Archived: Royal Brompton Hospital

Updated 22 February 2019

Royal Brompton Hospital in Chelsea, West London has more than 2,200 staff, five dedicated operating theatres, one hybrid theatre and four catheter laboratories. Royal Brompton Hospital has 312 beds, including for surgery, intensive care, respiratory, cardiology, paediatric, paediatric intensive care patients. 

Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity and took place between 16 and 18 October 2018.

Before the inspection visit, we reviewed information that we held about these services and information requested from the trust.

During the inspection we spoke with 100 patients and their relatives, and 100 members of staff including doctors, nurses, allied health professionals, managers, support staff and administrative staff. We looked at 21 sets of patient records and observed a range of meetings including multidisciplinary meetings, governance meetings, ward rounds and nursing and medical handovers.

Updated 22 February 2019

Our rating of services improved. We rated it as good because:

• The ratings of safe, responsive and well-led have improved, the ratings of effective and caring have stayed the same.
• Our rating for surgery and critical care services improved to good and the rating for children services stayed the same as good overall.
• The hospital had successfully implemented improvements highlighted during last inspection regarding the use of the safer surgery checklist, cleaning processes within theatres, safeguarding children training in recovery, theatre staffing and management and culture issues within theatres.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• The service had suitable premises and equipment and looked after them well.
• Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
• The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time. However, we found that the surgical service did not always follow best practice when storing medicines.
• Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.
• The hospital had enough staff with the right qualifications, skills, experience and training to keep patients safe from avoidable harm and abuse, and to provide them with the care and treatment they needed. Ward managers matched staffing levels to patient need and could increase staffing when care demands rose. All staff understood their responsibilities to safeguard patients from abuse and neglect, and had appropriate training and support.
• The hospital managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.

• Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.

• Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.

• The service made sure staff were competent for their roles. Except in surgery, managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. The unit had since introduced an animal therapy policy to enable dogs to be safely allowed on the unit for patients who wished to have them visit.
• Staff provided emotional support to patients to minimise their distress.
• Staff involved patients and those close to them in decisions about their care and treatment.
• The trust planned and provided services in a way that met the needs of local people.
• People could access the service when they needed it. Waiting times from treatment were and arrangements to admit, treat and discharge patients were in line with good practice.
• The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
• The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. However, staff survey results within surgery showed dissatisfaction in various areas.
• The trust used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.

However,

• We observed a few lapses in strict adherence to infection control procedures within critical care. Although the hospital controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
• Although the service provided mandatory training in key skills to all staff. The trust target was set at a comparatively low 70% or 80% depending on the mandatory training module and the compliance rates for mandatory training for some staff groups were below these trust targets.
• Although staff had training on safeguarding children and adults, the trust target was set at a comparatively low 75% and the compliance rates for mandatory training for some staff groups were below trust targets.
• Managers did not always effectively appraise staff’s work performance.
• There was no ratified strategy for critical care and children and young people services.

Updated 22 February 2019

We rated safe, effective, responsive and well-led as good and caring as outstanding. Our rating of this service stayed the same. We rated it as good because:

• The service made significant efforts to manage expectations around the step down process from PICU to the ward. The service had hired a nurse to lead on this and an advanced nurse practitioner worked to make the process more seamless.
• There was clear evidence of research, innovative and outstanding practice. For example, the Simulated inter Professional Team training (SPRint) had won national awards and the paediatric Extracorporeal Membrane Oxygenation (ECMO) service had positive outcomes.
• Staff spoke very highly of the culture of the service and the staff survey results were consistently high for workplace satisfaction.
• The service went above and beyond for its patients and patient families. Including the creation of social clubs for patients of all ages.
• The service took a consistently holistic approach to the care and wellbeing of parents and provided basic nursing training skills to patient family members.
• The service had good links with local safeguarding agencies and staff very supported by in-house safeguarding team.
• The service had a variety of link nurses and staff felt empowered and encouraged by managers to continue professional development.
• The service used a collaborative multi-disciplinary approach to care planning and even made use of external agencies and stakeholders.
• The service made special efforts to provide a home away from home for both patients and their families. They provided school curriculums for the patients and accommodation and food vouchers for family members as necessary.

