We have not changed the rating of this key question, as we have only looked at the part of the key questions that we had specific concerns about including the winter resilience questions. The purpose of this inspection was to check a specific concern we had about care and treatment for mental health patients, staffing, medicines and environment. We will assess all the key question at the next comprehensive inspection of the service.
The emergency department based at St Thomas’ Hospital provides consultant-led emergency care and treatment 24 hours a day, seven days a week to people across the London boroughs of Lambeth, Southwark and Westminster as well as people out of area.
We inspected the service using the winter resilience methodology. We did not inspect any other services as this was a focused inspection in relation to urgent and emergency care.
We carried out this unannounced focused inspection because we had concerns about the quality of services for mental health patients. We did not enter any areas designated as high risk due to COVID-19. The inspection framework focused on five key lines of enquiry relating to critical care, infection prevention and control, patient flow, workforce and leadership and culture.
During the onsite visit to the emergency department we became aware of concerns about the care of a mental health patient who had been in the department for three days due to lack of beds in an acute mental health setting for the patient to be transferred to. The issue was escalated to the NHSE&I and the clinical commissioning group (CCG).
We did an unannounced focused inspection of safe, responsive and well-led domain. We only looked at those areas in our standard plan for assessing pressure on emergency departments.
We did not rate this service at this inspection. The previous rating of outstanding remains.
We found:
- The service had staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risks well.
- Staff assessed risks to patients, acted on them and kept accurate care records. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
- 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.
- Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply these in their work. Staff were clear about their roles and accountabilities.
- We observed improvements in the physical environment where patients were rapidly assessed and treated. This was now consultant led with consultant cover for 16 hours out of every 24 hours.
- There were clear clinical care pathways and protocols in place, with pre-agreed parameters for patients being seen in designated areas.
- Patients received timely clinical input and assessment. We observed patients’ risk assessments were appropriately completed and that patients were reviewed based on their clinical needs.
- Staff were aware of, and used, the trust’s escalation processes in order to manage flow and reduce risks of crowding within the department.
- Staff understood how to manage infection prevention and control and all areas were visibly clean. Staff wore appropriate personal protective equipment (PPE) to keep themselves and others safe from cross infection.
- There were systems in place for infection prevention and control. All staff and patients adhered to personal protective equipment (PPE) guidelines. There were clear isolation and separation areas to manage the care for patients due to COVID-19.
- Staff kept detailed records of patients’ care and treatment. Records were clear, up to date, and easily available to all staff providing care. Patient records were managed securely.
However:
- The service did not have enough medical registrars to meet the recommended guidance for the department or be able to develop the service. There were insufficient numbers of medical registrars in post.
- The service did not always have enough substantive clinical staff to care for patients and keep them safe without using high numbers of temporary bank, locum and agency staff.
- Staff told us that at periods of high demand and increased capacity sometimes there could be a delay in adjusting and managing the ratio of nurse patient ratio.
- The service should ensure that records relating to decisions to administer rapid tranquilisation clearly identify the clinician who made the decision and details of the reason for administering the medication.
- The service should continue to participate in multiagency partnership arrangements for managing people experiencing mental health crises.
- People could access the service when they needed it and received the right care. However, this was not always promptly as waiting times from patient arrival to treatment and arrangements to admit, treat and discharge for mental patients were not in line with national standards.
- Although leaders and teams identified and escalated relevant risks and identified actions to reduce their impact, they were not always able to prevent reoccurrence. The service was not always managing issues early enough to prevent them from becoming problems.
How we carried out the inspection
We spoke with 12 staff including: the clinical lead, a consultant nurse, a practice development (PD) nurse, the head of urgent and emergency care, an emergency department matron, emergency department (ED) consultants and nurses.
The inspection was carried out over two days by a CQC lead inspector, supported by two CQC mental health inspectors and a consultant doctor as a specialist advisor with experience of emergency department care.
We carried out the unannounced part of the inspection from midday on a Monday 21 June 2021 from 12 noon till 9pm as this is usually a busy period for hospital emergency departments.
We reviewed 15 patient care records and we analysed information about the service provided by the trust following our inspection.
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.