University College Hospital & Elizabeth Garrett Anderson Wing

Updated 1 September 2023

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at University College London Hospitals NHS Foundation Trust

We inspected the maternity service at University College London Hospitals as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our ratings of the maternity service stayed the same and the ratings for the hospital remained the same. We rated safe and well-led as good, and the hospital rating remained as requires improvement.

University College London Hospital is a large teaching hospital located in central London. Maternity services are located in the Elizabeth Garret Anderson Wing. The maternity service at University College London Hospital provides consultant-led and midwife-led care for both high and low risk women. The hospital is a tertiary referral centre for complex maternal and fetal indications.

How we carried out the inspection

During our inspection of maternity services at University College London Hospitals NHS Foundation Trust we spoke with 35 staff including senior leaders, obstetric staff, specialist midwives, matrons, midwives, student midwives, maternity support workers, nursery nurses, clinical governance leads and safety champions to better understand what it was like working for the service. We interviewed leaders to gain insight into the trust’s leadership model and the governance of the service. We reviewed 6 sets of maternity and 10 medicine records. We also looked at a wide range of documents including standard operating procedures, meeting minutes, risk assessments, recent reported incidents as well as audits and audit actions.

We ran a poster campaign during our inspection to encourage pregnant women and mothers who had used the service to give us feedback regarding care. We received 48 feedback forms from women. We analysed the results to identify themes and trends.

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 11 December 2018

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

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• Staff were aware of how to monitor and respond to patients’ deteriorating condition, including sepsis. The service used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. The service used information to improve the service.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• There was effective multidisciplinary working among staff. Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• Staff involved patients and those close to them in decisions about their care and treatment.
• The trust planned and provided services in a way that met the needs of local people.
• The service took account of patients’ individual needs. Carers were identified and appropriate support provided by staff.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. We were informed that visibility of trust leadership team had improved since the last inspection. At this inspection, we found that all staff we spoke with told us that the trust leadership team was visible.

However:

• We observed a number of lapses in good infection prevention and control measures including four staff not bare below the elbow, and some staff not strictly adhering to appropriate use of personal protective equipment.
• We observed not all staff disposed of infectious material correctly.
• We observed two areas of dust in two departments: endoscopy and HASU.
• The service had suitable premises and equipment and looked after them well. However, we found two ward areas where resuscitation equipment was not secure and could be accessed by unauthorised persons.
• Mandatory and safeguarding training compliance rates for medical staff fell below the trust target.
• Though the service had effective systems for identifying risks, planning to eliminate or reduce them, we found that actions from risk assessments were not always implemented. For example, concerns around use of surveillance cameras within the endoscopy unit were not addressed effectively and some of the divisional leaders were not aware of the use of these cameras within the unit. We were concerned that staff process flow was prioritised over patients’ privacy and dignity. After this had been pointed out to the trust they withdrew the use of the screen while they reviewed their practice in this area.
• Senior leaders were clear of the business continuity plans for the service; however some charge nurse we spoke with were not aware of those plans.
• We found a mixed picture with regard to the staff of the trust and identification with trust vision and values. In some wards the trust vision and its underpinning values were well embedded amongst staff in the service. In other areas, more emphasis was placed on the vision and values for an individual service which matched with the overall trust vision and values.

Updated 15 August 2016

• The service had a robust process for ensuring incidents were reported and investigated. All staff were aware of their responsibilities to report and lessons were learnt where incidents had taken place. Patient risks were appropriately identified and acted upon with clear systems to manage a deteriorating child or baby.
• Care and treatment reflected current evidence-based guidelines, standards and best practice. The services participated in a number of national and local audits to measure their effectiveness and to drive improvements. Performance against the national neonatal audit programme and the national diabetes audit was better than the national average and there was evidence of local action plans to address any issues identified.
• Pain was being effectively managed and regularly monitored. Nutrition and hydration was being monitored and dietician input was available when needed.
• Children were cared for in a caring and compassionate manner. Their privacy and dignity was maintained throughout their hospital stay. Fully trained and registered children’s nurses and neonatal nurses throughout the service ensured that children and their families were informed about their care and were fully involved in any treatment decisions. Consent to care and treatment was obtained in line with legislation and guidance.

