team and the executiveboard were.Since the last inspection in May 2015 improvementshad been made to the department’s clinicalgovernance and risk management processes.

Medicalcare(includingolderpeople’scare)

Requires improvement ––– Hospital environments were not always ideal. Somewards were reported and observed to have highlevels of noise and heat. There was a lack of bedsidetelevisions or radios across the wards. There werebreaches in the fire resisting compartmentationacross the hospital site, which had been caused byprevious contractors drilling holes for data cablesand services.Although we observed good infection controlpractices on inspection, rates of both MRSA andClostridium difficile infections were high. Infectionprevention and control audits, as well as handhygiene audit results, showed consistently poorcompliance in some wards and departments.Although nursing staffing levels had improved sinceour last inspection in March 2015, some wards stillhad significant vacancy and turnover rates. On thesewards, there was a reliance on bank and agency staffto fill vacant shifts.There was a reliance on locum doctors across theservice, apart from in cardiology. This affectedcontinuity of patient care, particularly out-of-hours.Medical staff across the service were failing to meettrust targets for completion of mandatory training.For non-elective admissions, the standardisedrelative risk of readmission was high, particularly forgeriatric medicine. Patient outcomes in care of theelderly were limited by the lack of consultantgeriatricians to lead improvements within theservice. Junior doctors in geriatric medicinereported lower overall satisfaction than the nationalaverage in the 2015 National Training Survey. There

Summaryoffindings

Summary of findings


was also poor performance in measures such asavailability of clinical supervision out-of-hours andregional teaching. Although 2016 survey resultsshowed significant improvement, some issues stillremained.Medical and nursing staff completion rates in basiclife support were below the trust target, due to alack of external training sessions.There was still a backlog of National Institute forHealth and Care Excellence (NICE) guidance that wasawaiting confirmation of compliance across thetrust. The trust performed worse than the previousyear in a number of national audits.Some principles of good record keeping were notbeing followed. Fluid charts were not always filledout and medical entries were sometimes illegibleand unsigned.The pathology service was understaffed and unableto provide effective cover out-of-hours.The pathways for patients with cancer were notalways clear. The trust was consistently failing tomeet national indicators relating to 62-day cancertreatment. There was poor communication withtertiary centres, which caused delays with patientsrequiring tertiary treatment or diagnosis at otherspecialist hospitals. The trust performed slightlybelow the national average in the National CancerInpatient survey 2015.The trust was not meeting 18-week nationalindicators for non-urgent referral to treatment (RTT)times.Staff across the hospital told us that they could notalways discharge patients promptly due to capacityissues within the hospital or community provisionshad not been put into place. Some patients andrelatives felt that more could be done to involvethem in their care, especially surrounding discharge.Patients were not always able to be located on thespecialist ward appropriate for their condition,although management of these patients hadimproved since the previous inspection. The numberof patients moved four or more times per admissionhad increased, although the trust later told us thatthis data was inaccurate. In some wards, such asAsh, Gentian and Gardenia ward, bed moves wereconsistently occurring out of hours (between 10pmand 6am).

Summaryoffindings

Summary of findings


Patient information leaflets were not standardlyavailable in languages other than English. Althoughface-to-face and telephone translation services wereavailable, many staff were not familiar with how toaccess these.The Patient Advice and Liaison Service (PALS) didnot always respond to complaints in a timelymanner. There were no leaflets detailing how toaccess PALS and make a formal complaint onGentian ward at the time of our inspection.However, there was a significant improvement inboth the reporting of incidents and the sharing oflessons learned from these across the hospital. Staffwere aware of their responsibilities with regards toduty of candour requirements, confirming there wasan expectation of openness when care andtreatment did not go according to plan. Thegovernance structure had been revised to provide agreater level of accountability and oversight of risk.Nursing staff demonstrated an awareness ofsafeguarding procedures and how to recognise ifsomeone was at risk or had been exposed to abuse.They knew how to escalate concerns and wereup-to-date with appropriate levels of training.Patients were assessed for a variety of risks onadmission to the wards, using nationally recognisedtools.Medicines management had improved, with newprocesses in place to ensure the safety of patients.Much work had been done since the previousinspection to ensure that discharges were notdelayed due to unavailability of take homemedications.Nursing and medical staff completed a variety oflocal audits to monitor compliance and drive qualityimprovement. Staff told us that these led tomeaningful change across the service. Both localand national audits were overseen by a committee.In the National Diabetes Inpatient Audit (NaDIA)2015, the hospital scored better than the Englandaverage for nine indicators out of sixteen indicators.The standardised relative risk of readmission for allelective procedures was slightly lower than expectedwhen compared to the England average. This meant

Summaryoffindings

Summary of findings


that patients were less likely to require unplannedreadmission after non-emergency procedures,suggesting that the hospital’s care and dischargearrangements were appropriate.Patients were cared for in a caring andcompassionate manner by staff throughout theirhospital stay. Most medical wards performed in linewith the national average in the NHS Friends andFamily Test (FFT). Patients’ privacy and dignity wasmaintained at all times. The hospital facilitated anumber of forums and listening events to engagepatients in the development of the service.The trust performed above the national average inmeasures relating to training and appraisals in theNHS staff survey 2015. The majority of staff receivedannual appraisals on their performance, whichidentified further training needs and set achievablegoals. The trust was supporting nurses with therevalidation process. For all specialties apart fromgeriatric medicine, the trust scored above thenational average for most measures in relation tofirst year medical doctors in training (2015 NationalTraining Survey).There was evidence of effective multidisciplinaryworking within wards and across departments. Allmembers of staff felt valued and respected by theircolleagues.Psychological support for patients was easilyaccessible and timely. Patients were routinelyassessed for anxiety and depression on admission.The chaplaincy team offered comprehensivespiritual support to all patients, regardless ofreligious affiliation.People with complex needs, such as those livingwith dementia or a learning disability, were wellconsidered and cared for within the hospital. Staffmade reasonable adjustments to improve theirexperience of the service and supported themthroughout their inpatient stay. Information andenvironments had been adapted to make themmore suitable for these patients.The trust had developed a clinical vision andstrategy and communicated this to staff of all levels,enabling them to feel involved in the developmentof the service. Most nursing and medical staff

Summaryoffindings

Summary of findings


thought that their line managers and the seniorteam were supportive and approachable. The chiefexecutive and divisional leads held regular meetingsto facilitate staff engagement.Staff had awareness of what actions they would takein the event of a major incident, including a fire.Regular drills were held to ensure staff wereadequately trained in the event of emergencies.

Outpatientsanddiagnosticimaging

Requires improvement ––– Outpatients and diagnostic imaging services were intransition. The strategy for these services was indevelopment. There were a number of new seniormanagers who had introduced new qualityassurance and risk measurement systems. However,these were not fully embedded.Hand gel dispensers were in situ across outpatientsand diagnostic imaging but we did not observe staffor patients using them.The percentage of patients who did not attend (DNA)their appointment was above the England average.Staff told us they were not confident of meeting thenational indicator for patients waiting over 18 weeksby their target date of March 2017. The trust’sperformance for the 62 day cancer waiting time wasconsistently below the England average.Appointments cancelled by the hospital were alsohigher than the England average.Some staff in the diagnostics and imaging team saidthere was a lack of clarity around their roles andresponsibilities.However, there had been an 88% reduction in theoverall backlog of patients waiting over 52 weekssince May 2016.Staff were aware of how to report incidents andcould clearly demonstrate how and when incidentshad been reported. Lessons were learnt fromincidents and shared across the trust.The trust had changed their patient records systemand introduced the electronic patient record (EPR).There were appropriate protocols in place forsafeguarding vulnerable adults and children. Staffwere aware of the requirements of their roles andresponsibilities in relation to safeguarding.Patients’ and staff views were actively sought andthere was evidence of improvement anddevelopment of staff and services. Staffing levelsand skill mix were planned to ensure the delivery of

Summaryoffindings

Summary of findings


outpatient, diagnostic and imaging services at alltimes. All new staff completed a corporate and localinduction. . Staff were competent to perform theirroles and took part in benchmarking andaccreditation schemes.Medicines were found to be in date and storedsecurely in locked cupboards. Staff were able todescribe the procedure if a patient became unwell intheir department and knew how to locate the majorincident policy on the intranet.All the patients, relatives and carers we spoke withwere positive about the way staff treated people.There was a visible person-centred culture in mostdepartments. Patients and relatives told us theywere involved in decision making about their careand treatment. People’s individual preferences andneeds were reflected in how care was delivered.Work was in progress to conduct a demand andcapacity analysis to enable the service to develop amodel whereby the hospital could assess andeffectively manage the demands on the service. Thehospital was using a range of private providers toassist in clearing the backlog of appointments.Patients attending outpatients and diagnosticimaging departments received care and treatmentthat was evidence based. The service wasmonitoring the care and treatment outcomes ofpatients who were receiving outsourced care fromproviders in the private sector.Outpatients, diagnostic and imaging services hadintroduced extended clinics seven days a week toclear patient waiting list backlogs.There was a formal complaints process for people touse. Complaints information, as well as patientexperience information was fed into the trustgovernance processes and trust board with formalreporting mechanisms.Most local managers demonstrated good leadershipwithin their department. Managers had knowledgeof performance in their areas of responsibility andunderstood the risks and challenges to the service.There was a system of governance and riskmanagement meetings at both departmental anddivisional levels.

Summaryoffindings

Summary of findings


KingKing GeorGeorggee HospitHospitalalDetailed findings

Services we looked atUrgent and emergency services; Medical care (including older people’s care); Outpatients and diagnosticimaging.


Contents

PageDetailed findings from this inspectionBackground to King George Hospital 15

Our inspection team 15

How we carried out this inspection 15

Our ratings for this hospital 16

Findings by main service 17

Action we have told the provider to take 91

Background to King George Hospital

King George Hospital opened at its current site in Ilford in1995 and provides acute and rehabilitation services forresidents across Redbridge, Barking & Dagenham, andHavering, as well as providing some services to patientsfrom South West Essex. The hospital has approximately450 beds.

The trust was previously inspected in 2013, and due toconcerns around the quality of patient care and theability of the leadership team, the Trust DevelopmentAuthority (TDA) recommended that the trust be placed inspecial measures.

We returned to inspect the trust in March 2015. A newexecutive team had been appointed, including a new

Chair. Overall, we found that improvements had beenmade, however it was evident that more needed to bedone to ensure that the trust could deliver safe, qualitycare across all core services.

On this occasion we returned to inspect the trust inSeptember and October 2016, to review the progress ofthe improvements that had been implemented, to applyratings, and also to make recommendation on the statusof special measures.

We carried out a focused, unannounced inspection atKing George Hospital of the Emergency Department (ED),Medical Care and Outpatients & Diagnostics (OPD).

Our inspection team

Our inspection team was lead by:

Head of Hospital Inspection: Nicola Wise, Care QualityCommission (CQC)

Inspection Managers: Max Geraghty (CQC), David Harris(CQC), Robert Throw (CQC)

The team included CQC Inspectors, analysts, plannersand a variety of specialist advisors, including consultants,doctors, nurses, pharmacists, children and adultsafeguarding leads, and experts by experience.

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?

Detailed findings


Is it responsive to people's needs?

Is it well-led?

We initially carried out an unannounced focusedinspection of key core services at both King GeorgeHospital and Queens Hospital in September, and thenreturned in October to review the leadership andgovernance of the trust.

During this time, we reviewed a range of information weheld and asked other organisations to share what theyknew about the hospital, including the clinicalcommissioning groups (CCGs).

We held focus groups with a range of staff in the hospital,including doctors, nurses, midwives, allied healthprofessionals, and non-clinical staff. We interviewedsenior members of staff at the hospital and at the trust. Anumber of staff attended our ‘drop in’ sessions to talkwith a member of the inspection team.

Our ratings for this hospital

Our ratings for this hospital are:

Safe Effective Caring Responsive Well-led Overall

Urgent and emergencyservices

Requiresimprovement

Requiresimprovement Good Good Requires

improvementRequires

improvement

Medical care Requiresimprovement

Requiresimprovement Good Requires

improvement Good Requiresimprovement

Outpatients anddiagnostic imaging

Requiresimprovement Not rated Good Requires

improvement Good Requiresimprovement

Overall N/A N/A N/A N/A N/A N/A

Detailed findings


Safe Requires improvement –––

Effective Requires improvement –––

Caring Good –––

Responsive Good –––

Well-led Requires improvement –––

Overall Requires improvement –––

Information about the serviceThe adult emergency department (ED) saw 43,329patients between January and October 2016. Thepaediatric emergency department was responsible forseeing and treating 15,008 children during the sameperiod. Patients who attended the hospital first saw adoctor or nurse from an independent provider whoassessed if they need to attend the ED or if they weresuitable to attend the Urgent Care Centre (UCC), whichwas not provided by the trust.

We visited all the areas within the department, whichincluded: resuscitation (RESUS) for patients withlife-threatening conditions (which had two bays for adultsand one for children with), major injuries or Majors (a16-bed area for seriously-ill patients and included onehigh dependency bed, three single cubicles and 12double cubicles, one of which could be used as astep-down from resus), minor injuries or Minors (sixcubicles and one treatment room), the paediatric area(nine beds) and one observation wards consisting of fivebeds.

We spoke with 21 patients and relatives and 23 membersof staff. We examined 17 sets of medical notes for patientswho had been treated in the department.

Summary of findingsWe rated this service overall as requires improvementbecause:

• Lack of resuscitation training was rated as high onthe corporate risk register and compliance rates forresuscitation training were low for both doctors andnurses.

• One emergency department matron had in-dateadvanced paediatric life support training (APLS), butno nurse had in-date APLS training.

• Whilst the trust told us it confirmed all training doneby locum staff on their induction checklist, this didnot include full compliance with sepsis trainingas identified within a root cause analysis action plan.

• There was poor recognition of and response topatients with suspected sepsis.

• There were poor levels of hand hygiene compliance.

• The air handling unit in paediatrics and minorinjuries had been out of order for at least three weeksprior to our inspection. This made it difficult toregulate safe temperatures within which to storedrugs.

• There was a 59% vacancy rate amongst medical staffand the lack of senior medical staff was rated as high

Urgentandemergencyservices

Urgent and emergency services


on the corporate risk register. This resulted in a highdependency on the use of locum staff, who whilstfully qualified as doctors may not have worked in anemergency department previously.

• In addition, there was a shortage of paediatric nurseswhich was also rated as high on the corporate riskregister.

• The ED failure to comply with the four hour standardwas rated as extreme on the corporate risk register.

• Ambulance turnaround time did not meet thenational handover indicator for 64% of the timebetween June 2015 and May 2016.

However:

• Staff told us that they were encouraged to recordincidents and said there was good sharing of learningfrom incidents through e-mail, meetings and trainingdays.

• Junior doctors felt well supported by senior doctors.

• Walk-in patients were effectively streamed and somewere redirected back to their GP.

• Staff were compassionate towards patients and therewas a frail and older persons advice and liaison teamas well as dementia champion nurses in the ED.

• There was a designated observation ward which wasused to assess the community support needs ofvulnerable patients before being discharged.

• Patients told us they felt staff informed them of whatwas going on and staff told us they knew who thedepartmental leadership team and the executiveboard were.

• Since the last inspection in May 2015 improvementshad been made to the department’s clinicalgovernance and risk management processes.

Are urgent and emergency services safe?

Requires improvement –––

We rated safe as requires improvement because:

• There were low levels of training in resuscitation fordoctors and nurses which was also recorded as highon the latest trust risk register.

• At the time of this inspection, no paediatric nurse hadin-date advanced paediatric life support training.

• There were poor levels of hand hygiene compliance.

• There was a lack of evidence that learning andunderstanding of treating patients with suspectedsepsis was embedded.

• Ambulance turnaround time did not meet the nationalhandover indicator for 64% of the time between June2015 and May 2016.

• The air handling unit in paediatrics and minor injurieshad been out of service for at least three weeks priorto this inspection. This meant that fridges in whichdrugs were stored were unable to remain within safetemperature limits which resulted in medicationwastage.

• Patient records were not always kept securely kept.We saw that they were occasionally left on top ofrecord trollies and at other times, record trollies werenot securely locked.

• Compliance with safeguarding adults and childrentraining was low for doctors.

• There was a high dependency on locum doctors andlack of senior medical staff was rated as high on thecorporate risk register.

• The recent corporate risk register recorded there weretoo few paediatric nurses and rated it as high. Bestpractice guidelines state a minimum of one registeredchildren’s nurse on each shift, which the trust wasmeeting, however the trust recognised a need formore nurses to address vacancies.

However:




• Staff told us that they were encouraged to recordincidents and there was good sharing of learning fromincidents through e-mail, meetings and training days.

• We saw evidence that the duty of candour wasfollowed.

• Medication was appropriately stored, administeredand recorded.

• There was a high level of compliance withsafeguarding training in both adults and children fornurses and staff had a good understanding ofpotential safeguarding issues in relation to adults andchildren.

• The use of agency nursing staff had reduced since thelast inspection in March 2015.

Incidents

• The trust reported to the Strategic ExecutiveInformation System (STEIS), which records SeriousIncidents and Never Events.

• The trust had an incident report writing policy andused an electronic incident reporting system.

• The emergency department [ED] reported 29 incidentsto national reporting and learning system (NRLS)between August 2015 and September 2015, 53% ofthese incidents reported by ED resulted in low harmwith the balance rated as no harm. The maincategories of incidents reported were moisturelesions.

• There were no Never Events reported within EDbetween July 2015 and June 2016. Never Events areserious incidents that are wholly preventable asguidance or safety recommendations that providestrong systemic protective barriers are available at anational level and should have been implemented byall healthcare providers.

• Serious incidents (SI) are those that requireinvestigation. The department reported four SIsbetween August 2015 and April 2016, with nonedeclared between May and September 2016. All fourSIs have since been investigated and closed. We sawcopies of root cause analysis reports, which includedlessons learnt.

• The last CQC inspection in March 2015 highlighted thatthe department did not routinely assess or learn fromincidents which occurred. During this inspection, stafftold us this situation had been much improved andlessons learned from incidents were shared acrossteams. A monthly lessons learned log was completedand shared widely across specialities in a bulletin bythe trust board.

• Learning was shared in a variety of ways, includingduring the morning handover, via personal e-mail andon the intranet. We were shown examples of e-mailssent to staff which outlined incidents and learningfrom them. We observed a morning handover duringwhich staff were reminded of their responsibilities as aresult of a recent incident.

• Staff told us how SIs were also discussed at their ‘keepin touch’ days which were held four times per year.They said this provided them with valuableinformation and a chance to consider the learningfrom them.

• Patient Safety Summit meetings were held every weekand attended by multidisciplinary staff from alldivisions and co-chaired by the Medical Director andChief Nurse. The focus of these meetings was to reviewrecent serious incidents or a case study presentationand discuss what could be learnt and shared morewidely to prevent a similar incident happening again.

• We saw copies of 12 such meetings and noted that theminutes included the details of SIs and learning fromthem. For example, where an end of life patient had aDNAR (do not resuscitate order) in place from thecommunity, it was agreed that the palliative care teamwould work with the ED to establish a tool that couldbe used as the patient entered the front door.

• In addition to those meetings, there were monthly EDquality and safety (clinical governance) meetings. Wesaw that minutes from these meetings referred todepartmental risks as reflected on the corporate riskregister.

• Staff said they were encouraged to report incidentsand received direct feedback from their line manager,clinical leads and in teaching sessions. Staff were




aware of the incident reporting procedures and howto raise concerns, junior doctors and nursing staffshowed us how to report incidents on an electronicincident reporting system.

• However, agency staff told us they had no computerlog-in and were dependent upon an establishedmember of staff to record incidents on their behalf.Any follow-up to that incident came back to the e-mailaccount of the established member of staff and theagency member of staff did not always get feedback.

• There was a lessons learnt board visible in thedepartment for incident learning. Issues notedincluded storage of stools, fridge temperatures,pressure ulcer reporting, resus challenges, hoists andoxygen checklists.

Duty of Candour

• The duty of candour (DoC) is a regulatory duty thatrelates to openness and transparency and requiresproviders of health and social care services to notifypatients (or other relevant persons) of certain‘notifiable safety incidents’ and provide reasonablesupport to that person.

• We were told by the matron that she was confidentstaff understood their responsibility in fulfilling theirDoC which she felt was embedded in how theyworked.

• Staff told us that they had a good understanding oftheir roles and responsibilities in relation to the DoC. Aconsultant told us it was of paramount importancethat patients and relatives had confidence that thehospital was open and transparent and fulfilled theirduty of candour to them.

• We saw from minutes of weekly safety summits thatwhere relevant, a record was made that DoCresponsibility had been fulfilled to the patient or theirrelatives.

Cleanliness, infection control and hygiene

• The trust had up to date policies and procedures forhand hygiene and infection prevention and control.

• There were one case of hospital acquired MRSA andno incidence of C.Diff, or E Coli reported for the EDbetween November 2015 and August 2016.

• The trust audited hand hygiene compliance in the EDon a weekly basis. Data submitted to CQC for August2015 to August 2016 showed that results were verypoor. For example, compliance varied between a lowof 19% in August 2015 to 42% in December 2015.Figures for June, July and August 2016 were 77% 75%and 68% respectively.

• There were dispensers with hand sanitising gelsituated around the ED walls including the mainwaiting area and reception. We saw there were at leastthree which were empty during the course of ourinspection.

• During our inspection, we observed staff did notconsistently comply with hand hygiene practice. Notall staff regularly cleaned their hands as they movedaround the ED from one area to another, or whenleaving or entering the department. This was raised asa consistent issue on most staff meeting minutes wereviewed.

• We saw that vital signs equipment was not alwayscleaned before being used on another patient.

• Adequate supplies of personal protective equipment(PPE) were available and we saw staff using thisappropriately when delivering care. We noted thatstaff generally adhered to the “bare below the elbows”guidance in the clinical areas.

• Most of the equipment we examined such ascommodes, vital sign monitors, wheelchairs, toiletrising seats was visibly clean. We saw ‘I am clean’labels were in use to indicate when equipment hadbeen cleaned. We also observed staff cleaning beds assoon as they were vacated.

• We observed domestic staff cleaning the departmentthroughout the day and they undertook this in amethodical and unobtrusive way.

• Disposable curtains were used in the cubicles and wefound that most were clean and stain free with a cleardate of first use indicated on them.

Environment and equipment

• The air handling unit was not working on the day ofour inspection which affected paediatrics and minorinjuries areas. There were fans strategically placedaround the department to mitigate against this. Staff




told us this had been recorded as an incident 3 weeksearlier. However, we were told that it had madeworking conditions very challenging for staff anduncomfortable for patients as the weather had beenvery hot during most of the time when the coolingsystem was out of action. There was a lack of clarity asto when this situation would be addressed.

• We saw this had been added to the corporate riskregister on the first of August, with a review date set forOctober. The risk register referenced the fact thatdrugs fridges were unable to remain within safetemperature limits which resulted in medicationwastage.

• We noted that the drugs room temperature hadreached a maximum temperature of 25 degrees. Therewere fans in situ to control the temperature and wesaw an action plan in place should the temperatureexceed 25 degrees on seven consecutive days, whichincluded the relocation of perishable drugs.

• There was an over-full sharps bin in the department,which had a used cannula sticking out of the top. Thebin was removed immediately when we drew this tothe attention of a nurse.

• The paediatric resuscitation trolley was correctlystocked. Regular checks were carried out whichincluded twice daily checks of supplies, a weeklyopening of the trolley to check for out of date drugsand weekly testing of equipment. We looked at arecord of checks done for the previous six weeks andsaw there were no gaps. The nurse in charge told usthat staff understood the importance of carrying outthese checks and failure to do so could result indisciplinary action.

• There were three resuscitation bays in the adult ED,with one bay dual equipped for paediatricresuscitation. We saw that daily checks were made ofresuscitation trollies and equipment, however, thesewere not always done twice in accordance with thedepartmental policy. This was recorded in monthlyaudits.

• We checked three trolleys and mattresses and all wereclean. There were no tears in the mattresses andbrakes and cot sides were in working order.

• The secure room for mental health patients met thestandards set out by the Psychiatric LiaisonAccreditation Network. It had two doors which openedoutwards and a viewing window. Furniture wassecured to the ground and there were no ligaturepoints in the room.

• Data supplied by the trust showed that in almost allcases, equipment in paediatric and adult ED had beenserviced within the past 12 months.

Medicines

• Medicines were stored appropriately and controlleddrugs were kept in a locked cupboard. We checked thelogbook and saw checks were carried out twice daily.

• Fridges were locked to ensure safety and security ofmedicines. We saw a record which confirmed that staffchecked and recorded current fridge temperaturesdaily.

• The pharmacy reviewed ED drug supply requirementson a daily basis. We saw a member of staff had done adaily stock check and restocked items as needed. EDstaff said that each member took responsibility tonote low stock and place it on an order list.

• There were pre-filled syringes for emergencymedicines (adrenaline, atropine etc.) stored ontrolleys, which allowed nurses to access them quickly.These were stored in plastic boxes and on the day ofour inspection, we noted that the plastic seal on onebox was not correctly attached, which meant that thedrugs within could be easily accessed. We drew this tothe attention of the matron, who removed it fromservice immediately.

• Patient records contained appropriate documentationof medicines prescription and administration. We sawthat children’s weights were recorded in order toensure the correct dose was administered in relationto their weight.

Records

• Medical and nursing records were kept together in asingle set of patient notes, which were kept in a trolleyby the nursing stations. However, we saw that theywere not always securely kept. On at least three




occasions, we saw that patient records were left outon top of trollies, accessible to members of the public.We also observed that the record trolleys were notlocked at all times.

• We reviewed 17 records and saw that allergies wererecorded and where appropriate, analgesia andantibiotics were prescribed and administered in atimely manner.

• We saw that national early warning scores wererecorded in order to provide early warning of potentialclinical deterioration of the adult patient (NEWS) andpaediatric early warning scores (PEWS) were recordedon paediatric records.

Safeguarding

• The practice development nurse showed us thecurrent status of nurse training within the department.We saw that there was 100% compliance withsafeguarding adults training level 2 and 97%compliance with level 3 safeguarding children.

• Completion of safeguarding training by doctors wassignificantly lower. Compliance with safeguardingadults level 2 was 73% and safeguarding children level3 was 60%.

• We saw there were up to date adult and childrensafeguarding policies available for staff to access onthe intranet and staff whom we spoke with coulddemonstrate where to find them.

• There was evidence that the department had a robustapproach to child and adult protection. All childrenwho attended the department were immediatelyassessed to identify if they were ‘at risk’. The paediatricdepartment had access to social workers and a healthvisitor team who were located within the hospital.

• There was a site based safeguarding adults lead andcoordinator, a learning disability lead and a mentalhealth lead.

• The department had a safeguarding screening tool aspart of the booking in process. This not only helped toidentify if the patient was at risk, but also if anyonerelated to the patient could be at risk. It wouldidentify, for example, if there were unattended youngchildren at home or, in the case of adults, whether apatient’s partner could be at risk from the patient.

• The paediatric unit had effective working relationshipswith other professionals in the hospital and in thewider community. We looked at four sets of paediatricpatient notes and saw that the screening process hadbeen completed. We saw a record on one wherecontact had been made with a health visitor forclarification purposes.

• A nurse told us how there were regular safeguardingmeetings with police, social workers, a drugs andalcohol team and a domestic violence team. They saidthat these meetings helped to share knowledge andlearning about particular trends in the area and also toidentify at risk families.

• Staff in the paediatric ED demonstrated a good level ofknowledge of child protection issues. They spokeconfidently about how they remained vigilant aboutthe possibility of child protection issues whenever achild entered the department and how they wouldraise an alert.

• Staff we spoke with had a good understanding ofsafeguarding concerns for adults. They could giveexamples of ways in which an adult presented asbeing at risk. They showed us on the patient electronicsystem how they would raise an alert with thesafeguarding team.

• We noted that the following policies were out of date -Infectious diseases expiry date February 2015;Antibiotic collection plan expiry date June 2013; Masscasualties plan expiry date Oct 2013; Winter Resilienceplan expiry date Sept 2015.

Mandatory training

• We looked at the departmental nurse training matrixup to the end of October and saw there were highcompliance levels with most mandatory training.Moving and handling was 96% informationgovernance was 97% and equality and diversity was99%. In addition, infection prevention and control was99%.

• Compliance rates for medical staff with mandatorytraining were lower in some areas. For exampleinfection prevention and control was 89%, equalityand diversity was 87% and information governancewas 94%, but moving and handling was 100%.




