Queen's Hospital

Updated 22 December 2023

Barking, Havering and Redbridge University Hospitals NHS Trust is a large provider of acute services, serving a population of approximately 800,000 in outer North East London and Essex. The trust operates from two sites: Queen's Hospital and King George Hospital, with approximately 900 beds across both sites. The trust employs over 8000 permanent staff, sees over 300,000 attendees through their emergency departments and delivers over 7000 babies a year.

In the last year, Queen’s Hospital emergency department saw 60,806 adults and 23,333 children.

Patients present to the emergency department either by walking into the reception area of the urgent treatment centre which is managed by another provider and is co-located on one level with the emergency department of Queen’s Hospital or arriving by ambulance via a dedicated ambulance-only entrance directly into the emergency department. Patients arriving at the urgent treatment centre are assessed and directed to the trust’s emergency department if required.

The emergency department has different areas where patients are treated depending on their needs, including a rapid assessment and first treatment area (RAFT), resuscitation (resus), majors, same day emergency care (SDEC) and the children’s emergency department which is a separate unit with its own waiting area and bays within the department.

We last inspected the trust’s emergency departments in November 2022 due to ongoing concerns regarding the urgent and emergency care pathway and patient safety. The emergency department at Queen’s Hospital was rated overall inadequate. At this inspection our rating of Queen’s Hospital emergency department improved. We rated it is as requires improvement overall.

Updated 22 June 2018

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

• Compliance with mandatory training completion exceeded the trust’s standard of 90% in all courses for nursing staff, including in safeguarding.
• We found consistently good standards of adherence with infection control processes, which reflected improvements made since our last inspection.
• There was a consistent drive from staff at all levels to improve patient safety through effective risk management systems including audit and practice development.
• Staff demonstrated substantial knowledge in safeguarding principles and adapted trust and national guidance to meet the needs of their patient groups.
• Auditing was part of the trust’s strategy to ensure services were evidence-based, contributed to ongoing accreditation and benchmarked the service. This included on a local and national level.
• Several teams were research active and demonstrated how this resulted in improved patient outcomes. This included a reduced average length of stay in the respiratory wards and significantly improved community rehabilitation access for patients.
• The endoscopy service was accredited by the Joint Advisory Group (JAG) on GI Endoscopy, which meant care and treatment was benchmarked and audited against national and international best practice.
• Staff demonstrated kindness and compassion and the ability to communicate openly with patients. This was reflected in the results of the NHS Friends and Family Test and from our observations.
• Specialist teams were in place for learning disabilities and dementia care. The teams were readily available and ward teams had access to tools and training to aid communication and care.
• Significant work from allied health professionals had been focused on improving discharge planning and processes and improving access to community rehabilitation and reablement services.
• There was significant evidence of wide-reaching improvements in staff engagement from senior trust teams and ward leadership teams.

However:

• Mandatory training compliance amongst doctors was variable and did not meet the overall 90% standard.
• Results from monthly clinical records audits indicated highly variable practice, with significant and persistent poor performance in the completion of nurse-led transfer checklists.
• Although divisional risk and governance teams used risk registers, risks were not always reviewed in a timely manner and risks of up to 11 months had occurred with no effective control measures in place.
• Between November 2016 and October 2017 RTTs, as a percentage within 18 weeks, varied from 73% to 88%. This was worse than the national average.

Updated 7 March 2017

There was clear and sustained improvement from our previous inspection. This included the implementation of an audit programme that led to benchmarking of care standards and improvements in practice.

There was improvement in learning from incidents and how these were communicated with staff, including examples of changes in practice and policy as a result of learning.

Improvements had been made in nurse staffing levels, with an increase in recruitment and a reduction of turnover. Although there was still a vacancy rate of 11% in the nurse team, 15 new staff nurses were due to start and an overseas recruitment programme had been successful in attracting qualified nurses to the hospital.

Medical staffing levels were consistently good and medical care was consultant-led, with support provided by other clinicians with appropriate training and specialist knowledge.

Safeguarding procedures were robust and embedded in clinical practice and a system of meetings, staff training, supervision and audits acted as checks and balances to ensure children were protected from avoidable harm.

Services were benchmarked against the guidance and standards of national health organisations as a measure of good practice. This included audits of the care received by patients with diabetes and epilepsy. The outcomes of audits resulted in improvements to the service.

