The Care Quality Commission
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Barts Health NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider

All Inspections

11 September to 11 October 2018

During a routine inspection

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

  • All three hospitals we inspected on this occasion were each rated requires improvement overall.
  • Services at Whipps Cross University Hospital had improved. The previous Section 29a Warning Notice (Health and Social Care Act 2008), issued to the surgery service had been addressed. We rated the hospital as good in the effective and caring domains, and requires improvement in the safe, responsive and well-led domains.
  • The Royal London Hospital saw improvements across the services we inspected. We rated the hospital good in the effective and caring domains, and requires improvement in the safe, responsive and well-led domains.
  • We were disappointed to find that concerns in the maternity services at Newham University Hospital persisted and rated the service inadequate overall and issued the trust a Section 29a Warning Notice (Health and Social Care Act 2008) to address our concerns of poor quality care and leadership. We also rated the diagnostic service inadequate for the well-led domain. Overall, we rated the hospital requires improvement in the safe, effective, responsive, and well-led domains. Caring was rated as good.
  • We aggregated the rating for each domain at each location and then subsequently collated the overall aggregation to determine the trust rating across the safe, effective, caring and responsive domains. The effective and caring domains were aggregated as good, whereas the other domains were aggregated as requires improvement.
  • Between 9–11 October we carried out a ‘well-led’ review of the trust. Despite recognition there remained areas for improvement, partly evidenced by the concerns we found in maternity and diagnostics services at Newham University Hospital, we found demonstrable improvements to the leadership, governance and culture of the organisation and determined the trust well-led domain as good overall.
  • A follow up inspection of maternity services at Newham University Hospital on 14 and 15 January 2019 assessed progress in response to the Section 29a Warning Notice we issued to the trust. We found that appropriate steps to address these concerns had been taken and there was evidence of improvement to the safety and governance of the service.

8 - 9 June 2017

During a routine inspection

Barts Health is the largest NHS trust in the country, having been formed by the merger of Barts and the London NHS trust, Newham University Hospital NHS Trust and Whipps Cross University Hospital NHS Trust on 1 April 2012. Barts Health NHS trust serves a population of around 2.6 million in the area of East London.The trust has three acute hospitals: the Royal London Hospital, Whipps Cross University Hospital and Newham University Hospital, as well as two specialist sites: the internationally renowned teaching hospital St Bartholomew’s and Mile End Hospital(an acute rehabilitation site).

The trust has nine other locations registered with CQC, including two stand-alone birthing centres and a number of dental and primary medical service locations.

Across its multiple sites the trust has 1,706 general and acute beds, 220 maternity beds and 177 critical care beds. The trust employees over 16,000 staff with an annual turnover (total income) of £1.3 billion 2016/17. The trust deficit for 2016/17 was forecast £83m with an actual outturn of £70m.  The forecast for the current year (2017/18) is a £46m deficit control total.

Over a twelve month period the trust reported activity figures of 430,000 A&E attendances, 190,000 inpatient admissions. There were 15,700 deliveries and 2,027,000 outpatient attendances.

The CQC undertook a comprehensive inspection of The Royal London Hospital, Whipps Cross Hospital and Newham University Hospital between November 2014 and February 2015 and found serious failures in the quality of care and concerns that the management could not make the necessary improvements without support.

Following this inspection, the trust was placed in Special Measures and significant changes were made to the leadership and governance of the trust, including the appointment of a new chief executive and executive team. A further comprehensive inspection took place in July 2016 reviewing Whipps Cross University Hospital and the Royal London Hospital . In November 2016 we re-inspected Newham University Hospital. During this inspection we inspected five services – two of which (medical care and end of life care) had previously been rated as inadequate.

It was recognised, following these inspections, that progress had been made in a number of areas, however the trust continued to carry significant risk and therefore remained under the special measures regime.

Subsequent to the July 2016 comprehensive inspection and in addition to this bespoke well-led review the inspection team carried out a series of unannounced inspections of the following services:

  • Whipps Cross Hospital in June 2017 – the hospital had previously been rated as inadequate, we re-inspected three core services: surgery, end of life care and outpatient and diagnostic imaging.

  • The Royal London Hospital in July 2017 - one core service: maternity and gynaecology.

We also carried out an announced inspection of St Bartholomew’s Hospital in May 2017, where we inspected the following core services: critical care, medical services, surgery, and outpatient and diagnostics imaging. This hospital site had not been previously inspected under the new CQC methodology.