• However, concerns were expressed by several staffabout the poor level of compliance with resuscitationtraining. Matrons told us there was an expectation thatthey would deliver resuscitation training which hadthe potential to have a significant impact on theiroverall workload. The trust confirmed that at the timeof our inspection, there was a reliance on two matronsto deliver resuscitation training.

• We saw that the lack of available resuscitation trainingat all levels was on the latest corporate risk registerand was rated as high risk. The latest review of this riskshowed that it was partially assured as there wason-going development of all nurses in resuscompetency.

• We were told that locum medical and nursing staffwere provided via a third party organisation which wasresponsible for ensuring that all staff had appropriatetraining, including resuscitation training. The trustwrote that this was confirmed on an inductionchecklist when the member of staff presented to work.However, it was unable to supply us with data toevidence the fact that they were assured all locum andagency staff had appropriate resuscitation training.

• The trust had a threshold target of 90% for compliancewith resuscitation training. Data supplied to CQCdemonstrated that compliance rates for nursing staffwith level 2 adult basic life support (BLS) was 86% andlevel 3 adult immediate life support (ILS) 73%.Compliance with Level 2 basic paediatric life support(BPLS) was 87%.

• Compliance rates for medical staff with level 2 adultBLS was 77%. There was no data supplied forcompliance with level 3 adult ILS and the trust has notmade it clear to CQC whether any medical staff weretrained in adult ILS. Compliance with Level 2paediatric BPLS was 80%.

• Data supplied by the trust showed that nursing staffwere 92% compliant in adult basic resuscitation whilstmedical staff were 85% compliant with a target of90%.

• Figures for paediatric basic life support were at 86%for nurses and 80% for doctors, where the target ratewas 90% for all.

• Nurses were 73% compliant with intermediate lifesupport and 100% compliant with advanced lifesupport for adults (ALS).

• We were told that FY2 doctors were required to haveALS to work within the trust, and this was checked aspart of their induction into the Trust. The trust told usthat these doctors did not get signed off for their nextyear unless they had this level of resus training.

• Doctors were 92% compliant with ALS and 58%advanced paediatric life support (APLS).

• The data submitted confirmed whilst one ED matronhad APLS, no nurse in the department had. Apaediatric nurse told us that whilst all currentpaediatric nurses had basic paediatric life support(BPLS) and paediatric life support (PLS), all of theiradvanced paediatric life support training (APLS) hadexpired.

Assessing and responding to patient risk

• We were told that patients who arrived by ambulanceas a priority (‘blue light’) were transferred immediatelyto the resuscitation area. The ambulance servicecalled the hospital in advance for these cases and staffwere aware of their arrival so could plan accordingly.There were no priority calls on the day of ourinspection to observe this process.

• There was no ‘rapid assessment and treatment’ inplace for other patients who arrived by ambulance.Instead, there was a nurse-led assessment which wascarried out by a band 6 nurse. Following thisassessment, patients were seen by a doctor in order ofpriority based on their assessment score andcoordinated by the nurse in charge. The matron wespoke with told us this system worked well and hadthe effect of improving flow. There was no data for usto see how well this worked in relation to the nationalindicator set by the government of admitting,transferring or discharging 95% of patients within fourhours of their arrival in the A&E department.

• Ambulance turnaround time did not meet the nationalindicator for handover. The indicator for ambulancehandover was 15 minutes, however between June2015 and May 2016 there were 9,806 ambulances witha turnaround of more than 30 minutes at King George




Hospital (64% of all ambulance journeys), with 8% ofthese delayed over 60 minutes, known as a ‘blackbreach’. There had been no black breaches betweenJune and August 2016.

• Trusts in England have a national indicator for triaging95% of patients within 15 minutes of their arrival in theED. This means that they should have an initialassessment with a nurse or doctor. The percentage ofpatients seen within 15 minutes between August 2015and August 2016 averaged over 70%.

• We saw a root cause analysis (RCA) report of a seriousincident in February 2016 where a patient wasdischarged home with a working diagnosis of sepsisby the ED Team, which had a very poor patientoutcome. The RCA identified, amongst other thingsthat regular 30 minute observations were not carriedout by the nurse, in accordance with the sepsis carepathway. Included in the identified recommendationswithin the action plan was full compliance with sepsistraining for doctors and nurses including agencynurses and patients with a diagnosis of sepsis to bereferred to specialty and adherence to the sepsispathway (including 30 minute observations) as highpriority.

• Data submitted by the trust demonstrated that therewas an 85.5% compliance rate with adult sepsistraining and 82.3% compliance for paediatric sepsisamongst doctors. Compliance levels were higher fornurses with 98.3% compliance for adult sepsis and96.5% for paediatric sepsis.

• The trust told us that locum medical and nursing staffwere provided via a third party organisation that wasresponsible for ensuring that they had sepsis training.The Trust said it took responsibility via their localinduction checklist to check that this was the casewhen the member of staff presented to work.

• Data submitted evidenced that just 38.6% of patientsreceived antibiotics within the first hour of arrival toED in Q4 2015/16 and 46% in Q1 2016/17.

• The matron we spoke with recognised that theresponse to patients with a suspected sepsis was anarea of weakness within ED. They said this was acontinuous priority and acknowledged that figures forsepsis response rates were poor.

• One of the ways in which attempts were made toimprove this was by the recent introduction of aweekly sepsis huddle during which it was highlightedto staff the importance of recognising and treating apatient who presented with symptoms of sepsis atevery opportunity.

• Staff told us that there was a greater emphasisrecently placed on sepsis and they had receivedtraining on identifying and treating sepsis. Thosewhom we spoke with displayed a good level ofknowledge about treatment options.We saw the‘sepsis six protocol’ was used by clinicians in patient’snotes.

• Walk-in patients were seen by a streaming doctor ornurse, who decided if they were suitable for the UrgentCare Centre (UCC) or if they needed to go to the mainemergency department. If the doctor or nurse decidedthey were suitable for the UCC, a receptionist thenentered their personal details onto the computer withbrief details of the patient’s condition. If it was notappropriate for the patient to be seen in the UCC, theywere seen by the triage nurse from the A&Edepartment instead, who assessed their condition.

• We saw that patients in four cubicles could not accesstheir call bells, which were still attached to the wall.

• The department used a recognised National EarlyWarning Score (NEWS) to assess patients and identifyif their condition was deteriorating. We found thatthere were appropriately completed NEWS monitoringforms on those records we viewed. Staff we spoke withwere aware of the process and made frequent recordsof patients’ vital signs.

• However, data supplied by the trust showed that therewas inconsistent quality in recording of vital signs withoverall scores varying from 92% in May to 53% in Julyand 80% in September.

• This data indicated that 100% of NEWS werecalculated correctly for May and June whilst in Julyonly 80% were correct, August 90% and September90%.

• Staff in the paediatric ED used a paediatric earlywarning score (PEWS) to identify the deteriorating




child. There were four different PEWS records used,dependent upon the age range of the child. We sawthere were age appropriate PEWS on each of thepaediatric records we looked at.

• There was a paediatric sepsis trolley and a nurseshowed us the paediatric sepsis pathway which clearlyoutlined the protocol to follow in the event of a childhaving suspected sepsis.

Nursing staffing

• Data supplied by the trust showed that there was a12% nursing vacancy rate in ED, with band 5 nurseshaving the most vacancies.

• Most staff we spoke with told us how staffing hadimproved since the previous CQC inspection in March2015. They said that whilst the ED was busy, this wasdue to an increase in patient volume rather than lownumbers of staff.

• Nursing staff new to the department told us they hadexperienced a robust initial induction. Wesubsequently saw a copy of the ‘ED nurse orientationpack’. This was a comprehensive information packwhich aimed to introduce the nurse to the departmentand to assist with the development of knowledge andskills. The orientation pack included information onthe safe handling of medicines and the sepsis pathwayfor both adults and children.

• The matron told us that a recent merger of rotas withQueens’s hospital made it easier to have the correctskill mix in the department. If there was a shortage of aparticular band of nurse, then the merged rota made itpossible to assign the shift to a nurse from Queen’s.

• We saw the nursing e-roster and noted that there wasa reduction in the use of agency and bank staff in thetwo weeks prior to our inspection as staff recruitmentincreased.

• We looked at nursing rotas for the previous 12 weeksand saw there was a good skill mix. We noted thatmost vacancies were filled with bank staff and it wasevident from the rota that staff on training were notincluded as part of the rota on that day.

• We saw evidence of forward planning to create a skillmix of nurses. There were opportunities for staff towork extra shifts which were evenly distributedamongst the staff team.

• The matron told us the preference was to have twopaediatric nurses on duty in the paediatric ED at alltimes. However, there had been challenges toensuring this, although the merging of the nursing rotawith Queen’s hospital had eased the problem.

• Where there was only one paediatric nurse on duty,the mitigation was to rota a ‘paediatric competent’band 6 adult ED nurse. We spoke with a band 7 nursewhose responsibility it was to assess paediatricnursing competencies. They told us theseassessments had fallen behind schedule as a result ofadditional administration tasks they had to perform.However, these additional tasks were recentlyremoved from their workload and they expected toincrease the numbers of paediatric competent nursesin the department over the coming months.

• We saw the lack of adequate paediatric nursingcapacity was rated as high on the recent corporate riskregister.

Medical staffing

• Data supplied by the trust for September showed thatthere was a 59% vacancy rate amongst ED medicalstaff, with the largest vacancy rate for consultants(54%), specialty doctors (90%) and specialty registrars(32%) for ED.

• We saw that during the period September 2015 to2016, the average shift fill rate by permanent staff formiddle grade doctors varied between 33% and 55%,for junior doctors it was between 50% and 76% and forconsultants it varied between 22% and 67%.

• We saw that the most recent corporate risk registerincluded inadequate senior medical support as a highrisk which was placed on the register in June 2016.Reasons cited were the lack of senior support to resusand delayed decision making. This meant that thedepartment was reliant on locums, some of whomlacked the confidence to make decisions aboutpatient care.




• We saw that the most recent assessment of this riskwas that it was partially assured by the deployment ofstaff across both King George and Queen’s site.

• The cohort of consultants worked across both KingGeorge and Queen’s hospital sites. Data submitted toCQC confirmed that the establishment figure forconsultants was 18, whereas there were just 9.8 in postat the time of our inspection with the balance madeup of locum consultants.

• There was 24 hour on-site consultant cover in the EDon Tuesday, Wednesday and Thursday. On theremaining days, cover was between 08:00am and10:00pm, after which, the on-call consultant wasbased at Queen’s hospital, contactable by telephone,with registrar cover on-site at King’s hospital. Theconsultant we spoke with told us this wasproportionate to the differing demands of bothhospitals.

• There was a paediatric consultant based in thepaediatric ED from 9am to 10pm Monday to Friday,with a paediatric on-call consultant between 10pmand 9am. At weekends, on-site cover was between09:00am and 10:00pm, with support from the adult EDconsultant outside these times.

• Rotas we looked at for the previous 8 weeks confirmedthat the staffing levels reflected the information wewere given during our inspection.

Major incident awareness and training

• There was a head of emergency planning who workedacross both King’s hospital and Queen’s hospital site.They told us they had developed a major incidenttraining programme, which was a rolling programmedesigned to reach as many staff as possible. Staff hadto attend one and a half days training in order tocomplete the course. The head of emergency planningwas in the process of getting the training courseaccredited for continuous professional developmentpurposes.

• We were told that there was an annual chemical,biological, radiological and nuclear emergency(CBRNE) training day, when staff practised to get intofull CBRN suits.

• We inspected the major incident room. We saw ‘injuryspecific’ packs (eg: gunshot, toxic substances and

burns) and noted that all contents were in date andequipment had been recently audited. There wasportable blood pressure monitoring screens in stockas well as a decontamination tent. CBRNE suits hadbeen recently audited and inflated as evidenced byaudit date stickers. There were separate serviceoutlets (water, electricity) outside the equipmentroom beside the decontamination area.

• Staff whom we spoke with told us of a recent table topexercise held in conjunction with the London FireBrigade. Nurses could demonstrate how to access themajor incident plan on the intranet.

• However, we noted that the major incident plan waslast updated in Aug 2013 and the CBRN policy wasoverdue a review since February 2015.

• We were told that updated policies were in theprocess of being developed, to include the newtraining programme and more recent guidance onhow to respond to a CBRN emergency.

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


We rated effective as requires improvement because:

• We found a number of clinical guidelines on the trustintranet were out of date.

• There was issues with access to trust policies andguidelines for agency staff who had no computeraccess.

• The department performed worse than the nationalaverage in a number of Royal College of EmergencyMedicine (RCEM) audits, including sepsis and septicshock, asthma in children, and paracetamol overdose.

• There was little evidence of consent recorded onpatient’s notes.

• The ED should be able to demonstrate that they recordpatient’s skin integrity and fluid intake.

• Nursing and medical staff appraisal rates were belowthe trust target.

However:




• There was a pathway identified for point of careultrasound in ED.

• The department carried out a number of local auditsincluding a monthly pharmacy audit on safe andsecure management of medication.

• There was good pain relief support for adult andpaediatric patients.

• The department ran multidisciplinary keeping intouch (KIT) days in order to provide staff with trainingfor their development.

• There was protected time allocated for teaching fordoctors and nurses and junior doctors told us theyhad good support from senior doctors.

• There was good multi-disciplinary team work withinthe hospital and with external agencies.

Evidence-based care and treatment

• The department used a combination of NationalInstitute for Health and Care Excellence (NICE) andRoyal College of Emergency Medicine (RCEM)guidelines to determine the treatment they providedand local policies were written in line with these.

• Staff showed us how they would access the localguidelines on the trust intranet. They said they couldaccess these easily and frequently referred to them toensure they were working according to thoseguidelines.

• However, agency staff did not have computer accessand relied on permanent staff to enter information ontheir behalf.

• There were specific treatment pathways for certainconditions. For example; sepsis, fractured neck offemur, acute cardiac syndrome, renal colic and headinjury. We found evidence in patients’ notes that thefractured neck of femur had been correctly followed.We also saw there was a pathway identified for pointof care ultrasound in ED.

• However, it was apparent that the sepsis pathway wasnot always appropriately followed as evidenced inwhat has been previously written under the ‘safe’section of this report. This was acknowledged by amatron who told us that the response to patients witha suspected sepsis was an area of weakness within ED.

• Local audits included the recognition andmanagement of sepsis in the paediatric ED,documentation in the ED and managing safeguardingconcerns in the ED.

• Consultants told us they had a commitment toensuring that junior doctors were involved in localaudits to aid their learning.

Pain relief

• The trust scored similar to other trusts in the A&Esurvey 2014 related to pain relief being offered topatients.

• Staff we spoke with were aware of the appropriateguidance on providing pain relief to patients. We sawpatients being offered pain relief throughout ourinspection.

• Patent records we looked at contained completedpain charts and patients we spoke with told us theywere offered pain relief soon after they came into thedepartment.

• We saw leaflets in the children’s ED to describe levelsof pain, which were in child friendly design. Thisincluded a series of facial expressions, scored fromone to ten, depending on the severity of pain. We sawa nurse asking a child to point to the face that bestdescribed how they felt.

Nutrition and hydration

• The Malnutrition Universal Screening Tool (MUST) wasused to assess patients’ risk of being under nourished.

• However, audits submitted by the trust for February toAugust 2016 demonstrated that there were poorresults for the recording of skin care and fluid intake.For example, the skin care audit did not record anyscores for February May and June. The compliancerate for March was 90%, April 100% and August 56%

• Fluid chart audits for the same period looked ataccurate recordings of fluid intake and output. Therewere no results recorded for six of these months, Aprilwas the only month recorded and showed 100%compliance.

Patient outcomes




• There was trust wide participation in the RCEM auditreport 2013/14 for Severe Sepsis & Septic Shock,Asthma in children and Paracetamol overdose.

• It performed poorly in the severe sepsis and septicshock audit for oxygen administration, documentationof lactate levels blood culture levels and urinaryoutput in the emergency department.

• In the paracetamol overdose audit 2013/14, thedepartment performed lower than the Englandaverage in three of the four indicators, includingpatients receiving the recommended treatment in linewith MHRA guidelines (42%) and the proportion ofcases that received N-acetylcysteine (a medicationused to treat paracetamol overdose) within 8 hours ofingestion. The department was expected to meet thisstandard in 100% of cases.

• Recommended areas for improvement included EDclinicians to carry out a plasma test if unable toascertain overdose size, and better documentation ofcapacity to consent in patients who declinedtreatment.

• The asthma in children audit 2013/14 showed that thetrust performed well with timely recording ofrespiratory rate, oxygen saturations, pulse andtemperature and also the administration of oral orintravenous steroids in the ED. It did less well with there-evaluation of vital signs post bronchodilatoradministration.

• The department carried out a number of local auditsincluding a monthly pharmacy audit on safe andsecure management of medication, the results of thethree audits we saw were positive, with no issuesnoted. Other audits included a weekly check ofmedical charts to ensure they were signed and datedand whether any critical drugs were omitted. Therewere no problems identified with these audits.

• A trust wide audit of falls in ED in September 2016showed there was poor compliance with the fallspathway, where just 40% of patients had their fallspathways completed. 23% of patients had their lying/sitting blood pressure recorded and 20% had acompleted care plan.

• The department scored well in the September 2016trust wide skin risk assessment audit for body

mapping and scoring and reporting any initialpressure sore or skin break on arrival. However, theaudit found that there was no skin inspectiondocumented at care rounds.

• Data submitted to us following our inspectionrecorded no incidence of falls or acquired pressureulcers between April and July 2016. The data recordedthat there were no patients with a decision to admitrequired for audit during August and September.

• There was a peer review system where matrons fromother parts of the hospital audited patient notes forcompliance and legibility. The ED matron told us theirdepartment performed well in these audits. Wesubsequently saw a record of these audits for JuneJuly and August which showed compliance rates of84% 76% and 87% respectively.

• Consultants told us they had a commitment toensuring that junior doctors were involved in localaudits to aid their learning.

Competent staff

• We observed clinical practice by both doctors andnurses was within published guidelines. Staff werecompetent and demonstrated a good level ofknowledge and understanding of evidence basedpractice. They were aware of NICE and RCEMguidelines.

• Junior doctors told us they felt well-supported andhad access to training. There was protected timeallocated for teaching. They said they were givenlearning assignments and attended four hour teachingsessions twice a month.

• We were told that trust medical training options wereavailable to locum medical staff. However, the trustwas unable to provided CQC with a record of trainingcompleted by locums and it was not clear to CQC howthe trust had an oversight on locum training.

• We spoke with a consultant responsible for juniordoctor training. We were told that each junior doctor isassigned to a senior doctor for additional support.They are required to meet face to face every threemonths. All the junior doctors we spoke withconfirmed this and said they had open access tosenior doctors as required.




• A new electronic staff training system was launched inJanuary 2016. Staff told us this was a very easy way forthem to ensure all their training was up to date, as itrecorded all training they had done and all that theywere due to do.

• Medical staff told us there was good support whenthey needed to attend external courses as part of theirskill development. However, some nurses told us ithad become more difficult to get funding for externalcourses.

• A health care assistant told us they had been trainedto apply basic plaster casts to patients.

• One nurse told us that cannulation and plastering wasnot included on the paediatric nursing course. Theysaid this meant that they had to call for assistancewhenever these procedures were required, thusdelaying treatment for the patient. However, they hadaddressed this with the practice development nurseand expected to have the appropriate training in thenear future.

• Nursing staff spoke highly of ‘keep in touch’ days,which they attended in their individual teams threetimes per year. These days were planned and includedspecific training, such as sepsis, resuscitation anddementia awareness, as well as review of seriousincidents and learning from them. A member of thepsychiatric liaison team told us they frequently ransessions for staff about managing patients whopresented with mental health issues at these ‘keep intouch’ days.

• Staff told us that following challenging incidents in thedepartment such as a failed resuscitation, shortdebriefing sessions were organised to discuss learningand the impact on individual members of staff.

• Data submitted by the trust evidenced that appraisalrates for both nursing and medical staff were low withcompliance for nurses at 74% and for doctors 60%where the trust target was 85%.

Multidisciplinary working

• We observed good multi-disciplinary team workingand positive interactions across all staff levels withinthe department. Staff we spoke with told us there wasa good working relationship between all levels of staff.

• A consultant we spoke with told us the emergencydepartment had a good working relationship withother hospital departments and noted that staffacross the hospital acknowledged that the ED was acollective responsibility. They said that this facilitatedbetter patient experiences as it enabled more rapidadmission to other departments.

• Staff in the paediatric department described thepositive working relationship they had with local childsupport services. They told us how they engaged withthe child and family consultation service for childrenwho were under eleven years old, and with the childand adolescent mental health services for thosechildren aged between eleven and eighteen.

• We observed a handover from the ambulance serviceto the ED staff. These were well structured andensured that all the relevant clinical information aboutthe patient was conveyed appropriately. We spokewith a member of the ambulance service who told usthat whilst there were occasions when there weredelays in handing patients over, there was alwaysgood support from the ED staff.

• We spoke with a nurse from the frail and olderperson’s advice and liaison service (FOPAL). This wasan admission avoidance team. They told us that staffin the ED alerted them to all patients aged 75 andabove in the department. This enabled the FOPALteam to assess for vulnerabilities and share concernsand information with local social and communityservices. We were told that there was a high level ofsupport from ED staff which enabled patients to bedischarged in a planned and effective way.

• The trust hosted a 24/7 psychiatric liaison service(PLS) for a mental health trust. We spoke withmembers of this team who told us they had a verygood working relationship with nursing and medicalstaff, where each appreciated the other’s skills.

• PLS staff told us they had good access to the hospitalcomputer system. They spoke about doing jointassessments with staff and supporting ED staff byproviding mental health awareness training on their‘keep in touch’ days.

Seven-day services




• ED services for adults and children and the UCC wereopen 24 hours a day, seven days a week.

• There was 24 hour on-site consultant cover in the EDon Tuesday, Wednesday and Thursday. On theremaining days, cover was between 08:00am and10:00pm, after which, the on-call consultant wasbased at Queen’s hospital, contactable by telephone,with registrar cover on-site at King’s hospital. Theconsultant we spoke with told us this wasproportionate to the differing demands of bothhospitals.

• We were told there was a paediatric consultant basedin the paediatric ED from 9am to 10pm Monday toFriday, with a paediatric on-call consultant between10pm and 9am. At weekends, on-site cover wasbetween 9am and 10pm, with support from the adultED consultant outside these times.

• There was on-call radiology support available 24/7 fortrauma patients. For other patients, staff told usreporting on CT scans and x-rays was often slow andwas available only up to 11pm.

• The pharmacy was open Monday to Friday from8.30am to 5pm and on Saturdays from 8.30am to12.30pm. It provided a 24/7 on-call service outsidethese hours.

Access to information

• The department IT clinical management systemallowed staff to have access to detailed and timelyinformation to enable them to care and treat patientsin a safe and effective manner.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Data submitted by the trust showed that there was95% compliance with Mental Capacity Act training.

• We were told that training in relation to the MentalCapacity Act 2005 was incorporated into safeguardingtraining. Whilst most staff we spoke with were notfamiliar with the term ‘mental capacity’, theyunderstood what it meant once it was explained tothem.

• Staff told us consent was mainly obtained verbally forprocedures such as receiving medicines and minorprocedures.

• We found little evidence of consent recorded onpatient’s notes. Staff told us they obtained verbalconsent before engaging in any procedure with thepatient.

• Patients we spoke with told us how staff asked theirconsent before carrying out any procedures. We heardstaff asking patients their consent and this was donein an appropriate manner.

Are urgent and emergency servicescaring?

Good –––

We rated this service as good for caring because:

• The ED provided compassionate care and staffensured patients were treated with dignity and respectmost of the time.

• We observed that staff interacted with adults andchildren in a courteous compassionate andappropriate way.

• Patients and their relatives and families were keptinformed of on-going plans and treatment. They toldus that they felt involved in the decision makingprocess and had been given clear information abouttheir treatment.

• Staff provided emotional support to patients andrelatives and could signpost them to other supportservices if required.

However:

• Patient feedback response rates were low.

Compassionate care

• We observed compassionate care delivered by nursesand doctors, particularly to children. We observed anurse taking blood from a young child, and theyoffered reassurances throughout the procedure.

• Staff engaged in an open and positive way withpatients and their relatives. We saw how they tooktime to answer questions raised and were honest




about whether they knew the answer or not. At onepoint, we saw a nurse ask a doctor to explain to apatient about certain aspects of their care in order toprovide reassurance to the patient and their relative.

• Patient feedback was collected through the NHSFriends and Family Test. The trust recognised thatpatient response rates were significantly lower thanthe target of 20%. For example, response rates forApril, May, July and August 2016 were 3%, 17%, 16%and 13% respectively. The response rate for June was24%. Of these, positive responses varied between 79%and 90%.

• General observations confirmed staff respected theprivacy and dignity of patients.

Understanding and involvement of patients andthose close to them

• Most patients told us they felt informed about theprocesses in ED. They said that once treatment hadstarted, staff dealt promptly with their needs and mostfelt very confident about the explanations and carethey received.

• Parents accompanying their children in the children'sED were positive about the treatment their childrenreceived. They said the nurses and doctorsunderstood them and were supportive.

• Most patients and relatives commented positively onthe knowledge and professionalism of the staff whotreated them. We were told “the nurse was very gentlewhen she removed my drip”.

• Most patients we spoke with were positive about theirinteractions with all staff in the department.

• There were mixed views expressed about receptionstaff. Whilst some patients told us, “the reception staffwere polite and friendly, others said “some of thereception staff lacked compassion and seemed morekeen to speak to their colleagues rather than book mein.”

Emotional support

• The ED staff had a protocol on how to support relativeswho experienced bereavement. We witnessed how staffdealt with recently bereaved relatives in a most caringand compassionate way.

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

Good –––

We rated responsive as good because:

• Walk-in patients were streamed effectively, includingback to their own GP.

• The environment of children’s ED was child friendlyand well laid out.

• There was a frail and older persons advice and liaisonteam which worked closely with the ED department.

• There were dementia champion nurses in the ED.

• The trust hosted a 24/7 psychiatric liaison service.

• The observation ward was used to assess thecommunity support needs of vulnerable patientsbefore being discharged.

• Where possible, complaints were dealt with swiftly inorder to prevent escalation.

However:

• The ED failed to meet the four hour national standardfor treating or admitting patients. There was a steadydrop in the average four hour attainment performancebetween October 2015 and March 2016, though thishad steadily improved since April.

• Patients were not offered drinks on a regular basis.

• There was no viewing room where people could seetheir deceased relatives.

• It was unclear how complaints and the learning fromthem was communicated to staff.

Service planning and delivery to meet the needs oflocal people

• Certain categories of patients were not taken to thedepartment. These included children, certain cardiacpatients, stroke and gynaecology patients. Instead,they were taken directly to the other hospital in thetrust, Queen’s hospital, which had a wider range ofspecialisms.




• We were told that ambulances knew which patients totake directly to Queen’s. In the event of a walk-inpatient requiring support from a particular specialismwhich was unavailable at KGH, then they would bestabilised as required and transferred out to Queen’shospital with all relevant information about theircondition relayed to awaiting staff.

• Walk-in patients to the department were initiallyscreened by either a nurse or doctor from PartnershipEast London cooperative, which was hosted byBHRUT. We spoke with a nurse from this service whotold us the screening helped to direct patients to themost appropriate area. This could be to see a GP inthe urgent care centre, admission to the main ED or tobe redirected to their own GP or local communityservice.

Meeting people’s individual needs

• There was no provision to treat ophthalmological orgynaecological emergencies at King’s hospital. Wewere told that walk-in patients presenting with theseconditions would have an initial assessment and thenbe transferred to Queen’s hospital whilst ambulancesdealing with patients who presented with thosesymptoms took them straight to Queen’s hospital.

• The adult ED had a screen which displayed waitingtimes and was updated every two hours.

• The layout of the reception area challenged dignityand privacy. There was no ‘wait behind’ line and therewere four windows side by side where patientspresented, which made it possible to hear otherpatient’s problems.

• The reception desk was high which made it difficult tosee and communicate with a person in a wheelchair.We spoke with a receptionist about this and were toldthat when it was noticed there was a person in awheelchair, they would come out to speak with them.

• The relative’s room had been refurnished since the lastCQC inspection and appeared clean, with adequateseating. There was no separate viewing room wherepeople could see their deceased relative within theED.

• The environment of children’s ED was child friendly,with toys, books and a television. The reception area

was well laid out and based around the nurse’sstation. Children there could be observed by staff at alltimes. There were dedicated nursery nurses in thepaediatric ED who were well integrated into the team.