Practice development nurses provided support in staff development including competency assessments, training sessions and one-to-one support. In addition, staff were provided with the opportunity to develop specialist link roles. This represented part of a broader programme to encourage staff training and development.

A weekly multidisciplinary psychosocial meeting ensured patients with complex needs or those who needed community social support were reviewed by a specialist team. Staff used this meeting to plan complex discharges, review safeguarding alerts and ensure care and treatment met individual needs.

Feedback from patients and their parents was consistently good in the trust’s in-house ‘I want great care’ survey. Staff demonstrated kind, compassionate and friendly care in all of our observations and all of the parents we spoke with told us they were happy with the service.

Services were planned to meet the needs of the local population. This included Saturday outpatient clinics, a daily phlebotomy service and a weekly visit from a peripatetic local authority school teacher.

Two dedicated play specialists and two play workers were available in Tropical Bay and Tropical Lagoon wards and children had access to a range of activities, equipment and toys. This included two indoor play areas and a secure outdoor play area attached to Tropical Lagoon. A sensory room and mobile sensory equipment were also provided.

A dedicated paediatric learning disability nurse had introduced support resources for patients, including a children’s hospital passport and visual communication tools. This helped staff to build a relationship with patients who found it challenging to make themselves understood.

Transition services were in place for when a child moved into adult services. This was a structured approach that provided patients with gradually increasing levels of independence followed by the support of both children’s and adult’s nurses as they moved.

Clinical governance structures enabled staff to monitor risks to the service and involve patients and staff in improvements. This was achieved through various means including a patient safety summit, clinical safety and quality meetings, whole unit team meetings and the use of a risk register to track changes in risk status.

Changes to leadership in children’s services had been well received by staff and as part of the trust’s ongoing improvement programme, a new lead nurse was due to join the hospital in January 2017 with a remit of improving communication between hospital services and the care of young people.

Staff were encouraged to provide feedback on their work and hospital policies and this was acted upon. In addition, staff with an interest in research were supported to participate to help inform innovative practice.

However, environmental safety and waste management standards were not always consistent. This was because access to areas used to store sharps bins and waste was sometimes uncontrolled and there was a lack of compliance with fire safety guidance in some areas.

Multidisciplinary staff did not attend nurse and medical handovers or ward rounds and short staffing in therapies teams meant there was inconsistent input from physiotherapy and dietetics and no occupational therapy service. This was evident in the inconsistent standards of nutrition risk assessments in patient records.

Local audits identified documentation of consent to treatment as an area for improvement. Nursing staff were aware of this and handovers included a discussion of which patients had consent forms completed.

