All inspections: King George Hospital - Care Quality Commission

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, King George Hospital emergency department saw 44,482 adults and 9,240 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 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 King George Hospital was rated overall inadequate. At this inspection our rating of King George Hospital emergency department improved. We rated it is as requires improvement overall.

King George Hospital is situated in the London Borough of Redbridge, the hospital includes an emergency department (ED), an intensive care, services for children and young people, and a recently refurbished diagnostic imaging department. Despite being the smaller of the two trust hospital sites, activity at the hospital was increasing and the trust were establishing a site-based leadership team to improve the management and oversight of the services the hospital delivered.

In December 2021, we sent the trust a letter of serious concern following a focused inspection of emergency department (ED) care at Queen’s Hospital. At that time, we did not undertake an inspection to the King George Hospital site ED. Following that inspection at Queen Hospital ED, the team found significant concerns with the streaming and triage processes; the length of stay for patients within the department and subsequent overcrowding, ambulance handover times, and the delayed flow of patients from the hospital into the community. The Commission acknowledged that some of the issues the trust faced were complicated by wider challenges within the local health and social care system. The trust responded with action plans for improvement and this was followed up through reviews and engagement.

On this occasion, we extended the inspection to the emergency and medical divisions at both trust hospitals and we also inspected the well-led key question for the trust overall. Our unannounced inspection was conducted in the same week as an unannounced inspection of the urgent treatment centres (UTC) on both hospital sites. These UTCs are operated by another provider and are reported separately.

We found concerns in interfaces between the ED and the UTC, compounded by delayed admissions of patients to speciality services and social care.

Waiting times and flow through the department continued to be a significant concern. Other key aspects such as the use of incompatible computer systems, also contributed to the delays and increased the risk of error.

After the inspection, we told the trust and the UTC provider they must make improvements.

This inspection of King George Hospital also included a comprehensive inspection of diagnostic imaging.

Summary of urgent and emergency services at King George Hospital:

There were delays in moving patients into and through the department and on to wards. This resulted in delays in assessment and treatment for some patients. Poor hospital flow led to delays in accessing hospital beds for patients who required an admission.
People could not always access the service when they needed it and did not always receive care promptly. Senior clinical oversight of patients was not always evidenced which increased blockages in the department and delays to treatment.
There were medical vacancies in the emergency department (ED) and on some days, not all services operated fully due to staffing shortages. The ED did not always have enough medical staff with the right qualifications, skills, training and experience to provide the right, safe care at all times. This increased the risk of patients suffering avoidable harm. More consultants and junior doctors were required to run the department safely.
Staff did not always take account of patients’ individual needs or always make time to help patients understand their conditions. Staff did not always give patients the right types of food or enough to eat and drink, and pain relief was not always provided in a timely manner when it was required.
Patients did not always have an assessment of their infection risk and other clinical risks in a timely manner on arrival at the department and weren’t always treated according to their priority of need.
The use of multiple IT systems for reporting patient records caused risk of the deteriorating patient not being spotted, full notes not being available to ward staff, and difficulty recording observations using the electronic application in a timely manner.

However

Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service-controlled infection risk well.
Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients; key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity. They provided emotional support to patients, families and carers.

Summary of medical services (including older people’s care) at King George Hospital:

Services had enough staff to care for patients and keep them safe. Premises were visibly clean and well maintained. Staff managed medicine administration well. Staff identified and quickly acted upon patients at risk of deterioration.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
The trust planned care to meet the needs of local people and engaged well with other health care providers and system partners to plan and manage services.
Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.

However:

Medical speciality wards were not performing well in their IPC clinical audits. An improvement plan was in place to address this.
Not all services were completing relevant risk assessments in a timely and accurate way.
Staff did not always follow good principals of hand hygiene.
The service did not always involve patients as partners in their treatment and discharge processes.
Although the trust continuously worked on initiatives to improve flow with projects such as the Red2Green Team and having dedicated discharge coordinators in each medical ward, discharges were still done as Monday to Friday activity.
The hospital’s capacity has remained the same despite an increase in the number of attendances and complexity of cases being admitted to the medical wards.