However:

• We found two separate occasions of missed doses on the system and found that the prescribing IT systems did not communicate well with one another.
• The service had poor audit results for WHO surgical checklist compliance.
• Staff informed us that they had access to good learning opportunities but rarely had time to attend.
• The paediatric strategy was not dated and had no time scales for when it wanted to achieve key objectives.
• Mandatory training rates were below the trust target.
• Safeguarding training rates were below the trust target.
• Not all staff received an appraisal.

Updated 22 February 2019

Our rating of this service improved. We rated it as good because:

• We rated safe, effective, caring, responsive and well-led as good.
• Following our inspection in 2016, the service had made significant improvements in the leadership and safety of the critical care service. These improvements contributed to the safety of patients.
• The was an experienced leadership team who encouraged a culture of multidisciplinary team work, innovation and striving for excellence in care.
• Effective reporting and governance systems protected patients from harm and ensured a no-blame culture of learning when incidents occurred.
• Patients received effective, evidence-based care and patient outcomes were within the expected range. There was an extensive audit and research programme and an investment in finding new ways to improve patient outcomes.
• Appropriately qualified staff cared for patients. There were excellent training and development opportunities for nursing, medical and allied health professional staff. The percentage of nursing staff with the post registration qualification in critical care exceeded the recommended minimum guidelines.
• There was an embedded culture of supporting patients and their families during and after admission to critical care. The service was committed to engaging with patients and their relatives and tailored care to suit individual needs.

However:

• Enteral feeding products were stored in an unsecure area, this posed a contamination risk and potentially compromised patient safety.
• Although the service provided mandatory training in key skills to all staff and there was high uptake for mandatory training for medical and nursing staff in line with the trust target. There was lower uptake in the staff group which included health care assistants.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. However, we observed a few lapses in strict adherence to infection control procedures.
• Approximately one third of consultant shifts were covered by consultants working additional shifts.
• There was limited provision of hot beverages for visitors to the unit out of hours and the weekend.

Updated 10 January 2017

We rated this service as ‘good’ because:

• There was an open and transparent culture across the trust, where staff felt comfortable to express their views and approach managers with their concerns. Learning from incidents and complaints were shared across the specialist team and the trust, now that data had been coded in such a way to allow this.

• The environment and equipment in both the hospital wards and the mortuary was suitable for purpose. Infection prevention control (IPC) measures were followed by staff from the mortuary, specialist teams and whilst we observed care on the wards.

• Patient care records and risk assessments were appropriate, thorough and complete. They considered different treatment options and showed clear involvement of patient and relatives in treatment decisions. Pain relief, symptom control and nutrition and hydration were well managed and individualised to each patient. Individuals with complex needs were recognised and their care was tailored by the service.

• Capacity and consent issues were well understood by staff and correct procedures were followed in relation to these. Some issues around the completion of do not attempt coronary pulmonary resuscitation (DNACPR) forms had been picked up and were being addressed.

• There were enough specialist nurses on the palliative care team to enable them to see all patients on their caseload. Care was delivered by a range of skilled staff who participated in annual appraisals and had access to further training as and when required.

• A multidisciplinary team approach was evident both across the specialist team and across the hospital. Patients at the end of life were cared for compassionately and holistically, with input from psychology, chaplaincy, physiotherapists and other allied health professionals (AHPs) as necessary. The needs of relatives were also considered and addressed by the wards, specialist team and dedicated bereavement service.

• A recently developed EOLC strategy aimed to ensure that the specialist team were able to support other staff even further in the event of death. A detailed educational strategy was in place and due to be rolled out to ensure staff across the trust felt confident with caring for patients at the end of life. Regular meetings and forums took place that addressed issues in EOLC with various stakeholders. This included a specific EOLC steering group that met quarterly to discuss any issues specific to EOLC.

