Hammersmith Hospitals

Imperial College Healthcare NHS Trust provides acute and specialist healthcare for a population of around two million people in north west London and the surrounding areas. The trust has five hospitals Charing Cross, Hammersmith, Queen Charlotte’s & Chelsea, St Mary’s and the Western Eye. Charing Cross Hospital is an acute general teaching hospital located in Hammersmith, London.

Medicine and specialist medicine at Hammersmith Hospital sat under two directorates in the hospital; with the majority of the medical wards under the division of medicine and integrated care. The medical services include including renal, haematology, cancer and cardiology care and provides a regional specialist heart attack centre.

We plan our inspections based on our assessment of the risk to patients from care that is or appears to be less than good. We inspected the medicine and elderly care services because we had information giving us concerns about the quality of this service.

We last inspected the medicine and elderly care service in September 2014 as part of our comprehensive inspection program and rated the service as requires improvement. During that inspection we observed hospital discharges occurring after 10pm. We found that care plans for people living with dementia and diabetes were not used and we noted patients stayed in the hospital for longer than the national average. There were high vacancy rates among staff and it was not clear what the senior management was doing to address this.

During this inspection we found the overall quality of the medicine and elderly care services had stayed the same, but there were some positive changes. The service was rated as requires improvement. We rated safe and responsive as requires improvement, and we rated effective, caring, and well-led as good.

Our key findings were as follows:

• Signage on site was poor and therefore, there were many visitors and members of the public lost and wondering how to get to their desired location.

• We found the environment on some wards was poor. Staff submitted requests for repairs but the work took a long time to be carried out. Some wards had identified the areas requiring repair as a potential infection prevention and control risk in their risk registers. Staff on one ward told us they had been able to make some changes, which improved patient observation but the environment remained on the directorate risk register.

• The trust was not monitoring compliance with the Faculty of Medicine’s Core Standards for Pain Management Guideline (2015).

• Liquid medicines on two wards did not have a date recorded for when they were opened.One of those medicines was used to relieve severe pain and should be used within 90 days of opening. Staff were not following the trust’s policy, which stated that the date of opening should be recorded.Ten boxes of medicines and fluids for intravenous administration were out of date on one ward. The expiry date of one medicine was nine months before our inspection.

• The results of the national diabetes audit showed patient experience was rated below the national average and the rate of foot assessments was worse than other services.

• Patients could not access the patient advice and liaison service at Hammersmith Hospital. The service was advertised as being available but the office was closed and the telephone number provided was not manned.

• Some cardiac patients were not able to access cardiac rehabilitation because the service did not have adequate capacity.

• Some patients experienced delays in receiving their chemotherapy medicines. Staff told us about one patient whose chemotherapy infusion could not be fully administered because it had exceeded the time period in which the medicine was effective. There were problems preparing some medicines on the Hammersmith site and these were being transferred from another site in the trust.

• Staff told us patient transport between sites was a problem and patients were unhappy about the length of time they waited for transport between sites and for going home after treatment.

• Staff told us executive directors did not often visit the site.The Chief Executive had met with senior staff to discuss the trust’s strategy. They said they valued receiving information because major changes were taking place, which affected the hospital.

However,

• The service managed patient safety incidents well. Staff received feedback from incidents they had reported. Learning from incidents was included in a staff bulletin, which was circulated to staff in the medicine and integrated care division.

• Results of patient safety monitoring were displayed on ward noticeboards for patients and visitors.

• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

• Patients’ records were mostly electronic and staff described the benefits of medical staff being able to review test results or prescriptions from anywhere in the trust. Some wards were liaising with social services via email as part of planning patients’ discharge.

• Services participated in a wide range of national audits and benchmarked performance against other hospitals.

• Staff followed clinical guidelines and pathways, which were up to date and accessible on the trust’s intranet.

• Patients’ needs were planned and reviewed by multidisciplinary teams.Care of the elderly consultants worked with cardiology, renal and cardiac colleagues to plan the care provided to older patients.

• Governance arrangements were robust and had been revised to take account of recent changes in the management structure.

• The provider was working with commissioners and partners to plan services, which met the needs of the local population in Hammersmith and Fulham.

• Renal and haematology patients could contact the service day or night to discuss their symptoms and any care, which might be required.

• Patients with cardiac symptoms could access services at a new heart attack centre dedicated to provide specialist investigation and treatment.

• The complaints service was reviewed, resulting in improvements to the quality and timeliness of responses.

• Nurse managers described how services were co-ordinated and managed within the new multi-site divisional structure. They told us there was a site manager with responsibility for the operational co-ordination of services on the hospital site and between sites.

There were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• The trust must ensure all wards and departments follow the trust’s medicine management policies so that medicines are safe for administration to patients. In particular for date checking medicines and storing medicines in refrigerators.
• The trust must improve the proportion of medical staff completing mandatory training, level 2 adult safeguarding training in particular.