We carried out an announced well-led review of Barts Health between the dates 8th and 9th June 2017. This inspection was specifically designed to test the requirement for the continued application of Special Measures to the trust.

Prior to inspection we risk assessed services provided by the trust using national and local data and intelligence we received from a number of sources. We re-inspected all core services that had received a rating of inadequate to test whether significant improvements had been made since our previous inspection.

We were particularly encouraged by the improvements that have been made by the trust since our inspections of 2016. Our overall rating for the trust is now requires improvement; however, surgery at Whipps Cross University Hospital remains rated as inadequate.We were encouraged by the improvements seen in a number of areas, these were:

  • Improvements in a number of domains within the core services that we inspected.

  • Improvements in governance framework of the organisation.

  • The embedding of the site based Leadership Operating Model.

Whipps Cross University Hospital

In December 2016 we rated Whipps Cross University Hospital as inadequate. This was following a core service rating of inadequate in surgery and outpatients and diagnostic services.Surgery had previously been rated as inadequate under the domains of safe, responsive and well led. The domains of effective and caring were rated as requires improvement.

Following our unannounced re-inspection of June 2017 we continue to rate the surgery service as inadequate. We rated the domains of safe, responsive and well led as inadequate. We rated the effective domain as requires improvement. We saw improvements under the caring domain which moved from a rating of requires improvement to a rating of good.

Outpatient and diagnostic imaging had previously been rated as inadequate under the domains of responsive and well led. The domains of safe was rated as requires improvement and caring was rated as good.

Following our unannounced re-inspection of June 2017 we gave the service an overall rating of requires improvement. The domains of safe, responsive and well led were rated as requires improvement. The domain of caring was rated as good.

End of life care was previously rated as requires improvement across all domains, with an inadequate rating in the caring domain. Following our unannounced re-inspection of June 2017 we gave the service an overall rating of requires improvement. We rated all domains as requires improvement, with the exception of caring which we rated as good.

The Royal London Hospital

Maternity and gynaecology had previously been rated as inadequate. With a rating of inadequate in the safe and well-led domain, effective was rated as good, the caring and responsive domains were rated as requires improvement.

Following our unannounced re-inspection of June 2017 we gave the service an overall rating of requires improvement: effective was rated good, and a rating of requires improvement in the safe, caring, responsive and well led domains. 

St Bartholomew’s Hospital

We carried out the first inspection of St Bartholomew’s Hospital under the new inspection methodology. We rated the hospital as good. All core services received an overall rating of good; however, we rated the overarching well-led domain as outstanding. This was based on an outstanding rating in the well-led domain in both surgery and critical care.

Newham University Hospital

In January 2015 we rated Newham University Hospital as inadequate. We carried out a further inspection in November 2016 of five core services that were of greatest concern. At this inspection we found improvements in both medical care and surgery, where both core services were rated overall good. We subsequently gave the hospital an overall rating of requires improvement.

However, we found maternity services continued to require improvement and rated safe domain as inadequate. At the time of our well led review we had plans to return and inspect the maternity services in July 2017 to follow up on the trusts response to these concerns. 

Well led review

The rating for well led was ascribed as requires improvement which was improved from the previous inadequate rating afforded in 2015. The senior leadership team were visible, across the large multi-site organisation and described as approachable. Time and resource had been invested into improving the leadership and governance structures, risk management, culture of the organisation, including better staff engagement.It is apparent that the trust is on a journey of improvement and significant progress has been made. However, it is also clear that many implemented changes remain in their infancy and are not fully embedded.There is still significant further work to do to ensure that governance is managed consistently and service improvements are achieved across all sites.

Our key findings were as follows:

Are services safe?

During our previous inspection of Whipps Cross Hospital and the Royal London Hospital last July we highlighted:

  • Surgical site infections (SSI's) were not being effectively monitored or reviewed within surgery at the Whipps Cross University Hospital. During this inspection we found this had not improved.

  • We commented how the radiation safety needed attention. This included ensuring that personal protective equipment (PPE) checks were completed;this is equipment that protects the user against health or safety risks at work, for example lead aprons. We found that little or no action had been taken on this since the time of our last inspection

  • Staff told us it could take a long time to resolve maintenance of equipment and the environment in outpatients at Whipps Cross University Hospital. We were told similar things during this inspection.

