The Care Quality Commission (CQC) haspublished a report following an inspection of the urgent and emergency care department (ED) at St. Thomas’ Hospital, run by Guy’s and St. Thomas’ NHS Foundation Trust.
CQC carried out an unannounced inspection of the ED in June, to look at specific concerns relating to the care and treatment of mental health patients, as well as staffing, medicines and the overall environment.
The inspection looked at how safe and well-led services were, as well as how responsive it was to people’s needs. As no ratings were produced in relation to these key questions, the overall rating of outstanding for this service remains. St. Thomas’ Hospital is rated good overall.
Nicola Wise, CQC’s head of hospital inspection for London, said:
“During our inspection of the emergency department at St’ Thomas’ Hospital, staff told us that during the COVID-19 pandemic they had seen an increase in patients who had been admitted for psychiatric reasons, and there were often delays in discharging them to a service that could provide ongoing care, due to a shortage of beds.
“We saw that one patient with mental health issues had been in the department for three days waiting for a suitable bed in the psychiatric intensive care unit. We were so concerned about this that we contacted local stakeholders to make them aware of the situation so that they could take action and find a suitable service for the patient to be discharged to.
“Although staff expressed their frustration about not being able to give the quality of care they would like to give patients with mental health issues due to high demand, people could access the emergency department when needed and were assessed promptly by mental health professionals who were available 24 hours a day. Security staff were also trained in how to deal with a patient experiencing a mental health crisis. Staff told us that it was very easy to get an assessment under the Mental Health Act and that the local authority was usually very responsive when emergency mental health assessments were needed.
“It was also encouraging to see that staff made sure that patients living with learning disabilities and dementia received the necessary care to meet all their needs. Sunflower lanyards were given to people with learning disabilities so that staff could quickly recognise disabilities that may be unseen. Similarly, they used blue wrist bands to identify patients with dementia. The enhanced care team then provided additional support to these patients.
“A new protocol for responding to mental health emergencies has now been introduced in the emergency department to facilitate a rapid response, along with a training course on mental health. We will continue to monitor the situation and acknowledge the response the trust has taken to the increased demand.”
Inspectors found the following during this inspection:
- 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.
- The service had enough 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.
- Staff assessed risks to patients, acted on them and kept accurate care records which were easily available to all staff. 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.
- The service is now consultant-led with consultant cover for 16 hours out of every 24 hours. Patients received timely clinical input and assessment. People were reviewed based on their clinical needs and their risk assessments were appropriately completed.
- Improvements had been made in the physical environment where patients were rapidly assessed and treated. There were clear isolation and separation areas to manage the care for patients during the COVID-19 pandemic.
- Staff were aware of, and used, the trust’s escalation processes in order to manage flow and reduce the risk 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 to keep themselves and others safe from cross infection.
- Staff knew about any potential ligature anchor points and mitigated the risks to keep patients safe. Inspectors saw evidence of monthly and yearly ligature audits on each ward.
However:
- 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.
- The service did not have enough medical registrars to meet the recommended guidance for the department or be able to develop the service.
- 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 said that during periods of high demand and increased capacity there was sometimes a delay in adjusting and managing the ratio of nurse patient ratio.
- Although people could access the service when they needed it and received the right care, waiting times from patient arrival to treatment and arrangements to admit, treat and discharge people experiencing a mental health crisis, were not in line with national standards.
- Records relating to decisions to administer rapid tranquilisation need to clearly identify the clinician who made the decision, and details of the reason for administering the medication.
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