Summary of diagnostic imaging at King George Hospital:

The trust had declared a serious incident in August 2022 relating to the accuracy of their patient tracking list (PTL), where it was found that patients who should have been on the PTL awaiting an appointment for diagnostic imaging had not been. it was not clear at the time of inspection what the outcome of any clinical harm review was, either in relation to the extent of the harm or the number of people impacted.
Managers and staff did not appear to carry out a comprehensive programme of repeated audits to monitor safety and performance in Radiology.
On inspection we did not see evidence of emergency evacuation procedures for the radiology department. We were not assured that there were specific emergency evacuation plans for the radiology department, as well as regular scenario training for these plans.
There was no regular dedicated process for reviewing the quality and accuracy of information in patient records including for image quality.
Clinical guidelines and policies were kept on the intranet, however on inspection we found there was a lack of version control for policies. We found examples of policy documents on the intranet that had not been updated or reviewed, and there were examples of multiple versions of the same policy from different years.
The service did not have information leaflets or posters consistently displayed in communal waiting areas for diagnostic imaging.

However:

The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
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.
The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
Doctors and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development.
Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment
Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact.
The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy.

We carried out an unannounced focused inspection of the emergency department at King George’s Hospital on 20 January 2020, in response to concerning information we had received in relation to care of patients in this department. At the time of our inspection the department was under adverse pressure.

We did not inspect any other core service or wards at this hospital, however we did visit the admissions areas to discuss patient flow from the emergency department. During this inspection we inspected using our focused inspection methodology. We did not cover all key lines of enquiry.

This was a focused inspection to review concerns relating to the emergency department. It took place between 12pm and 7pm on Monday 20 January 2020.

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

The trust must:

Ensure that all clinical areas are kept clean and tidy at all times.

Ensure that all staff are aware of safeguarding and chaperoning policies in respect of the care of children and vulnerable adults and ensure that these policies are followed.

Ensure patients in the Fit2Sit area are adequately monitored and managed to be supported to stay safe.

Ensure that all fire exits and fire fighting equipment are clearly marked and free from clutter.

In addition, the trust should:

The trust should work with colleagues in the external provider operating the urgent care centre to improve the flow between the two services.

The trust should ensure that all NEWS/PEWS charts are consistently completed.

Professor Ted Baker

Chief Inspector of Hospitals

Our rating of services stayed the same. We rated it them as requires improvement because:

We inspected urgent and emergency services during this inspection to check if improvements had been made since our last inspection. The overall rating for the service was requires improvement. The rating for well-led and safe improved to good. Effective and caring remained good and responsive went down to requires improvement.

The overall rating for critical care improved to good. The ratings for effective, responsive and well-led improved to good, whilst safe remained the same as requires improvement and caring as good.

The rating for children and young people’s services stayed the same at requires improvement. The ratings for caring and well-led improved to good. The ratings for safe, effective and responsive stayed the same, as requires improvement.

The overall rating for end of life care stayed the same. Effective improved to good, whilst the other ratings remained as good.

We previously inspected outpatients services jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

Our rating of services stayed the same. We rated them as requires improvement because:

We inspected Urgent and Emergency services during this inspection as we wanted to see what improvements and changes had been made to the service. We rated the service overall as requires improvement, although the rating for effective improved from requires improvement to good.
We inspected Medical care (including older people’s care) and found the service had improved from requires improvement to good since out last inspection in 2016. The rating for effective improved to good.
We inspected Surgery and found the service had overall improved from requires improvement to good since our last inspection in 2016. However, the rating for well led went down one rating to requires improvement.