  • Theatre recovery at Whipps Cross University Hospital was being used inappropriately to look after critically ill patients overnight. This was still the case during this inspection.

We also found:

  • Investigations into Serious Incidents (SI’s) to be incomplete and did not comply with trust policy.

  • The trust had out of date policies and procedures for infection prevention and control (IPC).

  • The strength of the incident reporting culture differed by site.

  • We observed some staff did not adhere to the infection prevention standards and protocols.

  • We observed a number of infection control issues relating to the operating theatre environment at Whipps Cross University Hospital.

  • We found problems with the instrument decontamination service at Whipps Cross University Hospital, which had recently been outsourced to an external company used by the rest of the trust. We heard multiple examples of where instrument trays had arrived missing instruments or set out incorrectly. We were not assured that the risk presented by this was being managed effectively.

  • Nurses at Whipps Cross University Hospital raised concerns about the transfer of patients between CT and accident and emergency in the event of an emergency. The trust subsequently confirmed that there was no risk assessment for this transfer and we noted that it was not on the risk register.

  • The trust radiology information system (RIS) and picture archiving and communication system (PACS) systems were out of operation from two weeks prior to our unannounced inspection. At the time of inspection the trust were unable to give us any assurances that there was full knowledge of the overall quantity of images and data lost. However, following this inspection the Trust provided assurance to CQC that a restore from back up took place.

However:

  • During our previous inspection it was highlighted that the access to offices within the Margaret Centre was via a ward corridor, which meant that dying and palliative patients were inappropriately observed by staff and other visitors. Upon re-inspection we saw that this had been addressed. However, at the time of our unannounced visit, the Margaret Centre was in the process of being redecorated so it was out of use at the time.

  • At our inspection in July 2016, we found a lack of availability of notes for clinics at Whipps Cross University Hospital. We found this situation to be much improved during this inspection.

  • Previous inspections had reported on low staffing levels for Clinical Nurse Specialists (CNS’s) and consultant posts to support end of life care. Upon re-inspection we found funding had been allocated. These were not in post at the time of our inspection.

  • During our inspection in July 2016, we reported that there were insufficient numbers of staff in the radiology and diagnostic imaging department to manage the volume of work. We found this situation was improved.

  • At St Bartholomew’s Hospital there was a good incident reporting culture and learning from incident investigations was disseminated to staff. Staff were able to tell us about improvements in practice that had occurred as a result.

  • The surgery service at Whipps Cross Hospital had significantly reduced the number of surgical site infections in the last 12 months.

Are services effective?

During our inspection we found:

  • A number of clinical policies and protocols were out of their review date and did not reflect current best practice.

  • Staff understanding of sepsis policies was variable.

  • It was not clear whether surgical site infection (SSI) data was being collected.

  • At St Bartholomew’s Hospital the critical care service did not fully participate in providing data to Intensive Care National Audit and Research Centre (ICNARC), which was an expectation for critical care services.

  • We observed good examples of multidisciplinary (MDT) working in many areas. However, we heard that poor multi-disciplinary working between clinical teams and theatre scheduling staff at the Whipps Cross University Hospital site resulted in last minute theatre cancellations and theatre list problems.

  • There were gaps and inconsistencies in staff knowledge at St Bartholomew’s Hospital with regards to the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards.

However:

  • The trust participated in a range of national audits so that it could benchmark its practice and performance against best practice and other hospitals.

  • We observed DNACPR forms were in place and fully completed.

  • We found that the replacement for the Liverpool Care Pathway (LCP); the compassionate care plan (CCP) was in place throughout Whipps Cross University Hospital.

  • In the 2016 National Emergency Laparotomy Audit (NELA), the Whipps Cross University Hospital’s hospital performed within the top 20% of hospitals nationally, for three out of five measures.

  • Results from the national lung cancer audit indicated St Bartholomew’s Hospital performed better than the national average in every indicator.

  • The heart centre at St Bartholomew’s Hospital demonstrated an average ‘door to balloon time’ of 60 minutes, which was better than the national average of 90 minutes.

Are services caring?

During our inspection we found:

  • Staff demonstrated empathy and compassion towards patients.

  • Trust wide FFT data for April 2017 showed that 91% would recommend the service to friends and family whilst 2% would not.

  • Patients spoke highly of the staff and the care that they received.