• The paediatric ED did not have a dedicated playspecialist. The nurse we spoke with told us they couldaccess a play specialist from a ward, but this was doneinfrequently and there was not always one available atthe time. They told us that whilst they did not think thelack of play specialist affected their provision of care,they said it would be helpful.

• Adults with learning difficulties who attended the EDhad a hospital passport which assisted them toprovide hospital staff with important informationabout them and their health when they were admittedto hospital.

• There was a frail and older persons advice and liaisonteam (FOPAL) which worked closely with the EDdepartment. Their role was to assess patients over 75who were of concern and assist with admissionavoidance. They linked with community services,including social workers and allied healthprofessionals.They also offered general support andguidance to staff about frail elderly patients.

• In addition, there were dementia champion nurses inthe ED. Staff we spoke with demonstrated goodknowledge about how to support people living withdementia.

• The trust hosted a 24/7 psychiatric liaison service(PLS) for North East London NHS Foundation Trust.This team worked closely with ED staff to improve thequality of care experienced by those patients whopresented to the department and had an associatedmental health illness.

• Data collected of nutrition and hydration over a 10 dayperiod in October 2016 evidenced that there was goodnutrition and hydration offered to patients between8am and 3pm. However, it deteriorated later into theevening with no record of patients being offerednutrition or hydration after 9.30pm.

• We were told that a hostess offered food to patientsthree times per day. In addition to this, there were two




hourly comfort rounds, where patients were offereddrinks from a trolley, which was then recorded onpatient notes. We saw recorded evidence where drinkswere offered and accepted.

• However, we did not see evidence of this two hourlyround occurring on a regular basis. Some patients wespoke with told us they had not been offered anydrinks, despite being in the department for over twohours, whilst others said they had been offered a drinkas soon as they arrived.

• We were told that a housekeeper had recently beenappointed, and once they were in post, the view wasthat the provision of food and drink to patients wouldbe better regulated.

• There was a 24/7 chaplaincy service available. Therewere chaplains representative of several majorreligions including Church of England, Baptist, RomanCatholic, Islam, Judaism, and Sikhism. The hospitalprovided an on-site multi-faith room.

• Translation services were provided by Language Line –usually by telephone but sometimes on a face-to-facebasis.

Access and flow

• Trusts in England were given a national indicator bythe government of admitting, transferring ordischarging 95% of patients within four hours of theirarrival in the A&E department. The trust’s performancewith regards to waiting times was inconsistent and thenational indicator was very rarely met. The indicatorhad been met by the department on just one occasionbetween August 2015 and August 2016.

• There was a steady drop in the average four hourattainment performance between October 2015 andMarch 2016, with percentages decreasing month onmonth from 90% in October to 76% in March 2016.Thispercentage improved in April 2016 to 80% and 81% inMay.

• However, the trust performed better than the Englandaverage of 82% in attaining the four hour standard inJune July and August 2016 where data showedperformance at 90% 87% and 93% respectively. Staff

we spoke with attributed this to better bed availabilitythroughout the hospital, where the emphasis wasplaced on earlier discharges occurring morefrequently.

• We saw that failure to comply with the four hourstandard was rated as extreme and was added to thecorporate risk register in May 2016 and reviewed ateach meeting. The recorded concern was thatexcessive waiting times and the resulting potential fordelayed decision making impacted on patient care.

• The percentage of patients who left without beingseen was higher than the England average of 2.7% inall months between January 2016 and August 2016,with an average of 5.5% over these months.

• Patients who arrived by ambulance, other than thosewho needed to go immediately to resuscitation area,were seen by a rapid assessment and treatment band6 nurse. They listed patients to be seen by a doctor inorder of priority. This process ensured that patientsreceived an early diagnosis by a clinician andincreased the probability of a positive outcome.

• Patients who walked into the department were seenby a doctor or nurse at the front counter. They werethen either streamed to the A&E department, or, if lessserious, the UCC, which was open 24 hours a day,seven days a week and run by a separate provider.

• We saw the departmental escalation plan (fullcapacity protocol) which was issued in July 2016. Thisset out clear pathways and processes to be followedwhen there was a failure to deliver patient flowthrough the department as usual.

• The protocol gave guidelines on when it should beactivated. For example, when more than 30% ofpatients waiting for admission waited over two hoursfor a bed, when the volume of patients arriving perhour exceeded capacity (30 per hour). This was thenescalated to the declaring of an internal incident.

• Staff we spoke with were aware of this protocol andtold us it gave them reassurance to know it would beinitiated when required.




• Nurses in the paediatric ED told us they kept a supplyof simple antibiotics, inhalers, eye drops and inhalersin stock. This enabled patients to be dischargedquicker with these drugs, rather than having to collectfrom the pharmacy.

• There was an observation ward which had three bedswhich were not mixed sex beds. Beds were not for theuse of ward patients and there was one nurseassigned to monitor the patients at all times. Use ofthis ward helped to free up cubicles in the ED.

• The matron told us this ward was used for patientstransferred from ED who were ready for discharge, butneeded further assessment of their support needs inthe community before going home. For example,where a patient was deemed to be vulnerable, amember of the FOPL team would be requested tomake an assessment of need prior to discharge. It wasalso used on occasions when a potentially vulnerablepatient was ready for discharge during the night butthey could not go home at that time as they wouldrequire a support package of care.

• The observation ward was not used for those patientsliving with mental ill-health. We were told that this wasin the interest of safety for the all patients and staff.

Learning from complaints and concerns

• The department had a system in place for identifying,receiving, handling and responding to complaints andcomments made by patients and those acting on theirbehalf.

• Patient information on how to make a complaint orraise a concern with PALS was available on the trustwebsite. Publicity about complaints, in the form ofleaflets and posters, was visible in the department andmost patients told us they would raise any concernsdirectly with a nurse.

• ED received 18 complaints between February andSeptember 2016. The three most common causes forcomplaint were patient unhappy with treatment,delays and attitude of staff.

• We were told that complaints were initially dealt withby the matron. They said they tried to deal with anycomplaints directly with the complainant as soon asthey arose.

• However, it was unclear how complaints werecommunicated to staff as those whom we spoke withwere not able to tell us of any recent complaints orwhat learning if any was implemented because of acomplaint.

Are urgent and emergency serviceswell-led?


We rated well-led as requires improvement because:

• Levels of resuscitation for all staff were low, and hadbeen noted on the corporate risk register over a periodof time.

• There was no staff grade paediatric nurses trained inadvanced paediatric life support at the time of ourinspection.

• Whilst the trust told us it confirmed all training doneby locum staff on their induction checklist, this did notinclude full compliance with sepsis trainingas identified within a root cause analysis action plan.

• There was no divisional nurse lead at the time of ourinspection as this post was out for recruitment.

• Many staff with whom we spoke were unclear aboutthe future direction of the emergency department andthe impact this had on their job security.

However,

• The departmental understanding of risks and issuesgenerally corresponded with those described by themajority of staff. There was a greater emphasis placedon risk management and better oversight of the riskregister since the last CQC inspection in March 2015.

• Staff knew and put into practice the service’s valuesand they knew and had contact with managers at alllevels, including the most senior. Staff were able to tellus what the department governance arrangementswere.

• Staff knew who the departmental leadership team wasand also told us interacting with staff and patients.

• We were told that executive board frequently visitedthe department and local leadership was very visible




and supportive. The matron and lead nurse heldmorning briefings to update staff on issues andincidents which may have arisen the previous day andthe director of nursing did walkabouts at varying timesin order to give as many staff as possible theopportunity to speak with her.

Leadership of service:

• Leadership and management of the department wasshared between the two clinical leads and thematrons. These clinical leads shared their timebetween KGH and Queen’s, whilst the matrons weresite specific. The senior leaders, clinical director,clinical leads and matrons were all visible within thedepartment.

• There was no divisional nurse lead at the time of ourinspection as this post was out for recruitment.

• The recently created role of ED lead nurse was sharedacross the trust, with the person in post dividing theirtime between both hospitals.

• Staff told us they knew who the leadership team wasand also said that the executive board was visible. Thiswas reinforced by the fact that the board spent oneday on site each week and were frequently seenaround the various hospital departments interactingwith staff and patients.

• The director of nursing met with matrons each week,as well as doing walkabouts at different times in orderto give as many staff as possible the opportunity tospeak with her.

Vision and strategy for this service

• Staff knew that the corporate ethos was to take PRIDE(Passion, Responsibility, Innovation, Drive andEmpowerment – the trust vision) in patient care.Those whom we spoke with told us it was a simple butpowerful message and one which they tried to fulfil inthe course of their working day.

• Staff told us they had heard about changes to the EDover a number of years and many of those whom wespoke with were unclear about the future of thedepartment.

• A senior clinician told us there were plans whichwould affect the way in which the emergencydepartments of both King George and Queen’s

hospital were run in the future, this had only recentlybeen disseminated to senior staff and there was anexpectation that they in turn would share this withintheir teams.

• However, it was acknowledged that communicationwith staff could have been more forthcoming in orderto allay their fears about their future.

Governance, risk management and qualitymeasurement

• We looked at the most recent corporate risk registerand noted there were seven risks recorded, includingfailure to achieve the four hour standard, with a riskrating of extreme severity. Lack of adequate paediatricnursing capacity was rated as high as was inadequatelevels of senior medical support.

• Other risks included inability to provide responsivecare to patients in Resus, due to the lack of availabilityof medical and nursing resource and lack of availableresuscitation training at all levels both of which wererated high.

• From our discussions with staff, it was clear that theserisks were ones which they were aware of and hadconcerns about, in particular the lack of paediatricnursing capacity and lack of available resuscitationtraining.

• There were monthly ED quality and safety (clinicalgovernance) meetings. We saw that minutes fromthese meetings referred to departmental risks asreflected on the corporate risk register.

• The mortality committee met each month andminutes of two recent meetings sent to CQC showedthat ED was represented in one of these meetings. Theminutes from May 2016 reflected a wide range ofdiscussions, including a summary of the hospital-levelmortality indicator. It was noted that the figure for the12 month period to January 2016 was 98.9, a decreasefrom the previous 12 months (100.3) and which wasbelow the UK average.

• Most staff were able to tell us what the departmentgovernance arrangements were and told us whichindividuals had key lead roles and responsibilitieswithin ED.




• There was a short team briefing meeting everymorning at 7.30am, chaired by the matron and leadnurse to update staff on issues which may have arisenovernight and deal with any operational concerns. Wesaw a sample of 8 sets of minutes of meetings whichincluded an update on all recent incidents andlessons learned from them. We noted that poor handhygiene was a recurring theme.

• There were three bed meetings per day, during whichavailability of beds across the hospital was updated inrelation to the expected need of patients in ED.

• We were told that the formal monthly meeting ofnursing staff had become less frequent due topressures of work, but the intention was to restartthem since there were now more staff in post andpressures were lessening.

• There was a trust wide weekly multidisciplinarygovernance meeting, the discussion includedincidents and serious incidents, complaints andaudits. We saw this reflected in minutes subsequentlysubmitted by the trust.

Culture within the service

• Staff described the ED as all one team and a smalldepartment run with passion. Morale in thedepartment was described as stable.

• We observed good team working among nurses andmedical staff, and senior staff told us they werecommitted to supporting their staff in giving patientsgood care.

• Matrons told us they met with ward sisters every threemonths, which helped to promote openness and goodcommunication within teams. We saw minutes of theprevious two meetings and noted that the agenda waswide ranging and relevant to current issues within thedepartment such as concerns about low levels ofresuscitation training and storage of drugs. Actionswere recorded against these

Public and staff engagement

• Feedback from patients was obtained from the NHSFriends and Family test. Response rates were low, butof those responses gathered over the previous fivemonths, 87% of people surveyed would recommendthe emergency department at King George Hospital.

• 2092 staff at Barking, Havering and RedbridgeUniversity Hospitals NHS Trust took part in the 2015National NHS staff survey. This was a response rate of37% which was below an overall average responserate of 41% for acute trusts in England, butrepresented an increased response of 4% on the 2014staff survey.

• We looked at overall trust results of feedback fromstaff in the 2015 National NHS staff survey which wascombined for King George hospital and Queen’shospital. The trust scored better than the nationalaverage for staff motivation at work, quality ofnon-mandatory training, percentage of staffexperiencing physical violence from patients, relativesor the public in last 12 months, percentage of staffreporting errors, near misses or incidents witnessed inthe last month and effective use of patient feedback.

• However, the trust scored below the national averagefor percentage of staff believing that the organisationprovided equal opportunities for career progression orpromotion, percentage of staff satisfied with theopportunities for flexible working patterns, percentageof staff experiencing discrimination at work in last 12months, percentage of staff suffering work relatedstress in last 12 months and percentage of staffworking extra hours.

• There were information boards around the ED,including one which identified the nursing staff andtheir grade by the type of uniform they wore. Otherinformation boards included advice on how to givefeedback and information on quality of patient carefor the previous month.

• The trust issued press releases in April and June 2016in which it was proposed that there would be changesto emergency and urgent care at King George hospital.This included the overnight closure of the department.

• Prior to any changes being made, there would be aseries of reviews carried out by an independent team,including senior doctors.

• Following those reviews, there would be meetings ofthe trust board and the local clinical commissioninggroup held in public to reach a final decision toimplement the changes.




• We saw a draft copy of the trust board jointcommunications and engagement strategy plan forthe proposed changes. This identified the need forinternal staff communications to help staff tounderstand the timing and purpose of decisions andwhat it would mean for their work and how theycommunicated the proposal to patients.

• Some staff told us they did not feel consulted orinformed about the proposed changes in the way theED would function. They knew that there werediscussions at certain levels, but this information wasslow to be shared. We were subsequently told by asenior member of staff that engagement meetingswith all staff were planned for the month following thisinspection.

Innovation, improvement and sustainability

• The department had introduced a point of careultrasound (PoCUS). This enables clinicians to carryout ultrasound as required in the ED. It providesrelevant information at the bedside rather thantransferring a critically ill patient or risking exposure toradiation.

• The department plans to establish an academic unit in2017 to aid on-site education and development forclinical and nursing staff.





Effective Requires improvement –––


Responsive Requires improvement –––

Well-led Good –––


Information about the serviceMedical care encompasses a broad range of specialtiesthat use non-surgical interventions to assess, diagnoseand treat patients. At King George’s hospital, theseincluded wards that specialised in urology, strokerehabilitation, gastroenterology, care of the elderly, acutemedicine, endocrinology, endoscopy, cardiology andgeneral medicine. There was also a medical assessmentunit (MAU). During the course of this inspection, wevisited seven of the medical wards: Ash ward, Beechward, Erica ward, Fern ward, Gardenia ward, Gentianward and the MAU.

Between September 2015 and August 2016, there were12,141 admissions to the medical service at King George’shospital. Of these admissions, 54.3% were emergencyadmissions and 45.7% were elective. There were 5,323day case patients in total in the same period. There were176 inpatient beds and 36 day case beds within themedical division at the hospital.

We visited King George’s hospital as part of ourunannounced inspection on 8 September 2016 and againas part of a follow-up unannounced visit on 16September 2016. We spoke with 32 members of staffincluding health care assistants, nurses, trainee doctors,consultants, allied health professionals, senior staff,domestic staff and pharmacists. We spoke with ninepatients and three relatives. We reviewed 20 care recordsand 20 prescription charts. We observed staff interactions

with patients and those close to them. During andfollowing the inspection we requested a large amount ofdata in relation to the service, which we reviewed andconsidered when making our judgements.

Medicalcare

Medical care (including older people’s care)


Summary of findingsWe rated this service overall as requires improvementbecause:

• Hospital environments were not always ideal. Somewards were reported and observed to have highlevels of noise and heat. There was a lack of bedsidetelevisions or radios across the wards. There werebreaches in the fire resisting compartmentationacross the hospital site, which had been caused byprevious contractors drilling holes for data cablesand services.

• Although we observed good infection controlpractices on inspection, rates of both MRSA andClostridium difficile infections were high. Infectionprevention and control audits, as well as handhygiene audit results, showed consistently poorcompliance in some wards and departments.

• Although nursing staffing levels had improved sinceour last inspection in March 2015, some wards stillhad significant vacancy and turnover rates. On thesewards, there was a reliance on bank and agency staffto fill vacant shifts.

• There was a reliance on locum doctors across theservice, apart from in cardiology. This affectedcontinuity of patient care, particularly out-of-hours.Medical staff across the service were failing to meettrust targets for completion of mandatory training.

• For non-elective admissions, the standardisedrelative risk of readmission was high, particularly forgeriatric medicine. Patient outcomes in care of theelderly were limited by the lack of consultantgeriatricians to lead improvements within theservice. Junior doctors in geriatric medicine reportedlower overall satisfaction than the national averagein the 2015 National Training Survey. There was alsopoor performance in measures such as availability ofclinical supervision out-of-hours and regionalteaching. These results showed significantimprovement in the 2016 survey, but some issues stillremained.

• Medical and nursing staff completion rates in basiclife support were below the trust target, due to a lackof external training sessions.

• There was still a backlog of National Institute forHealth and Care Excellence (NICE) guidance that wasawaiting confirmation of compliance across thetrust. The trust performed worse than the previousyear in a number of national audits.

• Some principles of good record keeping were notbeing followed. Fluid charts were not always filledout and medical entries were sometimes illegibleand unsigned. On Ash ward, we also found that threesets of notes did not have the date of transfer to theward recorded. There were issues with two out ofseven sets of the Deprivation of Liberty Safeguards(DoLS) documentation that we reviewed whilst oninspection.

• The pathology service was understaffed and unableto provide effective cover out-of-hours at the time ofinspection.

• The pathways for patients with cancer were notalways clear. There was poor communication withtertiary centres, which caused delays with patientsrequiring tertiary treatment or diagnosis at otherspecialist hospitals. The trust performed slightlybelow the national average in the National CancerInpatient survey 2015.

• The trust was not meeting 18-week nationalindicators for non-urgent referral to treatment (RTT)times.

• Staff across the hospital told us that they could notalways discharge patients promptly due to capacityissues within the hospital or community provisionshad not been put into place. Some patients andrelatives felt that more could be done to involvethem in their care, especially surrounding discharge.

• Patients were not always able to be located on thespecialist ward appropriate for their condition,although management of these patients hadimproved since the previous inspection. The number

Medicalcare



of patients moved four or more times per admissionhad increased. In some wards, such as Ash, Gentianand Gardenia ward, bed moves were consistentlyoccurring out of hours (between 10pm and 6am).

• NHS England suspended endoscopy screeninginvitations to the trust for eight weeks from July 2016.There was a risk of delayed diagnosis of bowelcancer due to inability to provide a full screeningservice to the local population.

• Patient information leaflets were not standardlyavailable in languages other than English. Althoughface-to-face and telephone translation services wereavailable, many staff were not familiar with how toaccess these.

• The Patient Advice and Liaison Service (PALS) did notalways respond to complaints in a timely manner.There were no leaflets detailing how to access PALSand make a formal complaint on Gentian ward at thetime of our inspection.

• The NHS staff survey results were variable, with thetrust still scoring below the national average in manymeasures. Some comments we received from staffwithin the medical department reflected that theywere not always happy with the leadership ormanagement of the service.

However:

• There was improvement in both the reporting ofincidents and the sharing of lessons learned fromthese across the hospital. Staff were aware of theirresponsibilities with regards to duty of candourrequirements, confirming there was an expectationof openness when care and treatment did not goaccording to plan. The governance structure hadbeen revised to provide a greater level ofaccountability and oversight of risk.

• Nursing staff demonstrated an awareness ofsafeguarding procedures and how to recognise ifsomeone was at risk or had been exposed to abuse.They knew how to escalate concerns and wereup-to-date with appropriate levels of training.

• Patients were assessed for a variety of risks onadmission to the wards, using nationally recognisedtools. Magnetic symbols on patient informationboards identified those patients at particularly highrisk, of falls or pressure ulcers, for example.

• Medicines management had improved, with newprocesses in place to ensure the safety of patients.Much work had been done since the previousinspection to ensure that discharges were notdelayed due to unavailability of take homemedications.

• Nursing and medical staff completed a variety oflocal audits to monitor compliance and drive qualityimprovement. Staff told us that these led tomeaningful change across the service. Both local andnational audits were overseen by a committee. In theNational Diabetes Inpatient Audit (NaDIA) 2015, thehospital scored better than the England average fornine indicators out of sixteen indicators.

• The standardised relative risk of readmission for allelective procedures was slightly lower than expectedwhen compared to the England average. This meantthat patients were less likely to require unplannedreadmission after non-emergency procedures,suggesting that the hospital’s care and dischargearrangements were appropriate.

• Patients were cared for in a caring andcompassionate manner by staff throughout theirhospital stay. Most medical wards performed in linewith the national average in the NHS Friends andFamily Test (FFT). Patients’ privacy and dignity wasmaintained at all times. The hospital facilitated anumber of forums and listening events to engagepatients in the development of the service.

• The trust performed above the national average inmeasures relating to training and appraisals in theNHS staff survey 2015. The majority of staff receivedannual appraisals on their performance, whichidentified further training needs and set achievablegoals. The trust was supporting nurses with therevalidation process. For all specialties apart from

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geriatric medicine, the trust scored above thenational average for most measures in relation tofirst year medical doctors in training (2015 NationalTraining Survey).

• There was evidence of effective multidisciplinaryworking within wards and across departments. Allmembers of staff felt valued and respected by theircolleagues.

• Psychological support for patients was easilyaccessible and timely. Patients were routinelyassessed for anxiety and depression on admission.The chaplaincy team offered comprehensive spiritualsupport to all patients, regardless of religiousaffiliation.

• People with complex needs, such as those living withdementia or a learning disability, were wellconsidered and cared for within the hospital. Staffmade reasonable adjustments to improve theirexperience of the service and supported themthroughout their inpatient stay. Information andenvironments had been adapted to make them moresuitable for these patients.

• The trust had developed a clinical vision and strategyand communicated this to staff of all levels, enablingthem to feel involved in the development of theservice. Most nursing and medical staff thought thattheir line managers and the senior team weresupportive and approachable. The chief executiveand divisional leads held regular meetings tofacilitate staff engagement.

• Staff had awareness of what actions they would takein the event of a major incident, including a fire.Regular drills were held to ensure staff wereadequately trained in the event of emergencies.

Are medical care services safe?


We rated safe as requires improvement because:

• Infection prevention and control audits, as well ashand hygiene audit results, showed consistently poorcompliance in some wards and departments. Therehad been four cases of MRSA between Apriland September 2016, against a zero tolerance. In thesame period, there had been 18 cases of Clostridiumdifficile infection.

• There were breaches in the fire resistingcompartmentation across the hospital site, which hadbeen caused by previous contractors drilling holes fordata cables and services.

• There were some issues noted with records, such assome medical entries being illegible and unsigned. OnAsh ward, we also found that three sets of notes didnot have the date of transfer to the ward recorded.

• Medical staff were failing to meet trust targets forcompletion of mandatory training, across all topics.

• Staff completion rates in basic life support were belowthe trust target, due to a lack of external trainingsessions.

• Although nursing staffing levels had improved sincethe last inspection in March 2015, some wards still hadsignificant vacancy and turnover rates. On thesewards, there was a reliance on bank and agency staffto fill vacant shifts.

• Locum usage for medical staff was generally highacross the trust, especially in some specialities. Instroke services, rates of locum usage ranged between18.4% and 34.5% for the period of March 2016 toAugust 2016. In the same period, locum usage in careof the elderly services ranged between 15.6% and24.3%.

However:

• There had been an improvement in the reporting ofincidents and the sharing of lessons from these acrossthe hospital.

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• All staff were aware of their responsibilities withregards to duty of candour requirements, confirmingthere was an expectation of openness when care andtreatment did not go according to plan.

• The dispensing and administration of medication hadimproved, with prescription charts being usedcorrectly and processes being correctly followed andaudited.

• Nursing staff demonstrated an awareness ofsafeguarding procedures and how to recognise ifsomeone was at risk or had been exposed to abuse.They knew how to escalate concerns and wereup-to-date with appropriate levels of training.

• Patients were assessed for a variety of risks onadmission to the wards, using nationally recognisedtools. Magnetic symbols were used on patientinformation boards to identify those patients atparticularly high risk.

• Staff had awareness of what actions they would takein the event of a major incident, including a fire.Regular drills were held to ensure staff were trained foremergency situations.

Incidents

• Staff across the wards were aware of trust widesystems to report and record safety incidents and nearmisses. All staff we spoke with were familiar with theelectronic reporting system and how to navigate this.They were able to give examples of when they hadused the system to report appropriate incidents.Feedback and learning points from incidents wereshared with staff across the service via email andduring handovers, daily safety huddles and teammeetings. There were also quality and safety meetingsheld every two weeks which discussed themes andlearning from recent incidents.

• There were no “Never Events” reported within the trustin the 12 months prior to our inspection. Never eventsare serious incidents that are wholly preventable asguidance or safety recommendations that providestrong systemic protective barriers are available at anational level and should have been implemented byall healthcare providers.

• Between October 2015 and September 2016 the trustreported 550 incidents across specialist medical

services, and 243 incidents across the acute medicinedivision at King George’s hospital. Across bothdivisions, 54 incidents were categorised as a ‘nearmiss’, 38 were categorised as ‘moderate’ harm and themajority (696) were categorised as causing ‘low’ or ‘no’harm. The most common themes of these incidentswere pressure ulcers, falls, medication errors oromissions and staff shortages. Staff of all levelsconfirmed there had been a great improvement inboth the reporting and sharing of lessons learned fromincidents, with one junior doctor commenting thatthere had been ‘a real culture change’ in this respectover the course of the previous year.

• At King George’s hospital, there were 17 seriousincidents reported across the specialist and acutemedicine divisions between October 2015 andSeptember 2016. They all related to pressure ulcersand falls, apart from three cases, which related toinfection control, poor management of a deterioratingpatient and diagnostic delay. Senior staff that wespoke with were able to describe training they hadundertaken in the investigation of serious incidentsand gave examples of recent serious incidents thatoccurred in their clinical area. All serious incidentswere subject to a full root cause analysis investigationand action plans were developed where areas forimprovement had been identified. We saw detailedexamples of these for serious incidents that hadoccurred recently. A new group, which includeddivisional nurses, quality and safety advisors andmedical leads, had been initiated to provide a peerreview of serious incident investigations.

• One ward sister gave an example of an investigationshe was involved in in March 2016, which involved apatient fall. As a result, practice on the ward changedand all newly admitted patients were subsequentlyplaced in bays rather than side rooms to enable closersupervision. Nursing staff who had not completedtraining in falls prevention were booked into futuresessions. Patients at high risk of falls were also flaggedby placing a sticker on boards by their beds and staffmade sure to highlight this risk on handover sheets.

• Mortality and morbidity were considered during themonthly mortality assurance group. This group wasintroduced in 2015 as part of the ‘sign up to safety’initiative, which aimed to improve the monitoring and

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identification of mortality outliers to identify potentialareas where deaths could be prevented. Patientdeaths were adequately reviewed divisionally anddiscussed in order to identify trends or issues ofconcern that led to learning and subsequent actionsto improve care.

Duty of Candour

• Staff at all levels confirmed there was an expectationof openness when care and treatment did not goaccording to plan. They were aware of theirresponsibilities with regards to duty of candour. Theduty of candour is a regulatory duty that relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (orother relevant persons) of certain ‘notifiable safetyincidents’ and provide reasonable support to thatperson. The key principles of the duty of candourregulations were displayed throughout the wards thatwe visited. We saw examples of letters of apology topatients and their relatives from senior staff whenthings had gone wrong. Serious incident reports alsoshowed consideration of duty of candour.

Safety thermometer

• The NHS safety thermometer is a nationalimprovement tool for measuring, monitoring andanalysing harm to people and ‘harm free’ care. We saw‘quality of care’ boards on each ward that we visitedthat displayed the data relating to performance in keysafety areas such as patient falls, pressure ulcers,catheter acquired urinary tract infections and venousthromboembolism (VTE). These boards indicated howmany days had passed since the last incident of eachof these types.

• Safety thermometer data for the speciality of medicinereturned nil values for the period between June 2015and June 2016, despite many of the categoriesmeasured featuring regularly in incident reports. Thiswas due to the trust reporting the incidents under thespeciality of ‘mixed care’, which appeared to accountfor the vast majority of wards at the trust. Datarequested directly from the trust indicated variablelevels of compliance with safety thermometermeasures. Some wards, such as Erica and Gentianwards, scored consistently highly, with only onemonth (January 2016) falling below a score of 90% in

the period between January 2016 and June 2016.Beech and Gardenia wards scored over 90% in allmonths in the same period, with the lowest scores inJune 2016 (93.3%) and March 2016 (96%), respectively.Other wards, such as Fern and Ash, scored below 90%in four of these six months, with the lowest scores of76.7% and 85.7%, respectively, in June 2016.