Barking, Havering and Redbridge University Hospitals NHS Trust provides acute services across three local authorities: Barking & Dagenham, Havering and Redbridge. Serving a population of around 750,000 and employing around 6,500 staff and volunteers.

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 was previously inspected in 2013, and due to concerns around the quality of patient care and the ability of the leadership team, the Trust Development Authority (TDA) recommended that the trust be placed in special measures.

We returned to inspect the trust in March 2015. A new executive team had been appointed, including a new Chair. Overall, we found that improvements had been made, however it was evident that more needed to be done to ensure that the trust could deliver safe, quality care across all core services.

The trust has continued its improvement plan, working closely with stakeholders and external organisations. On this occasion we returned to inspect the trust in September and October 2016, to review the progress of the improvements that had been implemented, to apply ratings, and also to make recommendation on the status of special measures. We carried out a focused, unannounced inspection at King George Hospital of three core services – the Emergency Department (ED), Medical Care (including older people's care) and Outpatients & Diagnostics (OPD).

This inspection subsequently found that some improvements had been made and ratings have been adjusted accordingly. Overall, we have rated King George Hospital as requires improvement.

Our key findings were as follows:

Are services safe?

The percentage of patients seen on arrival in the emergency department (ED) within 15 minutes between August 2015 and August 2016 averaged 70%.
There was a lack of evidence that learning and understanding of treating patients with suspected sepsis was embedded within the ED.
Patient records were not always kept secure.
There was a high dependency on locum doctors and lack of senior medical staff in the ED.
There were too few paediatric nurses in the ED.
There were breaches in the fire resisting compartmentation across the hospital site, which had been caused by previous contractors drilling holes for data cables and services.
Medical staff were failing to meet trust targets for completion of mandatory training, across all topics.
Staff completion rates in basic life support were below the trust target, due to a lack of external training sessions. There were low levels of resuscitation training in the ED.
There were poor levels of hand hygiene compliance observed in the ED and in OPD.
Although a comprehensive induction programme was in place for all new diagnostic imaging staff, some new staff members did not know where to find the Local Rules.
The air handling unit in paediatrics and minor injuries had been out of service for at least three weeks prior to this inspection.
There had been an improvement in the reporting of incidents and the sharing of lessons from these across the hospital.
Staff were aware of their responsibilities with regards to duty of candour requirements, confirming there was an expectation of openness when care and treatment did not go according to plan.
The dispensing and administration of medication had improved, with prescription charts being used correctly and processes being correctly followed and audited. Medication in the emergency and OPD were found to be appropriately stored.
Nursing staff demonstrated an awareness of safeguarding procedures and how to recognise if someone was at risk or had been exposed to abuse.

Are services effective?

There was a backlog of National Institute for Health and Care Excellence (NICE) guidance that was awaiting confirmation of compliance across the trust.
Fluid charts were not always filled out and some patients did not like the food, or found it hard to eat.
Patient outcomes in care of the elderly were limited by the lack of consultant geriatricians to lead improvements within the service.
In the Lung Cancer Audit 2015, the trust was below expected standards for three key indicators relating to process, imaging and nursing measures.
The pathways for patients with cancer were not always correctly managed. There was poor communication with tertiary centres, which caused delays with patients requiring tertiary treatment/diagnosis at other specialist hospitals.
There was a lack of effective seven day working across the hospital.
The trust had updated all of their local policies since the last inspection, and these were regularly reviewed.
Nursing and medical staff completed a variety of local audits to monitor compliance and improvement.
Pain was assessed and well managed on the wards, with appropriate actions taken in response to pain triggers. There was a dedicated hospital pain team.
The majority of staff received annual appraisals on their performance, which identified further training needs and set achievable goals.
There was evidence of effective multidisciplinary working within wards and across departments. All members of staff felt valued and respected.
Patients attending OPD received care and treatment that was evidence based.

Are services caring?