  • In the 2016 cancer patient experience survey, 95% of patients said staff often or always took their worries seriously and patients commented that staff were always sympathetic.

  • There was a wide variety of support groups and emotional support available to patients.

However:

  • We found that patient’s privacy and dignity was compromised in the changing cubicles in the dental, inpatient and chest x-ray area of diagnostic imaging at Whipps Cross University Hospital.

  • Some patients at Whipps Cross Hospital told us that they were unsure about when they were due to be discharged.

  • Results from the 2016 cancer patient experience survey indicated there was room for improvement in how patients accessed private discussions with staff and in the sensitivity of staff when communicating.

Are services responsive?

During our previous inspection of Whipps Cross Hospital and the Royal London Hospital last July we highlighted:

  • Surgical services at Whipps Cross University Hospital were not responsive to patient needs.

  • Bed shortages on wards meant recovery areas were regularly used to nurse patients overnight. This continued to be the case during this inspection.

  • A high number of patients were discharged out of hours, this position had deteriorated since our last inspection.

  • There were capacity issues in some clinics at Whipps Cross University Hospital. During this inspection, we were told that these clinics continued to have similar capacity issues and this had not improved.

We also found:

  • SAFER processes were not embedded on the wards and it was unclear how this was being monitored by the service.

  • There was no hospital-wide electronic flagging system to identify patients living with dementia.

  • The hospital environment at Whipps Cross University Hospital was not dementia friendly and did not support patients' independence. Although work had begun to address this; two wards had been refurbished and another three wards were in the process of being refurbished.

  • Translation services were available to communicate with patients where English was not their first language. However, staff reported that they often used the family of the patient to translate when this was not available. This is not considered good practice.

  • The trust suspended monthly mandatory 18-weeks referral to treatment (RTT) reporting from September 2014 onwards.

However:

  • We found a range of specialist clinical services were available at St Bartholomew’s Hospital.

  • The trust’s carers’ policy allowed flexible visiting hours for carers of people living with dementia. Carers were encouraged to be as involved as much as possible in the patient’s care.

  • The trust consistently performed better than the 93% operational standard and England average for people being seen within two weeks of an urgent GP referral for cancer. 

  • The trust’s performance against the treated within 28 days of a last-minute cancellation standard had significantly improved and was now better than the England average.

  • Theatre utilisation rates at Whipps Cross University Hospital had improved since our last inspection.

Are services well led?

  • We found time and resource had been invested into improving the governance structures. The pillars of governance were in place; however this was not fully embedded or mature. For example, we found several clinical policies were out-of-date and based on old clinical guidance and legislation which has since been updated and clinical governance was not consistently managed across the sites.

  • We found that investigations of serious incidents did not comply with trust policy and reviewer training was variable.

  • We found complaints investigations did not comply with trust policy, including timescales for response; use and storage of investigation templates to evidence thoroughness of the investigation; lack of recording, monitoring and oversight of action plans.

  • We found the leadership and oversight of operational issues to be variable, according to site and, at times, false assurance was taken from data. This resulted in the leadership team not being fully sighted on operational issues.

  • We found gaps between the trust perception of recent IT failures and the impact at a local level. We found that contingency plans were variable according to site.

  • There were reports of bullying and harassment in different pockets of the organisation. Staff at Whipps Cross University Hospital told us they lacked confidence in the hospital’s HR department to deal effectively with concerns.

However:

  • We heard and saw evidence of the Listening into Action (LiA) campaign, which had resulted in tangible change across the organisation.

  • We saw evidence that Barts Health have developed a Leadership Development Strategy which was aligned against the organisational values.

  • The organisation had a new leadership operating model and was more embedded than on our last inspection.

  • We saw evidence that the Workforce Race Equality Standard (WRES) was discussed at a senior level and that the CEO was a key champion of this work.

  • Staff from Black, Asian, and minority ethnic (BAME) groups reported that they felt more engaged and included.

  • The BAME staff development programme had won national recognition.

We saw several areas of outstanding practice including:

  • We found the environment for cardiac patients at St Bartholomew’s Hospital was newly refurbished to a high standard. We received positive messages from staff about the positive impact of the recent investment and refurbishment of services.

  • In outpatients at Whipps Cross University Hospital staff spoke positively about a new system in place where notes were delivered the night before morning clinics. This meant staff could check the patient list to identify any missing records and make an urgent request for them.