• Patients were assessed for risk of pressure ulcers, VTEand falls on admission to each ward. An assessmentbooklet had been designed that incorporatedstandard assessments for each of these risks onadmission. Symbols were placed on the patientinformation board and by each bed to indicate if thepatient was at an elevated risk.

• The percentage of patients assessed for VTE risk within24 hours of admission varied across each ward butrarely exceeded 90%. In the period between Marchand August 2016, only Fern and Ash wards achieved90% compliance in two months out of the six,respectively. Gentian ward scored 100% in April 2016but for all other months, this fell below 90%, with thelowest percentage of patients recorded being 44.4% inMarch 2016. Gardenia ward and the medicalassessment unit (MAU) did not exceed 87.3% and86.3%, respectively.

• Staff had good access to tissue viability services,through referral to a specialist team. All nursing staffhad recently attended training sessions in tissueviability, due to the risk of pressure ulcer developmentbeing added to the corporate risk register in April 2016.Nursing staff were taught how to identify early signs oftissue damage and use the Braden scoring system andbody maps to record any changes in patients’ skinintegrity. There were tissue viability link nurses on theward who attended additional training and shared thiswith the wider ward team. On some of the wards wevisited, there were clocks by the side of patients’ bedsto indicate when they next needed to be turned.Pressure ulcer panels were held once a month todiscuss any incidents.

• Patients at risk of falling were nursed in beds that werecapable of being lowered to prevent them from fallingout. Bed rail assessments had been completed toenable these to be used to minimise the risk further.The prevention of falls was highlighted as a priority onmany of the ward safety boards and staff were able to

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access non-slip slipper socks for patients to promotesafe mobilisation. The wards had recently introduceda guide to medicines that contribute to falls that wasdisplayed on the inside of all medication trolleys to actas a prompt to nursing team when issuing medication.


• The trust had an infection prevention and control (IPC)policy and all staff received mandatory trainingrelating to this. Each ward also had an IPC link nurse.Link nurses act as a link between the ward and theinfection control team. Their role is to increaseawareness of infection control issues and motivatestaff to improve practice. There was also a lead IPCnurse for the trust and head of IPC, who staff wereaware of and knew how to contact if necessary.

• There were ‘cleaning matters’ boards on each wardthat displayed the work schedule for domestic staff, anexplanation of what areas were cleaned daily andencouraged patients to tell staff if something neededto be cleaned. Domestic staff told us there weresufficient supplies of cleaning materials available fortheir use. They were able to tell us about the nationalcolour-coding scheme for hospital cleaning materialsand equipment. This ensured that these items werenot used in multiple areas, therefore reducing the riskof cross infection.

• The wards and communal areas we visited were visiblyclean and tidy. Personal protective equipment (PPE)was available for staff to use. All wards hadantibacterial gel dispensers at the entrances and bypatients’ bedside areas. Green ‘I am clean’ stickerswere in use throughout the wards to inform colleaguesat a glance that equipment or furniture had beencleaned and was ready for use.

• Infection control audits were completed by theInfection Prevention and Control team (IPCT), withfrequency depending on the score the ward hadachieved in a baseline audit at the beginning of theyear. These looked at areas such as use of PPE, handhygiene, isolation, environment, decontamination ofcommodes and safe disposal of waste. Although Fernward scored 95% in this baseline audit, most medicalwards scored between 85%-94%, with Ash wardscoring just 81% and Gentian ward scoring just 82%.All wards with these lower scores were offered extra

support from the IPCT and action plans were agreed.Most wards showed an improvement in these scores inthe subsequent audits. However, data was notprovided for Ash, Gardenia, Fern or the medicalassessment unit (MAU).

• Staff responsible for cleaning knew of measures theyshould take to reduce the risk ofhealthcare-associated infections. Patients withsuspected or confirmed healthcare-associatedinfection were nursed in side rooms. There wasappropriate signage on these doors.

• Staff on the wards we visited wore appropriate PPEsuch as gloves and aprons and utilised effectivehand-washing techniques. Hand hygiene audit resultsfor some medical wards were good in August 2016,with Erica and Fern wards scoring 100%, and Gentianand Beech wards scoring 96%. However, othermedical wards performed less well, with Juniperscoring 84% and Ash ward scoring 85%. Hand hygieneresults on these two wards had consistently fallenbelow 90% since March 2016 or not been submitted atall. This was despite assurance from nursing staff thatissues from audit results were discussed in daily safetyhuddles and team meetings.

• The trust reviewed rates of MRSA infection ininpatients and highlighted four cases between Apriland September 2016, against a zero tolerance. For thesame period, 18 cases of Clostridium difficile infectionwere reported, against a trust target of 30 cases for theyear. Both of these issues were added to the riskregister and action plans were devised, including thedaily follow through of all affected patients and anincreased focus on hand hygiene audit completionand compliance. The lack of staff compliance withdecolonisation cleaning in regards to MRSA was alsohighlighted, with the policy being adapted to allowdecolonisation on admission. Any learning outcomesfrom continued monitoring were to be incorporatedinto the infection prevention and controlimprovement plan for the following year.


• The trust had identified breaches in the fire resistingcompartmentation across the hospital site, which hadbeen caused by previous contractors drilling holes fordata cables and services. At the time of inspection,

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approximately 70% of repair work had beenundertaken but some breaches still existed and werenot expected to be repaired fully until summer 2017.This issue had been added to the corporate riskregister.

• Equipment used on medical wards was clean andlabelled to indicate it was disinfected and ready touse. All portable equipment we checked had beenrecently serviced and labelled to indicate the nextreview date. Staff reported that it was easy to obtainequipment and that there were no issues when urgentrepairs were required. There had been a recentinvestment in new cardiac monitors on Gardeniaward, although the age of the angiography equipmentwas listed as an item on the divisional risk register. Thecost of replacing this equipment was beinginvestigated as the current servicing agreement onlyextended to March 2017.

• Disposable equipment was easily available, in dateand appropriately stored. The service has recentlyinvested in a computerised supply managementsystem, which monitored supply levels andautomatically placed orders when stock was low. Thesystem used PIN and fingered print access to identifywhich staff used which products. However, this wasnot yet live across all wards.

• There were safe systems for managing waste andclinical specimens. Staff used sharps appropriately;the containers were dated and signed when full toensure timely disposal, not overfilled and temporarilyclosed when not in use. There was one instance wherea sharps bin had been left in the corridor outside awaste disposal cupboard but this was remedied bystaff.

• Resuscitation equipment was available on all thewards we visited and tamper seals were in place.Emergency drugs were available and within the use bydate. Safety alerts had recently been circulated by theresuscitation team to indicate that emergency drugsshould be stored inside the resuscitation trolley, forsecurity purposes. Nursing staff carried out daily andweekly checks to demonstrate that equipment wassafe and fit for use, with appropriate actions recordedto report any missing or expired items.

Medicines

• Medicines were managed and stored appropriately onmost of the wards. Staff kept medicines andintravenous (IV) fluids in locked cupboards or roomswith restricted access to ensure security. Mostmedications were found to be in date, but we foundone refrigerated medicine that was four months out ofdate on Ash ward and one IV medication which wasfive months out of date on Beech ward. These werebrought to the attention of nursing staff, who removedthe items and alerted pharmacy immediately.

• Nursing staff checked medication fridge temperaturesdaily and took appropriate actions when these wereout of normal range. For example, we saw records toindicate that refrigerated medications on Ash wardwere temporarily moved to another ward when thefridge was found to be faulty. Pharmacy technicianshad recently trained all nursing staff in the safe use offridges and appropriate escalation of any issues.

• Temperatures of storage areas and treatment roomswere checked daily. On some of the wards, roomtemperatures had consistently exceededrecommended levels. Pharmacy staff were aware ofthis issue and had taken actions to mitigate this. On allwards where temperatures had exceeded therecommended temperature for seven days or more,red dots were placed on affected medications toindicate that their use-by date had decreased by twoweeks. Staff were advised to take any actions possibleto reduce temperatures, such as closing blinds,opening windows, using fans and switching lights off.The issue was reported to estates and an incidentform was completed. A working group made up of thelead nurse, assistant chief pharmacist and seniorpharmacists had been set up to address the issue.Pharmacy staff kept an operational spreadsheet foreach clinical area that recorded and monitored thefluctuations in temperature, any actions that had beentaken to tackle the issue and the total cost of anymedicine affected. The group was considering draftinga business case to introduce more effective roomtemperature controls across the hospital.

• We looked at the prescription and medication recordsfor 20 patients. All charts documented VTEassessments and the allergy status of patients.Appropriate arrangements were in place for recordingthe administration of medicines. Each chart had

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separate sections for different types of medications,including ‘critical medications’, which indicated tonursing staff which medications they should not bedelayed in obtaining. Records were clear and fullycompleted in most cases. They showed people wereusually given their medicines when they needed themand any reasons for not giving people their medicineswere recorded. In a few instances, nursing staff hadnot signed to indicate that they had given amedication, but this had been highlighted bypharmacy staff, who checked the records daily. Amonthly audit of omitted doses indicatedimprovement across the trust within the last year, with6.6% of medication doses being missed in July 2016,compared to 16% in October 2015. Staff wereencouraged to discuss omitted doses of medication intheir daily safety huddles.

• Incident reports were filled out in cases of medicationadministration errors, with the key themes beingidentified as omitted doses and administration errors.A weekly pharmacy development group discussed anymedication incidents and relevant audit results, aswell as a monthly operational group meeting. Amonthly medicines safety report was then sent to thesenior team, divisional leads and all pharmacists. Thisreport collated all divisional data and highlighted bothgood practice and key areas for improvement. Oneimprovement that resulted from this was thedevelopment of a ‘can’t find a medicine’ flow chart,which instructed nursing staff what to do whenmedicines were not available on their ward.

• Pharmacy staff reported that there had beensignificant changes across the service in the last twoyears. Staffing levels and support from managers werereported to be much better. There were currently twovacant posts in the service, one band 8a pharmacistpost and one part-time band 4 pharmacy technician.Both posts were currently being advertised forrecruitment. Staff reported that there were enoughstaff for the current provision of service but thatpharmacists may have to cover more than one ward inthe event of sickness.

• Staff told us the pharmacy services were easilyavailable and pharmacists visited the wards daily. Fourareas had ward-based pharmacists. Staff in otherareas indicated that they were able to contact the

pharmacist when required. The pharmacy team aimedto carry out medicine reconciliation within 24 hours ofadmission across all wards. Medicine reconciliation isthe process whereby the patients current medicationsare reviewed to ensure the most up-to-dateprescriptions are used. Nursing staff told us that thisusually took place on the same day as admission,apart from on weekends, when it took slightly longer.In the period between April and August 2016, between72% and 77% of patients had a drug historycompleted with 24 hours of admission.

• Controlled drugs were stored in locked cupboards andappropriate staff held the keys. Staff maintainedaccurate records of controlled drugs, which werechecked twice daily by two registered nurses. Nursingstaff were aware of policies on the storage andadministration of controlled drugs. A review ofmedications management in this area had taken placein the last year to ensure safe storage and security hadbeen adopted at ward level. Physical controls such asthe use of stamps during routine checks had beenadopted. Further actions such as improving thesecurity of release of controlled drugs to patients incare homes had been identified. Plans to review thecontrolled drug registers and modernise them werealso in discussion.

• Medicines were usually available to facilitate timelydischarge of patients who were going home. The issueof patients being discharged without take homemedications was added to the risk register in February2015 but much progress had been made to improvethe existing process. Ward-based pharmacists nowhelped to facilitate discharges in areas where theywere available. There was also a pharmacy dischargeteam who worked 11am to 4pm weekdays and couldbe bleeped to prepare take-home medications.Nursing staff were encouraged to order anymedications for anticipated discharges as soon aspossible. Some wards had introduced a named nurseresponsible for discharge planning to ensure this tookplace. A hospital-wide audit conducted in August 2016indicated that 89% of take-home medications weredispensed within two hours (against a target of 90%).The average turnaround time for these medications

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was 94 minutes. In the same month, 206 requests fortake-home medications came in after 4pm (29% of thetotal requests), which affected the timeliness of theirpreparation.

Records

• Information governance training was mandatory for allstaff working at the hospital. Completion rates fornursing staff in the acute medicine division stood at95% and 96% for nursing staff in the specialistmedicine division, against a trust target of 95%.However, only 78% of medical staff in acute medicineand 85% of medical staff in specialist medicine hadcompleted this training.

• Hospital staff used paper based patient records torecord patients’ needs and care plans, medicaldecision-making and reviews, and risk assessments.Nursing records were kept at the bedside in folders,whereas medical records were stored in lockedtrolleys near the nursing stations. Staff reported thatthere were no issues with this system as all the mainrisk assessments and care plans were recorded in theassessment booklets used across the trust.

• We looked at 20 sets of patients’ records. Informationwas concise and clear. Conversations with both thepatient and family were well documented anddetailed. Most notes were dated, signed and followedthe trust’s note writing protocol, apart from a fewinstances where entries by medical staff were notsigned and were illegible. On Ash ward, we found thatthree sets of notes did not have the date of transfer tothe ward recorded. This was raised with the wardsister, who told us that she would include this item onthe weekly audit programme for the following monthto ensure compliance.

• Documentation audits took place across the wardseach month to ensure that record keeping standardswere maintained. These looked at areas such aswhether contact details had been fully completed,assessments had been carried out, care plans hadbeen devised and whether entries were clear andlegible. A score of at least 80% compliance across allmeasures was desirable. In August 2016, Gentian wardscored only 65%. Senior staff told us that this was dueto the high number of agency staff used that monthdue to staff sickness, who were not familiar with the

note writing protocol. Nursing staff also told us thatdoctors did not always affix the stickers of cannulapacks into notes as expected, and that these weresometimes discarded as a result. Between June andAugust 2016, other wards scored consistently above90%, with only a few low results that showedimmediate improvement. For example, Gardenia wardscored only 46% in July 2016, but this had drasticallyimproved the following month, with an overall score of95%.

• We saw examples of good documentation practices,such as the use of charts to record challengingbehaviour displayed by those with communicationdifficulties (caused by stroke or dementia). Theseaimed to identify patterns and find the root cause ofthese behaviours so they could be remedied.

Safeguarding

• Staff demonstrated an awareness of safeguardingprocedures and how to recognise if someone was atrisk or had been exposed to abuse. Staff had access tothe up-to-date trust safeguarding policy on theintranet. Safeguarding was part of the trust annualmandatory training. In the acute medicine division,96% of nursing staff had completed safeguardingadults level 2 and safeguarding children level 2training (against a trust target of 90%). For acutemedical staff, these figures were 81% and 77%,respectively, falling short of the trust target. Inspecialist medicine, 97% of nursing staff hadcompleted safeguarding adults training and 95% hadcompleted safeguarding children level 2 training.Specialist medical staff fell short of the trust targetagain, with only 81% of doctors completing eachtraining course.

• However, both medical and nursing staff at all levelsknew who to contact if they wanted further advice andtold us that the safeguarding team supported themwhen they needed advice or guidance. Posters weredisplayed across ward areas detailing contact detailsof the relevant safeguarding leads. Most staff wereable to give examples of safeguarding referrals orconcerns that they had raised. There was a monthlysafeguarding and learning disability operations group,where any issues around safeguarding or staffawareness of processes around this, were shared.

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Mandatory training

• Staff received mandatory training on a rolling annualprogramme which was provided through a mix ofclassroom based sessions and e-learning. Seniornurses of band 6 and above were responsible forensuring that staff that they supervised wereup-to-date with their training. Compliance was nowmonitored through an online system, which alertedstaff and managers when their mandatory trainingwas due to expire. This had improved compliancerates across the service and upcoming trainingsessions were advertised during team meetings andsafety huddles. Some staff commented that somepractical sessions became fully booked quickly butthat the training department was usually responsive inadding extra sessions to meet demand.

• Mandatory training completion rates for nursing staffin the acute medical division were generally good, onthe most part exceeding the trust target of 90%. Theexception was basic life support, which only 83% ofnursing staff had completed in the last year. Nursingstaff in the specialist medicine division had exceededthe trust target of 90% in all mandatory training,including basic life support, which 93% of nurses hadcompleted.

• Training rates for medical staff were not as high acrossboth divisions. In acute medicine, completion ratesranged between 75% (conflict resolution) and 89%(infection prevention and control). In specialistmedicine, completion rates stood at between 71%(sustainability and waste management) and 91%(equality, diversity and human rights). Only 80% ofacute medical staff and 82% of specialist medical staffhad completed basic life support training. The issue ofoutdated basic life support training for both nursingand medical staff had been recognised by the trustand was due to limited capacity on courses runninguntil October 2016. In order to mitigate this, the trustplanned to use qualified trainers employed (in otherroles) in the division to run local courses to bring staffup-to-date. Additionally, the overall poor compliancewith statutory and mandatory training for doctors hadbeen identified divisionally as an area of

improvement, owed partly due to the accessibility oftraining and not fully functional reporting access.Doctors were being contacted individually byspecialist managers to improve their compliance.


• All patients were assessed on admission usingnational risk assessment tools in nutrition, falls risks,manual handling needs and skin integrity. Initialassessments were completed within 24 hours ofadmission, with the aim to identify any factor whichthe patient may need support with and to identify abaseline condition. We observed that processes werein place to ensure that a consultant reviewed allpatients within12 hours of admission, which was inline with agreed national standards.

• Magnetic symbols were used on some wards’ patientinformation boards to identify those patients whowere at risk of pressure ulcers, falls, had nutritional orcommunication needs, or those who were living withdementia. Boards also highlighted when patients hadsimilar names to one another, to avoid mistakes beingmade in their care or treatment.

• Patients at risk of deterioration were discussed in dailysafety huddles or ‘board rounds’, where members ofthe multidisciplinary team (MDT) gathered to reviewindividual patient treatment plans and conditions. Wealso witnessed comprehensive handovers betweennursing staff that discussed risks to particular patientsand appropriate actions that could be taken tomitigate these.

• Nursing and health care assistant staff monitored allinpatients regularly and used a National Early WarningScore (NEWS) to identify patients who weredeteriorating. Nursing staff used a separate chart torecord observations and corresponding NEWS. Welooked at two cases where a score had indicated a riskof deterioration and saw that this had beenappropriately escalated for review by a medic. In caseswhere the NEWS exceeded four points, staff used theadult sepsis screening tool to determine whether thiswas an issue. We saw sepsis decision trees and carepathways on each of the wards we visited.

• Nursing staff told us that doctors were responsive tobleep calls when they were concerned a patient wasdeteriorating. Junior doctors and registrars attended

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the wards out-of-hours when this occurred, usuallywithin thirty minutes, depending on urgency. Staffcould also access advice from the critical outreachteam, who were based at Queen’s hospital andworked Monday to Friday, from 8am to 6pm.

Nursing staffing

• Medical wards displayed nurse staffing information ona board at the ward entrance. This included thestaffing levels that should be on duty and the actualstaffing levels. This meant that people who used theservices were aware of the numbers of staff availablethat day and whether this met the plannedrequirement. This was in line with Department ofHealth guidance. Staffing levels were appropriate forthe acuity and dependency of patients. The Trust usedthe Safer Nursing Care Tool (SNCT) as an indicator forsafe staffing levels across relevant ward areas withinthe Trust.

• Staffing levels had improved since the last inspectionbut varied across the medical wards, with some areashaving more vacancies than others. Senior staff told usthat some wards had no problems recruiting staff tovacant posts. For example, Gardenia ward had threevacant nursing posts but these had already beenadvertised and candidates had been shortlisted. Theward sister had recently put forward a successfulbusiness case for an extra healthcare assistant (HCA)to work during the night to improve patient safety.Beech ward had just recruited one new nurse who wasdue to start work in October and had employed fivenew starters recently. Gentian ward had two vacantband 5 posts. One post had been filled and the otherwas out on a rolling advertisement.

• On other wards, recruiting staff into vacant posts wasmore problematic but there was recognition fromsenior staff that this was an issue and measures hadbeen taken to improve the situation. A trustrecruitment and retention group was established andmet monthly to drive action and monitor progress.Fern ward had 11 whole time equivalent (WTE) nursesagainst an establishment of 19. Nursing staff turnoverfor care of the elderly trust wide was 26.17% at thetime of inspection. Ash ward had filled two vacantband 5 posts with nurses waiting to start and twofurther band 5 nurses on long-term sick leave. Therewas also one vacant band 6 post and two vacant band

2 posts. We noted that nursing staff turnover fordiabetes and endocrinology trust wide wasparticularly high at 35.14%. Staffing levels on Ash wardhad been flagged as an issue on the risk register andmeasures such as increased matron focus andpresence and a three times daily review of nursestaffing and skill mix had been implemented on theward. Across the hospital, the recruitment of nursesfrom Italy and the Philippines had been undertaken.English classes were provided by the trust for thesestaff. Two consultants interviewed were bothcomplimentary about the nursing staff and the staffingreorganisation that they had implemented.

• Staff on Fern and Ash wards reported that bank andagency staff were used on a daily basis to fill gaps inthe nursing rota. Rates of agency and bank usage forthese specialities were indeed amongst the highest inthe trust. Trust wide, between 19.9% and 21.8% ofnursing shifts in diabetes and endocrinology serviceswere filled with bank or agency nurses between March2016 and August 2016. This figure was ranged between17.9% and 23.7% for care of the elderly wards in thesame period. Wherever possible, senior staff tried tofill shifts using regular bank or agency staff, or askedtheir permanent staff to swap shifts to ensure thatthere was an appropriate skill mix on each shift.Induction checklists were used to orientate new bankor agency staff to each ward. Some nursing staff toldus that some agency nurses were not appropriatelyskilled to care for patients, which meant extraresponsibility fell upon them. Issues with agencynurses were escalated to ward managers, who fed thisback to the nursing agency and asked them not tosupply these nurses again. Sometimes, staff weremoved from other areas in order to fill staff shortageson these wards.

Medical staffing

• Compared to other trusts, there was a greater relianceon junior doctors across both King George andQueen’s hospital. Medical staffing was made up of 33%consultants (against a 37% national average), 9%middle career doctors (against 6% nationally), 23%registrars (against 36% nationally) and 35% juniordoctors (against 21% nationally).

• Locum usage for medical staff was generally highacross the trust, especially in some specialities. In

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stroke services, rates of locum usage ranged between18.4% and 34.5% for the period of March 2016 toAugust 2016. In the same period, locum usage in careof the elderly services ranged between 15.6% and24.3%. Both the reliance on locum doctors and theinability to provide timely consultant senior medicalinput across both sites in specialist medicine wereidentified as issues on the corporate risk register.Advance reviews of rotas, sharing medical staffbetween sites, ongoing recruitment and a reduction inoutpatient activity (to free up consultant time) had allbeen agreed as actions.

• On Gentian ward (gastroenterology and care of theelderly), locum registrars and junior doctors wereheavily used, with only one trust junior doctor in post.One patient that we spoke with commented on thelack of continuity and familiarity with doctors incharge of their care. The medical assessment unit(MAU) did not have a stable consultant at present,relying on locums. Nursing staff commented that thiswas difficult as each consultant had a different way ofmanaging patients. Beech ward had consultant covertwo days per week and at other times was staffed by aregistrar and a junior doctor.

• Lack of consultant geriatricians was highlighted as arisk by medical staff on Fern ward. Only threeconsultants covered the rota here and there was areliance on locums, who specialised in generalmedicine rather than geriatrics. There were some gapsin the rota for registrars too. Staff therefore foundsome shifts on-call to be very busy. This shortage ofgeriatricians was a national issue and the trust waslooking into recruiting more specialist nurses in areassuch as falls and dementia care to fill this gap.

• Other wards such as Gardenia did not use locumconsultants and had seven-day consultant cover, withward rounds for cardiology patients taking place onSaturdays and Sunday reviews if necessary. Additionalcover for the medical side of the ward was provided bya ward-based consultant, registrars and junior doctors.There was one vacant post for a junior doctor position.


• There was an up-to-date emergency preparednesspolicy available on the electronic system. Staff hadawareness of what actions they would take in the event

of a major incident, including a fire. An empty ward onsite was used to practice fire safety drills on a weeklybasis. Staff also described training that they hadundertaken which detailed what they should do in theevent of a terrorist incident and how they shouldevacuate their ward, which was described as ‘veryuseful’.

Are medical care services effective?


We rated effective as ‘requires improvement’ because:

• Despite improvement since our last inspection inMarch 2015, there was still a backlog of NationalInstitute for Health and Care Excellence (NICE)guidance that was awaiting confirmation ofcompliance across the trust.

• Fluid charts were not always filled out and somepatients did not like the food, or found it hard to eat.

• For non-elective admissions, the standardised relativerisk of readmission was high, particularly for geriatricmedicine. Patient outcomes in care of the elderly werelimited by the lack of consultant geriatricians to leadimprovements within the service.

• In the Lung Cancer Audit 2015, the trust was belowexpected standards for three key indicators relating toprocess, imaging and nursing measures.

• In the 2015 National Training Survey, junior doctors ingeriatric medicine reported lower overall satisfactionthan the national average, as well as in measures suchas availability of clinical supervision out-of-hours andregional teaching. Although these results hadimproved significantly in the 2016 survey, some issuesstill remained.

• There was a lack of effective seven day working acrossthe hospital. We found there was a reliance on locumconsultant cover out-of-hours and that allied healthprofessionals worked only core office working hoursduring the week, with no cover at weekends. Thepathology service was understaffed and unable toprovide effective cover out-of-hours.

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• There were issues with two out of seven sets of theDeprivation of Liberty Safeguards (DoLS)documentation that we reviewed whilst on inspection.In one set of notes, there was no official extension tothe urgent authorisation present in the notes of apatient waiting for a best interests assessor to reviewthem (this should usually occur in seven days). Thetrust confirmed that the extension had not beenprinted out and placed in the patient file, as perprocedure. In another, there was no documentation orrecord of a DoLS application in the medical or nursingnotes, although this was found later by senior staff.

However:

• The trust had updated all of their local policies sincethe last inspection, and these were regularly reviewed.

• Nursing and medical staff completed a variety of localaudits to monitor compliance and improvement. Staffof all levels told us that these led to meaningfulchange across the service.

• Pain was assessed and well managed on the wards,with appropriate actions taken in response to paintriggers. There was a dedicated hospital pain team.

• The standardised relative risk of readmission for allelective procedures was slightly lower than expectedwhen compared to the England average. This meantthat patients were less likely to require unplannedreadmission after non-emergency procedures,suggesting that the hospital’s care and dischargearrangements were appropriate.

• In the National Diabetes Inpatient Audit (NaDIA) 2015,the hospital scored better than the England averagefor nine indicators out of sixteen indicators. Actionshad been taken to improve the service in thosemeasures where they were underperforming.

• For all specialties apart from geriatric medicine, thetrust scored above the national average for mostmeasures in relation to first year medical doctors intraining (2015 National Training Survey).

• The majority of staff received annual appraisals ontheir performance, which identified further trainingneeds and set achievable goals. Staff were satisfiedwith the quality of the appraisal process. The trust wassupporting nurses with the revalidation process.

• There was evidence of effective multidisciplinaryworking within wards and across departments. Allmembers of staff felt valued and respected.


• Trust policies were current and referenced accordingto national guidelines and recommendations. Thesewere accessible through the trust intranet for all staffthat had electronic access. All policies sampled wereup-to-date.

• Unsatisfactory compliance with National Institute forHealth and Care Excellence (NICE) guidance had beenidentified as a risk on the corporate risk register in2014. A number of measures had been put into placeto improve compliance, such as a monthly trust wideNICE guidance implementation committee. Thisreviewed current practice and developed action plansto ensure compliance with the latest NICE guidance.As of October 2016, the risk register still showed thatthere was a backlog of NICE guidance that wasawaiting confirmation of compliance.

• Patient assessments were based on national tools,such as the Malnutrition National Screening Tool(MUST) and the Braden scale for predicting pressureulcer risk. Care pathways based on national guidancewere in place for conditions such as sepsis, stroke andpressure ulcers. Staff showed awareness of these carepathways and we saw evidence of effective treatmentplans in nursing and medical records. For example,therapists on the stroke rehabilitation unit told us theywere meeting the requirement of NICE guidelines for45 minutes of daily therapy input per patient.

• There were examples of recent local audits that hadbeen completed on the wards. These includedcleanliness and documentation audits, as well astopics identified for improvement locally, such ascatheter care. Senior staff visited other wards ordepartments to ensure objectivity in their completion.Results of these audits and any learning were sharedwith staff in daily safety huddles. Some senior nursingstaff felt that the amount of local audits created a lotof work but did lead to positive change.