However:

• Despite the intention to introduce an educational plan, there were some existing issues with staff education and training at the time of the inspection. Ward staff expressed a current need for further training and support around the care of dying patients. Porters were broadly unaware of the procedures to follow in terms of IPC and there were no existing training records for porters at the Royal Brompton site. Despite a recent incident relating to the use of syringe drivers, only 47% of ward nursing staff had been trained in this competency.

• The trust had not introduced a validated assessment tool to document care of patients at the end of life when the Liverpool Care Pathway was discontinued in 2013. This meant a lack of consistency and knowledge across wards regarding care of patients nearing end of life.

• Data collection for issues relating to EOLC was currently an issue, limiting the amount of audit activity that the specialist team could take part in and use to improve patient outcomes.

• The specialist team’s core working hours were 8.30am to 5pm, Monday to Friday. This is contrary to national recommendations, stating that specialist palliative care should be available face-to-face, seven days per week. There was only specialist consultant presence on site at the Royal Brompton hospital one day per week, limiting face-to-face contact with patients.

• There was no lay member with responsibility for EOLC on the trust board.

Updated 10 January 2017

We rated the medical services at the Royal Brompton Hospital to be ‘outstanding’ overall.

• The nature of the diseases the service treats means that patients could be service users for years and even decades. This ongoing relationship was reflected in the ‘family’ feel of the division and was relayed back to us by patients, nurses, ward managers, consultants and members of the senior executive team.

• Feedback from patients and their relatives was consistently positive about the way staff treated them. There was a strong holistic, person-centred approach to providing care to patients.

• Staff were enthusiastic about the work they did. Consultants and senior service managers were ‘proud’ of the innovative care and research taking place at the hospital.

• The collaborative nature of the multidisciplinary workings was robust and the allied health professionals input into the care plan was outstanding.

• Staff were encouraged to raise concerns and report incidents and near misses. Learning from incidents was shared at ward meetings, Schwartz rounds and grand rounds.

• The clinical areas were all cleaned to a high standard by a domestic team who were proud to work at the trust.

• Staff levels were good and were reviewed each day to ensure that there was enough staff and the right skill mix to ensure effective patient care.

• People using the services were treated with dignity and respect and felt involved in their care plans. Patients informed us that they felt respected and cared for and had their choices and preferences listened and responded to in a timely manner.

• Several schemes took place within the trust to assist the social needs of the patient e.g. the Rb&hArts scheme. We observed a harp player on one of the wards, which patients responded to very positively.

• Best practice guidelines in relation to care and treatment were followed and the service was responsive to the needs of its patients.

• The service actively sought and responded to the views of the people using the service.

• Staff reported that their matrons, managers and department heads, supported them. We observed that staff and patients were engaged in the development of the service.

• The ward areas were well maintained and relatively free from clutter however, there were capacity issues. Staff on the wards felt as though there was not enough room for patients and these issues were highlighted on the trust risk register.

Updated 10 January 2017

We rated the service overall as Good because:

• There was a strong culture of reporting and learning from incidents. Incidents were discussed at staff meetings and clinical governance training events. Action was taken to reduce the likelihood of similar incidents occurring in the future.

• The number of (IRMER) incidents reported was higher in 2015 than the previous year. This had been investigated and improved reporting was demonstrated to be the main reason for the increase.

• Equipment in diagnostic imaging was well maintained with rolling programmes of servicing and checks.

• Hand hygiene audits in diagnostic imaging departments showed high levels of compliance

• Medicines were stored safely and patients were able to collect their prescriptions after their appointment from the pharmacy adjacent to the outpatient department.

• Clinical support assistants were trained and supervised by registered nurses to carry out a range of tests in advance of patients seeing their consultant.

• The outpatient and diagnostic imaging departments provided an effective service based on national good practice guidance and evidence based guidelines.

• There were good examples of innovation, such as nurse-led clinics to support patients with long-term conditions that had a positive impact on outcomes for patients.

• Clinical support staff were trained and supervised by registered nurses to provide a range of patients tests so that the results were available for the patients appointmentwith their consultant.