  • In the 2016 National Emergency Laparotomy Audit (NELA), the Whipps Cross University Hospital’s hospital performed within the top 20% of hospitals nationally, for three out of five measures.

  • Results from the national lung cancer audit indicated St Bartholomew’s Hospital performed better than the national average in every indicator.

  • The heart centre at St Bartholomew’s Hospital demonstrated an average ‘door to balloon time’ of 60 minutes, which was better than the national average of 90 minutes.

  • The trust’s carers’ policy allowed flexible visiting hours for carers of people living with dementia. Carers were encouraged to be as involved as much as possible in the patient’s care.

  • The trust consistently performed better than the national operational waiting time indicators for cancer care.

  • The development programme designed to support Black, Asian, and minority ethnic staff had won national recognition.

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

  • Address the environment within theatres at Whipps Cross University Hospital to ensure this meets the Department of Health’s standards set out within health building note (HBN) guidance HBN 00-09 ‘Infection control in the built environment’.

  • Ensure out-of-date equipment is removed from theatres at Whipps Cross University Hospital and ensure a robust process is in place to address this in a proactive manner.

  • Ensure daily cleaning records within the theatres’ anaesthetic rooms at Whipps Cross University Hospital are fully completed and that a robust audit process in place to provide organisational assurance.

  • Put measures in place to ensure staff are compliant with the hospital’s ‘arms bare below the elbow’ and hand hygiene policies.

  • Ensure robust processes are in place to monitor and review surgical site infections (SSIs) within surgery at the Whipps Cross University Hospital.

  • Ensure there are adequate numbers of staff trained to level 3 children’s safeguarding across the trust.

  • Ensure that the incident management process is applied consistently and that lessons learned from incidents and are embedded across the trust.

  • Take appropriate action to address patients being discharged out of hours (after 8pm).

  • Take appropriate action to ensure that patient records are stored securely in line with information governance standards.

  • Take appropriate action to ensure that personal protective equipment (PPE) checks are completed in line with the recommendations from the June 2016 radiation safety survey.

  • Take appropriate action to address out of date policies and procedures for infection prevention and control (IPC).

  • Take action ensure that clinical policies are within their review date and reflect current best practice.

  • Take appropriate action to address concerns with the instrument decontamination service at Whipps Cross University Hospital.

  • Take appropriate action to ensure that patient’s privacy and dignity is maintained in the changing cubicles in the dental, inpatient and chest x-ray area of diagnostic imaging at Whipps Cross University Hospital.

  • Take appropriate action to address areas where staff do not adhere with best practice for accessing trust translation services, where English is not their first language.

  • Put measures in place to ensure clinical governance is consistently managed across all hospital sites.

In addition the trust should:

  • Take appropriate action to ensure the 18 week waiting time indicator is met.

  • Take appropriate action to address capacity issues in outpatient clinics at Whipps Cross University Hospital.

  • Ensure the SAFER processes are embedded on the wards at Whipps Cross University Hospital.

  • Ensure that there are robust action plans to address nursing vacancy rates and use of agency staff, to maintain levels of safe patient care particular at weekends.

  • Ensure the trust clinical governance structure is effectively embedded across all sites.

  • Ensure that risk registers are reviewed and reflect the current risks of the services, with clearly identified mitigating actions to risks, controls and last review dates.

  • Ensure that the hospital’s standard operating procedure (SOP) for the use of theatre recovery overnight is adhered to.

  • Take appropriate action to address the issues causing theatre delays.

  • Take appropriate action to address concerns raised by staff regarding bullying and harassment and review the effectiveness of mechanisms in place to support staff.

  • Address delays in the maintenance of equipment and the environment in outpatients at Whipps Cross University Hospital.

  • Address the inconsistencies in staff knowledge at St Bartholomew’s Hospital with regards to the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards.

  • Take appropriate action to review the hospital environment and ensure it is dementia friendly and supports patient independence.

  • Ensure that investigations of serious incidents comply with trust policy.

  • Ensure that complaints investigations comply with trust policy, including timescales for response; use and storage of investigation templates to evidence thoroughness of the investigation; lack of recording, monitoring and oversight of action plans.

Professor Ted Baker

Chief Inspector of Hospitals

24 May 2016

During an inspection of Community health inpatient services

Essential elements to keeping the service safe were being routinely collected and regularly monitored. Individual assessments monitored specific areas of patient risk although subsequent action plans had not always been documented. The trust had taken appropriate action over safeguarding concerns that had been raised and had acted on poor practice.