In addition the trust should:

• The trust should ensure patients and carers have the same access to the trust’s PALs service as patients on other sites.
• The trust should ensure the cardiac catheter lab complies with the World Health Organisation (WHO) safer surgery checklist.
• The trust should develop plans for addressing problems with the preparation of oncology treatments at the Hammersmith site and ensure staff and patients are informed. The trusts should also monitor the number of treatments adversely affected by delays in providing oncology medicines.
• The trust should clarify and implement a pathway for access to Level 2 beds for Haematology patients
• The trust should support clinicians and managers to develop the planned investigation unit and to review how specialty medicine beds and wards were configured across the site.
• The trust should improve signage and the environment on the wards by addressing the backlog maintenance programme.
• The trust should improve the provision of cardiac rehabilitation services.
• The trust should ensure patients with diabetes are able to access foot care.
• The trust should ensure all staff particularly those caring for older people fully understand and follow the requirements of the Mental Capacity Act (2005).
• The trust should ensure adequate overnight SHO rota cover for clinical haematology.
• The trust should review the recording of patients’ own controlled drugs to make sure stock levels and administration can be clearly documented.

Professor Ted Baker

Chief Inspector of Hospitals

Hammersmith Hospital is an acute teaching hospital located in East Acton, London. the hospital was founded in 1912 and is currently a part of Imperial College Healthcare NHS Trust. The trust's central outpatient departments were located at St Mary's Hospital, Charing Cross Hospital and Hammersmith Hospital which were overseen by a single leadership team (Lead Nurse, Clinical Director and General Manager), with dedicated clinical and administrative leadership teams based on each site.

Our last comprehensive inspection of the trust was undertaken in September 2014 when we rated the outpatients and diagnostic imaging service at Hammersmith Hospital as inadequate. The purpose of this focused follow-up inspection was to inspect core services that had previously been rated as inadequate.

During this inspection we found the service had improved. We rated the outpatients and diagnostic imaging service at Hammersmith Hospital as good overall.

Our key findings were as follows:

• Outpatient staff learned from incidents by monitoring and discussing them at departmental meetings. The senior sister sent a newsletter staff in the department which included information about the results of incident investigations and the key learning points.
• Staff we spoke with were aware of the: ‘Ionising Radiation Protection - Dealing with Medical Exposures to Ionising Radiation Greater than Intended IR(ME)R trust policy, and how to access it.
• The trust’s Executive Quality Committee monitored the number of IR(ME)R incidents. Incidents were investigated and actions were put in place to reduce similar incidents occurring in future.
• 83% of staff working in outpatients felt encouraged to report errors and near misses.
• Clinical areas in the outpatient department were clean and tidy and staff told us they were responsible for ensuring clinic rooms were cleaned daily. Managers had been unhappy with the cleanliness of the department and had put a cleaning programme in place.
• There were hand-washing facilities and hand gel dispensers in every consultation room and we observed staff washing their hands and using hand gel between treating patients.
• There were warning signs informing staff and patients not to enter rooms when x-rays and other diagnostic test were underway. These were illuminated when the room was in use so that staff and patients knew not to enter.
• We found that medicines at the location were stored securely and appropriately. Keys to medicines cupboards and treatment rooms were held by appropriate staff. There was restricted access to rooms where medicines were kept via an electronic keypad. Medicines were stored in a safe manner.
• At our inspection in September 2014 we found records were not always available in clinic when patients attended for their appointment. At this inspection we found the trust were moving towards an electronic system for all patient records and the retrieval of paper records had improved.
• Arrangements were in place to safeguard patients from abuse.
• Nursing and medical staff accessed advice from the medial assessment unit. Patients were admitted if their condition required the level of care which could only be provided on a ward.
• The diagnostic imaging service used diagnostic reference levels (DRL’s) as an aid to
• optimising patients exposure to radiation. The levels of radiation for procedures were on display.
• Managers were auditing incidents where the diagnostic reference levels were exceeded.
• Staff in diagnostic imaging were aware of NICE guidelines and evidence based guidelines were in place.
• The diagnostic imaging department were working towards achieving the Royal College of Radiologist Imaging Accreditation scheme.
• Staff in the outpatient department used pathways which were based on national guidance. For example smoking cessation was discussed with patients attending the cardiology clinic.
• At our previous inspection we found clinics often started late but the trust were not monitoring this. At this inspection we found the trust had started to monitor when clinics started and how long patients were waiting.
• Staff had developed a process for updating patients every thirty minutes if a clinic was running late and patients appreciated being kept informed.
• A strategy had been developed for diagnostic imaging setting out a five year plan which included amongst other things, a plan to extend the service during weekdays and introduce weekend working.
• The outpatient improvement programme was having an impact on bringing about change.
• An outpatient service level agreement had been developed which set out how the central outpatient service and specialist teams would work together to meet the targets in a new performance framework.

We saw areas of outstanding practice including:

• The trust was transforming outpatient service across the trust through the outpatient improvement programme. A Patient Service Centre was being set up as the first point of contact for patients and plans had been developed for improvements to clinic environments, improving the quality and content of patient communication, increasing the availability of patient notes and monitoring clinic start and finish times.

​However, there were also some areas of practice where the trust needs to make improvements:

• The trust should improve performance against the two week wait (2WW) GP referral to first outpatient appointment standard for cancer and the 62-day GP referral to first treatment standard.
• The trust should improve performance against referral to treatment time (RTT) for non-admitted pathways for outpatient services.
• The trust should improve performance agains treferral to treatment time (RTT) for non-admitted pathways for outpatient services.
• The diagnostic imaging service should ensure they comply with updated guidance; for example, the Royal College of Radiographers guidance on x-raying patients with longstanding lower back pain.
• The trust should reduce waiting times for patients in outpatient clinics.
• The trust should reduce the number ofoverbooked or cancelled clinics.
• The trust should ensure the temperature of the outpatients clinic department is a comfortable temperature for patients.

Professor Sir Mike Richards

Chief Inspector of Hospitals