Archived: Royal Brompton and Harefield NHS Foundation Trust

We carried out a comprehensive inspection of the Royal Brompton and Harefield NHS Foundation Trust, this was the first comprehensive inspection under the new Care Quality Commission (CQC) methodology to inspecting hospitals. We carried out an announced inspection between 14 - 16 June 2016. We also undertook unannounced visits during the following two weeks.

We inspected six core services: Medicine, Surgery, Critical Care, End of life Care and Outpatient and diagnostic services, across both the Royal Brompton and Harefield sites and Children and Young People's Services at the Royal Brompton site only. We have rated the hospital trust as requires improvement overall.

Our key findings were as follows:

Is the trust safe?

• There were robust processes for ensuring that clinical incidents were reported and investigated. Staff were aware and understood of their responsibilities to report incidents and were open with patients when things went wrong. There were a range of forums and learning events for staff to receive feedback and learning from reported incidents.
• Staffing levels were tracked throughout the day and nursing staff would be moved according to need and agency or bank staff used to ensure safe staffing levels.
• The introduction of the electronic prescription system had reduced the number of medication related incidents and promoted the safe prescription and administration of medication.
• End of life care (EOLC) champions and practice educators had been introduced to each ward to help with training of staff and resources were available to general staff in supporting patients who were actively dying.

• There was, however, poor completion of the World Health Organisation (WHO) Safer Surgery checklist across both sites, despite staff discussions about patient safety risks with senior medical staff.

• We found infection control practice on the HDU at the Royal Brompton site to be compromised by the reuse of single-use intravenous saline fluid.
• Antibacterial hand gel, although present on wards was not obvious and we observed family members entering clinical areas without a clear reminder that antibacterial hand gel was necessary.

Is the trust effective?

• There was good evidence of multidisciplinary team working which underpinned the care provided to patients. Of particular note were the medicine teams at the Royal Brompton site, where we found evidence of the holistic needs of each patient as well as the clinical requirements of care being reviewed as part of their care.
• Patients undergoing surgery at the Harefield hospital had some of the best outcomes for cardiac, thoracic and cardiothoracic transplant (heart, lung and heart-lung transplant) in the country.
• The survival rate of patients who were treated with extracorporeal membrane oxygenation (ECMO) was higher than the international average measured by the Extracorporeal Life Support Organization.
• Care was provided in line with national best practice guidelines. The hospital performed very well in the Heart Failure audit.
• Wards had access to a full range of allied health professionals such as speech and language therapists, dietitians, tissue viability team, physiotherapists, clinical psychologists and a wide range of nurse specialists.
• Staff understood the principles of the Mental Capacity Act 2005 and Deprivation of Liberties Safeguards (DoLS).

• However, critical care services had not historically submitted data to the intensive care national audit and research centre. This meant patient outcomes and the quality of care was not readily comparable to national standards. However, staff had started to contribute to this just before our inspection, which would help them to benchmark practices in the near future.
• 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 limited, restricting the amount of audit activity that the specialist team could take part in and use to improve patient outcomes.
• A recent audit of do not attempt cardiopulmonary resuscitation (DNACPR) forms found that only 15% were fully filled out. Another national audit found that DNACPR forms were only in place for 67% of patients, although 89% had been recognised as being in their final phase of life.

Is the trust caring?

• We found patients received compassionate care by staff and were treated with dignity and respect. We observed staff being friendly and polite towards patients and visitors.

• Staff demonstrated a good understanding of the importance of privacy and dignity maintained this for patients and their relatives.
• The CQC national audit inpatient survey scores showed high levels of patient satisfaction for dignity and respect and care from staff. These were better when compared to other hospitals
• The Trust ran a “compassionate care programme” which encouraged staff to make improvements in patients’ care.
• Patients we spoke to felt involved in their care and treatment. Patients and relatives thought that they had sufficient opportunities to speak to a member of staff.
• Emotional support was provided by staff directly involved in the patients’ care.
• The hospital commissioned programmes to further enhance the hospital experience for patients and visitors. For example, the hospital arts programme offered visual and musical presentations to improve wellbeing.
• The chaplaincy team offered comprehensive spiritual support to those at the end of their lives.
• The specialist palliative care team had introduced memory boxes and overnight bags to support patients and their families at the end of life, making their final days and hours memorable and less stressful.

Is the trust responsive?