Referrals came from the trust’s local acute hospital and consultants worked across both sites for continuity of care. Therapy teams worked with patients and their families towards more independent living and the service was hoping to improve upon discharge processes and had taken on a discharge coordinator.

We observed staff and patients interacting in a positive way. All of the patients we spoke with were positive about the friendliness of staff and their readiness to offer help and support. We also came across examples where people had not been treated or spoken to with due dignity and respect. Senior staff had recently taken action on this and expressed a desire to raise standards of kindness and compassion.

11-14, 23, 30 November, 20 - 23, 30 January, 4, 6 February 2015

During a routine inspection

Barts Health is the largest NHS trust in the country, formed by the merger of Barts and the London NHS Trust, Newham University Hospital NHS Trust and Whipps Cross University Hospital NHS Trust on 1 April 2012. Barts Health NHS trust serves East London and a population of around 2.5 million. The trust has 1,946 beds, across 8 locations. The trust employs over 15,000 staff and had an annual turnover (total income) of £1.25 billion in 2013/14. The trust deficit for 2013/14 was £38 million and the forecast deficit for 2014/15 was £93 million.

Barts Health offers the full range of local hospital and community health services (Tower Hamlets) with one of the largest maternity services in England and end of life care provided in people's homes. The trust’s hospitals are home to world-renowned specialist centres, including centres for cancer, cardiac and trauma and emergency care and has one of Britain’s biggest children’s hospitals.

The trust has three acute hospitals, namely, Whipps Cross, the Royal London, and Newham University Hospital and has three specialist sites at the London Chest Hospital, St Bartholomew’s Hospital and Mile End Hospital. The trust also has two birthing centres at the Barkantine Birth Centre and the Barking Birth Centre.

We inspected Whipps Cross University Hospital in November 2014 as a direct response to concerns identified by our intelligent monitoring system and through other information shared with us. Following this inspection, and the significant concerns we identified on inspection, we then inspected both the Royal London and Newham University Hospital in January 2015.

Overall, this trust was rated inadequate. We identified significant concerns in safety, effectiveness, responsiveness and with the leadership of the trust. We found that caring at this trust requires improvement.

Our key findings were as follows:

  • The trust lacked strategy and vision, systems and processes were poor and required strengthening, the trust lacked confidence in its own data and could not confirm its position in achieving the majority of national standards.
  • The majority of staff were caring, compassionate and kind.
  • The majority of data that was available was trust wide, and wasn't available at a local level, which meant that individual services could not be held to account and scrutinised appropriately, and risks could not be identified and addressed.
  • The Clinical Academic Group structure which provided leadership across all sites was ineffective.
  • Safety was not a sufficient priority. Staff did not always recognise concerns and incidents. Some staff were discouraged from raising their concerns and there was a culture of blame.
  • When concerns, incidents and patient complaints were raised, or things went wrong, the approach to reviewing, investigating and learning was slow and in some cases absent. There was little evidence of trust wide learning and limited actions to improve patients' safety across the trust.
  • Safeguarding processes and practise were not always adhered to and we could not be confident that children and adults were appropriately safeguarded and that security needs were consistently met.
  • Staffing was a challenge across all three sites inspected and recommended standards were not always complied with. The trust was considerably reliant on temporary staff however process to support high usage of a flexible workforce were not robust.
  • The trust had low compliance with mandatory training. In January 2015 the trust reported that 46% of staff had received the mandatory training booklet. The trust had introduced the booklet as the way in which they would deliver there mandatory training programme.
  • The use of national clinical guidelines was not evident throughout the majority of services within the trust, and we had significant concerns in relation to End of Life care.
  • The application of early warning systems to assist staff in the early recognition of a deteriorating patient was varied, and their use inconsistent across the trust.
  • Patient outcomes were at or better than the national average across most medical and surgical specialties at the Royal London Hospital and were similar to or below the performance of other hospitals at the other sites we inspected.
  • Audits carried out to check compliance with the World Health Organisation surgical safety check list were remarkably low. Less than 1% of patients (who had undergone surgery) were audited and there had been eight Never Events for wrong site surgery in the last 14 months. We had raised concerns about compliance with the check list in November 2013.
  • The trust did not have a maternity dashboard to be able to understand the quality of the service being delivered, despite the trust being responsible for 15,715 (2013-14) births per year.
  • We met a very committed workforce who felt undervalued by trust leadership, but valued by their patients and colleagues. Junior doctors were incredibly positive when talking about the support and learning opportunities at the trust, and the leadership demonstrated by consultants.
  • There was limited evidence to demonstrate that information about the local population’s needs was used to inform the planning and delivery of services. The services provided did not reflect the needs of the population served and did not ensure flexibility, choice and continuity of care.
  • The emergency departments were not all meeting the national 4 hour waiting time target. The trust was persistently failing to meet the national waiting time targets. Some patients were experiencing delays of more than 18 weeks from referral to treatment (RTT). The trust had suspended reporting activity to the Department of Health.
  • Some patients had their surgery cancelled on multiple occasions due to a lack of beds. Patients well enough to leave hospital experienced significant delays in being discharged for a variety of reasons.
  • Complaints were not always managed in a timely or appropriate manner. The central complaints team did not have sufficient oversight and management of individual complaints. The management of complaints was decentralised to promote local accountability, but this had led to inconsistent complaint response times and an inconsistent approach to complaints handling.
  • There was lack of engagement with the workforce with low morale across the trust. The 2013 NHS Staff Survey for the trust as a whole had work related stress at 44%, the joint highest rate in the country for an acute trust. Only 32% recommend it as a place to work, which is third lowest in the country. There had been minimal improvements in the NHS Staff Survey 2014.
  • The trust continued to breach regulations that it was non-compliant with in November 2013 when we last inspected.

