Barking, Havering and Redbridge University Hospitals NHS Trust is a large provider of acute services, serving a population of over 750,000 in outer North East London. The trust operates from two sites; Queen's Hospital and King George Hospital.
Queens Hospital is the trust’s main acute hospital and opened as a private finance initiative (PFI) in 2006, bringing together the services previously run at Oldchurch and Harold Wood Hospitals. It is the main hospital for people living in Havering, Dagenham and Brentwood. The hospital has over 900 beds, including a hyper acute stroke unit (HASU). The Emergency Department (ED) treats over 150,000 walk-in and ambulance emergencies each year.
King George Hospital opened at its current site in Ilford in 1995 and provides acute and rehabilitation services for residents across Redbridge, Barking & Dagenham, and Havering, as well as providing some services to patients from South West Essex. The hospital has approximately 450 beds.
The trust had an annual revenue of around £560 million and projected year-end deficit of £11.9 million, at the time of the inspection. The trust employs 5,713 staff, with a budget for 6,676 staff. The trust provides a full range of adult, older people’s and children’s services across medical and surgical disciplines.
Over a twelve month period the trust reported activity figures of 101,685 inpatient admissions, which is made up of 52,536 emergency admissions and 49,149 elective admissions. Between the period of October 2015 and September 2016 there were 829,011 outpatient attendances, 280,795 attendances through the Accident and Emergency (A&E) department.
The CQC undertook a comprehensive inspection of Barking, Havering and Redbridge University Hospitals NHS Trust in October 2013 and found serious failures in the quality of care and concerns that the management could not make the necessary improvements without support. Following this inspection, the trust was placed in special measures in December 2013.
A further comprehensive inspection took place in March 2015. In this inspection it was recognised that progress had been made, however the trust continued to carry significant risks and therefore remained under special measures. Overall the trust was rated as requires improvement, with the responsive domain rated as inadequate.
We carried out an unannounced inspection of three core services between the 7th and 8th September 2016. We then carried out a further announced core service inspection, alongside a well led assessment between the 11th and 12th October 2016.
In March 2015 we rated the organisation as requires improvement. Following the recent core service inspection and well led review, the trust remains rated as requires improvement.
This inspection was specifically designed to test the requirement for the continued application of Special Measures to the trust. Prior to inspection we risk assessed services provided by the trust using national and local data and intelligence we received from a number of sources. That assessment led us to include four services (emergency care, medical services, outpatients and diagnostics and services for children and young people) in this inspection which were inspected at Queens Hospital and the King George Hospital. The remaining services were not inspected as they had indicated strong improvement at our last inspection and our information review indicated that the level of service seen at our last inspection had been sustained.
In our most recent inspection we were particularly encouraged by the significant improvements that have been made by the trust since March 2015. Our overall rating for the trust is now requires improvement and there are no areas rated Inadequate.
We were particularly encouraged by the improvements made in a number of areas.These were
- Improvements in a number of domains within the services that we inspected since our last inspection.
- Improvements in the overarching governance processes.
Queens Hospital
In March 2015 we rated the urgent and emergency care service as requires improvement overall, with an inadequate rating for the safe domain. Following our recent review we have rated
urgent and emergency care at Queens Hospital as requires improvement across the five domains.
In March 2015 medical care was rated as requires improvement within the safe, responsive and well led domains. Following the September inspection we recognised the progress made within the well led domain, along with the continued performance in the effective and caring domains, which we rated as good. The safe and responsive domains remain as requires improvement, resulting in an overall rating of requires improvement for medical care.
In March 2015 we rated services for children and young people as requires improvement, with an inadequate rating for the responsive domain. Following the October inspection we rated services for children and young people as good, with the safe domain rated as requires improvement.
In March 2015 we rated outpatients and diagnostics as requires improvement
, with an inadequate rating for the responsive domain. Following the September inspection we rated this service as good, recognising progress in the safe, caring and well led domains which we rated as good.
King George Hospital
In March 2015 urgent and emergency care was rated as requires improvement across all domains. Following the September inspection we rated this service as requires improvement, recognising the progress made within the caring and responsive domains which we rated as good.
In March 2015 medicine was rated as requires improvement across four domains (safe, effective, responsive and well led). Following the September inspection we rated medical services as requires improvement, with the caring and well led domains rated as good.