• Services were planned and staff were hired to ensure that the needs of local people were taken into consideration and patients were provided with as much choice as possible.
• The hospitals transport services provided services to patients across the UK and also picked patients up from Gatwick airport.
• Staff were aware of the patient complaint process and senior staff felt well supported by PALS in dealing with complaints and concerns.
• The trust consistently exceeded the target for cancer patients to be seen by a specialist within two weeks of urgent GP referral and to receive first definitive treatment within 31 days of diagnosis between quarter 3 of 2013/14 and quarter 2 of 2015/16.
• The percentage of diagnostic waiting times over six weeks was consistently lower than the England average between October 2013 and January 2016..
• The ‘did not attend’ (DNA) rate was below the England average from September 2014 to August 2015.

• However, due to the estate at the Royal Brompton site some of the rooms were dark and cramped, and some of the beds in the bays were close together due to limited capacity.
• 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.
• At the time of our inspection, there was no flagging system for patients with learning difficulties or dementia on the electronic records system.

Is the trust well led?

• Senior management and divisional managers were visible on wards and there were patient facing dashboards, which showed ward results at the entrance to each ward.
• We found high levels of cross-specialty collaboration at site level and a good system of sharing information across the sites.
• There was an effective system of clinical governance and risk registers were up to date and proactively managed. Learning from risk issues was disseminated to staff and staff understood their role within the hospital.
• The trust used innovative approaches to gather feedback from people who used services and comments and suggestions were actioned where possible.
• Innovation and improvement was encouraged through a variety of programmes. The leadership drove continuous improvement and staff were accountable for delivering change. Staff and patient innovation was celebrated.

• However, the hospital failed to meet four organisational KPIs in an end of life care national audit published in 2016, including there being no lay member with responsibility for EOLC on the trust board.
• Staff in surgery and theatres reported perceived bullying and harassment..

We saw several areas of outstanding practice including:

• The multidisciplinary workings of the medicine services at the Royal Brompton site offered both a clinical and holistic look at the patient’s needs.
• The Harefield transplant team pioneered the Organ Care System in cardiothoracic transplantation. This is a method for transporting and optimising potential donor hearts. Most other cardiothoracic transplant services have adopted this system. A lung transplant version has also been utilised.
• VAD team members were some of the most highly skilled in the UK. They could care for patients undergoing surgery for the insertion of an artificial heart without the need for the company who make the heart being present. No other service in the UK can provide this without the company being present.
• Patients undergoing surgery at the Harefield hospital had some of the best outcomes for cardiac, thoracic and cardiothoracic transplant (heart, lung and heart-lung transplant) in the country.
• The SPRinT training has won National awards. The training has been taught and has commenced at other hospitals Nationally with International interest. Team members are taking the model overseas later this year.
• Continuous research programmes within Cystic Fybrosis have International acclaim and use.
• Diagnostic and imaging services provided a number of examples of outstanding practice, including the department of imaging’s expertise in a range of inflammatory respiratory diseases including amongst others asthma, allergy, COPD, cystic fibrosis, idiopathic pulmonary fibrosis, and acute lung injury.
• The imaging departments research included exhaled inflammatory biomarkers, skeletal muscle biopsies, imaging, extensive lung physiology techniques, nasal and bronchoscopic sampling,, bronchial challenges, as well as a large range of preclinical techniques including models of asthma and COPD.
• The trust encouraged clinical and service innovation at all levels, through their Compassionate Care Programme, which has led to locally driven solutions.
• The Trust has commenced the development of local 'enthusing’ audits', a traffic light system utilised in theatres, given to the staff at the end of their shift, allowing them to indicate ‘how their shift was’. 

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

Importantly, the trust must:

• The hospital must ensure surgical staff are completing patients observational NEWS charts fully and escalating unwell patients.

Importantly, the trust should;

• Ensure all steps of the WHO five safer steps to surgery checklist are completed.
• Ensure a review of the congenital heart disease outpatient pathway to ensure any patients under follow-up are actively monitored and care packages are in place.
• Ensure Mental Capacity Act 2005 (MCA) and Deprivation of Liberties Safeguards (DoLS) training is included as part of the trust mandatory training programme .
• Ensure compliance with NHS national waiting times indicators such as 18 week Referral To Treatment and the Cancer Waiting Time 62 day standard.
• Ensure clinical process improvement works within outpatients are implemented in order to reduce in-clinic waiting times and delayed outpatient appointment start times.

Professor Sir Mike Richards

Chief Inspector of Hospitals