We saw several areas of outstanding practice including:

  • A surgeon had become the first in the UK to broadcast online a live surgical procedure using a pair of Google Glass eyewear. The procedure was watched by 13000 surgical students around the world from 115 countries and they also had the opportunity to ask the surgeon questions.
  • Pain relief for children following an operation had been audited to introduce different strengths of local anaesthetic in order to reduce the pain experienced post operation. This had been shared with other NHS organisations through a National Paediatric Conference.
  • The pain team for adults was well regarded by patients and staff at Whipps Cross University Hospital.
  • The Great Expectations maternity programme had led to a reported better experience for women. There had been a reduction in complaints regarding staff behaviour and attitude and an increase in women's satisfaction of the maternity service
  • Senior staff were trialling the Multidisciplinary Action Training in Crises and Human Factors initiative (MATCH). This was a framework within which Never Events and Serious Incidents could be discussed in an environment characterised by mutual respect and in which lessons learnt could be quickly introduced without damaging personal relationships. It was reported that initial results had been very promising. However, staff reported that whilst there had previously been plans to introduce this across the Trust, the financial pressures meant this was on hold.
  • The Royal London Hospital is a pioneer in trauma care. 25% of the patients attending the trauma service as an emergency had penetrative wounds, which is significantly higher than any other UK trauma centre. The survival rate at the hospital was approximately twice the national average and the service had regular national and international visitors wanting to learn from the service. The service had worked with the Armed Forces whilst on combat operations and had taken specific learning from this and applied it to the service.
  • In particular, the trauma service in conjunction with military colleagues had developed the concept of the ‘platinum ten minutes’ based upon techniques used to help save the lives of soldiers in combat situations. Through the use of fluid, plasma, active surgical intervention and rapid assessment at the scene more patients were arriving at hospital alive.
  • The Royal College of Physicians audit of stroke care rated the hospital as 97.5% for patient experience from diagnosis to rehabilitation - the highest result in London.
  • The Gateway Surgical Centre’s design, layout, forward planning, engaged staff and integrated care with members of the multidisciplinary team.

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

Importantly the trust must:

We identified that there are 65 "must do" actions across the three locations inspected, details are in the location reports.

Due to our level of concern across the trust we wrote to the NHS Trust Development Agency (TDA) to suggest they urgently consider special measures for the trust in March. The trust was place in special measures on 16 March 2015.

Professor Sir Mike Richards

Chief Inspector of Hospitals

13/11/2014

During a routine inspection

Barts Health is the largest NHS trust in the country, having been formed by the merger of Barts and the London NHS Trust, Newham University Hospital NHS Trust and Whipps Cross University Hospital NHS Trust on 1 April 2012. Barts Health is a large provider of acute services, serving a population of 2.5 million in North East London.

