King's College Hospital NHS Foundation Trusts_College... · 2019. 6. 12. · They were confident 90% of files pertaining to fit and proper persons were up to date, although they were

20171116 900885 Post-inspection Evidence appendix template v3 Page 1

King's College Hospital NHS Foundation

Trust

Evidence appendix King’s College Hospital

Denmark Hill

London

Tel: 02032999000

www.kch.nhs.uk

Date of inspection visit:

30 January to 21 February 2019

Date of publication:

12 June 2019

This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the

quality of service provided by this trust. It is based on a combination of information provided to us by the

trust, nationally available data, what we found when we inspected, and information given to us from

patients, the public and other organisations. For a summary of our inspection findings, see the inspection

report for this trust.

Is this organisation well-led?

Leadership

There had been several changes in the executive leadership since the previous inspection. The

previous chief executive officer role was held by a temporary executive managing director, and

the chairman’s posts had been filled by an interim since spring 2018. A new chief financial officer

was appointed in July 2018, and the director of quality assurance joined the team in October

2018, as was the interim trust’s chair.

Leadership had been strengthened at both main hospital sites. An executive director was

appointed from 11 February 2019, and two deputy directors of operations were to be appointed in

February too, one for planned care and one for emergency care. A chief operating officer on an

interim basis was due to start at King’s College Hospital in February, although the chair said the

interim roles added to the instability.

The interim CEO told us it was essential to get stability, and the interim chair had been ‘fantastic’,

engaging proactively with staff in what had been a difficult period. The interim chair said many of

the staff were deeply shocked at the time of his arrival. At that time, it was essential to engage

with clinicians, managers and the board. The problems needed to be identified before the trust

could consider how these were to be addressed, and to gain stability. Speaking with staff was

described as an essential action taken by the interim chair, as well as consideration of how to

shape the board and executive team. As a result, he had greater confidence through the

appointment of new team members.


It was acknowledged by the interim CEO that operational leadership had been the biggest

challenge, particularly regarding the chief nurse role. In addition to her other responsibilities she

had been asked to take on the role of chief operating officer during the past year, making her

brief far too wide. The chief nurse also held leadership responsibility for mental health within the

trust. There had been a strong focus on this area within the trust, as well as with partner

organisations.

The interim CEO recognised the PRUH and south sites felt isolated. He had tried to put the initial

stages of a new structure in place for this, acknowledging the need for high calibre leaders five

days a week to lead in an executive capacity. A separate temporary interim managing director

had been appointed for the PRUH and south sites, and there was a level of confidence in this

starting to drive changes. There was an expectation that once the emergency pathways were

established, things would improve at the PRUH, although there was work to be done on

clinician’s engagement there.

Regarding leadership working, we were told by the interim chair the triumvirate was not working

effectively. General managers had not been taught managerial techniques, and there was a

history of ‘moaning’. Service managers were said to be ‘burnt out’, and ophthalmology for

example, had three service managers in the past year. A level of disengagement meant the

bigger picture was not always seen or considered, for example, patient flow in some areas.

We were told by the company secretary there had not been any involvement of governors in the

appointment of either the interim CEO or interim chair. Governors were described as ‘disgruntled’

and having strained relationships. We were not able to speak with any governors to explore this

further. In our review of the council of governor’s minutes, we saw there had been considerable

focus on finances in the meeting for October 2018. However, overall the meetings were not very

active, with low attendance at two of the meetings we reviewed. Meetings were generally one

hour, three or four times a year, therefore it was not clear how engaged the governors were.

The trust stated it was satisfied that staff with director level responsibilities, including the non-

executive directors (NEDs), were fit and proper persons in accordance with Regulation 5 and

checks were carried out in line with their Fit and Proper Person (FPP) policy. We noted the board

meetings included a statement to confirm that all executives, the interim chair and non-executive

met the FPPR test. We found some information was missing from files we reviewed and were

told after our visit that appraisal information was held separately.

Overall responsibility for FPPR was held by the chairperson, who delegated this responsibility to

the company secretary. We were told that completion of the checks on appointment and yearly

reviews were the responsibility of the trust company secretary. On speaking to this individual,

they confirmed this was their responsibility. The company secretary explained how they met with

the chair once every year. They were confident 90% of files pertaining to fit and proper persons

were up to date, although they were aware of two files, which they were not as assured about.

