St Mary's Hospital

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.

St Mary’s Hospital is one of the two locations of Imperial College Healthcare NHS Trust which provides maternity and gynaecological services along with Queen Charlotte’s & Chelsea Hospital. The maternity services comprised of the birthing centre. The postnatal and antenatal ward with 35 inpatients beds. The labour ward having eight delivery rooms, two theatres and two birthing pools. Maternity triage services are provided by way of three beds; this is a short stay area and is open 24 hours per day, seven days per week. A day assessment unit operating by an appointment system or low risk referrals from the emergency department. There is an antenatal outpatient service. The FMU services included fetal and perinatal scans and post termination of pregnancy and specialist pre-pregnancy fetal counselling. Two neonatal intensive care unit (NICU) with 22 cots including four intensive care beds, four high dependency beds and 14 special care cots. St Mary’s Hospital also provides independently funded maternity healthcare service at the Lindo wing.

Medicine and specialist medicine at St Mary’s Hospital sat under two directorates in the hospital. The majority of the medical wards were under the Medicine and Integrated Care Division while cardiac, haematology  and oncology were under the Surgery, Cardiovascular and Cancer Division. Medical wards include acute assessment unit (AAU) and other assessment wards, a clinical decisions unit (CDU), care of the elderly wards, general medical wards and specialist wards such as respiratory medicine, gastroenterology and endocrinology. The hospital also hosts an endoscopy suite and discharge lounge.

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 maternity and medicine (including elderly care) services because we had information giving us concerns about the quality of this service.

We last inspected the maternity and medicine (including elderly care) in September 2014 as part of our comprehensive inspection program and rated the services as good and requires improvement respectively. For maternity during that inspection we found the risk of unsafe care had been mitigated by prioritising the needs of women in labour. However, the quality of care on postnatal wards was sometimes compromised. Evidenced-based care was promoted and there was an audit programme to assess compliance with best practice. There was an embedded multidisciplinary approach to learning from incidents and complaints. Specialist clinics assessed the needs of women with medical conditions. Specialist midwives and caseload midwives supported women who were at risk. There was training for midwifery staff and trainee doctors and opportunities for professional development. Staff were positive about their contribution to improving the quality of care and felt their contribution was recognised and valued. For medicine 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 over quality of the maternity service had changed from good to requires improvement. We rated safe, responsive and well-led as requires improvement and rated effective and caring as good.

During this inspection we found the overall quality of the medicine and elderly care services had stayed the same as at the previous inspection; although there had been some positive changes, the service continued to be rated overall as requires improvement ​. We rated safe and responsive as requires improvement and rated effective, caring, and well-led as good.

Our key findings were as follows:

In the maternity service:

• There was one Never Event reported between January 2016 and December 2016.

• Not all staff were able to give examples of learning from incidents or changes that had occurred as a result.

• The maternity services did not always follow the trust’s medicine management policies so that medicines were safe for administration to patients. In particular, for date checking medicines and storing medicines in refrigerators.

• Staff compliance with trust mandatory training was low and below trust target of 95%. For example, midwifery staff compliance with mental health/mental capacity training was 58% and consultant compliance with consent training was at 40%.

• We found that 84% of relevant maternity staff had CTG training.

• An audit of Intrapartum CTG “Fresh Eyes Buddy System” demonstrated that 87.5% of the notes were not meeting the standard.

• The environment was challenging due to the nature of the building and in some need of repair.

• The service did not monitor infant fall rates quality and the service’s safety dashboard information was not displayed for the public and patients. This meant that the public could not readily see information and statistics about the harms that had occurred in the maternity service.

• Midwives were required to scrub as scrub nurses for second and emergency theatre lists. However, the department was currently reviewing the competency framework for this.

• Between April 2016 and February 2017 90% of women had a named midwife, which was below target of 100% set by the clinical commissioning group as part of the clinical quality group acute quality metric.

• There was limited information available on the wards for women and their relative about how to make a complaint and how to access the Patient Advice and Liaison Service (PALS).

• We found two clinical guidelines that were out of date.

• Only 84% of midwifery staff had bereavement training.

• There was lack of visibility of executive team and senior leadership team on the floor.

• Not all staff were aware of the directorate vision and strategy.