Pain relief

• The hospital used a variety of tools to assess pain,depending on the needs of the patient. Nursing notes

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showed that the numeric rating scale (NRS) was themost commonly used and nursing staff conducted apain assessment using this tool with each comfortround undertaken (frequency varied on the acuity ofthe patient). The visual analogue scale (VAS) andnonverbal pain indicator checklists were used toassess pain in those with communication difficulties.Additionally, there was a detailed pain assessmentchart based on the World Health Organisation (WHO)stepladder for patients in acute or chronic pain.

• Appropriate actions were taken in relation to paintriggers to make patients more comfortable. We sawexamples in the records of pain control managed withPRN (pro re nata or administered as required) painrelief. Patients that we spoke with were generallyhappy that their pain was well controlled.

• Pain management and symptom control werediscussed daily in the nursing handovers, ward roundsand huddles. Patients could be referred to thededicated hospital pain team, who offered advice andsupport to patients who were experiencing painbecause of their treatment or illness. The team workedMonday to Friday 8.30am - 4.30pm and Saturday 9am -1pm.

Nutrition and hydration

• All patients were screened on admission to ensurethey were not at risk of malnutrition. The MUST(malnutrition universal screening tool) was used toidentify the risk level of each patient and this wasdocumented in each set of notes we saw. Whenscreening indicated a risk, staff took appropriateactions, such as the maintenance of food charts, theprovision of dietary supplements or referral to adietitian.

• Dietitians attended multidisciplinary team (MDT)meetings and contributed to discussions regardingappropriate nutrition and hydration. The speech andlanguage therapists worked closely with the dietitiansto establish the food and liquid consistency a patientmay require if a patient had difficulty swallowing.Assessments and advice from dietitians and therapistswere seen in the notes we examined.

• On some wards, stickers were used on patient boardsto detail dietary requirements such as specialiseddiabetic, finger food or puree diets. We observed ‘red

trays’ were in use, which alerted staff to patients whorequired support to eat. Adapted cutlery was availablefor those who needed it. Protected mealtimes were inforce, to ensure patients felt comfortable and safe tobe able to eat their meals without any interruptions.These had been introduced to minimise otheractivities on the wards and to ensure adequatesupport was provided to patients.

• Fluid charts were completed for patients identified asat risk of dehydration and regular mouth care wascarried out to ensure their comfort. In the majority ofapplicable cases, these were correctly completed, butwe saw two instances where no fluid intake had beenrecorded, despite the fact that patients had beendrinking fluids. In documentation audits carried outbetween June and August 2016, fluid input and outputtotal were not recorded accurately in the majority ofcases. Staff told us that hospital had recentlyintroduced smaller size water jugs in response tofeedback that many patients could not lift the heavierlarge jugs.

• Three patients we spoke with did not like the food,calling it ‘distasteful’ and ‘hard to eat’.

Patient outcomes

• At King George hospital, the standardised relative riskof readmission for all elective procedures was slightlylower than expected when compared to the Englandaverage. This meant that patients were less likely torequire unplanned readmission after non-emergencyprocedures, suggesting that the hospital’s care anddischarge arrangements were appropriate. However,for non-elective admissions, the standardised relativerisk of readmission was higher, particularly for geriatricmedicine. A care of the elderly consultant told us thatthe service was working hard to improve this situationand had seen positive changes, but that this waslimited by the lack of consultant geriatricians to leadimprovements within the service.

• The Myocardial Ischaemia National Audit Project(MINAP) is a national clinical audit of the managementof heart attack. In 2013/14, King George’s hospitalscored better than the England average for three offour indicators relating to diagnosis and initialmanagement of the type of heart attack measured bythe audit. Patients admitted to cardiac unit or ward

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reached 75.6% (against an England average of 55.6%)and patients that were referred for or had anangiograp hy (including after discharge) sat at 82.1%(against 77.9% as an inpatient and 80.3% afterdischarge across England). However, only 79.1% ofpatients were seen by a cardiologist or a member oftheir team, against 94.3% of patients across England.There was also no data submitted to measure episodeto treatment time and insufficient data submitted toreach conclusions regarding unadjusted mortalityrates for these patients. Overall, the hospital’sperformance in this audit had declined since theprevious year. The trust could not provide an actionplan devised as a result of this audit.

• In the National Heart Failure Audit (2013/14), thehospital performed equal to, or better than, theEngland average in six out of 11 measures. This againshowed an overall decline in performance from theprevious year when measured against the Englandaverage, when it performed better on seven measuresoverall. Areas where the hospital performed worseincluded: cardiology inpatient care (40% against anEngland average of 49%), discharge planning (75%against an England average of 86%) and prescriptionof angiotensin-converting enzyme inhibitors ondischarge (49% against an England average of 72%).Areas where the hospital performed better included:input from a consultant cardiologist (73% comparedan England average of 60%), input from a specialist(95% compared to 78% across England) and referral tocardiology follow-up (61% against an England averageof 54%). In response, the trust planned to revise theworkforce to include a new consultant, specialtydoctor, and heart failure specialist nurse. They alsoplanned to improve data submission to the next auditto provide more reliable results.

• In the National Diabetes Inpatient Audit (NaDIA) 2015,the hospital scored better than the England averagefor nine indicators, including staff knowledge ofdiabetes (71.2% against an England average of 65.5%)and staff awareness that a patient had diabetes(85.27% against an England average of 84.33%). Sincethe previous audit, the hospital had introduced atraining programme relating specifically to diabetesand insulin regimes. The hospital performed worsethan the England average for seven measures,including foot risk assessment, management errors

(30.3% compared to 23.94%) and insulin errors(27.27% compared to 22.6% across England). Seniorpharmacists told us of plans to set up an insulinincidents group to address this issue. Delayeddiagnosis for patients with diabetic foot conditionsdue to lack of a one-stop podiatry service had beenidentified as an issue on the risk register and thedivision were in the process of agreeing funding forthis at the time of inspection. It was also recognisedthat the trust do not currently have a standardprotocol/process for managing patients admitted tothe wards who were already on an insulin pump,which does not comply with NICE guidance. An actionplan to train staff and devise a pathway was underway,with a review date of November 2016.

• In the Lung Cancer Audit 2015, the trust was belowexpected standards for three key indicators relating toprocess, imaging and nursing measures. Only 78.7% ofpatients were seen by a nurse specialist (against anexpected standard of 80%). Only 80.9% werediscussed in a multidisciplinary team (MDT) meeting(against an expected standard of 95%). Only 64%received a pathological diagnosis (against anexpected minimum standard of 75%). These shortfallsare problematic as there is an association betweenclear diagnosis, access to nurse specialists, discussionby the MDT and subsequent receipt of anticancertreatment. Detailed action plans had been put intoplace to improve patient outcomes in this area. Forexample, interactions with primary care had been afocus to improve diagnostic waiting times, specialistnurses had been recruited and additional MDTs hadbeen introduced. Further work was being done tointroduce a nurse-led triage system and meet nationalcancer treatment indicators.

Competent staff

• There were reliable arrangements in place forsupporting and managing new staff, including acomprehensive induction and a supernumeraryperiod during which senior staff assessed their clinicalcompetencies. The trust ran a nurse preceptorshipprogramme that included five study days over thecourse of 12 months. These sessions covered topicssuch as communication, teamwork and effectivedelegation, medicines management and safe practice.One newly qualified band 5 nurse told us that these

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sessions not only taught her new skills, but alsoprovided a space in which she could share herexperiences with other new starters. Each new nursehad to meet regularly with an identified mentor andcomplete a reflective log.

• Junior doctors told us they were supported to learn,with access to effective teaching. The care of theelderly consultants, although stretched, told us theyhad worked hard recently to ensure that junior doctorswere released two afternoons per week for teachingsessions. The National Training Survey monitors juniordoctor experiences of education. In 2015, the trustscored above the national average for most measuresin relation to first year medical doctors in training, butfell short regarding access to educational resources.When considering geriatric medicine as a speciality,junior doctors reported lower overall satisfaction thanthe national average, as well as in measures such asavailability of clinical supervision out-of-hours andregional teaching. Although results hadimproved considerably in 2016, some of these issuesstill remained.

• Most staff told us they had received an appraisal in thelast 12 months to assess their continuing professionaldevelopment (CPD) needs and set realistic andachievable goals. Senior staff told us that some datarelating to appraisals had been lost in the transfer tothe new electronic system. Appraisals data providedby the trust indicated that between 70.9% and 81.7%of staff had received appraisals between April 2016and September 2016, with one anomaly of 18.3% indiabetes and endocrinology (falling from 84.3% in theprevious reporting period). Staff reported they weregenerally happy with the new appraisal system andprocess, which had improved access to CPDopportunities. Staff met with their manager after sixmonths for a review of their CPD and to measureprogress against any set goals. They had opportunitiesto undertake personal development opportunities toenhance their skills and were able to give examples offurther study days they had completed, such asdementia awareness, care of the critically ill patientand mentorship training. The trust scored higher thanthe national average for staff satisfaction with theappraisals process and overall quality of appraisals inthe NHS staff survey 2015.

• There were seven practice development nursesworking across both sites, who were responsible foridentifying training needs and delivering a sustainableeducational programme to improve the delivery ofpatient focused services amongst nursing staff. Mostwards also reported link roles for areas such asdementia, infection control and falls. These link nursesattended in-house update days in their subject andfed new developments and ideas back to the rest ofthe ward team.

• Nursing revalidation is the new process by whichregistered nurses are required to demonstrate on aregular basis that they are up to date and fit topractice. The trust had run open sessions around whatthe process involved and how to collate portfolioevidence. Specific training sessions had been given tothose who may be expected to act as confirmers tojunior nursing staff. Nurses we spoke with feltsupported with the revalidation process. Since April2016, when the process came into effect, 184 nursesacross the trust had successfully completed this. Onlyone nurse had failed to successfully revalidate.

• Since 2014, doctors have been required to undertakean annual appraisal as part of the ‘revalidation’programme for their professional registration (GeneralMedical Council, 2014). The trust provided us withinformation about consultants working in differentspecialties across the trust. In acute medicine, 87.5%of medical staff had received appraisals in the lastyear. In specialist medicine, 91.5% of staff hadreceived an appraisal.


• All relevant professionals were involved in theassessment, planning and delivery of patient care. Thecare records that we examined confirmed activeinvolvement from health professionals of alldisciplines where appropriate, including appropriatereferrals to specialist nurses or teams (such as thediabetic nurse or tissue viability service). Each wardhad a multidisciplinary team (MDT) meeting whichincluded doctors, nurses, occupational therapists,physiotherapists and other allied health professionals(AHPs) as appropriate.

• Daily ward meetings were held on most of the wardswe visited. These were called ‘board rounds’ and they

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reviewed discharge planning and discussed futureactions for those people who had complex factorsaffecting their discharge. Dedicated dischargecoordinators worked with ward staff to identify anypatients with ongoing care needs and link them inwith community teams and social services prior todischarge. A daily safety huddle also took place todiscuss and update the MDT on patients’ progress.

• All members of the MDT reported feeling valued andrespected. Doctors and nurses were complimentaryabout the support they received from one another andthe wider team. A newly qualified nurse described thedoctors on her team as ‘kind’ and described how theytook the time to teach her about conditions and guideher in management of patients. Although there wasone vacancy in the occupational therapy team forBeech ward, staff did not report any problems withreferral or access to the team.

• The trust had introduced Schwartz rounds across bothhospital sites to share working practices and increasesupport amongst staff of different disciplines.Schwartz Rounds are an evidence-based forum forhospital staff from all backgrounds to come togetherto talk about the emotional and social challenges ofcaring for patients. Staff that we spoke with hadvarying awareness of these sessions.

Seven-day services

• Most wards relied on locum on-call consultant coverout-of-hours, on evenings and at weekends. Juniordoctors and nurses told us on-call consultants werequick to respond and they usually arrived on sitewithin 30 minutes. However, only staff on Gardeniaward told us about consultant-led ward rounds on aSaturday.

• Most teams worked normal office hours. For example,the speech and language therapists were available onthe wards Monday to Friday 8.30am – 4.30pm, anddietitians worked core hours of Monday to Friday 9am– 5pm. Occupational therapists (OTs) worked andphysiotherapists worked core weekday hours 8.30am– 4.30pm, but provided an on-call service at weekendsif required.

• Pharmacy services were available 9am – 5pm onweekdays, with a late service that ran until 6.15 pm.The pharmacy discharge team worked alongside the

main service on weekdays, between 11am and 4pm.Weekend cover was provided on Saturdays between9am and 2pm and on Sundays between 9am until12pm. An on-call service, shared with Queen’shospital, was available out-of-hours. Nursing staffbelieved that this service was sufficient, as long as youordered any urgent medications on Friday. Pharmacystaff had also developed measures to help nurses,such as a ‘can’t find a medicine’ flow chart, whichinstructed nursing staff what to do when medicineswere not available on their ward.

• Diagnostic imaging provided a 24-hour, seven-dayservice with a combination of extended days andon-call cover. CT and MRI ran extended days duringthe week and at the weekend. Staff reported no issueswith accessing diagnostic testing out-of-hours.

• Pathology services were unable to provide anadequately staffed service outside of the core workinghours of 9am to 5.30pm, Monday to Friday. Outside ofthese hours, existing staff provided a service on avoluntary rostered basis, which meant staffingfluctuated. Although pathology services aimed toreturn test results to the wards within 60 minutes, thiswas not always possible. The issue had been added tothe corporate risk register and a staffing structurereview and ongoing recruitment was underway.


• There were sufficient computers available on all of thewards we visited, which gave staff access to trustinformation, protocols and policies. Paper copies ofkey policies were also available on the wards,although many of these were not the latest version.

• Clinical staff told us they had access to currentmedical records and diagnostic results such as bloodtests and imaging to support them to safely care forpatients. Admission documents and assessmentswere recorded in one booklet, which was kept withnursing records by the patient bedside. Patientobservations were also maintained at the patient’sbedside to ensure that they were easily accessiblewhen being reviewed.


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• Staff were able to give clear explanations of their rolesand responsibilities under the Mental Capacity Act2005 (MCA) regarding mental capacity assessmentsand Deprivation of Liberty Safeguards (DoLS). Themajority of staff we spoke with were aware of the keyprinciples surrounding capacity assessments, bestinterests meetings and who they would contact forsupport and advice. They were able to give exampleswhere DoLS applications had been made, such as theuse of mitts to prevent confused or unconsciouspatients from pulling out nasal tubes.

• There was a trust lead for DoLS, based on the groundfloor of the hospital, who provided support andtraining to staff as necessary. We saw evidence thatthey regularly emailed senior staff to remind them ofthe key issues surrounding capacity, and providedadditional training around topics such as independentmental health advocacy and the MCA itself. This wasnow part of mandatory training, with 95.1% of nursingand medical staff having completed this trainingwithin the last year.

• Whilst all seven assessments we reviewed clearlyrecorded specific decisions and the reasons for thejudgment made, there were some issues with some ofthe documentation reviewed. On Beech ward, therewas no official extension to the urgent authorisationpresent in the notes of a patient waiting for a bestinterests assessor to review them (this should usuallyoccur in seven days). When we asked staff about this,they told us that this was the job of the safeguardingteam, who would hold the paperwork centrally. Thetrust confirmed that the extension had not beenprinted out and placed in the patient file, as perprocedure. There was another patient on Gentianward, who had previously been subject to a DoLSapplication, which had been lifted. There was nodocumentation or record of the application in themedical or nursing notes. This was raised with thenurse in charge, who managed to find the applicationafter some time.

• There were systems in place to obtain consent frompatients before carrying out a procedure or providingtreatment, which we saw evidence of in patients’notes. We observed staff gaining consent frompatients before giving routine care and treatment,such as washing or adjusting their position in bed.

Are medical care services caring?

Good –––

We rated caring as good because:

• Patients were cared for in a caring and compassionatemanner by staff throughout their stay. Most medicalwards performed in line with the national average inthe NHS Friends and Family Test (FFT).

• Patients’ privacy and dignity was maintainedthroughout their hospital stay.

• Psychological support for patients was easilyaccessible and timely. Patients were routinelyassessed for anxiety and depression on admission.

• The chaplaincy team offered comprehensive spiritualsupport to all patients, regardless of religiousaffiliation.

However:

• The trust performed slightly below the nationalaverage in the National Cancer Inpatient survey 2015.

• Some patients and relatives felt that more could bedone to involve them in their care, especiallysurrounding discharge.

Compassionate care

• Staff consistently treated patients with dignity andrespect. Nurses and doctors introduced themselves topatients and sought permission to enter their bedspace. We saw that staff checked how patientspreferred to be addressed and explained anyprocedures they were about to undertake, gainingclear verbal consent. Ward staff drew curtains aroundbed bays when privacy was needed, such as when apatient was using a commode.

• Interactions between staff and patients were positiveacross the hospital. Staff were warm and caring, with acompassionate and sensitive manner. Patientsdescribed how the nursing staff were “kind” and “veryhelpful”, making sure they were always comfortableand their needs were met. One patient on Gentianward commented that the nurses were, “alwaysfriendly” and that, “you never get a rude nurse…

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sometimes I just don’t know how they do it.” Althoughpatients on some wards recognised that nursing staffwere stretched, most insisted that this did not affectthe service they received and that nurses always, “didtheir best”. We observed that call bells were usuallyanswered promptly, in line with the majority offeedback we received from patients. One patient wasunhappy with care that she had received in themedical assessment unit (MAU), where they allegedthey had to wait over 20 minutes for their call bell tobe answered. We could not find any evidence that thiswas widespread.

• We saw ‘thank you’ cards from patients and relativesdisplayed on Fern ward. Comments included, “all ofyour smiles, kind words, happy faces and caring goes along way towards a patient’s recovery”, and“yourcaring, politeness, jovial sense of humour makes it somuch more pleasant for patients”.

• The NHS Friends and Family Test (FFT) is a nationalinitiative to gain feedback from patients following theiradmission to hospital. The trust had a higher responserate than the England average, with most wardsscoring recommendation scores comparable to theEngland average of 96% (May 2016). Between Marchand May 2016, Gardenia ward scored 91-94%, Gentianward scored 94-100% and Fern ward scored 87-100%.In July 2016, Beech ward scored only 77.8%, but onlynine patients took part. The ward scored highly inregards to dignity and respect (4.7 out of a possiblefive) but only 3.7 for communication (from medics orAHPs). In August 2016, Gardenia ward scored highly onall measures, with all patients reporting that they wereeither ‘extremely likely’ or ‘likely’ to recommend theward. Individual comments reported that it was a“very happy ward” and staff were “always willing tohelp”.

• The trust performed mostly in line with, or slightlybelow, the national average in the National CancerInpatient survey 2015. A total of 1,033 respondentswere asked to rate their care on a scale of zero (verypoor) to 10 (very good). Respondents gave an averagerating of 8.5 (within the expected range), and 84% ofrespondents said that, overall, they were alwaystreated with dignity and respect when they were inhospital.

Understanding and involvement of patients andthose close to

• Most patients told us they felt involved in planningtheir care, and in making choices and informeddecisions about their future treatment. The majority ofpatients we spoke with knew what their prescribedmedications were for and felt that doctors wereproviding them with regular updates on theircondition and progress. One patient on the MAU hadbeen shown how to detach their drip stand so theycould mobilise and use the toilet independently.

• We observed staff involving patients and those closeto them during assessments on the ward giving themtime to ask questions or clarify comments. Weobserved a therapy assessment on Beech ward, wherethe therapists involved the patient as much aspossible and encouraged him to maintain hisindependence, whilst keeping him safe from the risk offalls.

• In the National Cancer Inpatient survey 2015, 74% ofrespondents said that they were definitely involved asmuch as they wanted to be in decisions about theircare and treatment. A further 75% of respondents feltthey were given complete explanation of test results inan understandable way (within the expected range)and 52% of patients were definitely told about sideeffects that could affect them in the future (against anational average of 54%). A further 89% ofrespondents said that hospital staff told them who tocontact if they were worried about their condition ortreatment after they left hospital (against an expectedlower limit of 91%). Action plans had been put intoplace to improve these results in all areas whereexpected standards had not been met. These includedimproving information sharing in MDTs, reviewingwritten patient information leaflets, communicationtraining for staff and improving collaborative workingwith community providers and GPs.

• Some patients and relatives felt that more could bedone to involve them in their care, especiallysurrounding discharge. One patient in the MAU hadbeen in hospital for some time and had discussedself-medication, but this had not been actioned.Another patient on Gardenia ward felt that theirtreatment pathway was unclear and the results oftheir diagnostic tests had not been explained to them

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properly. A relative on the same ward was concernedthat doctors were discussing the discharge of hermother but her family did not feel the patient wasready to go home. She was concerned that no one wasexplaining what help would be available in thecommunity and felt frustrated. Similarly, a patient’srelative on Beech ward was unclear of the dischargeplan going forward and was unsure about what wouldhappen when his wife returned home, despite herbeing in hospital for some weeks. FFT scores for Beechward in July 2016 showed a score of only 3.9 (out of apossible five) for information provision and four (out offive) for patient involvement.

Emotional support

• Most patients we spoke with were very positive aboutthe support they received from members of the MDT.The hospital had access to specialist nurses that couldoffer additional support and advice for example, forpatients with chronic conditions such as diabetes, orcomplex diseases such as cancer. In the NationalCancer Inpatient survey 2015, 92% of respondents saidthat they were given the name of a specialist nursewho would support them through their treatment.When asked how easy or difficult it had been tocontact their specialist nurse, 81% of respondents saidthat it had been ‘quite easy’ or ‘very easy’ (against anexpected lower limit of 82%).

• Patients were assessed for anxiety and depression onadmission, with individual items scoring between zeroand three, depending on their presence. Psychologyinput for stroke rehabilitation patients was accessedthrough the team based at Queen’s hospital. Patientscould either be taken across in hospital transport withan escorting nurse, or a member of the team wouldreview them on the ward if this was not possible. Otherwards were able to access support from the psychiatricliaison team and had access to agency mental healthnurses for those patients who required 1:1 care. Staffgave examples of recent occasions where they hadrequired assistance from mental health nurses and triedto employ the same agency nursing staff to achievecontinuity of care for the patient at this difficult time.Psycho-oncology services and complementarytherapies were both available on-site, as well as alcohol

liaison and counselling service for inpatients. However,nursing staff that we spoke with had not received anytraining specific to caring for patients with mental healthconditions.

Are medical care services responsive?


We rated responsive as requires improvement because:

• Patients were not always able to be located on thespecialist ward appropriate for their condition,although management of these patients hadimproved since the previous inspection. The numberof patients moved four or more times per admissionhad increased. In some wards, such as Ash, Gentianand Gardenia ward, bed moves were consistentlyoccurring out of hours (between 10pm and 6am).However, the trust later informed us that the datademonstrating an increased number of bed moveswas incorrect as they had been counting moves toother departments within the hospital as ward moves.

• Environments on some wards were not ideal, withhigh levels of noise and heat observed and reported.There was a lack of bedside televisions or radiosacross the wards, which some patients reported madethem feel isolated and bored.

• The trust had identified that the pathways for patientswith cancer were not correctly managed and thatthere was poor communication with tertiary centres,which caused delays with patients requiring tertiarytreatment/diagnosis at other specialist hospitals. Thisissue had been added to their risk register in August2016 and was currently being monitored by seniormanagers. Actions to improve this had already beenimplemented, such as a weekly call with tertiarycentres to identify issues at patient level and seekresolution.

• The trust was not meeting 18-week national indicatorsfor non-urgent referral to treatment (RTT) times.

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• NHS England suspended endoscopy screeninginvitations to the trust for eight weeks from July 2016.There was a temporary risk of delayed diagnosis ofbowel cancer due to inability to provide a fullscreening service to the local population.

• Staff across the hospital told us that they could notalways discharge patients promptly due to capacityissues within the hospital or community provisionshad not been put into place. The specialist medicinedivision was currently working on an early dischargeflow programme to address excessive lengths of stay.

• Patient information leaflets were not standardlyavailable in languages other than English. Althoughface-to-face and telephone translation services wereavailable, many staff were not familiar with how toaccess these.

• The Patient Advice and Liaison Service (PALS) did notalways respond to complaints in a timely manner.There were no leaflets detailing how to access PALSand make a formal complaint on Gentian ward at thetime of our inspection.

However:

• Diagnostic waiting time indicators were met by thetrust every month between May and August 2016,meaning over 99% of patients waited less than sixweeks for a diagnostic test.

• Much work had been done since the previousinspection to ensure that discharges were not delayeddue to take home medications. Ward-basedpharmacists helped to facilitate discharges in areaswhere they were available. There was also a pharmacydischarge team who worked 11am to 4pm toweekdays.

• People living with dementia received tailored care andtreatment. Care of the elderly wards had beendesigned to be dementia friendly and the hospitalused the butterfly scheme to help identify those livingwith dementia who may require extra help. Patientsliving with dementia were nursed according to aspecially designed care pathway and were offered 1:1nursing care from healthcare assistants with enhancedtraining. A specialist dementia team and dementia linknurses were available for support and advice.

• Support for people with learning disabilities wasavailable. There was a lead nurse available for supportand advice. Staff made reasonable adjustments forpatients with learning disabilities and there were easyread information leaflets available to explain treatmentsand support during their stay in hospital. There was amonthly safeguarding and learning disability operationsgroup.


• There was a local representatives panel, heldbi-monthly, to give updates to stakeholders includingHealthwatch and local councillors. Minutes indicatedthat service planning and delivery were a keycomponent of the discussions within these meetings.

• Some of the facilities and premises were appropriatefor the services planned and delivered. For example,elements of the care of the elderly wards had beenspecifically designed to meet the needs of patientsliving with dementia. The wards used a colour schemethat identified the bays, introduced ‘orientationclocks’ and improved signage, allowing patients tofind their way to toilets and shower rooms easily.There were plans to introduce clear signage,contrasting coloured areas and large clocks to otherareas of the hospital.

• Some of the patients we spoke with commented thatthe wards could be very noisy at night. We observedthat Fern ward was quite unsettled in the morning,with lots of corridor traffic and high noise levels. Thisimproved in the afternoon, although patients wespoke with confirmed that this level of disruption wasnot unusual. One patient that we spoke with was veryfrustrated as she was sharing a bay with other patientsliving with advanced dementia. The patient told us sheunable to rest or sleep at night and that nursesfocused their care on other “noisy” patients and said,“if I made more noise I would get more attention”.Patients also reported that the ward was very hot andthere were not enough fans to combat warmtemperatures in the summer. Although the trust hadinstalled Wi-Fi across both hospital sites, there was alack of bedside televisions or radios in the wards.Some patients without access to internet compatibledevices told us that this made them feel isolated andbored.

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• The trust had identified that the pathways for patientswith cancer were not correctly managed and thatthere was poor communication with tertiary centres,which caused delays with patients requiring tertiarytreatment/diagnosis at other specialist hospitals. Thisissue had been added to their risk register in August2016 and was currently being monitored by seniormanagers. Actions to improve this had already beenimplemented, such as a weekly call with tertiarycentres to identify issues at patient level and seekresolution.

Access and flow

• There were daily bed management meetings attendedby senior staff to plan patient admissions, transfersand discharges. Care pathway organisers helped tofacilitate patient flow throughout the hospital.

• Patients were not always able to be located on thespecialist ward appropriate for their condition,although ward staff told us that management of thesepatients had improved. Information provided by thetrust showed there was a shortage of medical bedsand a number of patients were placed on wards thatwere not suited to meet their needs (also known asmedical outliers). The specialist medicine division hadhighlighted this as an issue on their risk register,identifying that they were unable to place theirpatients in the correct speciality, resulting in outliers.

• Data demonstrated that 225 (3% of) inpatients weremoved four or more times per admission betweenSeptember 2015 and August 2016. This had increasedsince the previous inspection. In some wards, such asAsh, Gentian and Gardenia ward, bed moves wereconsistently occurring out of hours (between 10pmand 6am) with between 55 and 60 patients moved inthese times during August 2016. A patient on Gardeniaward told us that they had been transferred betweenmultiple wards during their nine day stay. However,the trust later informed us that the datademonstrating an increased number of bed moveswas incorrect as they had been counting moves toother departments within the hospital as ward moves.

• At King George hospital, the average length of stay forall elective and all non-elective patients was higherthan the England average, with the exception ofnon-elective patients in geriatric medicine.

• The bed occupancy rates between April and August2016 for King George’s hospital ranged between 83.4%(August) and 88.4% (May).