Updated 9 January 2020

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
• All areas we checked were visibly clean with minimal clutter in corridors or clinical areas.
• Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
• The critical care outreach team (CCOT) supported acutely unwell patients in other areas of the hospital, prior to their transfer to the critical care, and to follow up with discharged critical care patients.
• Although there were significant vacancies in nursing staffing, which could be considered a long-term risk, critical care wards were mitigating this risk as much as possible, and shifts were covered where necessary by bank staff.
• Senior medical cover was available 24 hours a day, seven days a week. Staff stated there was a positive relationship between the consultants and junior medical staff.
• The service used systems and processes to safely prescribe, administer, record and store medicines. Critical care wards had access to specialist pharmacy input that cover both trust hospital site.
• At the time of the last inspection there were inconsistencies in completion of drug charts and prescriptions. We reviewed medication charts in patient records and found them to be consistently completed.
• At the time of the last inspection we found there was limited use of systems to record and report safety concerns and incidents. Some staff were also unclear about the types of incident to report and were wary about raising concerns. On this inspection an incident reporting system was in place across the trust and staff knew how to report an incident and there was a positive reporting culture in place.
• The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance
• At the time of the last inspection, critical care wards did not have dedicated input from dieticians. Critical care wards now had full-time dieticians in post in both general and neuro intensive care wards. Staff we spoke with were very positive about the input of dieticians, who could attend ward rounds for patients, and provide advice and support as needed.
• Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and gave pain relief to ease pain.
• The service also contributed and uploaded data regularly to the Intensive Care National Audit Research Centre (ICNARC), which provides information/feedback about the quality of care to those who work in critical care to allow service benchmarking against similar critical care units nationally.
• The service actively engaged with the local critical care network to help support and improve delivery of high-quality care in the area. This included a peer review network and shared learning across London.
• At the time of the last inspection we identified that staff were not working together as an MDT. On this inspection staff stated they had good working relationship as a critical care team and across disciplines, and we observed this in effect on the wards. Staff stated they worked well together collaboratively, and this was supported by effective and approachable clinical leadership.
• Staff held daily multidisciplinary meetings to discuss patients and arrangements for their care. While on inspection we attended the morning handover and found it to be well attended by medical and nursing staff (including the CCOT), and Allied Health Professionals (AHPs).
• During the inspection we saw most staff treating patients with dignity, kindness, compassion, courtesy, and respect. Most staff explained their roles to patients (including identifying themselves to patients who were not conscious) and put patients at ease during any interactions.
• Patients spoke positively about the care they received and how they were treated on critical care wards. Patients told us staff were respectful and provided them with space to ask questions about their care.
• Critical care wards collected feedback from patients using the Friends and Family Test (FFT). Data showed that for July 2019, the average number of patients who were likely to recommend the service was above 95%.
• Most staff understood the impact that patients' care, treatment and condition had on their wellbeing. Staff stressed the importance of treating patients as individuals and this was reflected in the majority of interactions we observed.
• Patients who were approaching the end of their life or required palliative care could be supported by the trust palliative care team if necessary. The palliative care team worked collaboratively with the critical care staff to manage end of life patients. Critical care wards had developed a 24-hour care plan, with support from the palliative care team, to ensure the needs of end of life patients were well managed.
• Family members were positive about the care the patients received and stated that staff members were professional and welcoming. Family members also stated they were kept well informed of treatment plans.
• There were information leaflets for family members for each critical care ward. These leaflets contained information on visiting times, lead staff, and hospital amenities.
• The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care.
• At the last inspection we identified that there were insufficient critical care beds available for the population served by the trust. Since the time of the last inspection. The opening of Sky A HDU ward on the fourth floor had increased the capacity of the critical card wards by ten beds. Staff recognised this ward had a significant impact in managing increased patient activity within this time frame, as activity had noticeably increased.
• Critical care wards had access to a multi-disciplinary team of staff able to support the individual needs of the patients.
• Support for mental health patients was provided by referral to the local mental health trust psychiatric liaison service. The trust had a contract with this service and support/advice was available 24 hours per day.
• It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
• The hospital chaplaincy was available to meet the religious needs of the local population. The service had Christian, Muslim, and Jewish chaplains, and could also provide access to other local religious groups as needed. A duty chaplain was available on site seven days a week including evenings, and the service also offered a 24/7 on-call service.
• Critical care had a clear management structure in place. Staff we spoke with stated that the divisional leadership was visible on the wards and were approachable to staff.
• Staff demonstrated awareness of the trust values and information on these values was displayed on the critical care wards.
• There was a robust corporate governance framework in place which oversaw service delivery and quality of care. This included monthly speciality governance meetings across critical care, led by speciality leads and attended by ward staff, as well as hospital wide governance meetings.
• Senior leads and managers of the critical care service had a good understanding of risks to the service and these were appropriately documented in risk management documentation with named leads and actions.
• The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security systems.
• During the last inspection, the trust was advised that it should consider ways to engage patients in providing feedback specifically related to critical care services. On this inspection, we found improvements had been made as the service used the trust’s ‘I want great care’ database to provide internal information on critical care services.

However, we also found:

• Critical care staff were not meeting the trust target in mandatory training modules for resuscitation level 2 and 3. Data provided by the trust between April and June 2019 showed the compliance rate for resuscitation level 3 (adult immediate life support) for medical staff in critical care was 51.7% against trust target of 90%.
• We observed inconsistent staff compliance with IPC best practice guidance in relation to hand hygiene and ‘bare below the elbows’ protocols. IPC audits were not identifying issues with hand hygiene compliance as we observed on inspection.
• The newly opened general high dependency unit (Sky A) did not comply with some standards from the HBN 04-02 building regulations for critical care wards. This included no uninterruptible power supply (UPS) on the ward, bed spacing, and insufficient lighting. Sky A compliance with building regulations was now added to the divisional risk register.
• Evidence of the evening ward round was not always formally documented in the patient records. We observed ward rounds on inspection and found them to be well attended, with input from not only medical staff but other clinical disciplines
• We observed staff leaving patient case notes unattended on critical care wards, which did not comply with the information governance practices for the trust or best practice.
• At the time of inspection, a never event was identified at the other trust hospital site in critical care relating to a retained foreign object (a guide wire in a central venous catheter). This never event was similar to a number of similar incidents that had occurred between May and July of 2018. At the time of the 2018 never events, the trust put in place a number of Local Safety Standards for Invasive Procedures (LocSSIPs) to minimise the risk of the never event occurring. However, staff we spoke with on inspection were unaware of LocSSIPs or national guidance in place to minimise the risk of retained guide wires.
• Following inspection, the trust reported that the appraisal rate was 60% for critical care medical staff, significantly lower than the trust target.
• Staff understanding of the Mental Capacity Act and Deprivation of Liberty Safeguarding was variable, and some staff were not sure about when the principles of capacity would apply.
• At the time of inspection, the critical care service did not have a vision and strategy document.
• Although there was an assessment pathway for delirium and dementia, screening for dementia was inconsistently completed.
• Senior staff acknowledged that mixed sex breaches were a common occurrence on critical care wards. We saw that the service had reflected mixed sex breaches on the divisional risk register.
• The Royal College of Anaesthetists recommends that the occupancy rate for critical care wards is kept below 70%. Senior staff stated that the occupancy rate was above the 70% recommended due to continually high activity at the hospital.
• Following inspection, the trust provided information on the number of delayed discharges over four hours. Between April 2018 and March 2019. Between May and July 2019, monthly delayed discharges were between 38% and 47% on NITU and 51% and 60% on GITU.
• During the inspection we observed a few instances where staff did not identify themselves to patients or inform them about the care they were going to receive. In these cases, staff were occasionally seen to talk over the patient, even if they were awake, or not informing patients of their presence before delivering care.

Updated 9 January 2020

• All teams contributing to end of life care at the hospital were effective in delivering high quality services. Wards were well supported to deliver good quality end of life care to patients, which was supported by leaders, specialist teams and mortuary staff. End of life care was seen as everyone’s responsibility at the hospital.
• The specialist palliative care team and end of life care team supported ward teams to deliver end of life care to patients. This included hands on support in key areas such as symptom control, medication advice, syringe driver use, nutrition and pain management.
• Specialist teams, including mortuary staff, delivered a broad programme of education and training that supported staff in key aspects of care of the dying and deceased.
• There were a number of embedded initiatives in place that had improved the quality of services in end of life care, some of which had received national recognition and awards.
• Teams including bereavement services and the chaplaincy provided committed and caring services for those who were dying or had just lost a loved one.
• Mortuary services had worked to improve the quality of care for deceased patients.
• Palliative and end of life care teams were well led, with good support from the executive team. There was a clear strategy aligned to national standards and key metrics were being effectively monitored.

However,

• It was not possible to identify how many trained nurses had obtained competency in use of syringe drivers because there was no comprehensive list of who had received the training.
• Counselling services for non cancer patients was an unmet need trust wide.

Updated 1 October 2021

Updated 7 March 2017

There was evidence of significant improvements in outpatient, diagnostic and imaging services. There had been an 88% reduction in the overall backlog of patients waiting over 52 weeks since May 2016.

Staff were aware of how to report incidents and could clearly demonstrate how and when incidents had been reported. Lessons were learnt from incidents and shared across the trust.

The trust had changed their patient records system and introduced the electronic patient record (EPR).

There were appropriate protocols in place for safeguarding vulnerable adults and children. Staff were aware of the requirements of their roles and responsibilities in relation to safeguarding.

Patients’ and staff views were actively sought and there was evidence of improvement and development of staff and services. Staffing levels and skill mix were planned to ensure the delivery of outpatient, diagnostic and imaging services at all times. All new staff completed a corporate and local induction. Staff were competent to perform their roles and took part in benchmarking and accreditation schemes.

Medicines were found to be in date and stored securely in locked cupboards. Staff were able to describe the procedure if a patient became unwell in their department and knew how to locate the major incident policy on the intranet.

All the patients, relatives and carers we spoke with were positive about the way staff treated people. There was a visible person-centred culture in most departments. Patients and relatives told us they were involved in decision making about their care and treatment. People’s individual preferences and needs were reflected in how care was delivered.