The Board had seven committees which regularly met and were chaired by a non-executive

director. There were eight non-executive directors and one vacancy at the time of our inspection.

We were told the current NED team had skills gaps, for example, there was no NED with

strategic workforce development, and no one with good commercial skills or legal experience.

The interim chair said there was a lack of productivity from three of the NED’s, but that clinically

NEDs were ‘excellent’, providing challenge in board meeting accordingly. For example,


Emergency Department performance, which was poor. The interim CEO said they were unclear if

the NEDs had challenged the financial information prior to his appointment, but that they did now.

The financial director had reviewed his establishment as part of the recovery programme, and he

was aware of the contributory factors to the financial deficit.

In our focus group discussion with NEDs, they described having had a period of turmoil, but the

situation was starting to stabilise. They were excited to have a new finance officer and about the

incoming chief executive officer. We were told the leadership was good and there was more

stability across the board. There was recognition the financial situation would only be resolved

from a systematic approach, which the interim chair had been supporting. The financial director

had made it a priority to review his establishment as part of the recovery programme. The board

and executive leaders were aware of the contributory factors to the financial deficit.

Regarding the board functions, the NEDs explained how they had spent too much time on routine

paperwork but were now using their time in more valuable ways, allocating time in board

meetings to address important issues. The NEDs told us how the management structure at

PRUH had improvement and that this was good, as this was helping to give a strong sense of

community there.

Board Members

Of the executive board members at the trust, 0% were Black and Minority Ethnic (BME) and

31.3% were female.

Of the non-executive board members 6% were BME and 18.8% were female.

Staff group BME % Female %

Executive directors 0.0% 31.3%

Non-executive directors 6.0% 18.8%

All board members 6.0% 50.0%

(Source: Routine Provider Information Request (RPIR) – Board Diversity tab)

Leadership reporting lines to the Chief nurse included three directors of nursing for each division.

Urgent Care, Planned Care and Allied Clinical Services (UPACs), Networked care, PRUH and

south sites.

There were three associate directors of nursing at King’s and one vacant post at the PRUH. The

safer nursing care team sat under them. In addition, the Infection prevention and control team

nurses reported to the chief nurse, as she was also the director for infection prevention and control

(DIPC).

We spoke with the medical director about visibility of leaders, which they described as being

difficult. The focus of the medical director (MD) had been on medical colleagues and trying to

increase their engagement. We were told by the MD that the wish to look after patients was truly

engrained in the trust. However, it was a challenge having a trust split between two sites an hour

away from each other.

Leaders were aware of the areas of concern within the trust, such as; four-hour access targets;

referral to treatment times and 52-week waits, as well as estates and a backlog of maintenance,


and the financial measures. Actions to tackle these areas had been identified and included; a

recovery flow programme across the trust with a dedicated senior leader, a dedicated 52 -week

booking team and new 18-week recovery programme, which was to start in March 2019. Estates

matters, and maintenance were less easy to manage given the financial constraints.

Members representing staff side reflected on the leadership. We were told there had been

discussion about transformation and deficit but generally people had not been told how this

affected them, such as staff displacement. Staff said they had not had the opportunity to

collectively meet to negotiate. Further, points which needed to be discussed in meetings did not

get covered as representatives did not attend.

Vision and strategy

The trust’s vision was clearly stated in the strategy and 2016/17 objectives; ‘To give our patients

the best care globally, through innovation and continuous improvement.’ We asked the interim

CEO if there was sense of shared vision and values across all areas. The response was that

values should be lived across sites, and the leadership needed to create an environment to make

the values real. They added, it was difficult for staff to understand how the trust had got into its

current financial position. The vision at the time of our visit was being refreshed and this would

need the new CEO ownership as well as good staff engagement to bring to fruition.

At the time of the inspection the refreshed 2016 strategy was in use. The four strategic aims were;

best quality care, excellent teaching and research, skilled, motivated ‘can do’ teams, and top

productivity. Information about the strategy refresh had been communicated to staff through the

trust’s newsletter ‘PULSE’. The trust had additional strategic plans for these key areas. For

example, we saw the patient outcomes strategic plan for 2018-2020. The plan identified short and

medium terms actions, along with risks which could prevent the aims from being met, and who the

trust needed to work with.

It had been recognised more recently that the current strategy was complex with many objectives

and was said to be overly ambitious. There was recognition of the need for a more simplified

strategy, which should reflect what directorates wanted to achieve but reflected what the trust

already did well. We were told that this would help to strengthen commitment across the trust.