The trust has has three acute hospitals: the Royal London, Whipps Cross University Hospital and Newham University Hospital, and three specialist sites: The London Chest Hospital, St Bartholomew’s Hospital and Mile End Hospital – acute rehabilitation site. The trust also has two birthing centres: the Barkantine Birthing Centre and the Barking Birthing Centre.

Barts Health offers a full range of local hospital and community health services from one of the biggest maternity services in the country to end of life care in people’s own homes. The trust is also part of UCL partners, Europe’s largest academic health science partnership, whose objective is to translate research and innovation into measurable health gains for patients.

The Royal London hosts one of the country’s busiest trauma centres with state-of-the-art facilities and a dedicated paediatric accident and emergency (A&E) department. It is also the base of the London Air Ambulance service. Both Whipps Cross and Newham also have A&E departments. St Bartholomew’s Hospital has a minor injuries unit.

The trust covers four local authority areas: Tower Hamlets, the City of London, Waltham Forest and Newham. Tower Hamlets is one of the most deprived inner city areas in the country, coming seventh in a list of 326 local authorities. Fifty six per cent of the population of Tower Hamlets come from minority ethnic groups, with 56% coming from the Bangladeshi community. Life expectancy in the borough varies, with those who are most deprived having a life expectancy of 12.3 years lower for men and 4.9 years lower for women than in the least deprived areas.

By comparison, the City of London is more affluent, coming 262nd out of 326 in the Index of Multiple Deprivation. It is less ethnically mixed with 21% of the population coming from minority ethnic groups, the largest group being Asian with 12.7% of the population. Newham is again more deprived coming third out of 326 in the Index of Multiple Deprivation. Eighty per cent of the population of Newham come from minority ethnic backgrounds, with Asian being the largest constituent ethnic group at 43.5% of the population. Life expectancy for both men and women living in Newham is lower than the England average.

Finally Waltham Forest comes 15th out of 326 with a culturally mixed population. Nearly 48% of the population of Waltham Forest come from minority ethnic communities, with Asian constituting the single largest group at 10% of the population. All four of the local authority areas have young populations, with the majority of residents aged between 20 and 39 and the highest concentration aged 20 to 29.

The purpose of this report is to describe our judgement of the leadership of the trust and its ability to deliver safe, effective, caring, responsive and well-led services at each of its locations. Our judgement will refer to key findings at each location. For a more detailed understanding of the hospital findings, please refer to the relevant location report.

Barts Health was included in the first wave of the Care Quality Commission’s (CQC’s) new hospital inspection programme, as it had been shown to be at ‘high risk’ on several indicators in the new ‘intelligent monitoring’ system – which looks at a wide range of data, including patient and staff surveys, hospital performance information, and the views of the public and local partner organisations. Over recent years the trust has faced significant financial challenges and has been a persistent outlier on some key quality of care indicators, including:

  • Poor results on the cancer patient experience survey.
  • Non-achievement of the four-hour accident and emergency waiting time standard.
  • Poor results on the national staff survey.
  • A high number of never events (events so serious they should never happen).
  • Non-compliance with regulations recorded on several CQC inspections since it was registered, especially in maternity services and wards caring for older people.

In August 2013 we took enforcement action following an inspection of Whipps Cross University Hospital. We served Warning Notices in two clinical areas: the care of the elderly wards where we found that staff were not adequately supported, and the maternity services were we found the environment to be unclean and equipment not available.  During this inspection we checked that the trust had met the requirements of the Warning Notices – they had and so we were able to remove the Warning Notices. 

The trust’s board is well-established and is committed to improving quality. Quality initiatives have been developed across the trust, although many have only started within the past few months and it is too early to tell if they will deliver the required improvements. New systems are being embedded and the development of site-specific management is a welcome development. All senior nurses work clinically on Friday mornings, and on the first Friday of the month, all Executive Board members visit hospital wards. However, the visibility of the board is variable, with many staff being unaware of the ‘First Friday’ initiative. Morale across the trust is low, with staff being uncertain of their future with the trust and a perception of a closed culture and bullying. Too many members of staff of all levels and across all sites came to us to express their concerns about being bullied. Many only agreed to speak with us if they could be anonymous. In the 2013 staff survey 32% of staff reported being bullied; the average score for trusts in England was 24%. Staff told us they felt stressed at work and said there were not equal opportunities for career development. This must be addressed urgently if the trust’s vision is to be realised.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.