In March 2015 outpatients and diagnostics was rated as inadequate. This service received two ratings of inadequate under the safe and responsive domains. Following the September inspection we rated the service as requires improvement, recognising progress in the caring and well led domains which we rated as good.
The rating for well led has remained at requires improvement as ascribed in the 2015 inspection. However, the senior leadership team were visible and involved in clinical activity. Time and resource had been invested into improving clinical governance structures and risk management and the trust actively promoted innovation and improvement to the patient experience.
It is apparent that the trust is on a journey of improvement and significant progress is being made both clinically and in the trust’s governance. It is also clear that there is still further work to do to ensure that these improvements are sustained and that further progress is made.
Our key findings were as follows:
Are services safe?
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Compliance with infection prevention and control (IPC) practices across the services we inspected were found to be inconsistent.
- Rates of Methicillin-resistant Staphylococcus aureus (MRSA) infections had breached the trust zero tolerance target for the year.
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Fire safety standards in CYP services, including areas around the NICU were not always maintained.
- The emergency department (ED) cooling system at the King George Hospital had been out of order for at least three weeks prior to our inspection. This made it difficult to regulate safe temperatures within which to store drugs.
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Although nursing staffing levels had improved since the last inspection, some areas still had significant vacancy and turnover rates.
- We found high usage of locum across the organisation. Feedback from some locums was that access to training was poor and we had concerns that this meant they might not be appropriately skilled with up to date competencies.
- Since our previous inspection in March 2015 the organisation had improved its’ processes around incident reporting across both sites and staff told us that they were encouraged to record incidents.
- The inspection raised concerns about the diagnostic imaging department at the King George Hospital not comply with all the policies and procedures based on the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) and the Ionising Radiation Regulations 1999 (IRR99).
Are services effective?
- We found a number of clinical guidelines on the trust intranet were out of date. There was also issues with access to trust policies and guidelines for agency staff who had no computer access.
- The ED's performed worse than the national average in a number of Royal College of Emergency Medicine (RCEM) audits, including sepsis and septic shock, asthma in children, and paracetamol overdose.
- In medicine at Queens Hospital we found there was a backlog of National Institute for Health and Care Excellence (NICE) guidance that was awaiting confirmation of compliance across the trust.
- For non-elective medicine admissions, the standardised relative risk of readmission was high, particularly for geriatric medicine.
- Clinical staff completed a variety of local audits to monitor compliance and improvement. Staff of all levels told us that these led to meaningful change across the service.
- The standardised relative risk of readmission for all elective procedures was slightly lower than expected when compared to the England average. This meant that patients were less likely to require unplanned readmission after non-emergency procedures.
- In the National Diabetes Inpatient Audit (NaDIA) 2015, the hospital scored better than the England average for nine indicators out of sixteen indicators. Actions had been taken to improve the service in those measures where they were underperforming.
Are services caring?
- The majority of patients were positive about the care they received and we observed courteous interactions between staff and patients.
- Patients and relatives told us staff were respectful and helpful and gave them regular updates.
- We observed some negative interactions in the ED at Queens Hospital. We also observed a patient calling out for help and was ignored until we escalated to the nurse in charge.
Are services responsive?
- The percentage of patients being seen and treated within the ED recommended four hour timeframe at both hospital sites and the number of patients who left the department without being seen was worse than the national average.
- In medicine at the King George Hospital patients were not always able to be located on the specialist ward appropriate for their condition. In some wards, bed moves were consistently occurring out of hours (between 10pm and 6am).
- Environments on some wards in the King George Hospital were not ideal, with high levels of noise and heat observed and reported. There was a lack of bedside televisions or radios across the wards, which some patients reported made them feel isolated and bored.
- The trust was consistently failing to meet NHS waiting time indicators relating to 62-day cancer treatment. This issue had been added to the corporate risk register and actions had been undertaken to improve performance.
- The trust was not meeting 18-week waiting time indicator for non-urgent referral to treatment (RTT) times.
- The Patient Advice and Liaison Service (PALS) did not always respond to complaints in a timely manner.
- The ED’s at both sites worked closely with local GP’s to stream patients effectively, including back to their own GP.
- People living with dementia received tailored care and treatment. Care of the elderly wards at the King George Hospital had been designed to be dementia friendly and the hospital used the butterfly scheme to help identify those living with dementia who may require extra help.
Are services well led?
- Senior Leadership was visible and involved in clinical activity. Staff were positive about changes and were starting to feel more optimistic.