Work was in progress to conduct a demand and capacity analysis to enable the service to develop a model whereby the hospital could assess and effectively manage the demands on the service. The hospital was using a range of private providers to assist in clearing the backlog of appointments.

Patients attending outpatients and diagnostic imaging departments received care and treatment that was evidence based. The service was monitoring the care and treatment outcomes of patients who were receiving outsourced care from providers in the private sector.

Outpatients, diagnostic and imaging services had introduced extended clinics seven days a week to clear patient waiting list backlogs.

There was a formal complaints process for people to use. Complaints information, as well as patient experience information was fed into the trust governance processes and trust board with formal reporting mechanisms.

Most local managers demonstrated good leadership within their department. Managers had knowledge of performance in their areas of responsibility and understood the risks and challenges to the service. There was a system of governance and risk management meetings at both departmental and divisional levels.

However , we also found:

Outpatients and diagnostic imaging services were in transition. The strategy for these services was in development. There were a number of new senior managers who had introduced new quality assurance and risk measurement systems. However, these were not fully embedded.

We found alcohol hand sanitising gel dispensers in the ground floor outpatients waiting area and diagnostic and imaging department entrance were empty. Staff in the diagnostic and imaging department did not observe best practice guidance on hand washing or using sanitising gel between patients. The first floor outpatients’ department corridor was being used as a waiting area and this created a risk due to patients waiting in the corridor.

Privacy curtains were not being drawn in the main diagnostic and imaging department, and the emergency room in ophthalmology had bays that did not promote patients’ privacy and dignity. Phlebotomy waiting rooms were full and there appeared to be limited space for the phlebotomy service’s footprint to expand.

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 the standard for patients waiting less than 18 weeks by their target date of March 2017. The trust’s performance for the 62 day cancer waiting time was consistently below the England average. Appointments cancelled by the hospital were also higher than the England average.

Some staff in the diagnostics and imaging team said there was a lack of clarity around their roles and responsibilities.

Updated 22 June 2018

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

• In 2017, an extra 5000 operations and 95000 outpatient appointments had been undertaken as part of the trust’s recovery and improvement plan.
• The trust had achieved the target 5% reduction in falls per 1000 bed days.
• There had been some improvement on monitoring adherence to national guidelines and some improvement in completion of national and internal audits.
• Patients were protected from the risks of surgery by improved engagement in the ‘fiver steps to safer surgery’ checks in the operating theatre department.
• From November 2016 to October 2017 the trust’s referral to treatment time (RTT) for admitted pathways for surgery remained similar to the average for England.
• Risks to people were assessed, monitored and managed on a day-to day basis. Staff understood their responsibilities and actions required in identifying patients at risk from deterioration, harm and abuse.
• Staff were qualified and had the skills to carry out their roles effectively and in line with best practice.
• Patients’ individual needs were taken into account and the service was planned around the demands of the local people.
• Arrangements were in place to ensure patients with additional needs were supported and could access care.
• Staff understood and adhered to relevant legislation when obtaining consent for surgical interventions.
• Clinical governance systems had become more integrated since our previous inspection. This was enabled by the appointment of designated quality and risk advisors, and a nursing audit schedule.

However:

• The surgical division did not meet its targets for patients to be seen within 18 weeks.
• Staff and managers were unable to confirm the number of clinically significant wound infections on the surgical wards in the past year and unable to identify trends in infection in the hospital. We were told that the infection prevention and control team did not have a system to identify trends in infection.
• Seven-day services were not provided by therapy staff which could cause delays in rehabilitation and discharge planning.
• The service had been unable to deliver an increase in discharge rates between 8am and 12 noon.
• Compliance with mandatory training for medical and dental staff was below the trust’s target.
• Compliance with appraisal for therapy staff was below the trust’s target.
• There was limited access to counselling and psychology services for patients.
• There was some evidence of multidisciplinary working between medical staff, nursing staff and allied healthcare professionals. However, multidisciplinary team meetings and ward rounds did not always include all necessary staff.
• Recording and reporting of local audits across the division was inconsistent. An electronic reporting system introduced in 2017 for this purpose was not being used.
• The temperature of medicines storage was not monitored in all areas.
• General Surgery and ENT patients at Queen's Hospital had a higher expected risk of readmission for non-elective admissions than the average for England.

Updated 22 December 2023