Updated 15 August 2016

• There were effective systems in place to protect patients from harm and a good incident reporting culture.
• Learning from incident investigations was disseminated to staff in a timely fashion and they were able to tell us about improvements in practice that had occurred as a result.
• Safe numbers of staff cared for patients using evidence-based interventions. There was good access to seven-day services and the unit had input from a multidisciplinary team.
• Staff at all levels had a good understanding of the need for consent and systems were in place to ensure compliance with the Deprivation of Liberty Safeguards.
• There was good local leadership on the unit and staff reflected this in their conversation with us.
• Staff and patients were engaged in decision making on the unit and provided feedback about the service.
• The unit was engaged in research a large team of nurses and doctors dedicated to the research programme.

Updated 11 December 2018

We previously inspected gynaecology jointly with maternity so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

• Incident reporting systems were in place and there was a good culture of reporting, investigating and learning from incidents.
• There were effective arrangements in place to safeguard patients from abuse and mitigate the risk of it happening.
• Infection prevention and control processes were carried out in accordance with local and national policy, and infection rates were lower than the national average.
• Staffing levels were planned, implemented and reviewed to keep people safe. Medical cover was available 24 hours a day, seven days a week.
• Emergency equipment was easily located, accessible, and ready for use.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Audits and quality outcomes were conducted at departmental level, to monitor the effectiveness of care and treatment.
• Medical staff, nurses, midwives and other allied health professionals supported each other and worked collaboratively to ensure patient-centred and effective care.
• Emotional support was provided by people with appropriate skills and experience.
• Feedback from patients about their experience of care was consistently positive. Patients were treated with respect and dignity.
• Patients received same day diagnosis and treatment, via walk-in clinics in gynaecology outpatient and gynae-oncology outpatient services.
• Referrals for treatment and consultations for additional services were arranged in a timely manner.
• It was clear to patients how to complain or raise a concern.
• There was a clear statement of vision and values driven by quality and safety, which was understood by staff at all levels.
• The leadership team was knowledgeable about the service’s performance, priorities, and the challenges it faced and were taking some action to address them.

However:

• Medical staff did not meet compliance targets for completion of mandatory training.
• There were delays in the overall pathway from referral to treatment for some patients and the overall 62-day cancer waiting time target was only met in 77.2% of cases in 2017/18 against the national target of 85%. The trust informed us this was associated with a high rate of late referrals from other organisations, and that 87.5% of patients referred directly to UCLH were treated within 62 days of GP referral, meeting the national target of 85%.
• Staff we spoke with were unclear about the arrangements for the governance of the termination of pregnancy services and there was no formalised audit programme to allow outcomes to be compared with other benchmarks, and enable improvements in practice.
• There was no system to ensure effective oversight and review of staff objection to being involved in termination of pregnancy.

Updated 14 January 2014

We found that the trust was improving support for people at the end of their lives.

The trust had recognised the need to increase the staffing levels in its palliative care team and was taking action to do this.

The trust was no longer using the Liverpool Care Pathway. It had been recently replaced by an interim “Excellent care in the last days of life – Individualised care plan.”

We found that staff were caring and responsive to patients’ needs. There was a good working relationship between the different support services that were available. We received positive feedback from relatives of patients.

However, the trust was not ensuring that the paperwork for patients who had been assessed as not requiring resuscitation (do not attempt resuscitation or DNAR) was always fully completed. We found examples where there was no evidence recorded of discussions with the person or their family members and there was no consultant signature to indicate they had reviewed the order.

We found that the trust was seeking to develop and improve its End of Life service. It had an End of Life Board to provide senior leadership in developing the service at the trust. A five-year strategy for End of Life is currently at draft stage.

