Great Ormond Street Hospital for Children NHS Foundation Trust

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

• Overall, we rated effective and caring as outstanding, responsive and well led as good, and safe as requires improvement. We rated two of the trust’s eight services as outstanding and six as good. In rating the trust, we considered the current ratings of the five services not inspected this time.

Our full Inspection report summarising what we found and the supporting evidence appendix containing detailed evidence and data about the trust is available on our website.

We rated well-led for the trust overall as good.

Great Ormond Street Hospital for Children NHS Foundation Trust is one of four dedicated children's hospital trusts in the UK. The trust operates from a single site in central London. It is the largest paediatric centre in the UK for intensive care, cardiac surgery, neurosurgery, cancer services. nephrology and renal transplants. Children are also treated from overseas in their International and Private Patients’ (IPP) wing. There are more than 50 different clinical specialties at Great Ormond Street Hospital (GOSH). Together with the UCL Institute of Child Health, it forms the UK’s only academic biomedical research centre specialising in paediatrics. Its status as a Specialist Children’s Hospital means that most of the children treated are referred from other hospitals or overseas.

We carried out this inspection as part of our comprehensive acute hospital inspection programme adapted for dedicated children's hospitals. The trust was rated as low risk in the CQC intelligent monitoring system. The inspection took place between 14 and 17 April and unannounced inspections took place between 1 and 3 May 2015. We also inspected the Children and Adolescent Mental Health Services ( CAMHS) provided by this trust as part of our inspection.

Overall this trust was rated as Good. We rated it outstanding for being effective and caring. We rated it good in providing safe care. We rated it requires improvement for being responsive to patients needs and in being well-led.

We rated medical care and end of life care as outstanding. We rated critical care, child and adolescent mental health services and transitional services as good. We rated surgery, and outpatients and diagnostic imaging as requires improvement.

Since our inspection, the trust alerted us to long-standing problems with the reliability of their patient information systems, which affected the validity of the trust’s reporting of referral to treatment (RTT) times. This had the potential to delay the admission of patients waiting for non-emergency treatment. We have reflected these problems in our assessment of services in this report.

Our key findings were as follows:

• All staff working at the hospital were extremely dedicated, caring and proud to work for the hospital.
• We saw high levels of care, professionalism and innovative treatment of patients who had been referred for care by other hospitals.
• The culture was very open and transparent. Parents and children were kept fully involved in their treatment. There was an evident commitment to continually improve the quality of care provided. Children and young people were involved in decision making as far as possible.
• We saw good examples of duty of candour in practice. Staff were very open when things had gone wrong, expressed full apology and offered full support to parents, children and carers.
• The new Chief Executive was very visible, had shared his vision for the trust and had gained the early respect of staff members.
• The executive team were well known to members of staff and patients and did regular walkabouts on the wards.
• There was outstanding care demonstrated in all departments where there was a tangible level of staff working together in pursuit of excellence of care. All supported the mission statement of the trust which was " the child first and always".
• When decisions were made to stop treatment, this was done thoroughly and with good governance via the ethics committee and always with maximum consultation with parents or carers.
• The reporting of incidents was fully embraced by all members of staff we spoke with. Incidents were thoroughly investigated and learning obtained and shared with all staff across the hospital.
• End of life care was embedded in all clinical areas of the hospital and not seen as the sole responsibility of the palliative care team.
• Where the trust had completed a refurbishment or rebuild, the facilities were modern, extremely child friendly and conducive to excellent patient care and dignity. There remained some wards, not yet refurbished, rebuilt or relocated where the environment was less good. The hospital recognised this and was in the middle of a total refurbishment/rebuild project.

We saw several areas of outstanding practice including:

• Clinicians from other hospital services delivered specialist training on physical health issues for CAMHS staff. In return CAMHS staff provided training and expertise to other departments across the hospital, for example on learning disabilities and autism.
• Because the hospital is treating many patients that could be treated at very few hospitals in the UK it is developing ground breaking clinical guidance which it is sharing with clinical colleagues in the wider medical community.
• The hospital has developed a pocket-sized guide to help staff working with children with learning disabilities.
• The Feeding and Eating Disorders Service (FEDS) received 100 % approval in the latest Friends and Family test with 93% saying they were extremely likely and 7% saying they were likely to recommend the service.
• The Psychological Medicine team provided an outreach service across the country where necessary.
• Staff in CAMHS were actively involved in research in their specialist areas including Autism and Feeding and Eating disorders.
• CAMHS introduced a screening tool for mental health problems and the psychological medicine team conducted a study to improve the understanding of the patient experience, diagnosis, treatment and outcomes regarding non-epileptic seizures in children.
• The FEDS and MCU (Mildred Creak Unit)teams developed a policy around re-feeding syndrome to increase understanding of the issue.
• In critical care there were excellent mortality and morbidity meetings, and robust safety monitoring of all patients.
• The Intensive Care Outreach Network(ICON) and Clinical Site Practitioners (CSP) are part of the hospital at night service and hold responsibility for any deteriorating child 24 hours a day, seven days per week.
• In pharmacy services the chief executive receives monthly reports of prescribing errors; a daily check ensures all electronic prescriptions are screened before the end of each weekday (Monday to Friday)and patients are informed by text message when prescriptions are ready.
• In transitional care young people feel empowered by the Young Persons' Forum.
• Joint transitional care clinics are held with on-going hospital providers.
• In outpatients weekly education sessions were protected to ensure staff maintained currency in mandatory areas and had the opportunity to take part in further specialist training from a clinical educator

However, there were also areas of poor practice where the hospital needs to make improvements.

Importantly the hospital must:

• Resume WHO checklist audits in surgery
• Ensure that there are clear arrangements for reporting transitional care service performance to the board.
• Ensure that its referral to treatment (RTT) data and processes are robust and ensure that staff comply with the trust's patient access policy in all cases.
• Ensure greater uptake of mandatory training relevant to each division to reach the trust's own target of 95% of staff completing their mandatory training.
• Ensure that, particularly in critical care, communication between senior nurses and senior medical staff is enhanced and that the contribution of nursing is fully reflected in the hospital's vision.

In addition the hospital should:

• Ensure early improvements in the environments of wards which have not been refurbished, rebuilt or relocated.
• Standardise radiation protection training for junior radiologists to overcome inconsistencies caused by short rotations.
• Develop a dedicated advocacy service for its Child and Adolescent Mental Health service ( CAMHS).

Professor Sir Mike Richards

Chief Inspector of Hospitals