• The trust did not submit any referral to treatment time(RTT) data to NHS England in the reporting period(June 2015 – May 2016), for unknown reasons. TheNHS Constitution gives patients the right to accessservices within maximum waiting times. This isnormally 18 weeks for non-urgent conditions. Thetrust was not meeting this national indicator, withdata provided directly indicating that between 64.3%and 73.7% of patients being treated within 18 weeks oforiginal referral between September 2015 and August2016.

• In the trust’s annual report 2015/16, they reported that96.1% of patients with a diagnosis of cancer receivedtheir first treatment within 31 days of decision to treat(against a national indicator of 96%). In 2016,performance against the 31-day nationalindicator continued to be good, achieving 100% forevery month between March and July, apart from inApril, when only 83.4% of patients were seen. In thesame annual report, the trust reported that only 74%of patients were receiving their first treatment from theinitial GP referral within 62 days (against a nationalindicator of 85%). This continued to be an issue in2016, with between only 25% and 80% of patientsmeeting the 62-day national indicator between Marchand July. The trust was aware that it was failing toachieve this national indicator and attributed this topoor pathway management for specific tumourgroups (urology, upper GI and colorectal), capacityand workforce issues, in addition to diagnostic testsoccurring too late in the pathways. An action plan wasdevised to improve this, which included theengagement with partners via the London CancerVanguard programme to escalate issues and delays,regular review of capacity with additional clinics beingrun regularly and a recruitment plan being put intoplace. A cancer programme board monitoredperformance on a weekly basis and strengthenedtracking of all patients on a 62-day pathway.

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• Diagnostic waiting time indicators were met by thetrust every month between May and August 2016,meaning over 99% of patients waited less than sixweeks for a diagnostic test. In April 2016, the trust fellshort of this, achieving 98.4%.

• The trust had identified a risk of delayed diagnosis ofbowel cancer due to inability to provide a fullscreening service to the local population. NHSEngland suspended endoscopy screeninginvitations to the trust for eight weeks from July 2016.This was due to staff leaving the service and wasadded to the risk register in the same month. Anaction plan had been put in place to mitigate this. A0.2 whole time equivalent (WTE) locum colonoscopistwas employed to run an additional list and providebackfill cover when substantive consultant was onleave. By October 2016, all substantive staff were inpost and invitations were restarted, with 33% ofinvitations being sent out.

• The medical assessment unit (MAU) was sometimesunable to function effectively because it was not ableto move patients promptly to other speciality wardswithin the hospital due to lack of bed availability. Theaverage length of stay on MAU was intended to be48-72 hours but this often meant patients stayed onthe ward for a week or longer.

• Staff across the hospital told us they could not alwaysdischarge patients promptly because communityhospital beds were not available or suitable ongoingcare arrangements or equipment were not in place.On Beech ward, nursing staff told us that this hadrecently become even more problematic because ofthe closure of an acute stroke unit in another Londonhospital, so there were not the same community linksfor these patients. A Joint Assessment and Dischargeteam, which included both nurses and social workers,worked together with ward staff and patients whosedischarges were delayed or complex. The specialistmedicine division was currently working on an earlydischarge flow programme to address excessivelengths of stay, which was included as an item on thedivisional risk register in August 2016.

• There was a discharge lounge, where patientsawaiting transport for discharge were transferred inorder to ease the pressure of beds on the wards.Patients arrived at the discharge lounge with their

take-home medications and were usually collected bytransport by 8pm at the latest. Ward-basedpharmacists helped to facilitate discharges in areaswhere they were available. There was also a pharmacydischarge team who worked 11am to 4pm toweekdays. Nursing staff were encouraged to order anymedications for anticipated discharges as soon aspossible. Some wards had introduced a named nurseresponsible for discharge planning to ensure this tookplace.


• On most wards we visited, there was a ‘good to talk’board, which included information on how to contactthe patient advice and liaison service (PALS), languageservices, chaplaincy support and how to provideinformal feedback. There were also boards on everyward that explained who different key staff were andincluded pictures of the different staff uniforms in use,explaining what role each one signified.

• The medical inpatient service aimed to ensure thatsupport was available for patients with complexneeds. A training course was being piloted thatincluded training in areas such as falls prevention,caring for people living with dementia and mentalcapacity. One of the matrons told us how sheattended this training and then shared her knowledgewith other staff on Fern, Gentian and Erica wards.

• Staff used a cognitive assessment tool to identifypatients with memory issues on admission. A jointdelirium clinic with a psychiatrist from another trustalso took place at the Queen’s site to enable the rapidassessment of patients who had recently becomeconfused. This determined whether the cause of theconfusion was dementia or, something more easilytreated, such as a urinary tract infection. A memoryclinic had been introduced at King George’s hospital,to provide assessment, diagnosis, treatment andtherapeutic interventions to those experiencingmemory loss.

• Wards used a butterfly symbol on patient informationboards to indicate that a patient was living withdementia. Patients living with dementia were nursedaccording to a specially designed care pathway andwere offered 1:1 nursing care from healthcareassistants with enhanced training, who provided

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stimulation and company. Family members and carerswere encouraged to be involved in their care as muchas possible and ‘this is me’ booklets were produced toensure staff were familiar with the best ways toapproach caring for each patient. Red trays at mealtimes were used to alert nursing staff the patient mayrequire extra help and finger food was available forthese patients. Staff had received in-house training oncaring for people living with dementia. All staff wespoke with were aware that these patients neededextra support and were able to describe how theywould provide them with person-centred care. Aspecialist dementia team (based at Queen’s hospital)and dementia link nurses were available for supportand advice.

• There were dementia carers coffee mornings,facilitated by the dementia team, to provideinformation and support to carers and relatives ofpatients living with dementia. The trust worked withexternal organisations and charities to provide furthersupport and advice to patients and their families uponleaving the hospital.

• Support for people with learning disabilities wasavailable. There was a lead nurse available for supportand advice. Staff worked collaboratively with thecarers of learning disabilities patients to meet theirindividual needs. Staff made reasonable adjustmentsfor patients with learning disabilities such as openvisiting and allowing carers to stay overnight. Therewere easy read information leaflets available toexplain treatments and support their stay in hospital.Nursing staff also told us that hospital passports wereused for patients with learning difficulties, but couldnot locate this in the file of a patient currently on oneof the wards.

• There was a monthly safeguarding and learningdisability operations group, where any issues aroundcaring for patients with learning disabilities ordementia were discussed. Regular audits were carriedout around staff awareness and knowledge of caringfor patients with these complex needs. The resultswere shared at the monthly meetings and any actionpoints to take forward were agreed.

• Patient information leaflets were not standardlyavailable in languages other than English. Althoughface-to-face and telephone translation services were

available, many staff were not familiar with how toaccess these. They told us that they used familymembers to communicate with patients whose firstlanguage was not English. There are several issueswith this, such as potential unreliable informationtransfer, reluctance to deliver bad news andunfamiliarity with medical terminology. A patient onGardenia ward told us that the language barrier hadbeen a problem during their stay as they only spokeHindi and translation services had not been effectivelyaccessed. However, we saw one example of goodpractice on Beech ward, where one Chinese patienthad been provided with Chinese symbols mounted oncard to communicate simple messages.

• Within the catering menu there were many options tocater for those with different nutritional requirements.Menu items catered for those with food allergies andprovided halal, kosher, vegetarian and vegan options.However one patient we spoke to, who was vegan,told us she had not been provided with sufficientdietary options, such as dairy-free milk.

• Chaplaincy services for patients requiring spiritualsupport were available. There was a multi-faith chapelon-site for worship, with an ablutions room availablefor people from the Muslim faith. Staff said thehospital chaplains had a visual presence around thehospital and were easy to contact through theswitchboard. Representatives from most majorreligions were available, including Church of England,Catholic, Islam, Judaism, and Sikhism.

• There was access to psychological support for thoseundergoing cancer treatment through the MacmillanInformation Centre. All specialist nurses were alsotrained in level two psychology. Patients also hadaccess to a variety of support groups classified bycancer type. In the National Cancer Inpatient Survey2015, 75% of respondents said that hospital staff gaveinformation about support groups (against anexpected lower limit of 78%).


• Staff told us that informal complaints were dealt withat ward level. Formal complaints were handled by thePatient Advice and Liaison Service (PALS) or the

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complaints department. There were leafletsthroughout most wards detailing how to access PALSand make a formal complaint, although none wereseen on Gentian ward at the time of our inspection.

• The acute medicine division as a whole received 122complaints between April and September 2016.Analysis across the trust showed that the top themesof complaints were treatment, staff attitudes, security,communication and diagnosis.

• The trust reported that it was currently 100%compliant with acknowledging written complaintswithin three working days (August and September2016). PALS attempted to respond to verbalcomplaints within five working days, but would agreea final timescale with the complainant in eachindividual case. The overall complaint had improvedfrom 78.3% in July 2016, up from just 14.8% in June2016. Minutes from clinical quality review meetingsindicated that PALS responses to complaints weresometimes not timely. Between April and June 2016,only 60% of complaints were replied to within thetimescale agreed with the complainant, against a trusttarget of 85%. For example, minutes from June 2016indicated that 13 responses across the trust wereoverdue against a zero tolerance. These had beenescalated to speciality managers.

• The trust conducted a survey of 159 patients that hadmade complaints between September 2015 andSeptember 2016. Of these patients, only 65% ofpatients were satisfied with the time frame of thecomplaints investigation process. However, 84% ofpatients felt they were given an apology whereappropriate and 80% of patients felt that lessons werelearned from the complaint and appropriate actionswere taken.

• Complaints data was discussed monthly at both theclinical quality review meeting and the patientexperience and engagement group. Any themes orlearning were then shared with wider staff groupsthrough the integrated quality and safety report, teammeetings and divisional newsletters.

Are medical care services well-led?

Good –––

We rated well-led as good because:

• The trust had developed a clinical vision and strategyand communicated this to staff of all levels, enablingthem to feel involved in the development of theservice.

• The governance structure had been revised to providea greater level of accountability and oversight of risk.

• Most nursing and medical staff thought that their linemanagers and the senior team were supportive andapproachable. The chief executive and divisional leadsheld regular meetings to facilitate staff engagement.

• Quality improvement and research projects took placethat drove innovation and improved the patientexperience. Regular audits were undertaken, overseenby a committee. The hospital facilitated a number offorums and listening events to engage patients in thedevelopment of the service.

Leadership of service

• The trust had restructured the management of theservice in 2015/16, establishing six clinically leddivisions, each with a divisional clinical director,divisional nurse and divisional manager. This meantthat medical services fell under either the specialist oracute medicine divisions. New appointments hadbeen made within the divisions, such as the additionof two new matrons within the specialist medicinedivision.

• Most staff felt positive about these changes. Juniornursing staff described their ward managers andmatrons as approachable and supportive, confirmingthat they were available at all times for advice, evenwhen working cross-site. A few staff commented thatthis could sometimes cause administrative delays, butdid not directly affect patient care.

• The senior divisional leaders were described as visibleand proactive by some nursing and medical staff, whotold us that they were looking into areas of concernand engaging staff in the process of incrementalpositive change. One consultant believed hisdivisional leaders gave him the opportunity to be

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autonomous but also offered oversight and supportwhere necessary. Other staff were not as enthusiastic,describing them as just “okay” and believing theycould be more involved in the clinical management ofthe hospital.

• The executive team held various regular meetings withstaff of all levels. The chief nurse met with staff of band6 and above every week to discuss challenges facedon the wards. There was also a ‘breakfast with theboss’ meeting, where staff of all levels could meet withthe chief executive. Divisional managers alsosometimes attended daily board meetings on thewards.


• The trust had adopted a set of values based on theirinvolvement with a consulting organisation, whichemphasised person-centred care and anevidence-based quality improvement culture. Thesewere now fully embedded within the service, based onthe acronym ‘PRIDE’, which stood for Passion,Responsibility, Innovation, Drive and Empowerment.All staff we spoke with were aware of these values.Medical staff told us that the values-based approachgave them more of a sense of ownership andempowerment, changing things across the hospital forthe better.

• The approach of continuous, incrementalimprovement was emphasised across the trust. Thefocus for all improvement work within the trust wasthe elimination of waste, the standardisation of work,mistake proofing and a methodology aimed primarilyat reducing flow times and response times to patients.The goal of the trust was to become a learningorganisation that engaged staff at every level. As such,this approach had been incorporated into the staffappraisal process.

• There was a five-year plan which had been developedin partnership with system leaders and organisationsacross north east London (with 2016/17 being the firstyear of the plan). This plan described how serviceswould collectively work to deliver sustainable servicesto the local population, and was aligned to theemerging trust clinical services strategy. The planinvolved working closely with commissioners to defineand manage clinical pathways. In December 2015, the

trust had conducted a stakeholder audit to identifystrengths and weaknesses and find a way of workingtogether with other organisations to improve services.For example, for diabetes, the trust was alreadyworking with commissioners to ensure a single jointservice operated across both community and acuteservices in the region. This would mean patients couldeasily access the most appropriate care for them andthe local health economy as a whole could managedemand. This pathway included escalationmechanisms to consultant level, in the case ofdeteriorating patients. The trust planned to use this asa model when tackling issues such as the nationalcancer treatment indicators, where the 62-dayindicator was currently in breach.


• It was clear the service had taken steps to addresssome of the issues identified during our previousinspection, such as the review of serious incidents andthe reporting culture surrounding these. Where risksstill remained, such as the reliance on locum doctors,these issues had been added to both the divisionaland corporate risk registers to be monitored. Riskswere graded according to likelihood and impact. Boththe acute and speciality medicine divisions hadup-to-date risk registers that included mitigation andaction plans. Issues on the risk registers aligned to theconcerns that staff identified.

• There were several groups which aimed to improvegovernance and risk management across the trust.The clinical outcome and effectiveness groupdiscussed topics such as national targets, audits, carepathways, medicine optimisation and NICEcompliance. The patient safety group focused ontopics such as incidents, infection prevention andcontrol, medicines safety and safeguarding. Thepatient experience group discussed areas such ascomplaints, dementia, nutrition and volunteering. Thepeople and culture committee examined issues suchas staffing, training and equality and diversity.Discussions from these meetings all fed into themonthly quality assurance committee, whichconsidered governance and risk management issuesas a whole. However, some staff told us that thiscommittee was often poorly attended.

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• There were also regular senior nurses meetings, aswell as divisional and ward meetings where risk andgovernance issues were discussed with a wider staffgroup. The frequency of these meetings varied acrossdivisions, with some specialties or wards meetingevery two weeks, and some every three months.Senior staff were able to tell us how their ward’sperformance was monitored, and how performanceboards were used to display current informationabout the staffing levels and risk factors for each ward.

• The divisions had an audit calendar, which was usedto monitor services and compliance against nationaland local standards. Nursing staff participated in localaudits, and although some told us that this increasedtheir workload, they could see how resultinginformation was shared amongst teams to promoteimprovement. There was an audit committee that metfive times a year to oversee both external and internalaudits.


• Staff of all levels said they felt supported and able tospeak up if they had concerns. Nurses told us therehad been a shift away from ‘blame culture’, towardslearning from mistakes and ‘near misses’. Most feltcomfortable to raise concerns with local managers,but were also aware of formal whistleblowingprocedures and policy. The independent guardianservice was now into its third year and helped staff toopenly raise their concerns in confidence.

• Staff of all levels told us they were happy working atthe hospital and felt they contributed to creating apositive work environment. All staff we spoke withspoke positively of their local teams, speaking of thepositive changes that had occurred since the lastinspection. They commented on improvements innursing morale and empowerment, making the wardsmore enjoyable to work on and reducing stress andsickness. New starters felt supported and able to askquestions. Although the NHS staff survey results werebelow average for acute trusts, staff who workedacross sites told us that there was a big difference inworking at King George’s hospital. They described theatmosphere as more friendly and relaxed thanQueen’s hospital.

Public engagement

• The medical service engaged with patients, relativesand patient representatives to involve them indecision making about the planning and delivery ofthe service. Weekly patient safety summits, run by themedical director, offered patient partners theopportunity to discuss incidents, safeguarding andother issues that affected patient care. Medical staffthat we spoke with confirmed that they receivedminutes from these meetings via email. The trust hadalso introduced a patient experience and engagementgroup in 2015, which provided a forum for staff toengage with and receive feedback from keystakeholders including patients and carers. Listeningevents, held in conjunction with Healthwatch, focusedon the highest number of Patient Advice and LiaisonService (PALS) enquiries and formal complaints,allowed patients the chance to ask seniormanagement questions around issues raised. Thetrust produced leaflets that summarised concernsarising from these meetings and stated what had beendone to address these. Other wards, such as Fernward, invited patients to come and talk to ward staffabout their experiences of care.

• In April 2016, the trust awarded the contract fordelivering and reporting of the Friends and Family Test(FFT) to an external organisation. This organisationprovides continuous, real-time collection, monitoringand analysis of quantitative and qualitative patientfeedback. This was rolled out fully across the trust inJune 2016 and at the time of inspection, onlinepatient surveys were live. King George’s hospitalreceived 13,282 online reviews to date (as of 10October 2016), with an average rating of five stars (outof five). Nursing staff reported that this had reallyhelped to improve both patient confidence in thehospital and staff morale, as it helped put positiveexperiences in the public domain.

• The trust included patient stories as part of thecorporate trust induction. A patient story, based onreal life experiences from the hospital, was presentedeach month at the board meetings so that leaderscould hear first-hand about how patients felt aboutthe care they had received.

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• There were 217 active volunteers at the end of June2016. The roles volunteers undertook varied fromwelcoming patients to the hospital and helping themfind their way, to chaplaincy and clerical positions.There was a dedicated volunteer of the year award.

Staff engagement

• Staff attended various ward and divisional meetings,as well as additional forums such as monthly seniorsisters meetings, specialist nurse forums andnon-medical prescribing forums, where appropriate.The meetings were designed to foster staffengagement, share information and drive forwardimprovement. Staff had been consulted on thechanges taking part across the service, and for themost part, told us that they felt engaged with theservice as a whole.

• The trust conducted various local surveys andengagement with the NHS staff survey which hadincreased to 37% in 2015. This meant that it was nowalmost in line with the national average (41%). In theacute medicine division, staff were satisfied withsupport from their immediate line management andthe level of training and support they received. In fact,the quality of non-mandatory training, learning &development across the trust was rated in the top 20%of comparable trusts. In care of the elderly, staff feltsatisfied with opportunities to use their skills andshow initiative. They felt involved in importantdecisions and felt that senior managers acted on stafffeedback. Communication between seniormanagement and staff was noted to be effective.These measures had improved across most of thetrust from the last survey, and staff motivation wasnow within the top 20% of comparable trusts.

• There were some issues in the staff survey results. Staffin the endocrinology department reported that theyfelt harm may be caused to the public through ‘nearmisses’ or errors they had witnessed in the last month(83% against trust average of 30%, which was in linewith the national average). This was also higher thanthe trust average in acute medicine. Ingastroenterology, staff felt that managers did notinvolve staff in decisions (57%) and did not act on stafffeedback (53%). In care of the elderly, as well as acutemedicine, discrimination and abuse from the publicwere also perceived as particularly high. Across the

trust, the percentage of staff experiencingdiscrimination at work was higher than the nationalaverage, as well as those reporting bullying andharassment. The number of staff believing that thereare equal opportunities for career progressedremained unchanged from the previous survey andwas lower than the national average. Action plans hadbeen developed as a result of these issues, with staffbeing encouraged to increase incident reporting andraise concerns at the time they happened, thedevelopment of two-way communication and anincrease in forums for staff to raise concerns. Therewas also a focus on releasing staff to attend divisionalmeetings to improve communication andengagement with senior managers.

• The trust celebrated the achievements of staff byhaving a ‘star of the month’ which colleaguesnominated. There were also annual staff awardceremonies, based around the trust values, whichawarded staff in categories such as ‘Hospital Hero’,‘Working Together’ and ‘Pursuing Excellence’. Staffcould also receive ‘terrific tickets’ at any time to thankstaff for going above and beyond.


• The trust was chosen as one of five trusts in thecountry to be mentored by the Virginia Mason Institute(the USA’s ‘Hospital of the Decade’) as part of afive-year improvement programme. Clinicians andleaders from the institute were teaching staff aboutthe principles and systems that they used. The trustplanned to focus on continuous, incrementalimprovement, focusing initially on improving theexperience of the admission process (first 24 hours ofcare) and diagnostics, particularly the way wecommunicate results of investigations betweenclinical teams and patients.

• Most staff were positive about the involvement they hadin the development of services and innovative practice.They were able to attend conferences and presentpapers. In care of the elderly, much work had been donein ensuring that patients living with dementia receivedgood care. Across the trust, 12 new positions ofspecialist healthcare assistants (HCAs) had beeninstated to ensure that people with living dementiareceived safe and compassionate care, without relyingon existing or agency nurses. Integrated case

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management was now possible for care of the elderlypatients, with virtual meetings with GPs and communitymatrons taking place. Other senior staff had submittedbusiness cases for additional staff support. For example,on Fern ward, an advert was out to post for a band 2housekeeper to check equipment, make sure

appointments kept and get patient feedback. There wasalso a plan in place to bring staffing levels up to 1:7instead of 1:8. However, a few staff we spoke with feltthat there could be more of a focus on research withintheir department.

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Effective Not sufficient evidence to rate –––


Responsive Requires improvement –––

Well-led Good –––


Information about the serviceKing George’s Hospital (KGH) offers a range of services andclinics for outpatients, including: general surgery, ear, noseand throat (ENT), breast surgery, cardiology, nephrology,respiratory medicine, neurology, orthopaedics, trauma,urology, opthalmology, clinical oncology, endocrinology,rheumatology, gastroenterology, general medicine,anti-coagulation, pain management, and dermatology.

The centralised appointment booking system for BarkingHavering and Redbridge University Trust (BHRUT) waslocated at King George’s Hospital.

Between March 2015 and March 2016 the Trust saw 817,013patients in their outpatients department across two sites.

The main OPD was located near the main entrance areaand was divided into further sub-waiting areas, includingthe phlebotomy department. Cardiology was located onthe first floor and symptomatic breast services in aseparate area on the ground floor.

KGH also provides a full range of diagnostic imaging,including general radiography, computed tomography (CT),ultrasound, magnetic resonance imaging (MRI), nuclearmedicine and interventional radiology. The serviceperformed approximately 44,500 examinations each monthacross both Queens and King George’s Hospital. Theradiology department supported the outpatient clinics aswell as inpatients, emergency and GP referrals.

Outpatient services had an action plan in place to makeimprovements following recommendations from theprevious Care Quality Commission (CQC)

During our inspection we spoke with 12 patients and 27members of staff. Staff we spoke with included receptionand booking staff, nurses of all grades, radiologists, clericalstaff, radiographers, doctors and consultants.

We observed care and treatment. We also reviewed thesystems and management of the departments includingthe quality and performance information.


Outpatients and diagnostic imaging


Summary of findingsWe found the outpatients and diagnostic imagingservices required improvement.

• Outpatients and diagnostic imaging services were intransition. The strategy for these services was indevelopment. There were a number of new seniormanagers who had introduced new qualityassurance and risk measurement systems. However,these were not fully embedded.

• Hand gel dispensers were in situ across outpatientsand diagnostic imaging but we did not observe staffor patients using them.

• The percentage of patients who did not attend (DNA)their appointment was above the England average.Staff told us they were not confident of meetingthe national indicator for patients waiting over 18weeks by their target date of March 2017. The trust’sperformance for the 62 day cancer waiting time wasconsistently below the England average.Appointments cancelled by the hospital were alsohigher than the England average.

• Some staff in the diagnostics and imaging team saidthere was a lack of clarity around their roles andresponsibilities.

However , we also found:

• There was evidence of improvements in outpatient,diagnostic and imaging services. There had been an88% reduction in the overall backlog of patientswaiting over 52 weeks since May 2016.

• Staff were aware of how to report incidents andcould clearly demonstrate how and when incidentshad been reported. Lessons were learnt fromincidents and shared across the trust.

• The trust had changed their patient records systemand introduced the electronic patient record (EPR).

• There were appropriate protocols in place forsafeguarding vulnerable adults and children. Staffwere aware of the requirements of their roles andresponsibilities in relation to safeguarding.

• Patients’ and staff views were actively sought andthere was evidence of improvement anddevelopment of staff and services. Staffing levels andskill mix were planned to ensure the delivery ofoutpatient, diagnostic and imaging services at alltimes. All new staff completed a corporate and localinduction. Staff were competent to perform theirroles and took part in benchmarking andaccreditation schemes.

• Medicines were found to be in date and storedsecurely in locked cupboards. Staff were able todescribe the procedure if a patient became unwell intheir department and knew how to locate the majorincident policy on the intranet.

• All the patients, relatives and carers we spoke withwere positive about the way staff treated people.There was a visible person-centred culture in mostdepartments. Patients and relatives told us they wereinvolved in decision making about their care andtreatment. People’s individual preferences and needswere reflected in how care was delivered.

• Work was in progress to conduct a demand andcapacity analysis to enable the service to develop amodel whereby the hospital could assess andeffectively manage the demands on the service. Thehospital was using a range of private providers toassist in clearing the backlog of appointments.

• Patients attending outpatients and diagnosticimaging departments received care and treatmentthat was evidence based. The service was monitoringthe care and treatment outcomes of patients whowere receiving outsourced care from providers in theprivate sector.

• Outpatients, diagnostic and imaging services hadintroduced extended clinics seven days a week toclear patient waiting list backlogs.

• There was a formal complaints process for people touse. Complaints information, as well as patientexperience information was fed into the trustgovernance processes and trust board with formalreporting mechanisms.

• Most local managers demonstrated good leadershipwithin their department. Managers had knowledge of




performance in their areas of responsibility andunderstood the risks and challenges to the service.There was a system of governance and riskmanagement meetings at both departmental anddivisional levels.

Are outpatient and diagnostic imagingservices safe?


We rated safe requires improvement because:

• The audiology room venting system was not working.

• Hand gel dispensers were in situ across outpatients anddiagnostic imaging but we did not observe staff orpatients using them.

• The inspection raised concerns about the diagnosticimaging department not complying with all the policiesand procedures based on the Ionising Radiation(Medical Exposure) Regulations (IR(ME)R) and theIonising Radiation Regulations 1999 (IRR99). Theseregulations are to protect patients, staff and the public.

• Although a comprehensive induction programme was inplace for all new diagnostic imaging staff, some newstaff members did not know where to find the LocalRules. Local Rules are produced to satisfy therequirements of the Ionising Radiation Regulations(IRR1999) and are designed to enable the work withinthe diagnostic imaging department to be carried outsafely and in accordance with the regulations.

However, we also found:

• Staff were aware of how to report incidents and couldclearly demonstrate how and when incidents had beenreported. Lessons were learnt from incidents and sharedacross the trust.

• Procedures were in place for the prevention and controlof infection and maintenance contracts were in place tomake sure specialist equipment was serviced regularly.The outpatients department had introduced adecontamination room in the previous 12 months.

• The trust had changed their patient records system andintroduced the electronic patient record (EPR),

• There were appropriate protocols in place forsafeguarding vulnerable adults and children, and staffwere aware of the requirements of their roles andresponsibilities in relation to safeguarding.




• Staffing levels and skill mix were planned to ensure thedelivery of outpatient, diagnostic and imaging servicesat all times. The staffing issues in diagnostic imaginghad been addressed from the previous report and newstaff were in post. Agency staff were used to manage theworkload the musculoskeletal ultrasound.

• The majority of staff had completed the requiredmandatory training.

• All medicines in outpatients and diagnostic imagingwere found to be in date and stored securely in lockedcupboards.

• Staff were able to describe the procedure if a patientbecame unwell in their department and knew how tolocate the major incident policy on the intranet.

• The outpatients department had introduced key padprotected notes rooms for each base area, to ensurepatient’s information was protected.

Incidents

• The service had systems in place to ensure thatincidents were reported and investigated appropriately.All the nursing and medical staff we spoke to stated thatthey were encouraged to report incidents via theelectronic incident data management system.Radiography staff informed us they were encouraged toreport incidents which occurred in their working area.All the staff we spoke with were confident to reportincidents via the trusts electronic reporting system.

• There was a total of 433 incidents reported between 1September 2015 and 15 September 2016.There hadbeen no never events and 13 serious incidents requiringinvestigation reported between July 2015 to June 2016to the strategic executive information system, (STEIS).

• There were 3 open incidents on the day of theinspection in diagnostic imaging. The quality lead forthe directorate showed us the categories of theincidents and how they had been assigned to a leadmember of staff for further follow up. Senior staff told usthey received weekly emails with updates on incidentsand a timeline within which to respond.

• Incidents were monitored by the trust’s riskmanagement team for trends. The lead sent electronicincident reports to team leaders monthly.