Patients were cared for in a caring and compassionate manner by staff throughout their stay. Most medical wards performed in line with the national average in the NHS Friends and Family Test (FFT).
Patients’ privacy and dignity was maintained throughout their hospital stay.
Psychological support for patients was easily accessible and timely. Patients were routinely assessed for anxiety and depression on admission.
The chaplaincy team offered comprehensive spiritual support to all patients, regardless of religious affiliation.
Some patients and relatives felt that more could be done to involve them in their care, especially surrounding discharge.

Are services responsive?

The ED failed to meet the four hour national indicator for treating or admitting patients.
There was no viewing room in the ED where people could see their deceased relatives.
The trust was consistently failing to meet national 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 national indicators for non-urgent referral to treatment (RTT) times.
The percentage of patients who did not attend (DNA) their appointment was above the England average.
13% of appointments were cancelled by the hospital. This was higher than the England average of 7.2%.
NHS England suspended endoscopy screening invitations to the trust for eight weeks from July 2016. There was a risk of delayed diagnosis of bowel cancer due to inability to provide a full screening service to the local population.
Staff across the hospital told us that they could not always discharge patients promptly due to capacity issues within the hospital or community provisions had not been put into place.
Patient information leaflets were not standardly available in languages other than English. Although face-to-face and telephone translation services were available, many staff were not familiar with how to access these.
The Patient Advice and Liaison Service (PALS) did not always respond to complaints in a timely manner.
Diagnostic waiting time indicators were met by the trust every month between May and August 2016, meaning over 99% of patients waited less than six weeks for a diagnostic test.
There had been an 88% reduction in the overall backlog of patients waiting over 52 weeks since May 2016.The hospital was using a range of private providers to assist in clearing the backlog of appointments where there were most demand for services.
Ward-based pharmacists helped to facilitate discharges in areas where they were available. There was also a pharmacy discharge team who worked 11am to 4pm weekdays.
Walk-in patients were streamed effectively in the ED, including back to their own GP.
People living with dementia received tailored care and treatment. Care of the elderly wards 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. Patients living with dementia were nursed according to a specially designed care pathway and were offered 1:1 nursing care from healthcare assistants with enhanced training. A specialist dementia team and dementia link nurses were available for support and advice. There were also dementia champion nurses in the ED.
Support for people with learning disabilities was available. There was a lead nurse available for support and advice.
There was a frail and older person’s advice and liaison team which worked closely with the ED.
The environment of children’s ED was child friendly and well laid out.

Are services well led?

The trust had developed a clinical vision and strategy and communicated this to staff of all levels across the hospital.
There was a system of governance and risk management meetings at both departmental and divisional levels across core services, however this had not yet developed effectively in some areas at the time of inspection. An external organisation had worked with the trust on ensuring their governance structures were more robust.
Quality improvement and research projects took place that drove innovation and improved the patient experience. Regular audits were undertaken, overseen by a committee. The hospital facilitated a number of forums and listening events to engage patients in the development of the service.
Most nursing and medical staff thought that their line managers and the senior team were supportive and approachable. The chief executive and divisional leads held regular meetings to facilitate staff engagement. However, some comments we received from staff reflected that they were not always happy with the management or leadership.
The trust could not evidence how they maintained records to ensure they knew their locum staff had up to date training in sepsis management
Many staff with whom we spoke were unclear about the future direction of the ED and the impact on job security.
Monthly nurse staff meetings in the ED had become less frequent due to pressures of work.

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 make their stay in hospital easier and reduce any emotional distress.

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 more quickly by a clinician.
Take action to improve levels of resuscitation training.
Ensure there is oversight of all training done by locums.
Take action to improve the response to patients with suspected sepsis.
Take action to address the poor levels of hand hygiene compliance in ED.

