Newham University Hospital

Updated 17 September 2021

Background to Newham University Hospital

Newham University Hospital provides maternity services to women in the London Boroughs of Newham and Barking. Between June 2020 and June 2021 Newham Hospital had 5,903 births. The booking and antenatal clinics take place at one end of the hospital where there are five ultrasound rooms.

A consultant led delivery suite on the first floor has 15 delivery rooms and a midwifery-led birthing unit has 10 rooms. A four-bedded recovery/observation unit caters for women who require close monitoring. This area is staffed by nurses and midwives with specialised training.

Staff have access to two obstetric theatres 24 hours a day. Larch ward, on the ground floor, has two sections, an 11-bed antenatal ward and a postnatal ward with 34 beds. There are two bays for transitional care. There is a further bay that staff can open if the ward is very busy. Six single rooms can be used by women with a medical need, or as amenity rooms for which a fee is paid.

A maternity day assessment unit, to which women can walk in during opening hours is open between 8am and 8pm to assess women over 18 weeks of pregnancy, and triage is open 24 hours a day. An early pregnancy unit is open 9am to 5pm on weekdays and 9-2pm at weekends for women with complications of early pregnancy. A maternity helpline is available from 10am to 8pm.

The service is supported by a local neonatal unit that cares for babies born from 27 weeks’ gestation who need breathing or feeding support or short term intensive care, sometimes before being transferred to neonatal intensive care unit which provides the highest level of care to babies.

How we carried out this inspection

We carried out this unannounced focused inspection in response to concerns we received about the safety and quality of the maternity services. The concerns related to the governance and culture of the service. As this was a focused inspection our inspection activity focused only on parts of the safe, effective and well led key questions. This means we did not look at all key lines of enquiry in each of the domains.

We inspected maternity care throughout the maternity unit so we could get to the heart of the patient experience. During the inspection to understand the patient journey and make sure that women and babies were kept safe we visited triage, the antenatal ward, the postnatal ward, Larch ward, the delivery suite, the midwifery led birth centre, maternity assessment unit and the maternity booking centre.

We did not inspect the community midwifery team because the services were carrying out care within the community and we did not visit community services on this inspection.

We did not rate this service at this inspection.

The team that inspected the service comprised of a CQC inspector, an obstetrician specialist advisor and a midwifery specialist advisor.

The team spent a day on site at the registered location and carried out a desk top review of data the provider sent following the onsite inspection. We carried out telephone interviews with senior staff in the days following the onsite inspection.

On the day of the inspection we visited triage, antenatal clinic, post-natal ward, Larch ward, the maternity assessment unit, the maternity booking centre, the delivery suite and the midwifery led birthing centre. We spoke with 28 staff members including; service leads, matrons, midwives, doctors and midwifery care assistants. We looked at 10 sets of notes, 10 sets of medication charts and NEWS charts, reviewed a wide range of documents including; policies, meeting minutes, action plans, prescription charts, risk assessments and audit results.

We did not rate this service at this inspection. The previous rating of requires improvement remains. We found:

• Not all staff adhered to the trust uniform policy.
• The medical leadership structure was not fully embedded with all medical staff and some staff were unsure of their responsibilities.
• Some staff were not given enough time to complete their specialist roles.
• Safety champions were not visible, and staff were not always aware of the safety champions role and responsibility.
• There was a lack of information available to women in languages other than English.
• There was a perceived culture of blame amongst some staff.

However:

• The senior leadership were visible and well received by all staff.
• The service managed serious incidents well with actions and learning disseminated to all staff.
• Staff understood how to protect women from abuse and the service worked well with other agencies to do so.
• Staff collected safety information and shared it with staff, women and visitors.
• Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations and planned care to meet the needs of local people.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 12 February 2019

Our rating of this service went down. We rated it as requires improvement because:

• A significant number of medical staff were not meeting the trust target of 85% in their mandatory training modules, including key modules such as Basic Life Support (60%), and Infection Prevention and Control (74%). The trust did not have an action plan to address this issue.
• In the 30 patient records we looked at, risk assessments were not consistently completed. Risk assessments for falls, pressure ulcers, and National Early Warning Scores (NEWS) were not consistently recorded. This meant that oversight of patient risk was not consistent, and patients may have been at unnecessary risk without sufficient safety or monitoring measures in places. It also meant patients at risk of deteriorating may not be picked up as quickly as possible.
• On several occasions we found patient records trolleys unsecured and patient record booklets unattended in corridors, as well as computer terminals unlocked. This lack of security presented a risk to patient confidentiality, as well as clinical records being lost.
• We found that recording of capacity assessments and decisions on deprivation of liberty safeguards (DoLS) were not consistently documented appropriately in patient records. The nursing records contained a proforma pathway for assessing if a patient needed a DoLS application, however this was not being used consistently. We also found staff understanding of when patients needed an assessment under the Mental Capacity Act (MCA) and DoLS application was variable. Some staff were not able to demonstrate awareness of when MCA and DoLS assessments would be necessary. Safeguarding leads for the trust stated they recognised that there were gaps in training and understanding for MCA and DoLS which was due to a lack of staff in the safeguarding team.
• Some family members of patients we spoke with were concerned that patients who needed assistance eating were not supported to do so by staff, and so were not finishing meals. We observed nursing staff taking meals to patients and discussing supporting patients to eat, but also observed patients with meals that were not able to eat without support.
• The nursing records contained a section for completion on pain and comfort. In the records we viewed we found this to be inconsistently completed or not completed. This meant that pain management for some patients may not be as effective as it could be.
• Data provided by the trust showed that as of December 2018, appraisal rates of nursing staff on some wards in the Emergency and Acute Medicine division did not meet the trust target of 90%, with the lowest ward being 70%.
• The ECIP report stated that the ambulatory care model was in its infancy, staffing was variable and that the service ran extremely limited hours with strict exclusion criteria. We observed that the consultant presence on the ACU was extremely stretched between seeing patients and triaging referrals from GPs.
• Although the trust had an overall strategy for Newham hospital, some of which related to medical wards, there was no overall clinical strategy for the Medicines Divisions. Staff we spoke with across medical wards were unsure of the future development plans for medical wards at Newham Hospital.

However, we also found:

• The environment on the medical wards and areas we visited was visibly clean and tidy. Staff also followed the trust’s infection control policy, using personal protective equipment such as gloves and aprons, and adhered to the trust’s ‘bare below the elbow’ policy.
• Staff were aware of policies and protocols in relation to the administration of medication, and we observed adherence to these protocols. Staff recorded administration on medication charts, and performance was maintained through regular audits by the pharmacy team. Controlled drugs (CDs) were also managed safely and securely.
• Medical wards investigated all incidents and used learning from investigations to improve the delivery of care. Incidents were reported on and discussed through the divisional governance structure, and from this, actions were identified to minimise the risk of repeat occurrences. Staff also told us they were encouraged to report incidents by managers, and we found there was a positive attitude towards raising concerns.
• We observed care on medical wards during our visit and found it was delivered in line with evidence-based guidance such as those published by National Institute for Health and Care Excellence (NICE), the Royal Colleges and other relevant bodies, and was supported by local guidelines and standard operating procedures.
• Patients received screening and assessment for sepsis on medical wards and were managed in line with national guidance. A sepsis screening and management tool was in use across wards and each ward had a sepsis trolley, which allowed staff to start the sepsis 6 care bundle quickly for any patient identified as being a risk. The hospital had established a local multidisciplinary sepsis team responsible for coordinating sepsis promotion and education at the hospital, monitoring sepsis outcomes, and delivering sepsis specific improvement projects.
• Throughout our inspection we saw consistent evidence of multidisciplinary team (MDT) working across all disciplines and wards. The delivery of patient care included healthcare professionals from all backgrounds necessary, and MDT input was well reflected in patient records. During our inspection, we saw regular consultant-led multidisciplinary meetings and ward rounds attended by various disciplines. Daily MDT meetings were in use seven days a week to review patients, and we observed that they were attended by a consultant, nurse in charge, discharge co-ordinator, bed managers, junior doctors, social workers, and therapies co-ordinator.
• Staff and senior leads informed us that monthly clinical boards, which included several medical specialties, included representation from patients or family members who have used those service. Clinical staff we spoke with were very positive about the input of the patient experience contributors, and felt that they helped to ensure the patient voice was appropriately considered when discussing changes to service delivery or performance.
• There were several specialist staff available to medical wards to support patients with complex needs. This included a dementia and delirium team who supported the dementia and delirium pathway, and a specialist learning disability nurse (shared across sites) that supported patients diagnosed with a learning disability and/or autism spectrum disorders.
• In November 2017, an Emergency Care Improvement Programme (ECIP) team, which included involvement from NHS Improvement and NHS England, were invited to review current practice in acute medicine and offer suggestions for improvement. The team visited the observations unit, clinical decisions unit, ambulatory care unit, and took time to meet with staff. The report stated that the model for the observations unit is complex but it works for the site, however capacity within the Observation Ward was a challenge for the size of the medical take. The report was also positive about the ward rounds system and medical staffing.
• Staff were generally positive about working for the trust and felt valued. Staff stated there was a strong multi-disciplinary team working culture within the organisation, and that managers were supportive and accessible. Morale amongst staff we spoke to was generally positive. Medical staff we spoke with felt there was a positive relationship between consultants and junior doctors, and that there were good opportunities for learning for junior doctors.
• There was a clear governance structure within the division and staff at all levels were clear about their roles and what they were accountable for. Medical wards had systems in place for monitoring and reporting on risk and performance at ward and divisional level.