• Incidents were standard agenda items at monthly‘incident reporting’ meetings. SI investigations weresent to departmental leads prior to the meetings. Themonthly were attended by a staff representative fromeach service area. Where incidents had been reported afull investigation had been carried out and steps weretaken to ensure lessons were learnt. Action plans wereproduced following investigations. These weremonitored and tracked to completion at subsequentmeetings. Staff told us that learning from incidents inother parts of the trust was cascaded at team meetingsand huddles.

• The matron and senior sister received safety alerts andwas responsible for taking action to respond to relevantalerts. This included discussion of alerts at the huddlemeeting. Staff told us completed actions would bereported to the Department of Health’s (DOH) centralalerting system, (CAS).

• The outpatients department had produced writtenguides for staff on how to report an incident using theinternet. This gave staff step by step guidance ofrecording and reporting incidents.

• Staff told us they understood their responsibilities toreport incidents using the electronic reporting system,and knew how to raise concerns. Staff confirmed theyreceived feedback on incidents that took place in otherareas of the service as well as their own. Staff andmanagers told us they were satisfied there had beenimprovements in staff incident report and there was aculture of reporting incidents promptly within both theoutpatients department. Incidents were audited on thetrust’s electronic reporting system by the riskmanagement team.

• Diagnostic imaging services had procedures to reportincidents to the correct organisations, including CQC. Atthe time of the inspection, there were no reported caseswith the CQC for the KGH site.

• Documents related to the IR(ME)R and IRR99 regulationswere held on the computer shared drive for diagnosticimaging. The local rules for KGH had not been updatedsince 2014 and the procedures that all employers arerequired to have in place when using ionising radiationhad also not been updated since 2012. Thedocumentation was difficult to locate on the computer.




• There was a record of IR(ME)R training for non-medicalreferrers on the noticeboard in the staff area which hadbeen put in place on the first day of the inspection.There was no record of this staff member on theelectronic file for non-medical referrers.

• The last IR(ME)R audit undertaken in 2014 showed KGHwas non-compliant with several requirements. Theaction plan had not been updated to demonstrate anyprogress on these issues.

• There is a contractual imposed on all NHS providers ofservices to 'provide to the service user and any otherrelevant person all necessary support and all relevantinformation' in the event that a 'reportable patientsafety incident' occurs. Staff and managers we spokewith were aware of and able to explain the ‘duty ofcandour’. Staff told us the ‘duty of candour’ wasincluded in the trust’s safeguarding training, and theywere honest with patients if clinics were running lateand offered patients’ opportunities to re-bookappointments.


• Policies and procedures for the prevention and controlof infection were in place and staff adhered to “barebelow the elbow” guidelines. Personal protectiveequipment was readily available in all clinical areas andwe observed staff using it. Alcohol gels were availableoutside of all clinical rooms on the outpatientsdepartment with clear signage asking staff and patientsto gel their hands prior to entering.

• Patients using clinical rooms were cared for in a clean,hygienic environment. All of the clinical areas we visitedwere clean and well maintained. We inspected toiletsand sluices and found them to be clean.

• Clinical waste was removed and bins for sharp itemswere correctly assembled and labelled.

• The outpatients department had a link nurse forinfection prevention and control (IPC) that wasresponsible IPC in the outpatients department. Thedepartmental link nurse liaised with the trust’s IPCspecialist nurse.

• The outpatients department were in the process ofintroducing a decontamination room. Staff told us theyhad received advice from the hospital’sdecontamination consultant in developing the room.

The room was waiting for couches and ear, nose andthroat (ENT) chairs to be delivered. The matron hadarranged for staff from Queens Hospital to providedecontamination training for staff at the outpatientsdepartment.

• Clean equipment in the room had ‘I am clean’ stickers toensure staff knew the equipment was clean and readyfor use. 20 staff had received training indecontamination in April 2016. A private equipmentprovider was also providing regular training for staff indecontamination of scopes.

• We observed cleaning taking place and saw cleaningschedules which were up to date. The matron told usthey did ‘walk arounds’ regularly to monitor cleanliness.The trust’s executive team also did regular ‘walkarounds’ as part of a programme of safety inspections.

• Not all cleaning records for diagnostic imagingdepartment were up to date and we saw that roompreparation sheets used in ultrasound had not beencompleted for several months. This meant we wereunable to see documentation that the room cleaningchecks had been done.


• The audiology room venting system was not working.The room was small and did not have any other meansof ventilation such as windows. We saw a patientexperience an episode of dizziness and breathlessnessin the room. The patient said this was due to a lack of airin the room. The patient was attended by theoutpatients’ matron and a nurse and recovered quickly.However, staff in the audiology clinic told us they hadreported the lack of ventilation to the hospital “sometime ago” and they were not aware if the estatesdepartment had visited to assess the system.

• Maintenance contracts were in place to ensurespecialist equipment was serviced regularly and faultsrepaired.

• Safety testing for equipment was in use across theoutpatients and diagnostic imaging departments andthe equipment we reviewed had stickers that indicatedtesting had been completed and was in date.

• Staff told us the resuscitation lead had reviewed theoutpatient department’s resuscitation practice in 2015.We found the resuscitation trolleys located throughout




the departments were locked and medicines and stockinside the trollies were appropriate and had beenchecked daily. Staff reported that these checks werehigh priority. Defibrillators were tested on a daily basis.Overall, most oxygen cylinders we looked at were indate. The matron in the outpatients department hadintroduced a daily ‘walk around,’ where either thematron or senior sister checked records and equipmenton all the outpatient resuscitation trolleys. Theresuscitation trolley in diagnostic imaging was secureand sealed. Regular checks had been completed andimprovements on the process had been made since thelast inspection.

• Portable oxygen and suction equipment was availablein the outpatients department. We found the equipmentwas checked daily.

• The hospital were involved in the hospital’s ‘life study’meetings with the estates department with the intentionof moving medical gases off-site. All relevant staff weretrained in the safe use and storage of medical gases.

• The ‘Base 3’ waiting area dealt with orthopaedicpatients. Staff told us high back chairs were on orderand would be in place by November 2016.

• We observed plenty of specialised personal protectiveaprons for diagnostic imaging staff and patients to wearas required to give protection from ionising radiation.Staff were also seen wearing personal radiation dosemonitors which were monitored in accordance with therelevant legislation.

• Radiographers did not perform additional QualityAssurance (QA ) on a regular basis. The tests were doneby medical physics and staff were informed by email.Staff were keen to undertake these tests so that theycould monitor the safety of the equipment more closely.Weekly QA tests and daily room set up checks forultrasound had not been recorded since January 2016

• Clear signage and safety warning lights were in place inthe diagnostic imaging departments to warn peopleabout potential radiation exposure.

• Staff told us there was lack of organised storage in thedepartment. One x-ray contained a large ladder leaningagainst the wall which was a potential hazard to bothstaff and patients.

• The mammography room was no longer used since thebreast screening contract had been awarded to anotherprovider in 2015. The equipment had been left unusedfor several months with no immediate plans as to whatto do next.

Medicines

• Medicines were stored in locked cupboards and therewere no controlled drugs or intravenous fluids held inthe outpatients department. The outpatients’department senior sister did weekly ‘walk arounds’these included checks on the contents of medicinescupboards to ensure medicines were in date and noinappropriate items were being stored in the cupboards.

• Lockable fridges were available for those drugs needingrefrigeration; temperatures were recorded daily whenthe department was open. Fridge temperaturerecordings were within the required range.

• Quarterly medicines storage audits were undertaken.The results showed staff followed medicines storagepolicies appropriately.

• Some nursing staff were nurse prescribers; these weremembers of staff who had undertaken further training toenable them to prescribe medicines in clinics.

• Prescription pads were stored securely and theirappropriate use monitored.

• Pharmacy staff reinforced medicine safety instructionsand information to patients when they collected theirprescriptions following their consultation. Many of thespecialist nurses also provided information and supportabout medication as part of the patient’s consultation.

• Pharmacists had access to GP summaries which meantprescribing errors were less likely.

• We checked the contrast throughout the diagnosticimaging department and all bottles of contrast werefound to be in date.

Records

• In the outpatients department patients’ records weremanaged in accordance with the Data Protection Act1998.

• The trust had changed their electronic system inDecember 2015 with the introduction of the electronicpatient record (EPR), having previously used the patient




administration system (PAS). The EPR provided staffwith access to patient letters, reports, imaging and testresults. Most patient records were paper based,including risk assessments. Most staff we spoke withcommented positively on the EPR.

• The trust had launched ‘iFit’ a records managementsystem in to address identified issues in regards tomissing information in patient records, the over use oftemporary records, and the tracking of patient records.Outpatients’ department staff had completedworkshops on the iFit system.

• Paper based notes were kept in locked keypad trolleys.The outpatients department had introduced a key padprotected notes rooms for each base area, to ensurepatients information was protected. Patients attendingan outpatient appointment would be booked in atreception. Their notes would be retrieved from thedoctors’ pigeon hole in the notes room at the time oftheir appointment and taken to the clinical room.

• However, we found sets of patient notes in an unlockedand unsupervised room which was accessible by thepublic. This was brought to the attention of the servicelead and the room subsequently locked.

• We viewed six patients care records. For example,patients discharge summaries and referral letters werein their care records, together with risk assessments thatincluded a record of patients’ allergies, activities of dailyliving (ADL), whether they were at risk of venousthromboembolism (VTE), and whether they had anassessment of mental capacity.

• Information governance was part of the trust’smandatory training. Staff told us they had receivedinformation governance training. Staff said the trust hadprioritised staff updating information governancetraining in the previous 12 months.

• Staff at the eye outpatients department told us therehad been improvements in clinical preparation and thishad resulted in their being fewer episodes ofinformation being missing from patients’ notes.

• The trust used a radiology information system (RIS) andpicture archiving and communication system (PACS).This meant patients radiological images and recordswere stored securely and access was passwordprotected.

• We saw evidence that the radiographers had checkedand documented patient pregnancy status in line withdepartmental protocol.

• Evidence of consent was also observed as completedand appropriate.

Safeguarding

• Safeguarding policies and procedures were in placeacross the trust. These were available electronically forstaff to refer to. We reviewed the trust’s safeguardingadults’ policy. This had a flowchart identifying the trust’ssafeguarding governance structure. The policy alsosignposted staff to associated policies and procedures,for example, the trust’s ‘Prevent’ policy and theprevention and management of violence against staffpolicy.

• The outpatients department had a link nurse forsafeguarding. The staff we spoke with was aware of theirroles and responsibilities and knew how to raise mattersof concern appropriately. Most staff were able todescribe different types of abuse. However, thephlebotomy clinic staff told us there was nosafeguarding link staff for phlebotomy.

• The outpatients department senior sisters office had thecontact details of the local authority safeguarding teamand domestic violence unit displayed on the officenotice board to enable staff in having easy access tocontact information.

• Bank staff received the same safeguarding training aspermanent staff and ad hoc training was also providedby safeguarding team as and when required.

• We saw evidence that the staff were 100% compliantwith level 1 training and 92.8% for level 2 adult trainingand 91.5% compliant for level 2 child training.

• Safety procedures were observed in radiology to ensurethe right patient got the right scan at the right time.

• The outpatient department mandatory trainingspreadsheet for September 2016 recorded that moststaff training was up to date. Mandatory trainingincluded: fire safety, health and safety, moving andhandling, paediatric and adults resuscitation.

• Mandatory training was available via on-line courses aswell as face to face.




• Radiology management told us that all radiographerswere up to date with their mandatory training and allstaff we spoke to confirmed this.

• Figures showed compliance of 91.3% for mandatorytraining as a whole against a trust target of 90%.Radiology staff exceeded the trust target in all subjectswith the exception of basic resuscitation.

• Training for staff in basic life support was mandatory inthe outpatients department, this included staff workingon the departments’ reception desk.


• There were arrangements in place to deal withforeseeable medical emergencies. Senior managers toldus that escalation of risk was normally done from a wardlevel. Ward managers discussed risk with their linemanagers who escalated to the service director, thenonto the risk register if required.

• Referrals were immediately logged onto the EPR, whichidentified patients who were at risk of deteriorating.

• If a patient became unwell in outpatients, the servicehad a clear protocol to follow. Staff would assess thepatient using the National Early Warning Score (NEWS)and either treat the patient within the department or, ifthe department could not meet their clinical need,transfer the patient to the emergency department for afull assessment and treatment.

• KGH was supported by an ‘in-house’ radiationprotection service. They provided the radiationprotection advisor (RPA), radiation waste advisor (RWA),medical physics expert (MPE), for diagnostic imaging,nuclear medicine, and provided support for lasers andmagnet use within diagnostics throughout the trust.

• There were radiation protection supervisors (RPS)allocated to the department. One RPS told us they hadnot had training for several years and did not fulfil theduties of an RPS due to other demands on their time.There was no evidence of training records for the RPSrole on the shared drive.

• Dose reference levels had been established for the X-rayrooms. Automatic exposure factors were used in all x-rayrooms viewed. This is acceptable practice as long as theexposure parameters have been optimised.

• They were no local rules visible on the mobile imagingequipment or in the x-ray rooms. These were located onthe shared computer drive but were difficult to locate. Ittook several attempts to locate the correct file.

• The risk assessments in ultrasound had expired in June2015 and were currently not up to date.

• There was one risk on the trust wide risk register relatingto a backlog of plain film reporting from 2012/2013. Wewere assured, following discussions with radiologymanagement that work had been done to address thismatter to reduce the risk to patients. In 2012 there was abacklog of 15,384 reports to be done. The latest figuresin April 2016 demonstrated only six reports wereoutstanding.

• Radiography staff within the reporting team told usthere was no current backlog with their workload. Allurgent reporting was done in less than 30 minutes butthere was no data to confirm this.

Nursing, radiology and administration staffing

• Nursing services in the outpatients department wereprovided by the outpatient nurses and clinical nursespecialists (CNS).

• Staff told us there were sufficient nursing staff to ensureshifts were filled in line with their agreed staffingnumbers. A safe staffing dashboard was displayed in theoutpatients department. This showed details of therequired levels of staffing, and actual levels present oneach day. Staffing levels were adequate, as was therequired skill mix at the time of our visit. The matrondemonstrated an online acuity tool which was used toassess the required staffing levels for each day.

• There was a bank for nursing staff so the hospital hadcover for staff sickness and holidays. Bank staff had aninduction and mandatory training was provided. Manyof the bank staff had worked at the hospital before andwere familiar with the trust’s processes.

• The radiography staffing vacancies had now been filledwith the exception of ultrasonographers. Agency staffcovered the gaps in the rota to offer the musculoskeletalservice. Any agency radiography staff were given athorough induction programme.

• We spoke to a new member of staff who had completeda trust and departmental induction..




Medical staffing

• Clinical staffing in all outpatient and imagingdepartments was good. However, staff at the urologyclinic told us there was an unfilled consultant post andthis had led to staff struggling with clinics.

• Staff at the neurology clinic told us they had receivedtrust funding for three new registrar posts and two newrheumatologists.


• Staff in the outpatients department were aware of thetrust’s business continuity policy; senior staffunderstood their roles and responsibilities within amajor incident. Staff told us there were staff allocated toassist in the event of a major incident.

• The outpatients department had a contingency plan inplace for junior doctors’ strikes. This included: lettersbeing sent first class to all patients with appointmentsaffected by the strike, updating staff at the call centre ofclinics affected by strike action. Reception staff beingprovided with a list of patients affected by strike actionas well as patients attending clinics.

• The service manager told us the hospital followed upevery junior doctor’s strike with a lessons learnedsession in the team meeting as part of the hospital’scontingency planning.

• We noted there was a major incident procedure forimaging, which was also part of the wider hospital majorincident policy.

Are outpatient and diagnostic imagingservices effective?

Not sufficient evidence to rate –––

The outpatients and diagnostic and imaging service wereinspected but not rated for effective. We found:

• Patients attending outpatients and diagnostic imagingdepartments received care and treatment that wasevidence based.

• Early work was in progress for imaging to gainaccreditation with the Imaging Services AccreditationScheme (ISAS).

• Imaging local rules for the hospital had not beenupdated since 2014.

• Staff were able access appropriate pain relief forpatients.

• The service was monitoring the care and treatmentoutcomes of patients who were receiving outsourcedcare from providers in the private sector.

• All new staff completed a corporate and local induction.

• Staff worked together in a multi-disciplinaryenvironment to meet patients’ needs. Specialist nurseswere available in a wide range of specialities.Information was shared with the patient’s GP followinghospital attendance to ensure continuity of care.

• Staff were competent to perform their roles and tookpart in benchmarking and accreditation schemes. Staffwere supported in their roles by on-going specialisttraining and development opportunities.

• The outpatients department and diagnostic andimaging services had introduced clinics Monday toSunday to clear patient waiting list backlogs.


• There was a comprehensive set of treatment guidelinesbased on guidance from the National Institute forHealth and Care Excellence (NICE). Doctors in theoutpatients department were able to show us that theywere complying with best practice guidance. Diagnosticservices were delivered in accordance with Departmentof Health and Royal College of Radiologists guidance.

• Staff were familiar with their use and they were easilyavailable on the trust’s intranet. Any changes werediscussed at governance meetings and updated asnecessary. Staff told us changes to policies orprocedures would be discussed at daily huddlemeetings and team meetings.

• We viewed a selection of trust policies including thechaperone policy. The chaperone policy had beenreviewed and ratified in October 2015 and was next duefor review in November 2016.

• We found staff in the phlebotomy clinic followednational guidelines and had standard operatingprocedures (SOPS). Staff received instant updates viaemail if there were changes in guidance or SOPS.




• The pathology department had full Clinical PathologyAccreditation (CPA) and was in the process of moving toan internationally renowned quality standard formedical laboratories (ISO 15189)

• The blood transfusion service was fully compliant withthe Medicines and Healthcare products RegulatoryAgency (MHRA)

• The trust had established a combination of local andnational diagnostic reference levels (DRLs) withinradiology. DRLs are typical doses for examinationscommonly performed in radiology departments. Theyare set at a level so that roughly 75% of examinationswill be lower than the relevant DRL. They are notdesigned to be directly compared to individual doseshowever, they can be used as a signpost to indicate tostaff when equipment is not operating correctly. Morework needed to be done to complete the DRLs on theKGH site.

• The RPA told us they would be introducing newEuropean protocols to enable the department tobecome accredited with the Imaging ServicesAccreditation Scheme (ISAS).

• Imaging protocols for radiology were regularly reviewedand involved the input of the wider team.

• All radiology reports were done in-house and none wereoutsourced. Radiology reporting times were now beingmonitored on a departmental dashboard since June2016.

Pain relief

• Staff were able access appropriate pain relief forpatients within outpatient department clinics.

• Staff told us they could bleep the pain managementteam who would attend to a patient experiencing pain.

• Records confirmed that patients’ pain needs wereassessed before undertaking any tests in the majority ofcases.

• Staff at the pain clinic told us they had receivedapproval to expand the service and were in the processof interviewing a psychologist and a further pain nurse.

Patient outcomes

• The trust had introduced a performance pack as a resultof a ‘deep dive’. The deputy chief operating officer (COO)

said the data from the analysis had been used todemonstrate to clinicians how the changes in theoutpatient department’s working processes had beenmeasurably beneficial for patients.

• The hospital were using a range of private providers toassist in clearing the backlog of both admitted andnon-admitted patients where there was the mostdemand on the service. The deputy chief operatingofficer (COO) told us the hospital looked daily at patientsreferred to a private provider and tracked andmonitored their care and treatment. The COO showedus documents that evidenced how the hospital met withproviders weekly and identified where patients were ontheir care and treatment journey. For example, the 1September 2016 performance report recorded thatoutsourcing had resulted in an average of 98 patientsreceiving outsourced care and treatment a month sinceApril 2016.

• All of the patients we spoke with attending for animaging appointment were positive about attending theservice.

• An IR(ME)R audit was last done in 2014. We looked at theaction plan and saw that KGH was not compliant withthe audit. We did not see an updated action plan. TheRPA told us the IR(ME)R procedures were being updatedbut these still currently showed a review date of 2012 onthe electronic system.

• Radiology management told us they Did Not Attend(DNA) rates were low within the service. A newcentralised radiology booking system had been out inplace over the last few months. We spoke with theproject team and it was evident the change process tothe new system was being closely monitored andimprovements made

Competent staff

• Staff received regular supervision and team meetingswithin outpatients. Team meetings had recently beenput in place for diagnostic imaging.

• 52% of radiology staff had completed an appraisal. Thiswas recorded as a rolling figure. Department leads toldus all staff would complete their appraisals within the




correct timeframe. However, the mandatory trainingspreadsheet for the outpatients department, September2016, recorded that 27% of staff had an up to dateappraisal, this was below the hospital’s target of 85%.

• Data provided by the hospital recorded that on the 16August 2016, across the cancer division, 76.6% of staffhad received an annual appraisal. This was below thehospital’s target of 90%.

• Competency assessments were in place for outpatientsand diagnostic imaging and induction processes were inplace for new staff. All new staff completed a corporateand local induction. Senior staff in diagnostic imagingtold us the local induction pack was being revised.Induction checklist were recorded on outpatient staffelectronic training records.

• We spoke with health care assistants (HCA) andobserved the care they were giving in clinical areas.Some HCA’s were trained for specific tasks, for exampletaking blood or taking physiological measurements.HCA’s told us they received direct supervision fromregistered nurses. HCA’s told us their electronic trainingrecords recorded any specialist training they hadundertaken and they received emails to notify themwhen training updates were due.

• Staff were able to obtain further relevant qualifications.Staff said there was a range of in-house trainingopportunities.

• Staff were supported with revalidation of theirregistration with their professional regulatory bodies.

• Health care assistants had ‘development days’ wherestaff could look at practice issues and learning frompractice.

• The outpatient department had a range of link nurses

• Completion of mandatory training was a high priority forall staff and managers we spoke to.

• We saw evidence of role development for radiographerswhich included film reporting in plain film, breast andchest x-rays. The radiographer led reporting service waseffective in keeping reporting turnaround times withintarget levels.

• Some radiography staff were trained in cannulation andtheir competency checked before starting this advancedskill.

• Radiographers told us that new departmental clinicalleadership was supportive of radiographer roleprogression.

• We saw that all employed radiography staff wereregistered with the Health Care Professions Council(HCPC).Managers checked the registration of their staffregularly.


• Outpatients department nursing staff told us there wasincreased cross site working with the outpatientsdepartment at Queens Hospital with outpatientsnursing staff from both hospitals offering additionalcover. However, staff also highlighted that differentclinics at both sites limited the number of nursing staffthat could cross site work. Some of the diagnosticimaging staff worked across both sites but this was quitelimited.

• The outpatients’ department matron managed both theoutpatients department at Queens Hospital and KingGeorge’s Hospital and diagnostic imaging had a generalmanager across both sites.

• There were no formal meetings between phlebotomyclinic staff at King George’s Hospital and QueensHospital. However staff rotated between both sites,including managers. Cross site working was on a basis ofplanned and emergency planning.

• There were regular multidisciplinary team (MDT)meetings in the outpatients department which werewell attended by other healthcare team members,including radiology.

• The outpatients department had link nurses forsafeguarding, learning disability, wound managementand palliative care.

• Therapists including OT and physiotherapists were partof the outpatients department MDT.

• Staff in the outpatients department told us theycollaborated closely with doctors and physiotherapists.

• Staff at the audiology service told us they had “littleinteraction” with staff at the outpatients department.

• Patient information was shared with GP’s followingoutpatients’ department attendance to ensurecontinuity of care.




• The hospital worked closely with a range of externalproviders as an aspect of their demand and capacitymanagement. We viewed the trust’s demandmanagement report dated 1 September 2016, thiscontained updates in regards to redirectedappointments. As at the week ending 28 August 2016the trust had redirected 6,747 patients via plannedschemes with external providers.

Seven-day services

• Outpatients’ clinics operated from 9.00am to 5.00pmMonday to Friday. However, the department hadintroduced clinics until 10.30pm from Monday toSunday. As a result there were regular weekend clinicappointments in the outpatients department. Weekendclinics had been introduced to reduce the outpatients’department waiting lists and patients’ referral totreatment times (RTT).

• Diagnostic imaging provided a 24-hour, seven dayservice with a combination of extended days and on-callcover.

• CT and MRI ran extended days during the week and atthe weekend.


• Staff across all the departments we visiteddemonstrated how they could access the informationneeded to deliver effective care and treatment in atimely way from the EPR. Staff showed us how they usedthe EPR to gain access patients test results.

• Diagnostic results were recorded on patient EPR’s,giving staff across the trust immediate and up to dateaccess to patients’ records.

• The outpatients department had a preparation room.Staff received up dated patients’ clinical information inthe preparation room in readiness for clinics. Paperrecords we saw were up to date and written clearly.

• The outpatients department had introduced a clinicco-ordinator who took all calls and messages to theservice and disseminated information to staff. There wasa rota that identified nursing staff that were covering therole. Staff said the introduction of a co-ordinator hadimproved communication in the department.

• Staff in the audiology clinic told us the computer theyused for bookings had broken down six weeks ago. Thismeant they were taking all bookings as paper copies.

• The trust used a radiology information system (RIS) andpicture archiving and communication system (PACS).This meant patient’s radiological images and recordswere stored securely and access was passwordprotected.


• We saw nursing staff in the outpatients departmentseeking consent before carrying out tasks. Verbalconsent was observed in the X-ray room. Staff we spokewith understood the need for consent and ensuring thiswas recorded appropriately.

• Staff in outpatients and diagnostic imaging worked onthe principle of implied consent. Most of the patients wespoke with told us the staff had explained the proposedtreatment or test and had confirmed with them thatthey had consented before any examination ortreatment had taken place.

• If written consent was required for more complexprocedures this was obtained in outpatients clinics bymedical staff.

• Clinical nurse specialists were able to describe theprocess of assessing capacity when obtaining consent.

• The safeguarding team delivered training on mentalcapacity, deprivation of liberty safeguards (DoLS), andprevent. There was also information available to staff onthe trust intranet.

• Staff were aware of their duties and responsibilities inrelation to patients who lacked mental capacity; theydemonstrated a good knowledge and understanding ofMental Capacity Act (MCA) and Deprivation of LibertiesSafeguards (DoLS).Staff in diagnostic imaging reportedthey had received update training at a recent staffmeeting.

• Staff knew the procedures to follow to gain consent andunderstanding from patients, including involving otherprofessionals. Carers were encouraged to escort theirrelative to appointments where needed to offer support.




Are outpatient and diagnostic imagingservices caring?

Good –––

We rated caring good because:

• All the patients, relatives and carers we spoke with werepositive about the way staff treated people. There was astrong, visible person-centred culture in mostdepartments. Staff offered care that was kind andpromoted people’s dignity. We observed staff beingcaring and supportive in interactions with patients andtheir families.

• Patients and relatives told us they were involved indecision making about their care and treatment.People’s individual preferences and needs werereflected in how care was delivered.

• Staff demonstrated awareness of people’s needs andthe limitations associated with their conditions.Patients’ psychological and emotional needs wereappropriately supported.

Compassionate care

• Most patients in the outpatients department spokepositively about the staff that supported them with theircare and treatment and considered themknowledgeable and professional. We did not receive anynegative comments from patients, their relatives orcarers about staff attitudes or behaviour towards themin the outpatients department. A typical comment was,“The staff are friendly, they always talk nicely to me, Ifeel respected.” Another patient told us, “The doctorsare very caring and ask me how I am feeling and if I haveany pain.” However, another patient told us, “The staff atthe weekend seem stressed.”

• We saw the matron and outpatients nurse attending toa patient who had become faint in the audiology room.Overall, the outpatients department respected patients’privacy and dignity. The department had moved theclinical observations area from a public waiting area tothe assessment room. This ensured patient privacywhen undergoing tests such as blood pressure andweight.

• We observed chaperones working in the ultrasounddepartment.

• Staff we spoke with were very proud of the care andsupport they provided to patients and their families.Receptionists were welcoming and friendly. We sawporters and housekeeping staff interacting with patientsin a caring manner.

Understanding and involvement of patients and thoseclose to them

• Overall, patients and relatives told us they were involvedin decisions about their care and treatment. Forexample, one patient told us, “They explained mytreatment to me.”

• Managers and staff told us actions were being taken toaddress patients missing appointments, includingsending texts to patients’ mobile phones, wherepatients were in agreement to receive them.

• A patient in the outpatient department told us, “Thedoctor is very nice, they ask me to come in a week earlyfor bloods, so that they have the results ready for today.The doctor has been wonderful.”

• The outpatients department had a patient visual displayunit call system that informed patients when it was theirturn in clinic.