In addition the trust should:

Endeavour to recruit full time medical staff in an effort to reduce reliance on agency staff.
Increase paediatric nursing capacity.
Ensure there is a sufficient number of nurses and doctors with adult and paediatric life support training in line with RCEM guidance on duty.
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 that all policies are up to date.
Improve appraisal rates for nursing and medical staff.
Ensure that consent is clearly recorded on patient records.
Regularise play specialist provision in paediatric ED.
Ensure that patient records are stored securely.
Ensure staff and public are kept informed about future plans for the ED at King George hospital.
Continue plan to repair breaches in the fire compartmentation as detailed on the corporate risk register.
Continue to monitor hand hygiene and infection control across all medical wards and follow action plans detailed on the current corporate and divisional risk registers.
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.
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.
Increase staff awareness of the availability of interpretation services.
Ensure leaflets detailing how to make a formal complaint are available across all wards and departments.
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 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 18 week waiting time indicator is met in the OPD.
Ensure the 52 week waiting time indicator is consistently met in the OPD.
Ensure the OPD 62 day cancer waiting time is consistently above 85%.
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.
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

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 covers three local authorities; Barking & Dagenham which has very high levels of deprivation, and Havering and Redbridge which are closer to the national average. Havering has a relatively elderly population by London standards.

King George Hospital is in Ilford. It is a modern local hospital providing acute and rehabilitation services for residents across Redbridge, Barking and Dagenham and Havering and some services to patients from South West Essex.

We inspected the trust in October 2013, and found there were serious failures in the quality of care and concerns that the management could not make the necessary improvements without support. I recommended to the Trust Development Agency (TDA) that the trust be placed in special measures in December 2013.

Since the inspection a new executive team has been put into place including a new chair, new members of the board, a chief executive, medical director, deputy chief executive, chief operating officer and a director of planning and governance. The executive team has been supported by an improvement director from the TDA.

The trust developed an improvement plan ('unlocking our potential') that has been monitored and contributed by all stakeholders monthly and published. The purpose of this re-inspection was to check on improvements, apply ratings and to make a recommendation on the status of special measures.

Overall, this hospital requires improvement. End of life care services were rated as good, its Outpatients and diagnostic imaging service were rated as inadequate and all other services were rated as requires improvement. Of the five key questions that CQC asks, we rated the hospital as good for caring. We rated the hospital as requires improvement for safe effective, responsive and well-led.

Our key findings were as follows:

Improvements had been made in a number of services since our last inspection.

Safe

Safety was not a sufficient priority. There was a backlog of serious incidents and the quality of investigations into serious incidents lacked detail to ensure failings were understood and lessons were learned.
There were insufficient systems, processes and practices to keep patients safe. Lessons were not learned and improvements were not made when things went wrong.
Recruitment had been on-going however there was not always enough medical and nursing staff to meet the needs of patients.
The management of medicines needed improving to ensure safe management and administration.
Patient safety could be compromised due to the layout and the inadequate alarm system in the Phlebotomy clinic in Outpatients.

Effective

Radiology staff felt that their competencies for CT scanning were not appropriately maintained.
Patients' needs were assessed and care and treatment was delivered in line with evidenced-based guidance.
Patient outcomes were varied.
Pain relief and nutrition and hydration needs were assessed and met.
Consent, Mental Capacity Act 2005 and Deprivation of Liberty Safeguards were well understood by the majority of staff and part of a patients plan of care.

Caring

Some national surveys have found that staff were not always compassionate. In response, staff had focussed on involving patients, keeping them informed and treating patients with dignity and respect.
During our inspection we saw and heard of compassionate and kind care and emotional support being provided.

Responsive

Urgent and emergency, children and young people and outpatients services were not responsive to patients' needs.
The emergency department was not meeting the national four-hour waiting time target introduced by the Department of Health.
The hospital was persistently failing to meet the national waiting times target. Some patients were experiencing more than 18 weeks from referral to treatment time (RTT).
Speech and language therapists were not trained to care for patients who had tracheostomies.