Updated 12 February 2019

Our rating of this service improved. We rated it as good because:

• The service had taken steps to address the requirement notice set at the previous inspection and there were improvements to all the previous concerns we reported.
• The trust had invested heavily in the new Rainbow Centre and the new environment was clean, tidy and very well-maintained. New equipment on the unit was well-maintained. Infection prevention and control (IPC) was managed safely and effectively, all clinical areas were visibly clean and staff complied with current IPC guidelines.
• There was a good overall safety performance across paediatric and neonatal services and there was culture of learning to ensure safety improvements. Learning was shared from incidents.
• There were appropriate systems for staff to monitor and escalate deteriorating patients. Staff had a good understanding of safeguarding and there were robust security measures in place to prevent unauthorised access to both the Rainbow Centre and neonatal unit. Medicines and Controlled Drugs were stored appropriately and patient records were completed to a good standard.
• Staffing was generally well managed and nurse staffing levels had improved since our previous inspection. Medical staffing was stable, but there was a need for more consultant doctor capacity.
• Care pathways for CYP services were delivered in line with referenced national clinical guidelines. The service conducted routine quantitative and qualitative audits to review and benchmark practice. The hospital participated in local and national clinical audits for which the service performed well against other similar hospitals.
• There were appropriate processes in place to ensure that patients’ nutritional and pain relief needs were met.
• Staff reported a supportive and developmental environment with good learning opportunities to maintain and develop their skills and knowledge. Student nurses and doctors in training reported a supportive educational environment with good supervision. There was an effective multidisciplinary team (MDT) working environment which supported patients’ health and wellbeing.
• Clinicians were involved in some national research projects as well as local public health promotion initiatives.
• Staff were caring and child-centred and they interacted with patients, their family members and carers in a polite and friendly manner. Children and young people were spoken with in an age appropriate way. The people we spoke with during the inspection were very happy with their care and treatment. Staff spent time with children to help make their experience more comfortable, relaxed and home-like. There were appropriate and sensitive processes for end of life care. The service signposted patients and their families to local services and support groups.
• There were improvements to the post-operative recovery area which was decorated with child friendly transfer images on the walls in a consistent theme with other areas of the CYP service. There were new dedicated family rooms in the Rainbow Centre.
• Flow within children and young people services from admission, through theatres, wards and discharge was mostly managed effectively.
• There was comprehensive provision to meet the individual needs of children and young people, including vulnerable patients and those with specific needs. The hospital had introduced a learning disability ‘passport’ system to record individual patients’ specific needs. There was specific equipment for staff to use to help engage and care for children and young people with learning disabilities. Staff had sufficient access to appropriate translation and advocacy services.
• Parents and families could seek support and advice from a community lead practitioner and could access a family support worker. The hospital play therapist provided a comprehensive programme of play support to children across all paediatric areas. There was sufficient provision of clear and accessible patient literature.
• Most CYP specialities were meeting referral to treatment targets (RTT) and CYP services received very few formal complaints.
• The hospital provided a wide variety of child friendly food and snacks with specific menus for children and young people. The children’s outpatients’ department was flexible with appointment times and parents told us this better suited their needs.
• There was trust-wide strategy for CYP services which incorporated the Rainbow Centre and neonatal unit. There was an established and stable service leadership team and staff told us they were visible, approachable and supportive. There was improved leadership capacity in the Rainbow Centre with dedicated matrons for the Rainbow Centre and NNU. There was an inclusive and constructive working culture within the services.
• Governance and risk management processes were effective, documentation was completed appropriately and concerns were escalated. There was clear representation of children and young people services at hospital board level.
• There were some examples of innovative practice, including dedicated blood gas analyser machines in the Rainbow Centre and NNU for instantaneous blood test results. The CYP service had also co-designed tailored training for clinicians to equip them with skills to support young people in mental health crisis.