Updated 1 September 2023

Updated 11 December 2018

We previously inspected outpatients services jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

• The service provided mandatory training in key skills to all staff and made sure overall staff compliance rates met the trust target.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe and to provide the right care and treatment. Where a gap in skill was identified, staff were encouraged to broaden their skill set to ensure continuity of care for all patients.
• The service made sure staff were competent for their roles. Staff were encouraged to undertake continuous professional development, so the trust was ensured staff were competent for their roles and were able to provide an effective service.
• Different groups of staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them with kindness and respect.
• The trust planned and provided services in a way that met the needs of local people. The trust ran out-of-hours clinics for certain specialities in order to meet patient needs.
• The service took account of patients’ individual needs. Volunteers were available within the department, to guide patients to clinics and appointments as required.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The CEO worked within a specialist clinic on a regular basis, and was available to staff of all grades to answer any questions.
• The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. The trust conducted friends and family test (FFT) surveys, participated in the NHS staff survey, as well as including both staff and patients in the development of innovations.

However:

• The trust performed worse than the 85% operational standard for patients receiving their first cancer treatment within 62 days of an urgent GP referral. Performance was also worse than the England average for all four quarters of 2017-2018.
• The did not attend (DNA) rate for the hospital’s outpatient department was worse than the national average.
• The trust did not take part in the national patient choices scheme which enables patients to select the time, date and location of their initial appointment.
• Patients found it difficult to contact the department via telephone to discuss their appointment.
• There was a lack of confidentiality at the checking-in desk for patients.
• The fracture clinic waiting area was overcrowded and had a lack of available seating for patients waiting for their appointments. However, to address this and reduce patient wait times, the fracture clinic was running virtual appointments.
• Signage in the department was not always clear. Patients found it confusing and difficult to locate clinics.
• Patient records were not always stored securely. Paper records were stored in cabinets that were unattended and unlocked.
• There was a backlog of GP discharge letters in the IT system and there were delays for non-urgent letters being sent out via the new electronic system.

Updated 15 August 2016

• Staff demonstrated good knowledge of the process of reporting; investigating and learning from incidents. We saw good evidence of local and trust wide learning from incidents that had occurred. There were on-going improvements in the use of the World Health Organisation (WHO) Safer Surgery checklist. Staff demonstrated that this was embedded in their practice and audit data demonstrated this was carried out to a high standard.
• We saw staff treating and caring for patients with compassion, dignity and respect. Patient feedback was positive. Patient outcomes were monitored through internal and external audits and benchmarked against other services.
• There was a strong focus on improvement from all levels of staff when results were less them optimum.There was good multidisciplinary team (MDT) working between doctors, nurses and other allied health professionals throughout patient pathways.

Updated 11 December 2018

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

• The department did not meet the Department of Health’s standard of 95% for time to treatment and decision to admit, transfer or discharge.
• Similar to the previous CQC inspection, we found that patient documentation was not consistently completed.
• There was inconsistent documentation of pain scores in both adult and paediatric patient records.
• Nursing and medical staff training compliance rates were below the trust target for both paediatric basic life support and safeguarding children level 3.
• At the time of this inspection, there was no parallel assessment of a patient’s physical and mental health needs. Patients with mental health needs could leave the emergency department before their mental health assessment.
• There was a backlog of GP discharge summaries not sent out to surgeries.

However:

• Consultant cover improved and now met the Royal College of Emergency Medicine recommendation of at least 16 hours cover seven days a week.
• Incident reporting and shared learning was significantly improved.
• There was an improved culture in the department. Staff told us the more recently established leadership team was very visible and consulted with them about proposed changes and improvements. They said they were proud to work for the hospital and felt well supported by their colleagues. We observed good team working amongst staff of all levels.
• Staff followed national professional standards and guidelines to achieve the best possible outcomes for patients receiving care and treatment.
• We observed staff listening to patients and discussing aspects of their care. We saw several examples of kindness showed to patients.
• Leaders were realistic about the challenges they faced in order to continue to improve the delivery of service and make it more sustainable. There was a three year improvement plan which most staff were aware of and were optimistic would improve the quality of the service.