11 Feb to 11 Mar
During a routine inspection
Our rating of the trust stayed the same. We rated it as requires improvement because:
We rated safe and responsive as requires improvement. Effective, caring and well-led were rated good.
This is an organisation that runs the health and social care services we inspect
Our rating of the trust stayed the same. We rated it as requires improvement because:
We rated safe and responsive as requires improvement. Effective, caring and well-led were rated good.
Our rating of the trust stayed the same. We rated it as requires improvement because:
Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website .
This is the second comprehensive inspection of Lewisham and Greenwich NHS Trust; our first being carried out in 2014. At that inspection, we rated the trust as requires improvement across each of the five key questions; safe, effective, caring, responsive and well-led.
Due to CQC receiving increased number of complaints and concerns being reported by patients, relatives and staff, we undertook a further inspection of the emergency department and medical services at the Queen Elizabeth Hospital in June 2016. We rated both services as requires improvement.
This most recent inspection was carried out to determine whether the hospital had made progress following their 2014 comprehensive inspection and 2016 focused inspection.
Following this most recent inspection, we have again rated the trust as requires improvement across the five key questions and requires improvement overall.
We rated both of the main locations as requires improvement overall.
Community services was rated as outstanding overall; this was attributable to the effective care and leadership of children, young people and family community services provided in the borough of Lewisham.
In light of the concerns which existed with regards to the emergency care pathway at Queen Elizabeth Hospital, a system wide risk summit was convened shortly following the announced inspection period. Stakeholders across the health economy committed to work with the trust to address the concerns including patient flow across the emergency pathway. A subsequent visit to the trust on 19 May 2017 by a small team of inspectors and a specialist advisor for emergency medicine confirmed that a number of changes had been made to the emergency pathway. This included increased monitoring of the quality of care provided within the emergency department; improved access to physical beds as compared to trolley's, so as to reduce the risk of patients developing pressure damage; improving ownership and relations of the challenges faced by those working in the emergency department. The trust acknowledged that significant work was still required across the emergency care pathway however representation of key members of the health system were present on 19 May 2017 and all were committed to working together to improve outcomes for patients.
Our key findings were as follows:
We saw several areas of outstanding practice including:
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
In addition the hospital should:
Chief Inspector of Hospitals
Overall rating for this core service GOOD
We rated safe, effective, caring, responsive and well led as good.This was because
However:
Overall rating for this core service Outstanding
We rated community children and young people’s (CCYP) services outstanding because:
However, we also found:
During the inspection, the team looked at many areas. The detail of their findings is within the main body of the report. However in summary we found that:
Elements of the acute medical pathway (which is based on a different model on each site) are not providing optimal flow of patients through the hospital. This includes difficulties in accessing critical elements of some patient pathways provided externally to the Trust.
On the Queen Elizabeth (Greenwich) site the A&E environment is not considered by the inspecting team to be fit for purpose.
On the Queen Elizabeth (Greenwich) site, following admission via A&E, delays in access to investigation were witnessed, and also delays in accessing specialist internal opinion and by external transfer to specialist units.
Trust-wide issues around waste management were identified. The inspection team identified a number of areas where clinical waste was stored (including bins containing used hypodermic needles) that were not securely locked. We saw this in a number of places at various times. We considered this to be a risk to safety of patients and public.
The approach taken by the executive team to the formation of a single, inclusive organisation is appreciated by staff on both sites. Despite acknowledgement and appreciation of the executive teams approach to the formation of a single, inclusive organisation on the Queen Elizabeth site, staff at the focus groups on that site remained concerned in view of their recent experiences.
The review team felt that the Executive Team should plan to re-evaluate their management capacity to address the issues described at regular intervals to ensure that this remains adequate.
We did however also see areas of good practice. These included
The single governance structure, including increased clinical involvement and the appointment of senior clinicians from the Queen Elizabeth (Greenwich) site to 4 Divisional Director roles, is also appreciated by staff on both sites.
The staff on both sites are committed to high quality care and this is a focus of their work.
During our visit, members of the Patients Association looked at the way the trust handles complaints. Much of their findings are in the appropriate sections of this report; however in summary they found that:
In some wards (particularly medical wards) patients told us that they felt there was a lack of staff as call bells were sometimes not answered for 30 minutes. Patients use call bells to alert staff to an issue or request help. It is not possible to judge the severity or significance of the request until the call bell is answered. Response to call bells should therefore be prompt.
There are shortages of staff in many areas. In some areas, there were insufficient staff to meet the needs of patients. Programmes are in place to fill some of these vacancies; but these staff are not yet in post. In A&E at Queen Elizabeth, there is a staffing review underway, but we noted a heavy reliance on agency staff.
The trust had lost some posts on the QE site when it was part of the previous South London Healthcare trust. Work was underway to address this and nurse specialists were being employed to address the issues identified.
The scope and role of Health Care Assistants (HCA) within the trust was clearly understood. HCA’s were never expected to work beyond the scope of their role and training. This ensures patients are treated by an appropriately trained individual.
We did observe that the e-rostering system can generate an unworkable shift patterns, for example by rostering too many long days in succession. This risks staff health and also compliance with the rotas.
We saw that hand hygiene and personal protective equipment (gloves etc) were available in clinical areas. This means the trust are ensuring staff are able to use infection control procedures. However we saw that compliance with hand hygiene (particularly amongst medical staff) was poor. This causes a risk of cross infection for patients.
We saw that the trust system for managing clinical waste were poor. Many areas with clinical waste were easily accessible by the public, and we observed this on numerous days. This presents an infection control and safety risk to the public.
The acute medical pathway is based on a different model for each of the two main sites. Neither model appears to provide optimal flow. This is restricting egress from A&E.
Despite acknowledgement and appreciation of the Executive's approach to the formation of a single, inclusive organisation on the QE site, staff at all of the focus groups on that site remained concerned in view of their recent experiences.