However, we also found:

• Completion of some mandatory training modules, particularly for medical staff was slightly below trust targets. Managers were aware of this and plans were in place to address it.
• Medicines management was generally good; however, at the time of the inspection there was no system for recording the balance of FP10 forms against what was available. We notified the trust pharmacy team and a check process was subsequently put in place.
• Some staff in the NNU told us there was a need for further investment in new equipment on the unit.
• Some doctors in training found the work intensity and acuity challenging and some felt they were working to the limits of their competency and capacity.
• There was limited access to dedicated on-site paediatric allied health professions. Senior staff were aware of this and there were plans to increase staffing in this area.
• Consent processes in CYP services did not always follow best practice as direct consent of the child was not always sought.
• The route from paediatric theatre back to the Rainbow Centre was not optimal, from a patient perspective, as patients had to be transported through the Rainbow Centre reception, which could potentially be distressing for some children.
• Most CYP outpatients’ clinics were delivered in the Rainbow Centre, however some services were provided in the main hospital outpatients area which was not a child friendly environment. Senior leaders of the service were aware of this and were working to further consolidate CYP outpatients provision in the Rainbow Centre.
• The hospital had some transition pathways for young people moving from CYP to adult services, however for some services this was more structured than others. Some teenagers we spoke with did not have transition plans in place.
• There were isolated examples of potential risks which were not recorded on the service risk register.
• There were some isolated comments from nurses in the Rainbow Centre and NNU about perceived bullying and harassment and not feeling supported or listened to when they raised concerns, but this was not representative of most of the feedback we received from staff.

Updated 12 February 2019

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

• Staff did not always clean their hands when entering the unit or before patient contact.
• Cleaning records were not kept to show whether the environment or equipment had been cleaned and when. The “I am clean” green stickers were also not used consistently to show what equipment was clean and ready to use.
• The service did not comply with building guidelines for critical care services due to a lack of bed and storage space, and insufficient hand-wash basins. We raised this as a concern in 2015 and at this inspection in 2018 found no action had been taken. Furthermore, senior managers could not provide us with assurance that these issues were going to be resolved in a timely way. We saw that these environmental concerns put patients, staff and visitors at risk.
• Equipment used for the transfer of patients to and from the critical care unit was not regularly checked.
• Oxygen cylinders were stored without safety notices in place.
• Records to show equipment servicing were not kept up-to-date.
• Whilst nursing staffing numbers had improved significantly since our last inspection, we found that the coordinator for the critical care unit was counted as part of the staffing numbers at times, opposed to being supernumerary as required and that six of the seven middle-grade doctors employed were locums. However, we were told that three middle-grade doctors had been appointed to post and due to start at the end of October 2018.
• Seven of the 15 policies and procedures staff had access to were either not up-to-date or not the most recent version available.
• There was no policy in place for the management of sedation.
• The trust reported a sickness rate of 5.8% for nursing staff in critical care; this was higher than the trusts target of 3%.
• The critical care unit did not use patient diaries.
• The relative’s room did not meet the needs of the people who used it. It was small, dull, with a sofa bed which was marked and appeared unclean, and there were no beverage making facilities available. We raised this concern in 2015 and found minimal action had been taken to improve this area. However, following this inspection in 2018 the trust told us they had taken immediate steps to paint the room, add a lamp and table and had ordered a water cooling machine for the room.
• Out of hours discharge rates remained high. Between January to September 2018, 43% of all critical care unit discharges took place between 10:00pm and 6:59am. We also raised this as a concern in 2015.
• Delayed discharge rates for patients ready to step down from the critical care unit remained high. Data from January to September 2018 showed that there had been 78 delayed discharge incidents of more than eight hours during this time period, with 21 of these discharges exceeding 72 hours. We raised this same concern at our inspection in 2015.
• There was a lack of information available to patients and those close to them in alternative languages other than English.
• The service did not collect data to show the amount of level three admissions to the critical care unit which occurred within four hours of making the decision to admit.
• There had been no needs assessment of the local population served to support the planning of the critical care service provision.
• There was no formalised vision and strategy for the critical care service.
• There was a lack of formalised action plans in place for identified risk. This included for delayed and out of hours discharges.
• The Critical Care Outreach Team (CCOT) and the critical care follow up clinic lacked supporting operational policies and procedures.