- Time and resource had been invested into improving clinical governance structures and risk management since the past inspection in March 2015.
- Quality improvement and research projects took place that drove innovation and improved the patient experience.
We saw several areas of outstanding practice including:
- The hospital provided tailored care to those patients living with dementia. The environment in which they were cared for was well considered and the staff were trained to deliver compassionate and thoughtful care to these individuals. Measures had been implemented to m ake their stay in hospital easier and reduce any emotional distress.
- The trust had awarded the neonatal and community teams for their work in providing babies with oxygen home therapy, which improved the quality of life for families.
- 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. This had been positively evaluated and received a high standard of feedback from parents and patients.
- Child to adult transition services were comprehensive and conducted with the full involvement of the patient and their parents. This included individualised stages of empowering the person to gradually increase their independence, the opportunity to spend time with paediatric and adult nurses together and facilities for parents to spend the night in adult wards when the young person first transitioned.
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
- Ensure all patients attending the ED are seen by a clinician in a timely manner.
- Take action to improve levels of resuscitation training.
- Ensure there is oversight of all training done by locums, particularly around advanced life support training.
- Take action to improve levels of resuscitation training.
- Take action to improve the response to patients with suspected sepsis.
- Take action to address the poor levels of hand hygiene compliance.
- Ensure fire safety is maintained by ensuring fire doors are not forced to remain open.
- Ensure staff have a full understanding of local fire safety procedures, including the use of fire doors and location of emergency equipment
- Ensure hazardous waste, including sharps bins, is stored according to related national guidance and EU directives. This includes the consistent use of locked storage facilities.
In addition the trust should:
- Endeavour to recruit full time medical staff in an effort to reduce reliance on agency staff.
- Ensure there is sufficient number of nurses and doctors with adult and paediatric life support training in line with RCEM guidance on duty.
- Improve paediatric nursing capacity.
- Improve documentation of falls.
- Document skin inspection at care rounds.
- Document nutrition and hydration intake.
- Review arrangements for the consistent sharing of complaints and ensure that learning is always conveyed to staff.
- Make repairs to the departmental air cooling system.
- Ensure policies are up to date and reflect current evidence based guidance and improve access to guidelines and protocols for agency staff.
- Take action to improve the completion of early warning scores.
- Improve appraisal rates for nursing and medical staff.
- Regularise play specialist provision in the paediatric ED.
- Consider how to improve ambulance turn around to meet the national standard of 15 minutes.
- Ensure staff and public are kept informed about future plans for the ED.
- Restructure the submission of safety thermometer data to match the current divisional structure.
- Monitor both nursing and medical staffing levels. Follow actions detailed on corporate and divisional risk registers relating to this.
- Monitor and improve mandatory training compliance rates for medical staff. Improve completion rates for basic life support for nursing and medical staff.
- Review out-of-hours provision of services and consider how to more effectively provide a truly seven day service.
- Continue to work to improve endoscopy availability and service, as detailed on the corporate risk register.
- Make patient information leaflets readily available to those whose first language is not English.
- Ensure leaflets detailing how to make a formal complaint are available across all wards and departments.
- Ensure consent to care and treatment is always documented clearly.
- Ensure each inpatient has an adequate and documented nutrition and hydration assessment.
- Ensure there are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.
- Ensure there are appropriate processes and monitoring arrangements in place to improve the 31 and 62 day cancer waiting time indicator in line with national standards.
- Ensure the 18 week waiting time indicator is met in the outpatients department.
- Ensure the 52 week waiting time indicator is consistently met in the outpatients department.
- Ensure percentage of patients with an urgent cancer GP referral are seen by a specialist within two weeks consistently meets the England average.
- Ensure the number of patients that ‘did not attend’ (DNA) appointments are consistent with the England average.
- Ensure the number of hospital cancelled outpatient appointments reduce and are consistent with the England average.
- There is improved access for beds to clinical areas in diagnostic imaging.
- Address the risks associated with non-compliance in IR(ME)R and IRR99 regulations.
- Ensure the number of hospital cancelled outpatient appointments reduce and are consistent with the England average.
- Ensure diagnostic and imaging staff mandatory training meets the trust target of 85% compliance.
- Develop a departmental strategy in diagnostic imaging looking at capacity and demand and capital equipment needs.
- Improve staffing in radiology for sonographers.
Professor Sir Mike Richards
Chief Inspector of Hospitals