Well-led

The trust are not committed to delivering all the measures in their published clinical strategy, which impacted on the delivery of services and the needs of patients, and staff morale.
The new executive team was making improvements. The board was visible and engaging with patients and staff.
The leadership and culture were open, transparent and focussed on improving services.
The governance structures did not ensure that responsibilities were clear and that quality, performance and risks were understood or managed.

We saw several areas of outstanding practice including:

The values of the trust - passion, responsibility, innovative, drive and empowerment (PRIDE) were well known and embedded in the culture of the people working at the trust.
The new executive team were visible and engaged.
There was lots of involvement from the local community and voluntary organisations. The foyer had lots of people giving information for patients and visitors about services in the local area.
Patients referred for cardiology appointments were seen within seven days.
The critical care outreach team provided a ‘critical care follow up outpatient’s clinic’ for patients who required support after leaving hospital. This ensured patients were making progress in the months following their admission.
The critical care outreach team had devised a tracheostomy discharge checklist for patient’s leaving the hospital with a tracheostomy. The checklist supported teaching key competencies to patients, family and carers in how to support a person with a permanent tracheostomy.
We observed the critical care team supporting patients and their families with their individual needs in a flexible, thoughtful, patient, considerate and caring manner; this support and care extended through to their colleagues.
The end of life care service was patient focussed and end of life care needs was well understood by the majority of staff from all staff groups.

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

Importantly, the trust must:

Have clear governance with integrated systems and processes to support staff to provide care and treatment safely.
Ensure serious incidents are understood, investigated and lessons are learned promptly.
Review systems for sharing good practice across the divisions and trust wide.
Ensure compliance with all national guidelines and trust policies for medicines management.
Improve the service planning and capacity of outpatients by continuing to reduce the 18 week non-admitted backlog of patients as well as ensure no patients waiting for an appointment are coming to harm whilst they are delayed, reduce the did not attend, hospital cancellation and hospital changes rates and improve the 31 day cancer wait target.
Improve the IT systems so they are up to date and the IT strategy is implemented and supports clinical staff to carry out their duties.
Ensure all services for neonates, children and young people are responsive to their needs.
Ensure the radiology is fit for purpose and fulfils its reporting timescales, particularly for CT scans.
Continuously review staffing levels and act on them at all times of the day.
Include a dietician as part of the critical care multidisciplinary team in line with the core standards for intensive care guidance.
Comply with the Duty of Candour legislation.
Display the numbers of staff planned and actually on duty at ward entrances in line with Department of Health guidance.
Ensure safe management and administration of medicines.
Ensure that all incidents including patient falls are accurately reported electronically
Ensure that patients who sustain a fall receive a medical review in a timely manner.
Ensure that medical outlying patients have an identified medical team to review their care and an agreed escalation plan in place
Ensure that speech and language therapists are trained and competent to care for patients who have tracheostomies.
Ensure that entries made by medical staff in patient records comply with the expected professional standards
Ensure that medical staff in the Emergency Department receive appropriate supervision.
Ensure adequate provision of resuscitation equipment in Outpatients.
Ensure compliance with COSHH regulations.
Ensure patient records are kept securely and that patient confidentiality is maintained.
Ensure radiologists are confident and competent when performing CT scans.

In addition the trust should:

Consider increasing the target rates for mandatory training.
Review the accessibility of the radiology services and consider a duty radiographer structure.
Continue to improve patient record availability at outpatient clinics.
Review the environment in Outpatients to improve the waiting and reception areas.
Consider ways to increase multidisciplinary team working within critical care.
Consider ways to engage patients in providing feedback.
Review the number of medical staff cover for the medical wards at night.
Review the staffing levels on Ash Ward.
Ensure that junior medical staff are aware of the trust's complaints procedure.
Ensure that nurses understand the importance of the recommendations stated by the speech and language therapy team.
Consider ways to increase multidisciplinary team working within critical care.
The hospital should review its response to major incidents including equipment, staff training and practical testing.
The Emergency Department should review its poor performance in FFT scores and develop a plan for improvement.
The Emergency Department should ensure that all staff are fully consulted upon, and aware of future plans for the department.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT or the Trust) is a large provider of acute services, serving a population of over 750,000 in outer North East London. The Trust has two acute hospitals: Queen’s Hospital and King George Hospital. Accident and Emergency (A&E) departments operate from both of these hospitals. It also provides services from the Victoria Centre and Barking Hospital but does not manage them. King George Hospital was built in 1993 and is the main hospital for Barking and Redbridge. Queen’s Hospital opened in 2006 and brought together the services previously run at Oldchurch and Harold Wood Hospitals. It is the main hospital for Havering, Dagenham and Brentwood. There are plans to reconfigure services from King George Hospital to Queen’s Hospital.

The Trust covers three local authorities; Barking and Dagenham which has very high levels of deprivation. and Havering and Redbridge which are closer to the national average. Havering has a relatively elderly population by London standards.

This report relates to King George Hospital and there is a separate report for the overall Trust.

The findings of the inspection team identified the following areas for improvement:

The Accident and Emergency Department does not provide safe care all of the time. There is a lack of senior medical staff supported by middle and junior grade doctors, and an over-reliance on locum doctors. Medical staff from other specialities are not reviewing patients within the agreed timescales and are not doing enough to relieve the burden on A&E staff. Patient flow through the Trust is poor from when they attend A&E through the Acute Medical Unit and medical wards requires improvement.

We could not be assured that patients always received safe and effective care on surgical wards, and medical wards. The completion of nursing documentation was inconsistent and if patients were transferred to King George Hospital there were no documented handovers. Delayed discharges and high occupancy rates meant that the service could not be as responsive as required and this put unnecessary pressure on departments and increased the risk of poor outcomes for patients.

Some aspects of End of Life care also need to be improved.

Administration in the outpatients department is very poor which impacts adversely on patient care.

The maternity and children’s care services were good, with no significant areas requiring improvement.

We focused our inspection on how well the hospital cared for elderly patients. This was because most of the concerns that the public have raised with CQC about King George Hospital have been about this area. Although elderly patients can be found on most wards at the hospital, we inspected three wards where almost all of the patients were elderly, Elm, Erica and Fern.

Patients who use the service were given appropriate information and support regarding their care or treatment. Patients we spoke with told us that they had been involved in decisions about their care and treatment. One patient told us, 'they tell me what is going on, and when I will be going home'.

Patients' needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Most of the patients we spoke with were positive about their care. One person told us, 'if you've got to be away in hospital this is the place to be. Everyone's really lovely, friendly atmosphere, enough attention'. One family member told us, 'dad has been in here four times and I love it'.

Patients were supported to be able to eat and drink sufficient amounts to meet their needs. Most of the patients said that they liked the food they received. They told us that there was enough food to eat and they were offered hot and cold drinks throughout the day. Patients' nutritional needs where assessed and specialist advice was obtained when needed.

Patients who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Patients told us that they felt safe in the hospital and that they felt comfortable with reporting any concerns they had to staff.

There was enough qualified, skilled and experienced staff to meet patients' needs. Overall patients said they felt there were enough staff, one person said ' I don't like to bother them as they are very busy, but when I do need help they always come and help me'. Another patient told us, 'if I need to go to the toilet they don't usually come straight away, but after a few minutes which is fine'.

We undertook this review because we were following up on compliance actions which the trust had declared compliance with. The review focused on pressure sores, pneumonia care pathway, management of medicines incidents as well as training for temporary staff.

We asked the trust to provide evidence to support their compliance.

We undertook a visit to Beech Ward because we were following up on compliance actions the hospital had declared they were compliant with.