However, we also found:

• Numerous improvements had been made following the concerns we raised in 2015. This included improvements to medical and nursing staffing numbers, a practice development nurse had been in post for the past year, the number of cancelled elective operation rates had reduced, staff understanding about the Mental Capacity Act and consent was satisfactory and better governance systems were in place.
• More than 85% of nursing and medical staff had completed their mandatory training which was above the trust target. This included annual training on sepsis management which incorporated the use of sepsis screening tools and sepsis care bundles.
• There were plans being actioned to increase the CCOT service to a 24-hour, seven day a week service. Staff had access to the hospital’s mental health liaison service 24 hours, seven days a week.
• Staffing requirements were reviewed regularly. Medical and nursing staffing levels and skill mix was good.
• Patient’s healthcare records contained holistic needs assessments and were complete, containing all the information staff needed to deliver safe care and treatment to patients.
• Medicines were stored and disposed of safely. Medicines were prescribed and administered in line with relevant standards for medicines management.
• Incidents were reported and investigated appropriately, with lessons learnt, identified and changes to practice made where required.
• Data showed that safety performance over time was good. For example, data from the NHS Safety Thermometer for August 2018 showed 100% harm free care.
• People’s care was assessed and planned based on evidence-based practice, with service participation in national benchmarking clinical audits.
• There was a designated dietician for the unit who was available Monday to Friday, with robust protocols in place for staff to follow out of hours. People’s nutrition and hydration needs were identified, monitored and met.
• People’s pain was assessed regularly and managed effectively, including for those with difficulties communicating.
• Outcomes for people’s care and treatment were routinely monitored and collected, generally showing intended outcomes of people being achieved or, if not met, information was used to improve outcomes.
• Staff had the skills, knowledge and experience to deliver effective care, support and treatment. There were competencies in place for all nursing levels and 67% of nurses had completed the post registration award in critical care nursing.
• Staff, teams and services throughout the hospital were involved in assessing, planning and delivering care and treatment for people using the critical care service. We saw that the multidisciplinary team (MDT) consistently worked well together.
• There was consultant presence seven days a week, with an on-call rota out of hours where a consultant was present within 30 minutes as needed. There was physiotherapy support seven days a week and pharmacist support available 24 hours a day, seven days a week.
• Staff consistently treated people using the service and those close to them with kindness and compassion. There were also additional support services available for people living with dementia, a mental health concern or learning disability who required this.
• As much as possible people who used the service or those close to them were actively involved in making decisions about their care, support and treatment. Advocacy services were available.
• People’s privacy and dignity needs were always respected including during physical or intimate care and examinations.

Updated 17 December 2019

This was a follow up inspection to assess whether the trust had made enough progress in response to the requirement notice issued in September 2019. We did not inspect all domains, but focused on

Safe and Well led.

The trust had drawn up an action plan and had put in place new systems to deal with the main concerns in safety and governance. Many senior staff were doing everything in their power to take the service forward. However, sustainable improvements were not seen in every area.

We did not identify any breaches of regulation and rated safe as requires improvement to reflect that although improvement was seen we were not assured of long-term sustainability. We rated well led as Good to reflect the improvement seen since the last inspection.