• A recent serious incident identified weakness within the trust governance process and they had requested an external review of maternity clinical governance structure by Royal College of Obstetricians and Gynaecologists.

• Maternity wards were in a dated building, which did not provide an optimum environment for women.

• Throughout the maternity service, there was poor signage navigating to different parts of the maternity service.

• Not all risks identified by us during the inspection were on the maternity service’s risk register and senior divisional leadership team did not had the oversight of all the problems at St. Mary’s site.

In the medicine service:

• Staff on medical wards were not meeting the trust targets for almost all modules of mandatory training, including safeguarding, resuscitation, and infection prevention and control.

• Medical wards were not meeting targets for MRSA screening set by the trust.

• The vacancy rate for nursing staff across medical wards at St Mary’s Hospital was significantly higher than the England average.

• We noted that a number of medications checked on the medical wards had passed their expiry date, and some wards were not following the trust policy on refrigerator temperatures.

• Staff we spoke with stated that security could be slow to respond to incidents, and there were concerns this could result in staff being more exposed to aggressive or threatening patients.

• We found some inconsistency amongst nursing staff and junior medical staff in their understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

• Medical services at St Mary’s Hospital did not meet the NHS England national indicator for 18 weeks referral to treatment (RTT) times.

• Discharge forms from the wards were inconsistent or incomplete, and this could result in delays to patients’ discharges from the discharge lounge.

• Data provided by the trust show patients being discharged out of hours between 22:00 and 07:00, suggesting patients being moved out of the hospital at unsociable hours.

• The hospital signage was not up to date and does not provide patients or visitors with information how to access the wards.

However,

In the maternity service:

• Safeguarding vulnerable adults, children and young people was given sufficient priority and staff take proactive approach to safeguard and focus on early identification.

• Staff had good understanding of the major incident and fire safety plans.

• Information about people’s care and treatment and their outcomes was routinely collected and monitored. This information was used to improve care.

• There was participation in relevant local and national audits and there were detailed follow up action plans to ensure improvement in patient care.

• Consent to care and treatment was obtained in line with legislation and guidance.

• All women we spoke with on antenatal, postnatal and labour ward were positive of their experiences, and the kindness, skill and supportiveness of staff.

• Between April 2016 to February 2017, 0.7% of all births at St Mary’s Hospital (SMH) were home births and in January there were no home births, which was below the trust maximum target of 1%.

• Staff were conscious of the need to protect the dignity and privacy of women in all areas of the service. Curtains were drawn around beds during examination all time and during ward round to ensure privacy.

• Specialist staff offered sensitive bereavement support for women suffering miscarriages or stillbirth.

• Services were planned and delivered in a way that met the needs of the local population.

• Women were given a choice of times and dates for antenatal clinic appointments.

In the medicine service:

• There were systems in place for staff to report incidents, and for incidents to be discussed in clinical governance meetings.

• Staff we spoke with stated the electronic records system was accessible, and that they had received training in use of the system as part of their induction.

• We reviewed trust policies on delivering clinical care throughout medical wards and found them to be in date and in line with best practice guidelines.

• Local and national audits were used to benchmark care, treatment and practice against guidance established by a range of organisations that represented best practice.

• Patients we spoke with were very positive about their experiences on the medical wards, particularly regarding their interactions with staff. We observed positive interactions between staff and patients throughout the medical wards we visited.

• There were measures in place to manage patients being cared for on wards outside of the specialty for which they were admitted. The hospital also had systems in place to increase capacity to meet the needs of the local population during winter pressures.

• The introduction of complaints investigators had much improved response times and the quality of investigations for complaints.

We saw several areas of outstanding practice including:

• The trust had introduced Side by Side for Alzheimer’s patients, an initiative by the Alzheimer's Society service which helps people with dementia to access recreational activities. This included arts and crafts, harmony singing and Friday afternoon tea parties.

• The trust developed a nutrition pathway called the Nutrition Support in Hospital (NoSH) which was designed to ensure patients particularly people with dementia, received the food and drink they need while in hospital without losing the independence they had before admitted to the hospital.

• The Medicine and Integrated Care Division introduced a nurse-led cirrhosis clinic offering improved screening to patients at high risk of developing of severe complications from substance misuse, such as liver cancer. The clinic recently won the “Innovative Project of the Year” award from St Mungo’s homelessness charity.