• Patients told us they received instructions with theirappointment letters and were given written informationas required. We observed staff in the diagnostic imagingdepartment escorting patients and their families to thecorrect waiting are for their examination and explainingwhat was to happen next to them

• The outpatients department took part in the‘iWantGreatCare’ patient experience survey.Departments we visited had boxes where patients couldleave comments or suggestions using the formsprovided.

• There was a range of printed information available topatients and their families and carers, including a rangeof information leaflets and literature for patients to readabout a variety of conditions and support services.

• The services had a chaperone policy in place to protectpatients and staff.

Emotional support




• Staff told us King Georges Hospital multi-faithchaplaincy could provide listening and emotionalsupport if requested to all patients.

• The hospitals psychological service providedpsychological and psychiatric consultation, assessmentand therapeutic intervention to patients and theirfamilies and carers.

Are outpatient and diagnostic imagingservices responsive?


We rated responsive requires improvement because:

• Staff told us they were not confident of meeting thenational indicator for patients waiting over 18 weeks bytheir target date of March 2017.

• The percentage of patients who did not attend (DNA)their appointment was above the England average.

• The trust’s performance for the 62 day cancer waitingtime was consistently below the 85% England averagefrom 1 March 2015 to 31 May 2016.

• 13% of appointments were cancelled by the hospital.This was higher than the England average of 7.2%.


• Work was in progress to conduct a demand andcapacity analysis in partnership with a private companythat specialised in risk and trend analysis to develop amodel whereby the hospital could assess and effectivelymanage the demands on the service.

• There had been an 88% reduction in the overall backlogof patients waiting over 52 weeks since May 2016.

• The hospital was using a range of private providers toassist in clearing the backlog of appointments wherethere were most demand for services.

• There was a formal complaints process for people touse with investigation, and response to thecomplainant. Complaints information, as well as patientexperience information was fed into the trustgovernance processes and trust board with formalreporting mechanisms.

• Breast screening services had been discontinued in thetrust but patients were able to access a mobile vanwithin the car park of the hospital.


• The deputy chief operating officer (COO) had joined thehospital in April 2016 and had conducted an analysis ofpatients that had waited for an appointment for over 52weeks. As a result the hospital identified that a further6000 appointments were required to provide thesepatients with care and treatment. An action plan andtimescales were in place as a result of the analysis.

• Work was in progress with the outpatients departmentto conduct a demand and capacity analysis inpartnership with a private company that specialised inrisk and trend analysis to develop a model whereby thehospital could assess and effectively manage thedemands on the outpatients department. Managers toldus the model would be used to inform how much extracapacity needed to be built into the system.

• Managers told us there were a variety of models for theoutpatients department. This included a traditionaloutpatients model, nurse led clinics and rapid accessservices. For example, the King George’s Hospital offereda rapid access prostate clinic as well as a 'one stop'haematuria, (blood in the urine), clinic.

• Outpatient department appointments offered a mixtureof nurse and medical led clinics. General outpatientnursing services included a variety of tasks and tests,which included: dressings; injections; phlebotomy,blood tests; urine tests; body mass index (BMI)measurements, blood pressure measurements; andadministration of medicines.

• There were plans for the outpatients department tomove into the area occupied by a G.P service next to theoutpatients department. This would provide a newreception area and an increased phlebotomy area.

• The medical director told us the trust were holding jointmeetings with primary care providers, for example GPs,to look at patient pathways and how GPs assessed andreferred patients for appointments. As a result the trustwere changing GP referral templates which wouldprovide GP and hospital staff with more information.




• Minor operations were completed in clinical rooms, withthe exception of dermatology which would be referredto Queens Hospital outpatients department.

• The second MRI van was now leased by the trust and notoutsourced to an external provider.

• The removal of the breast screening service meant thatthe equipment and room were not in use.

Access and flow

• The trust’s outpatients and diagnostic imagingdepartments offered 817,013 appointments between 1March 2015 and 1 March 2016. 542,590 were first orfollow up appointments.

• At King George’s Hospital 22% were new referrals. Thiswas below the England average of 24.8%. Mostappointments were follow-up appointments andaccounted for 43% of all the appointments provided.This was below the England average of 54.5%. Theoverall follow up to new rate for the trust was in thelowest quartile of hospital trusts. However, from March2015 to February 2016 the follow up to new rates forKing George’s Hospital were similar to the Englandaverage.

• The percentage of patients who did not attend (DNA)their appointment was 10%; this was above the Englandaverage of 6.8%. Managers said they recognised that theDNA rate was too high. The hospital had introduced aninitiative whereby patients would not be dischargedfollowing their first missed appointment; they wouldinstead be given three weeks’ notice.

• An average of over 600 bloods were taken daily by thephlebotomy service.

• Staff at the outpatients administration team told usthere had been a problem with patients not receivingreminders due to a system failure. This had beenidentified and rectified, but staff thought this had been acontributory factor with the DNA rate.

• The trust’s performance for the 62 day cancer waitingtime was consistently below the 85% England averagefrom 1 March 2015 to 31 May 2016.

• The outpatients department service manager told usthe ‘demand and capacity analysis’ had identified allpatients that had exceeded a 52 week wait. In responsethe hospital had introduced a patient tracking list (PTL)

where the data was validated by a private company.However, the hospital’s information management andtechnology team (IMT) was in the process of taking thedata validation in-house. The IMT team would beresponsible for collating the referral to treatment (RTT)PTL.

• No RTT non-admitted or incomplete pathways data waspublically available. Mangers told us the hospital werenot reporting or publishing their RTT due to the 52 weekwait. Staff told us the hospital wished to ensure the RTTPTL as the hospital wished to ensure the validationsystem was robust. Senior managers told us the hospitalwas on-track to clear the backlog of patients waitingover 52 weeks for an appointment by the end ofSeptember 2016.

• The RTT performance pack dated 1 September 2016recorded there had been an 88% reduction in theoverall backlog of patients waiting over 52 weeks sinceMay 2016.The trust had analysed the trajectory for thesepatients and were 387 appointments ahead of theplanned target.

• Staff told us they were not confident of meeting thenational indicator for patients waiting over 18 weeks bytheir target date of March 2017.

• The percentage of people with an urgent cancer GPreferral seen by specialist within two weeks had fallenbelow the England average in quarter four, October toDecember 2015.

• The percentage of patients (all cancers) waiting lessthan 31 days from urgent GP to first definitive treatmentwas around the 95% standard.

• Between November 2015 and March 2016 the trust hada high proportion of people waiting over six weeks fordiagnostic tests when compared to the Englandaverage. However, the trend was from a peak in January2016 to below the England average in April and May2016. The trust reported that over 99% of patients werenow seen within six weeks.

• 13% of appointments were cancelled by the hospital.This was higher than the England average of 7.2%. 11%of appointments were cancelled by patients. This wasalso higher than the England average of 6.6%.

• The trust’s medical director told us the trust had anestablished harm, panels which had reviewed the




admitted patients’ pathway to assess degrees of patientharm. Three minor harms had been identified as a resultof the review. The trust had also sampled 10% ofnon-admitted patients and identified no harm topatients with the longest waits. The assistant medicaldirector had continued to review patients via ‘dipchecks.’

• The medical director told us the challenge for the trustin regards to RTT was patients waiting 18 to 52 weeks.The medical director said there had been a number ofdiscussions with the COO with regard to patient safetywhilst patients waited for an appointment. The medicaldirector highlighted that the numbers of patientswaiting for appointments was reducing. The hospitalhad introduced initiatives to reduce patients RTT,including reviewing patients arriving in the emergencydepartment (ED) to establish if the presenting problemwas related to an outpatient’s departmentappointment.

• We viewed the ophthalmology overarching action planupdate dated 5 September 2016. The action plan wasregularly reviewed. On-going actions included allpatients receiving their follow up appointments prior toleaving the clinic and the provision of timely follow upappointments, which had a target date for completionof 30 September 2016.

• Staff told us clinics were sometimes delayed by patientshaving more complex conditions that required extratime. Staff said they would speak with patients that hadappointment times delayed, and that they alwaysannounced delays in clinic schedules in the waitingroom as well as delay notices being broadcast in thewaiting room.

• Staff at the rheumatology clinic said managers weremonitoring potential RTT breaches and they wouldreceive an email prompt from managers when there wasa potential RTT breach for a patient. This was echoed bystaff from the neurology clinic who told us how toreduce patients RTT was discussed at team meetingsand junior doctors were offered training in completionof RTT forms. Staff at the outpatients administrationteam monitored patients from first appointment andalso confirmed that RTT waiting times were monitoredby the COO.

• GP’s could use the outpatients’ department ‘choose andbook’ online appointments system, e-referrals, or paperbased referrals. Consultants triaged referrals andsecretaries booked appointments. Staff told us patientscould rearrange appointments if the allocated timewasn’t convenient, once they had received anappointment letter.

• Staff said same day appointments could be arranged forurgent referrals as departments scheduled urgentappointments daily.

• The outpatients department had introduced ‘quality ofcare’ tracking lists for patients to monitor individualpatients’ access to assessment, diagnosis andtreatment. The patients waiting time and time of theirappointment were being monitored as an aspect of thetrust’s demand and capacity review.

• The trust had a call centre based in King George’sHospital. The call centre handled approximately 6000calls a week. The answer rate for the call centre was 95%and the time to answer calls was an average of 46seconds. The outpatient clinics were in the process ofreviewing their directory of services (DOS). These arepathways that provide the call handler with real timeinformation about services available to support aparticular patient and ensure they are directed to theappropriate service.

• Patients could receive text reminders for outpatients’appointments. However, staff told us patients had to‘opt in’ to the text reminder service due to dataprotection, as the service was provided by a privatecompany. A few patients we spoke with in theoutpatients department and phlebotomy clinic told usthey had received their text reminder before they hadreceived an appointment letter. Staff told us this waspossible due to letters being prepared manually. Staffadded that this was being addressed as the trust wasoutsourcing their electronic mailing system fromOctober 2016 to a private provider with the aim ofspeeding up outgoing mail processes.

• The hospital had introduced a ‘quick triage’ service forpatients with non-complex needs. This involved patientshaving blood tests, initial assessment, height and




weight measured, and MRSA screening. Staff told us the‘quick triage’ had been introduced as the outpatientsdepartment had recognised the need to be creative inspeeding up patients’ access to care and treatment.

• The referral to treatment time (RTT) for the audiologyclinic was four to six weeks. Staff told us follow upappointments had a 10 week waiting time.

• The outpatients department had installed large screensthat carried messages for patients, including the currentwaiting time. The waiting time on display at the time ofour visit was 45 minutes. We saw that on the day wevisited most people were seen within the 45 minutewaiting time.

• If clinic appointments in outpatients were delayed stafftold us they would inform patients verbally of waitingtimes. The large screen also informed patients ofdifferent consultants who were working to enablepatients to understand why some patients appeared tobe going into their appointment before them.

• Clinicians decided when patients could be discharged.Staff told us patients being discharged would beadvised about support following discharge.

• We asked patients about attendance at appointments.Some patients told us they had cancelled theirappointments due to personal circumstances but hadbeen dealt with politely and always offered analternative.


• The outpatients department had access to a range ofsupport to meet patients’ individual needs including:physiotherapy.

• The outpatient department had introduced newreception desks with a dip in the desk, these made faceto face interactions with reception staff accessible towheelchair users. Separate waiting areas in theoutpatients department had ‘pods’ to check patientsinto clinics on arrival.

• Staff we spoke with told us there was a lot of focus in theoutpatients department on how services could meet theneeds of patients with a learning disability or patientswith dementia. For example, the outpatients

department had a phlebotomy clinic for patients withlearning disabilities. The diagnostic imagingdepartment staff were less able to communicate clearlyhow they made adaptations for specific patient needs.

• Staff at the outpatients department told us theysupported people with learning disabilities regularly.Staff said letters could be provided in ‘easy read’ formatsor large print. Staff said if they were aware of avulnerable adult attending an appointment they wouldprovide assistance.

• There were learning disability notice boards and noticesin the outpatients department’s waiting area in easyread format explaining how people with a learningdisability could access assistance in the department.

• The outpatients department used the hospital passportscheme for patients with learning disabilities. This was adocument patients could take to their appointmentswhich carried information about the patients personal,communication, and health care needs.

• Arrangements for patients with complex needs werediscussed at morning ‘huddle’ meetings. This includedpatients with learning disabilities or mental healthissues being provided with a room where they couldwait away from other patients where this would bebeneficial.

• There was provision for bariatric patients in the form ofbariatric treatment table in the treatment room. Staff indiagnostic imaging were able to tell us the weight limitsfor the CT table and how they would undertake a riskassessment prior to proceeding with an examination ifthere were any concerns.

• Staff told us the trust’s accessible communications teamcould provide printed information in a range oflanguages upon request.

• Interpreters offering both face to face and telephoneinterpreting could be pre-booked for patients that didn’tspeak English. Staff told us some members of staff alsospoke other languages and could be approached to actas an interpreter.

• The outpatients department had replaced the furniturein the outpatients department waiting areas in the




previous 12 months. The department had alsointroduced television screens that showed newsprogrammes with subtitles and visual display units forclinics.

• The number of seats in the phlebotomy clinic had beenincreased. On the day we visited there was ampleseating for the number of patients using the clinic. Stafftold us there were still waiting issues in the phlebotomyclinic on Monday and Tuesday, but patients would beoffered seating in the “base three waiting area, but theycan’t see the appointment screen from there.” However,plans were in place to develop the phlebotomy area inDecember 2016. Staff added that if the phlebotomyclinic was “very busy” they had the option of sendingpatients to Loxford.

• The neurology clinic was provided by the hospital’s daycare unit. However, the outpatients department hadneurology ‘hot clinics’, these were clinics running in theevening and at weekends.

• The outpatients department would remain open forpatients that were being admitted and waiting for a bedwhere a bed had been identified. If a bed had not beenidentified and patients wait was likely to be late in theevening, staff said they would transfer the patient to thehospital’s emergency department until a bed was ready.A senior sister said, “Staff are really supportive of stayinglate with patients waiting for admissions.”

• The outpatients department had a publishing companythat provided free magazines for the waiting area forpatients to read whilst waiting for their appointments.The company updated the magazines monthly.

• The outpatients department had introduced children’splay areas in adult waiting rooms for patients attendingappointments with children.

• Patients attending the outpatients department hadaccess to a coffee shop in the hospital’s main receptionfor snacks and tea and coffee.The outpatientsdepartment had introduced water dispensers in thewaiting rooms to ensure patients their carers andfamilies had access to free drinking water.

• The outpatients department had recently opened achildren’s waiting room in the outpatients department.This had child friendly décor and a small range ofchildren’s toys and books.

• The hospital had a multi-faith prayer room that wasopen 24 hours a day. Staff told us people of all faithscould use the room and all were welcome to the regularservices. These were Christian prayer on Wednesdaysfrom 12 noon to 12.30pm, and Muslim Jummah prayerson Friday from 1.00pm until 2.00pm.


• Staff told us they spoke with patients regularly toprevent any concerns that patients or families had fromescalating. There was a formal complaints process forpeople to use with investigation, and response to thecomplainant. Complaints information, as well as patientexperience information was fed into the trustgovernance processes and trust board with formalreporting mechanisms. Staff told us most complaintsrelated to waiting in the waiting room and waiting timesfor appointments.

• Most patients we spoke with told us that they knew howto make a complaint and would feel comfortablemaking a complaint. A patient told us, “I would ask tospeak to the manager if I had a complaint, but I haven’thad anything to complain about.”

• The outpatients’ department general information boarddisplayed the complaints procedure.

• Information regarding the Patient Advice and LiaisonService (PALS) and how to contact them was displayedin prominent areas in all the departments we visited.

• Staff had access to an easy read complaints policy forpeople who required information in this format.

• Staff in both the outpatients and diagnostic imagingdepartment told us they always tried to addresscomplaints or concerns immediately to see if they couldbe addressed by the team. If it could not be resolved bythe team, staff told us people would be given thecontact details of the patient advice and liaison service(PALS).

• The deputy COO told us the external clinical harmreview panel reviewed complaints monthly. The panelswere also attended by representatives from the CCG andPALS.

• The medical director told us the hospital had reviewed247 complaints via PALS. Eight of these were related topatients’ referral to treatment time (RTT).




Are outpatient and diagnostic imagingservices well-led?

Good –––

We rated well-led as good because:

• Staff knew and understood the vision of the trust. Wefound that most local managers demonstrated goodleadership within the department and the division.

• Managers had knowledge of performance in their areasof responsibility and understood the risks andchallenges to the service.

• Managers and clinical leads were visible andapproachable.

• There was a system of governance and riskmanagement meetings at both departmental anddivisional levels.

• Patients’ and staff views were actively sought and therewas evidence of continuous improvement anddevelopment of staff and services.


• Outpatients and diagnostic imaging services were intransition, and the strategy for these services was indevelopment.

• There were a number of new senior manager that hadintroduced new quality assurance and riskmeasurement systems. However, these were not fullyembedded.

• Diagnostic imaging services were working at fullcapacity in some modalities. We did not see a clearstrategy to deal with the increasing demand.

Leadership of service

• Senior managers we spoke with had knowledge ofperformance in their areas of responsibility and theyunderstood the risks and challenges to the service. Mostsenior and middle managers we spoke with told us theexecutive team were supportive. Most managers told usthey had confidence in the CEO and the board.

• The COO had overall responsibility to co-ordinateoutpatients services and two deputy COO’s had been

recruited. Most staff in the outpatients department toldus the divisional lead for the cancer division and theservice manager were approachable. The matron in theoutpatients department had worked for the trust for 11years. Staff told us locally outpatient departmentmanagers were more visible in the department.

• The trust had introduced a divisional leadersprogramme to provide divisional leads with divisionalmanagement skills and knowledge.

• Senior managers told us the managerial skills andknowledge of local managers was “a bit mixed.” Seniormanagers told us, “overall managers and staff haveembraced changed; most staff have come on board.”

• Monthly outpatients’ and diagnostic imaging teammeetings took place to ensure staff received informationand feedback regarding incidents and complaints andwere kept informed of developments within the trust.Most staff we spoke with felt supported and valued intheir role.

• There was a CEO forum which some staff told us theyhad attended and reported back to their teams. Thisfacilitated an effective channel of communicationbetween the board and staff.

• The staff we spoke with in diagnostic imaging wereoverall happy with the new leadership and felt lessstressed than the previous inspection. They now feltlistened too and were hopeful the department wouldmove forward.


• Managers told us the outpatients and diagnosticimaging services were in transition, and the strategy wasin development. The strategy would be based on the‘demand and capacity’ model the hospital wasdeveloping with a private provider of risk and trendanalysis. We were told the model would streamlinescheduling and reduce waits, as well as determining thestaffing needs of the service in response to servicedemand.

• The outpatients department had a mission statementand philosophy of care. This was displayed in the sisters’office. The diagnostic imaging department hadrelatively new leadership. They expressed a desire tokeep moving in the right direction after internal specialmeasures lifted from the service.




• All of the staff we spoke with were aware the trust hadintroduced an improvement agenda and the trust’svision and values were related to this. The trust valueswere based on the acronym, ‘PRIDE’, which stood for‘passion, responsibility, innovation, drive, andempowerment.’ Staff were expected to demonstrate thecore values of the trust.

• Several staff in diagnostic imaging told us they felt thedepartment was now more stable under newleadership.


• The outpatients department were part of the cancerdivision, with the divisional lead feeding back to theboard.

• The hospital were introducing a range of governanceprocesses, but these were relatively recent and not fullyembedded. The hospital had introduced a ‘performancepack’ suite of reports that provided information on RTTperformance. The deputy COO told us the reportsprovided the hospital with “clear visibility andaccountability” with the aim of reducing the number ofpatients waiting for over 52 weeks for their care andtreatment. Information from the suite of reports wasincluded in outpatients’ teams’ daily reports.

• We viewed the performance pack 1 September 2016.The pack demonstrated that the hospitals RTT hadconsistently reduced between May 2016 and August2016. For example, the total incomplete PTL hadreduced in the period by 867 but was still 47,574. Theincomplete patients waiting from 18 to 51 weeks hadreduced by 200, but still stood at 13,634, but this was asignificant reduction from the May 2016 figure of 18,157.The incomplete patients over 52 week had reduced inthe May 2016 to August 2016 by 41, but 317 patientswere still waiting over 52 weeks.

• The medical director told us the board were pragmaticand recognised that due to the size of the waiting lists itwould take time to meet the national waiting listindicator. The medical director said there had beensignificant reductions in RTT PTL and also recognisedthe efforts of staff at all levels in reducing these.

• The CCG attended the hospital’s performancemanagement office (PMO) RTT programme boardweekly with the trust’s executives.

• The performance pack was regularly reviewed at weeklymeetings. These included the PMO operational meetingand the access board meeting.

• There were monthly head of division and head of servicemeetings. Learning from divisional and service levelmeetings was disseminated to team leads, whodisseminated learning from divisional meetings at teammeetings.

• The hospital had introduced a programme of supportivemeasures as part of the hospital’s improvementprogramme. Clinics in supportive measures includedgastroenterology and neurology.

• New governance procedures had been introduced in thediagnostic imaging department. A performancescorecard measured departmental performance acrossboth Queens Hospital and KGH. We reviewed thescorecard which demonstrated results against key targetareas. More work was needed to fully complete thescorecard with the required data.

• The action plan for the haematology and immunologydepartment in place in 2014 was now completed. Seniorstaff told us they had recently joined the cytology andhistopathology departments to form a cellularpathology department. Cross site training of staff tookplace to improve processes and efficiency across theservice.


• Managers we spoke with told us staff had engaged withthe ‘performance pack’ and reports initiative. However,a few staff we spoke with told us they felt that managershad imposed the pack on them; but, other staff werepositive about their introduction. A typical commentwas, “the staff have worked really hard to make changeshappen.”

• Most staff we spoke with reported that morale was goodand had improved across outpatients and diagnosticimaging. Most were positive about services and feltpositive about their role and contribution to this.However, a few staff told us they did not feel fullyconsulted on how they felt and what they would like tochange.




• We observed radiography staff able to take breaks in anewly renovated courtyard in the centre of thedepartment. Staff told us this was a welcome additionand made good use of the space. Senior leadership toldus it was now time to value the staff and retain anddevelop talent.

• The chief executive officer had an open door policyallowing staff to make their thoughts and opinionsknown. There were mechanisms in place forwhistleblowing.

• Staff told us a culture of reporting incidents andconcerns was encouraged. The electronic incidentreporting system prompted staff to record whether Dutyof Candour (DoC) requirements had been fulfilled.

Public engagement

• People with learning disabilities had advised theoutpatients department on making the departmentmore learning disability friendly. We saw ‘it’s good totalk’ patient information boards in the outpatientsdepartment that carried posters and information forpeople with learning disabilities.

• We saw a group of volunteers providing information onhospital volunteering and support groups in thehospital corridor.

• The outpatients department had introduced ‘you said,we did’ boards. For example, the board acknowledgedthat the department needed to get better at “reducingwaiting times.”

• The matron had introduced ‘meet the matron’ days,these were days when the matron ran a stall in theoutpatients department providing both verbal andwritten information on staff roles, different outpatientsdepartment specialities and clinics, as well as answeringany questions patients, families and carers might have.

Staff engagement

• Staff were invited to add to the matron’s outpatientdepartment improvement plans at monthly staffmeetings. Staff were also updated on the hospital’simprovement plans at the meetings.

• Staff had access to independent and confidentialcounselling and support services via the hospital’soccupational health department.

• Several staff told us they felt proud to work for the trust,they felt more improvements could be made regards tochange and how the process was communicated.


• Most of the staff we spoke with reported improvementsat the hospital. The outpatient’s manager conceded thatwaiting lists were still long, but highlighted theimprovements the hospital had made over the previous12 months in reducing these. Staff in diagnostic imagingwere able to show improvements in waiting times andreporting times. The radiography staff in the reportingservice were to be commended for their ‘can-do’attitude and professionalism in driving the serviceforward.

• The hospital had introduced the ‘performance pack’ togive aid managers and staff in managing theoutpatients’ department demand and capacity andreduce waiting lists.

• The hospital had introduced a ‘quick triage’ service forpatients attending outpatient clinics with non-complexneeds. This involved patients having blood tests, initialassessment, height and weight measured, and MRSAscreening.




Outstanding practice

• The hospital provided tailored care to those patientsliving with dementia. The environment in which theywere cared for was well considered and the staff were

trained to deliver compassionate and thoughtful careto these individuals. Measures had been implementedto make their stay in hospital easier and reduce anyemotional distress.

Areas for improvement

Action the hospital MUST take to improve

• Ensure all patients attending the ED are seen morequickly by a clinician.

• Take action to improve levels of resuscitation training.• Ensure there is oversight of all training done by

locums.• Take action to improve the response to patients with

suspected sepsis.• Take action to address the poor levels of hand hygiene

compliance in ED.

Action the hospital SHOULD take to improveEmergency Department

• Endeavour to recruit full time medical staff in an effortto reduce reliance on agency staff.

• Increase paediatric nursing capacity.• Ensure there is a sufficient number of nurses and

doctors with adult and paediatric life support trainingin line with RCEM guidance on duty.

• Improve documentation of falls.• Document skin inspection at care rounds.• Document nutrition and hydration intake.• Review arrangements for the consistent sharing of

complaints and ensure that learning is alwaysconveyed to staff.

• Make repairs to the departmental air cooling system.• Ensure that all policies are up to date.• Improve appraisal rates for nursing and medical staff.• Ensure that consent is clearly recorded on patient

records.• Regularise play specialist provision in paediatric ED.• Ensure that patient records are stored securely.• Ensure staff and public are kept informed about future

plans for the ED at King George hospital.

Medical Care

• Continue plan to repair breaches in the firecompartmentation as detailed on the corporate riskregister.

• Continue to monitor hand hygiene and infectioncontrol across all medical wards and follow actionplans detailed on the current corporate and divisionalrisk registers.

• Monitor both nursing and medical staffing levels.Follow actions detailed on corporate and divisionalrisk registers relating to this.

• Monitor and improve mandatory training compliancerates for medical staff. Improve completion rates forbasic life support for nursing and medical staff.

• Continue to work to improve endoscopy availabilityand service, as detailed on the corporate risk register.

• Make patient information leaflets readily available tothose whose first language is not English.

• Increase staff awareness of the availability ofinterpretation services.

• Ensure leaflets detailing how to make a formalcomplaint are available across all wards anddepartments.

Outpatients and Diagnostics

• Ensure there are appropriate processes andmonitoring arrangements to reduce the number ofcancelled outpatient appointments and ensurepatients have timely and appropriate follow up.

• Ensure there are appropriate processes andmonitoring arrangements in place to improve the 31and 62 day cancer waiting time indicator in line withnational standards.

• Ensure there is improved access for beds to clinicalareas in diagnostic imaging.

• Address the risks associated with non-compliance inIR(ME)R and IRR99 regulations.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


• Ensure the 18 week waiting time indicator is met in theOPD.

• Ensure the 52 week waiting time indicator isconsistently met in the OPD.

• Ensure percentage of patients with an urgent cancerGP referral are seen by a specialist within two weeksconsistently meets the England average

• Ensure the number of patients that ‘did not attend’(DNA) appointments are consistent with the Englandaverage.

• Ensure the number of hospital cancelled outpatientappointments reduce and are consistent with theEngland average.

• Ensure diagnostic and imaging staff mandatorytraining meets the trust target of 85% compliance.

• Develop a departmental strategy in diagnostic imaginglooking at capacity and demand and capitalequipment needs.

• Improve staffing in radiology for sonographers.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

Regulated activity

Treatment of disease, disorder or injury Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

We had concerns around the governance of theemergency department including the handling ofinvestigations of incidents, risk management, oversightof resuscitation training, and infection prevention andcontrol management. The service must address thisincluding:

1. Taking action to improve levels of resuscitationtraining.

2. Ensure there is oversight of the training competenciesof locum doctors, particularly around advanced lifesupport training.

3. Take action to improve the response to patientswith suspected sepsis.

4. Take action to improve poor levels of handhygiene compliance.

This was a breach of Regulation 17(2)(a) and 17(2)(b)

Regulated activity

Treatment of disease, disorder or injury Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

We saw that failure to comply with the fourhour standard was rated as extreme and was added tothe corporate risk register in May 2016 and reviewedat each meeting. The recorded concern wasthat excessive waiting times and the resulting potentialfor delayed decision making impacted on patientcare. The percentage of patients who left withoutbeing seen was also higher than the England averagein all months between January 2016 and August 2016.

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


1. Ensure all patients attending the ED are seenmore quickly by a clinician.

This was a breach of Regulation 12(2)(a).

This section is primarily information for the provider

Requirement noticesRequirementnotices