Updated 12 February 2019

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

• Whilst the service had an education strategy for end of life care, the trust did not follow the national standard for end of life care training for all staff, as end of life care training was not mandatory. End of life training was mandated by the National Care of the Dying Audit of Hospitals (NCDAH) 2014-2015 across all staff groups.
• There was no robust system to identify review and learn from information that related to end of life care or performance measures for the specialist palliative care team to report on.
• Alarm checks of the DHU temperatures out of hours and at weekends were not being monitored by security staff on a two-hourly basis as detailed in the ‘Newham Mortuary Temporary Body Fridges Alarm Escalation Procedure Out of Hours’. However, the trust provided evidence to show that the checks undertaken exceeded best practice guidance according to the Human Tissue Authority.
• Most of the ward staff we spoke with had not received formal training in syringe drivers.
• Incidents related to deceased patients were reported but not discussed at the end of life steering group. It was not clear how learning from these incidents were shared with the wider service.
• Pain assessments and pain scores were not completed consistently.
• The end of life service was not meeting the National Institute for Health and Care Excellence (NICE) guidelines for adults to provide palliative care services face-to-face seven days a week. This had not changed since the last inspection in November 2016.
• Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms were not always completed correctly. This meant that the trust could not be assured that DNACPR decision were made appropriately and were in line with national guidance.
• Although we saw evidence that palliative and end of life care patients had plans of care which included the patients preferred place of death, the service had not consistently collected data to evaluate this.
• Although the Compassionate Care Plan was in place, there was variation in how consistently this was completed.
• Medical staffing in the SPCT was 0.9 whole time consultants (WTE). This was an increase of 0.4WTE since the last inspection. The trust recognised that consultant levels were still below the ‘Helping to deliver commissioning objectives’ (Dec 2012) based upon the total number of hospital beds.

However, we also found:

• The trust had further developed the end of life care strategy and an action plan for delivery was in place.
• Staff we spoke with told us the specialist palliative care team were very visible and accessible and worked collaboratively with staff on the wards in providing end of life care. Staff were positive about the support provided by the specialist palliative care team.
• The specialist palliative care team were knowledgeable about their role and responsibilities regarding the safeguarding of vulnerable adults and children.
• During our last inspection we found poor standards of cleanliness and upkeep in the mortuary. At this inspection we found end of life care facilities provided for the use of patients and their families were visibly clean, tidy and well maintained. this included the multi-faith rooms and the viewing room. Cleaning schedules in the DHU were now in place.
• Medicines were readily available to patients requiring treatment for palliative and EoLC. The specialist palliative care team worked closely with medical staff on the wards to support the prescription of anticipatory medicines. Since the last inspection a clinical nurse specialist in palliative medicine had been trained as a non-medical prescriber.
• The specialist palliative care team had access to the liaison psychiatry service provided by a neighbouring mental health trust
• End of life care policies and procedures were based on national guidance and the trusts strategy was based on the ‘Ambitions for palliative and end of life care: a national framework for local action 2015 – 2020’.
• The service had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• Staff treated people with dignity, respect and kindness. Staff were seen to be considerate and empathetic towards patients. Feedback from relatives was very positive about the staff and felt they could ask staff questions about their loved one’s care and treatment.
• Staff provided emotional support to patients to minimise their distress.
• Staff involved patients and those close to them in decisions about their care and treatment. Feedback from relatives confirmed the staff communicated with them and their relative in a way that helped them understand their care, treatment and condition.
• The trusts bereavement policy took account of different faiths and cultures in how to deal with death.

Updated 17 September 2021

Updated 12 February 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated the service as requires improvement because:

• The hospital was not undertaking medical records audits but we were told by the general manager that they planned to do this soon. This had been raised in our last inspection. Further to our inspection, we were however provided with data to show that the service was monitoring notes availability, showing results of 95% and 94% in March and June respectively, against a target threshold of 95% - 98%.
• Medical records did not always arrive with a patient’s referral letter.
• The service was not participating in any national audits.
• The only local audits that the service was participating in were hand hygiene and medicines management audits.
• Data showed that the service still had a high ratio of follow-up patients to new patients.
• Though the service had introduced some targeted work to address the high DNA (did not attend) rate, the rate was still higher than the England average and was the highest out of all hospitals within the trust.
• The West Wing waiting area, which was run by a different division, did not provide adequate space or privacy for patients, despite this being raised as an issue in the last inspection.
• Though the trust had only started reporting RTT again since April 2018, the performance of RTT from this date to August 2018, showed results of 85% against a trust target of 92%.
• Though risks were being effectively managed, the service only had one risk on their risk register, despite high DNA rates and follow-up rates.
• The service had just entered into a new site based structure, which meant that it was difficult for us to appraise the leadership.
• Though the service had plans to monitor patient outcomes in the near future, they were not currently being monitored at the time of our inspection.