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

Importantly, the trust must:

• The maternity and medical service must ensure that they always 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 service must improve compliance with its mandatory training for all staff groups.

• The maternity service must ensure to ensure there is comprehensive oversight of problems and that the risk register is reflective of all risks within the directorate.

• The service must improve the management of CTG monitoring. This should include improving CTG training rates for relevant maternity staff and improvements in the "Fresh Eyes Buddy System" to ensure standards are met

• The trust must take action to ensure medical wards are meeting resuscitation training requirements for their staff.

• The trust must ensure they implement the recommendations made in the Royal College of Obstetricians and Gynaecologists (RCOG) report from April 2017, 'Review of Maternity Services at Imperial College Healthcare NHS Trust, St Mary's Hospital site'.

In addition the trust should:

In the maternity service:

• Ensure that up to date safety thermometer and key relevant information are displayed on the quality improvement boards.

• The service should ensure that second theatre and emergency theatre lists are appropriately staffed.

• The service should ensure that all clinical guidelines are up-to-date.

• The trust should ensure that there is more visibility of executive and senior leadership team.

• The service should ensure a consistent approach and more user friendly patient information available and displayed in wards including information about PALS.

• The service should urgently review and improve the signage for the various maternity wards and department, particularly for fetal medicine unit.

• The service should address the estates issues related to kitchen and patient shower areas.

In the medicine service:

• The trust should improve performance of the number of staff on medical wards completing mandatory training in relation to trust targets.

• The trust should ensure medical wards are meeting targets for MRSA screening set by the trust.

• The trust should ensure that medications are not retained past their expiry date, and medication refrigerators are within the temperature range identified in the associated trust policy.

• The trust should ensure there is a clear process for a timely response from hospital security to incidents or staff being expose to violence and aggression.

• The trust should ensure staff have a clear understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

• The trust should improve the consistency and completeness of discharge information for patients transferred to the discharge lounge.

• The trust should improve hospital signage, ensure it is up to date and provides clear information for visitors on how to access the wards.

• The trust should ensure that patients are not discharged out of hours (between 10pm and 7am), without a clear reason for doing so, a robust discharge plan in place, and a safe place to discharge patients.

Professor Edward Baker

Chief Inspector of Hospitals

St Mary's Hospital  is an acute general teaching hospital located in hospital in Paddington, London. The hospital was founded in 1845 and has been operated by Imperial College Healthcare NHS Trust since 2008. 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 St Mary's 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 St Mary's Hospital as good overall.

Our key findings were as follows:

• Staff felt there was a positive incident reporting culture that promoted honesty within a ‘no blame’ culture. Staff at all levels told us they felt supported when they submitted incident reports and felt the level of feedback was appropriate.
• All areas met or exceeded the trust’s 90% compliance target with hand hygiene and ‘bare below the elbow’ policies.
• Staff followed appropriate medicine management procedures that reduced the risk of incorrect doses and administration. Medicines were stored according to manufacturer instructions and mistakes were acted upon to reduce the risk they could happen again.
• The number of patients seen in outpatients with temporary notes as a result of their case records being unavailable was better than the national benchmark maximum of 4% of patients.
• Safeguarding processes were well established and staff demonstrated appropriate knowledge of them. All staff had access to trust safeguarding policies. Clinical staff in sexual health and HIV services had a higher level of safeguarding training that enabled them to safely care for vulnerable and at-risk patients, including those complex needs and challenging social circumstances.
• Processes were in place to ensure children and young people seen outside of paediatric services were cared for using appropriate safeguarding policies. Staff used monthly multidisciplinary safeguarding meetings to review such instances.
• Staff in diagnostic imaging used the World Health Organisation (WHO) surgical safety checklist for radiological interventions and the Society of Radiographer’s ‘pause and check’ process as part of a robust risk management process.
• Consultant and nursing cover was generally adequate to meet demand. Where staff sickness might impact the ability to run a clinic, specialist registrars were able to provide some cover. Staffing levels were determined by the length of clinics and number of patients and according to consultant job plans.
• Staff in each service provided care and treatment that was benchmarked against the guidance of national bodies of practice, including the Medicines and Healthcare Products Regulatory Agency, National Institute of Health and Care Excellence, the Faculty of Sexual and Reproductive Health and the British HIV Association.
• Between January 2016 and December 2016, the hospital met the two week wait target for cancer referrals in every month.
• Waiting times in diagnostic imaging were better than the national target of six weeks for the five core diagnostic services between April 2016 and December 2016.
• Dedicated radiation protection advisers and radiation protection supervisors were in post and provided oversight for diagnostic imaging services to comply with Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2006 and the IR(ME) Amendment Regulations 2011 safety guidance.
• Staff spoke positively about the annual appraisal and professional development record process and said they had been able to secure training and development activities as a result.
• There was evidence of multidisciplinary working, including with safeguarding and infection control teams and between specialties. Weekly and fortnightly cross-site multidisciplinary meetings took place in diagnostic imaging that enabled clinicians to support each other and strategise complex cases.
• Staff treated patients with kindness and a friendly manner during all of our observations, including in clinical and non-clinical settings.
• Reception staff demonstrated understanding and patience when dealing with anxious or flustered patients and we saw reception staff in the Jefferiss Wing treat people who were waiting outside with particular compassion while they waited.
• Patients consistently told us they felt welcomed and valued in the service and they found staff attitudes to be memorable because of their warmth and positivity.
• When clinics were delayed or disrupted staff maintained communication with patients every 30 minutes and offered them water and advice about the delay and options for rebooking. .
• The volunteer service had started a pilot programme in main outpatients to scope the potential benefits and impact on patient experience of having a team based there permanently.
• An outpatient improvement programme was in place to reduce waiting times and delays to clinics. A new standard operating procedure enabled senior staff in main outpatients to escalate to the management team if a doctor was late for a clinic that resulted in delays to patients. We saw this worked well during our observations.
• In November 2016, main outpatients had achieved a turnaround time of 10 days for 95% of referrals, which was the trust target.
• A new complaints and concerns policy enabled complaints to be recorded, investigated and resolved within the trust’s 40 day maximum target. The new system also enabled services to identify trends in complaints to drive improvements.
• A new general manager and seniornursein main outpatients had conducted a significant nursing and leadership review of the service and restructured it to deliver results in the outpatient improvement programme.
• All of the staff we spoke with were positive about the overall vision and future strategy for the trust. Most staff also felt empowered to promote positive change and provide suggestions for improvement in their own local services.
• Clinical governance structures helped staff to manage risks to services and involved an appropriate range of staff in most cases. Risk registers were updated regularly and staff with appropriate experience and knowledge managed these.
• The majority of staff we spoke with felt positively about the leadership in their service and described a work culture that facilitated development and innovation. This was particularly the case in cardiac, sexual health and HIV services.
• Feedback from patient engagement was used to improve services, particularly with regards to staff communication in main outpatients and the role of trust volunteers.
• Individual services engaged with their staff teams to improve working conditions and deliver better patient services. This included through consultation on working patterns and the implementation of a working group in diagnostic imaging to identify solutions to some of the challenges the team faced.
• Staff felt recognised and rewarded for their work through trust and local initiatives and spoke positively of opportunities to work with colleagues in other areas to gain a better understanding of how they worked.

​ We saw several areas of outstanding practice including:

• The senior team in the Jefferiss Wing, including sexual health and HIV services, demonstrated a sustained track record of building staff skill mix and service sustainability through promoting specialist training, practice education and rewarding performance.This resulted in positive impact on the local population because it meant people who were vulnerable or at-risk received timely support and treatment.
• The outpatient improvement programme had begun to deliver results in a relatively short space of time and the process, involving staff consultation and a restructured leadership and governance team, meant clinic delays had been reduced and communication with patients improved.

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

• The hospital should ensure all staff working in clinical areas have appropriate fire safety training and an understanding of local evacuation procedures.
• The hospital should ensure incidents are fully investigated within a reasonable timescale in such a way that allows trends to be identified so as to ensure the service remains safe.
• The hospital should ensure contractors providing services are able to respond within a reasonable time to complaints made by patients against the trust in cases that involved both providers.
• The hospital should ensure doctors in training have up to date mandatory training in all required areas.
• The hospital should ensure pre-qualification allied health professionals have up to date mandatory training in all areas.
• The hospital should ensure each radiology practitioner has a documented local induction for checked competency in working under IR(ME)R guidelines.

Professor Sir Mike Richards

Chief Inspector of Hospitals