• Staff were competent and supported to provide a good quality service to patients. Staff were skilled in their specialist area and were supported in their roles by ongoing specialist training and development opportunities.

• There were effective multi-disciplinary teams in place within the hospital and links with specialists from other trusts.

• Audits were carried out in CT and other diagnostic imaging services which reviewed practice against guidelines and set goals for improvement

• All the patients we spoke with told us they felt as if they were treated as individuals. Many patients had visited the hospital regularly for several years and told us they knew staff well and always felt supported.

• Services supported patients to self-manage their care where possible helping them to retain their independence and reduce the number of times they had to travel to the hospital.

• Staff considered patient’s personal circumstances when organising care and organised counselling to support patients.

• Patients emotional and psychological needs were assessed as part of the treatment process.

• Patients told us they received instructions with their appointment letters and were given written information as needed.

• Appointments between outpatients and diagnostics were co-ordinated to allow patients to have diagnostic procedures whilst waiting for consultation minimising the time that patients spent in hospital.

• Staff described how patients in vulnerable circumstances were accommodated in the department and their appointment could be escalated if required.

• Long term patients were given an emergency number to contact if they needed to be seen urgently and could be seen on weekends on the ward by medical cover staff.

• Radiology had slots available to urgently accommodate patients travelling long distances avoiding them making multiple journeys.

• The trust met the national standard for referral to treatment rates each month for non-admitted pathways between April 2015 and March 2016 with the exception of October 2015.

• The trust consistently exceeded the target for cancer patients to be seen by a specialist within two weeks of urgent GP referral between quarter 3 of 2013/14 and quarter 2 of 2015/16 aside from quarter 1 of 2014/15 and to receive first definitive treatment within 31 days of diagnosis.

• The percentage of diagnostic waiting times over six weeks was consistently lower than the England average between October 2013 and January 2016 with the exception of July 2015.

• There were clear governance and risk management processes in place.

• Staff in diagnostic imaging felt they contributed to improvements at work.

• The results of the 2015 staff opinion survey by staff group showed radiology scores for staff engagement were higher for radiology staff than many other clinical teams in the trust.

• Staff in outpatients and diagnostic imaging spoke highly of the trust’s leadership who were visible throughout the Royal Brompton departments.

However,

• The trust consistently breached the target for patients to wait less than 62 days from urgent GP referral to starting treatment between quarter 3 of 2013/14 and quarter 2 of 2015/16. The trust was not actively working with referring trusts to improve pathways and referral times

• We were told the service did not record the time patients arrived in clinic, so waiting times were not routinely monitored.

• The Brompton outpatient service risk register highlighted that patients had to wait for longer than 12 months to be seen in the adult congenital heart disease clinics. The service was unable to see patients who had been referred. Patients often became unwell before they could be seen in clinic and there were problems reviewing follow up patients who had received their surgery.

• Figures provided by the trust showed 27% of clinics started late for the period April 2015-March 2016.

Updated 22 February 2019

Our rating of this service improved. We rated it as good because:

• The ratings of safe, responsive and well-led have improved, the ratings of effective and caring have stayed the same.
• The service had successfully implemented improvements highlighted during last inspection regarding the use of the safer surgery checklist, cleaning processes within theatres, safeguarding children training in recovery, theatre staffing and management and culture issues within theatres.
• The service had improved the percentage of cancelled operations where the patient was not treated within 28 days and the average length of stay. However, the average length of stay was higher compared to the England average.
• The service controlled infection risk well. Surgical site infection rates were lower than national benchmark.
• The service provided care and treatment based on national guidance and monitored the effectiveness of care and treatment.
• Staff cared for patients with compassion and took account of patients’ individual needs.
• The service used a systematic approach to continually improving the quality of care by creating an environment in which excellence in clinical care would flourish.

However:

• Compliance rates for mandatory training were below trust targets.
• The service did not always follow best practice when storing medicines.
• Managers did not always effectively appraise staff’s work performance.
• Cancellation rates and referral to treatment times were worse than national average.
• Staff survey results showed dissatisfaction in various areas.