However, we also found:

• Improvements had been made in compliance with Infection Prevention and Control training, though compliance will still slightly under target threshold. Hand gel sanitisers were visible, full and in use across the outpatient areas that we had visited. The Health Central Outpatients Department, had week-on-week 100% hand hygiene compliance between May 2018 and August 2018.
• Staff were 100% compliant in Safeguarding Adults Training Level 1 and 2. Staff were also 100% compliant in Level 1, 2 and 3 Safeguarding Children Training.
• Improvements had been made with staff being able to access the electronic system to report incidents, as well as receiving feedback following incidents that had been submitted.
• All staff members bar one had received an appraisal, with clear objectives being set out, which hadn’t been the case previously. The remaining appraisal date had been organised.
• We saw episodes of good care with patients and carers being in full understanding of what was being explained to them.
• Patient satisfaction forms showed that patients were extremely likely to recommend the service to friends and family if they needed similar care or treatment.
• Patient waiting times were clearly articulated to patients, both on a notice board and through nurse announcements.
• The trust was performing better than the England average for cancer waiting times.
• Between September 2017 and August 2018 there were 3 complaints which went through the formal complaints process. In addition there were 20 complaints received through PALS. For the formal complaints, all were responded to within 25 days.
• The culture within the outpatient’s service was described by staff and managers as good, with senior staff being described as very supportive.
• Under the new structure for outpatient services, several new meetings had been devised such as an Outpatients Transformation Board, where any decisions or changes to the new site-based structure would be discussed.

Updated 28 April 2017

We found that there was much improvement made in the hospital’s surgical services from the time of our last inspection in January 2015, when four domains were rated as requires improvement and one as inadequate. During this inspection, we found that four domains were good and one required improvement.

There was a new site based management team and a more robust clinical governance structure which meant there was better oversight of risk. Staff expressed a greater level of confidence in management and general morale was high. We found that there were reduced numbers of staff vacancies and better planning of skill mix. Staff reported on a supportive learning environment with good continuous professional development opportunities.

Patient flow was well-managed and there were no surgical site infections for knee and hip replacements and length of stay for elective and non-elective surgical patients was better than the England average.

The majority of patients we spoke with were happy with the care and treatment they received and we observed kind and compassionate care being given.

However, we also found:

There were low levels of training amongst certain groups of staff in Level 2 safeguarding adults and safeguarding children.

Updated 12 February 2019

During our previous inspection of the urgent and emergency care service, which took place in January 2015, we asked the trust to improve processes/referrals for safeguarding children in the emergency department; improve multidisciplinary working in the emergency department; and provide suitable consultant cover in the emergency department, in line with the College of Emergency Medicine recommendation.

During this inspection we found that the trust took appropriate actions to address those three requirements and they improved in all three areas.