Members of staff told us they were pleased with the improvements made since our previous visit and that the matron carried out regular checks on how the ward was improving.. One member of staff told us 'the ward is much better now, before patients weren't being got up out of bed unless we got them up, now those who are well and able are got up every day by the nursing staff'.

Improvements in the ward were also reflected in the comments made by the majority of patients; although a minority of patients were less satisfied.

During our inspection a local MP was also undertaking a visit to the ward. The MP recognised improvements and that staff were 'more attentive' and the patients 'a little happier'.

We carried out this inspection in the maternity unit in response to concerns raised with us by a member of staff. The inspection was unannounced and took place during the evening so that we could talk to staff from both the day and the night shifts. We spoke with eleven members of staff. On this occasion we did not speak to patients as we were following up very specific concerns which could not have been answered by talking to patients.

Most staff told us that there was a range of appropriate equipment available both in the ward and in the two theatres. They also told us that equipment was checked to ensure that it was kept in working order. For example one member of staff said, 'There is enough equipment and people are not at risk from a lack of, or faulty equipment.'

Staff also told us that staffing levels and skill mixes were usually okay. They acknowledged that on occasions staff were transferred between hospitals to cover shortages but said that this did not place patients at risk. One member of staff said, 'Sometimes staff have to move between hospitals because they are short staffed but I don't feel that this leaves patients at risk. It sometimes makes it harder for the staff left behind as they are busier than usual.' A midwife told us that they could usually provide one to one care for women in labour.

We undertook a visit to Beech Ward because we had received concerning information from some current and former patients as well as their relatives. We had been told of some staff being unkind to patients as well as concerns regarding privacy and dignity issues, we were also told of patients waiting a long time for the buzzers to be answered (including whilst using the toilet at night). We were also told that sometimes staff shouted at patients and each other.

Our visit took place during a Saturday afternoon and evening, we talked to patients and their relatives about the care patients received. We also talked to staff about the issues. It was the perception of staff that they were 'stretched' because of shortfalls in staffing. They said they felt this had an effect on the care they were able to give. Some staff also felt this impacted on their stress levels which resulted in arguing amongst themselves. There were mixed perceptions about how patients were cared for, some staff felt care could be better, others considered care to be of a good standard.

Patients also had mixed views on the care they received. Some told us the care they received was good, patients and their relatives also commented that some staff were 'better than others'. One patient told us; "Some staff are not lovely, some shout" another told us; "All the staff are friendly'.

Patients and their relatives told us that although they were supposed to get out of bed most days, in accordance with their care chart, this did not always happen and sometimes they stayed in bed all day.

Some patients felt buzzers were answered quickly, within about 15 minutes. Other patients and some staff told us that it can take a long time for buzzers to be answered. Staff said that it was difficult to always answer the buzzers when they were busy.

We were told by staff and management that following a serious complaint the trust had already started to tackle the concerns and take action to address the situation.

We spoke to a number of patients (and their relatives, if they were present) on two wards, the accident and emergency department, and the discharge lounge. The majority of patients and their relatives stated that they were satisfied with the care and treatment that they had received at King George Hospital. Patients told us that they had been treated well by the staff on the wards.

Most patients and their relatives told us that they were very satisfied with the care and treatment that they received at King George Hospital. Patients said that they were treated in a polite and respectful manner and that their dignity and privacy was promoted well. Patients told us that they received straight forward information and had been able to make decisions about their treatment and discharge planning. Patients told us that they were offered a wide choice of food and sufficient quantities. There were mixed opinions regarding how appetising the food was. People told us that food was served at the right temperature and that they were given support.

We spoke to people who use the services and found that in general they were happy with the care provided by the hospital

All Inspections

Summary of urgent and emergency services at King George Hospital:

Summary of medical services (including older people’s care) at King George Hospital:

Summary of diagnostic imaging at King George Hospital:

Professor Ted Baker

Chief Inspector of Hospitals

Professor Sir Mike Richards

Professor Sir Mike Richards