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

• Staff treated patients with compassion and kindness. Feedback from patients and relatives was generally very good and they felt they were treated with courtesy, respect, and compassion by staff. Patients felt able to speak about their worries and said staff at the hospital were compassionate.
• Staff ensured patients’ privacy and dignity was respected when providing care by closing the door to side rooms and drawing curtains in bays. Doctors and nurses introduced themselves to patients and carers and explained what their role was.
• Staff involved patients and relatives in care planning and decision-making process. It was demonstrated by staff in all specialties and roles. Patients and relatives were given opportunities to ask questions and staff gave them time to do this. They were told when they needed to seek further help and what to do should their condition deteriorate after discharge from the department.
• The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred, or discharged within four hours of arrival in the emergency department. The department performed better than the England average and other emergency departments managed by the trust.
• Nurses and doctors, we spoke with had a good knowledge of safeguarding protocols and awareness of issues they should be concerned about when treating adults, children, and young adults. They spoke of appropriate examples were safeguarding protocols were initiated by members of staff. There were appropriate arrangements to ensure children and young people who harm themselves were seen and assessed by suitable mental health professionals.
• Areas we visited were tidy, clean, and uncluttered. Staff adhered to principles of infection control and prevention.
• There was sufficient consultant cover provided to meet the needs of the department.
• Junior and trainee nurses worked adequately supervised and any new staff worked supernumerary shifts. They were provided with good development opportunities and felt competent to perform tasks needed to provide effective care and treatment.
• There was a good culture of teaching and learning in the department. Doctors training was consultant led, pre-planned and tailored to the needs of the emergency department.
• Multidisciplinary team working within the department was well embedded part of the department’s work. Nurses, healthcare assistants and doctors spoke of teamwork and joint working and the way in which it enhanced good working relations as well as improved patient safety.
• The ED staff understood their responsibilities in relation to patients who lacked the mental capacity to make decisions about their care and treatment and the key principles of the Mental Capacity Act 2005 (MCA). They understood their duty to act in the patient’s best interests.
• People's physical, mental health and social needs were holistically assessed, and their care, treatment and support was delivered in line with legislation, standards, and evidence-based guidance, including NICE and other expert professional bodies, to achieve effective outcomes.
• Access to a psychiatric liaison team was available for patients within the hospital at all times. Mental health liaison team responded to referrals very promptly. The care records we looked at confirmed that patients had been seen within the one-hour target time.
• Staff used appropriate discharge arrangements for people with complex health and social care needs.
• Staff we approached spoke positively about members of the senior management team who were visible, approachable, and aware of problems faced by the front-line staff. Divisional and local leaders were clear about their roles and knew which areas they were accountable for and to whom. They had suitable systems to allow them to effectively perform their tasks and support delivery of the service. The department used information available through performance reports and local audits to inform and improve service planning.
• Information about the outcomes of people's care and treatment routinely collected and monitored. The trust took part in external audits and benchmarked patients’ outcomes against trust’s emergency departments as well as nationally.
• The department had a long-term strategy that focused on providing core emergency service, focussing on the needs of emergency patients, and targeting the delivery of high quality emergency care.
• Teams were well motivated and focused on delivering quality care. Staff were positive and optimistic about the future of the trust.
• The trust engaged patients and staff. They monitored patients feedback and summarised themes to support improvement within the department.

However, we also found:

• Quality of individual patient’s records was variable. Some areas were not consistently captured in paediatrics department; for example, there was no safeguarding information recorded on two records. We also noted missing information related to sepsis screening, pain scores, or early warning scores.
• Medical staff met the 85% completion target for only three out of 24 mandatory training modules.
• In the paediatric emergency department, staff used a side room to nurse children and adolescents who needed support for their mental health conditions. This room and its en-suite shower room was not risk assessed for ligature risks and had many ligature points including handles, door closures and taps.
• From May 2017 to April 2018, Newham Hospital reported a vacancy rate of 21.4% for nursing staff in urgent and emergency care services, this was higher than the trust target of 6.3%. The hospital reported a turnover rate of 16.6% for nursing staff in urgent and emergency care services, this was higher than the trust’s target of 13%. Newham Hospital reported a vacancy rate of 19.2% for medical staff in urgent and emergency care services, this was higher than the trust target of 6.3%.
• Hand hygiene audits were not always undertaken.
• NEWS audits provided by the trust showed that audits within the ED were not taken regularly.
• We observed that patients did not always receive pain controlling medication promptly. Staff did not always use the pain scoring tool accurately.
• In the 2016/17 Severe sepsis and septic shock audit, Newham Hospital emergency department did not meet any of the national standards.
• From July 2017 to June 2018, the trust’s unplanned re-attendance rate to A&E within seven days was worse than the national standard of 5% and worse than the England average.
• The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment should be no more than one hour. The trust did not meet the standard for five months over the 12-month period from July 2017 to June 2018.
• From August 2017 to July 2018, the trust’s monthly median total time in A&E for all patients was higher than the England average.
• The department’s risk register was not updated with many risks placed on the risk assessment more than 2 years old. Out of 17 entries one was entered in 2013, two in 2014, and three in 2015.
• Investigators that analysed incidents root causes and contributory factors did not refer to incident specific shared learning routes. They made generic statement such as “national reporting and learning service [system] will be used for promotion of wider learning”. It was not recorded if patient or their relatives had an opportunity to contribute to terms of reference or engage in the investigation process.