Non-executive directors told us the strategy was very important, and they wanted it to bottom up,

with more clinical involvement. They wanted a cultural change, with a strategy that was outward

looking and embraced academic elements.

The interim chair told us they had been disappointed in the current strategy, which had good long-

term aspects related to areas such as haematology, liver, neurological services and major trauma.

However, other areas had not been focused early enough on, such as cardiovascular,

ophthalmology and dental.

We were made aware of the emergence of a new strategy, which under the direction of the

director of strategy was being developed. This was based around four outcome areas: an

empowered and engaged workforce; excellent local care with global reach, cutting edge research,

and able to invest in our future. We saw a copy of the strategy and heard information in our

discussions with senior leaders about its progress. Accepting the strategy was not yet complete,

we observed and fed back the lack of inclusion of mental health, which had only been referenced

in the five-year outcomes in respect to work in system partnerships. However, we were informed

the clinical strategy would include the current priorities of the mental health board, the system

priorities of the local care partnerships, including One Bromley and the King’s Health Partners

(KHP) Mind and Body programme, which was being embedding throughout the organisation.


Discussion with staff side representatives suggested there had been a lack of staff engagement in

the process of the strategy development. However, we saw clear information demonstrating wide

stakeholder engagement, including opportunities for staff to contribute across sites. We saw too,

further opportunities taking place during the remaining month and March, when the strategy was to

be cascaded to test the language amongst other factors.

The board had been involved in discussions about the strategy within its meetings. However, the

director of strategy said there had not been any meetings solely held for strategic discussions. The

incoming chief executive officer would provide further opportunity for its progression to be

determined.

The director of strategy responded to our questions around support and scope to carry out their

role. They told us support had been ‘patchy’ due to the changes in leadership. However, they had

found the board very keen on supporting the development of the strategy and had provided

necessary challenges.

We asked what the measures of success would be for the new strategy. The director of strategy

told us it was important to have a strategy that was ‘feasible and real’, with a mixture of qualitative

and quantitative analysis.

We spoke with the chief nurse about the vision and strategy. They explained that it was key to

have local services on both main sites and networked services which covered south England. The

demographics of areas in which the trust sat were different, and therefore needed a different

approach. The strategy for Bromley was focused on integrated care for example. The new strategy

was building on the long-term plan and feeding up from the bottom, although it was acknowledged

there was still work to do.

The chief nurse did not expect all staff to know about the strategy at this stage. They added the

staff ought to be able to identify four key strands, and that people were the trusts most important

asset. The strategy had been discussed at all the boards.

We asked the medical director about the development of the clinical strategy and consultant

involvement in this. The response was that it was too embryonic to say that every consultant had

been engaged.

Divisional directors told us it was challenging to get staff at all levels to understand the divisional

trust strategies. They said information had been communicated and there was a plan which linked

different pieces of work to the various staff groups. It was reported that communications around

the strategy were developed locally, as not all issues need to be communicated to all areas. It was

dependent on if it was relative to the clinical area or if relevant to all.

In our discussion with the chief pharmacist they were asked how they monitored progress against

delivery of the pharmacy strategy and how it was reviewed. The response was there was a site-

specific business plan, and a pharmacy specific plan, to address such aspects of; medicines

tracking for out of stock medicines, with associated KPI indicators. These were reported to the

board.

Culture

Non-executive directors who spoke with us said there had been big improvements in the culture,

although the PRUH remained an issue. They told us there was a need to focus on vacancy rates

and the staff appraisals were important. The staff survey was described as a useful means of


understanding some of the problems, as was information from the speak up guardian. They said

the ‘people committee’ were working closely with human resources, and staff were key to quality

improvement.

In our discussion about the culture within the trust the chief nurse said; ‘there isn’t one culture

here. It’s variable, and it’s a friendly welcoming place, with a warmth, which over rides everything,

but there are pockets of real concern,’ including bullying and harassment. They added that, ‘there

was something about how they prepared people to lead.’ The other area of concern was related

to power imbalances between medicine and nursing or medicine and medicine.

Other leaders we spoke with expressed personal worries about the leadership changes and how

this impacted upon the culture. There was recognition of work to be done around the people

component, including health and wellbeing, although work was progressing with the latter.

The trust had made consideration of staff health and well-being. They launched a zero tolerance

campaign called ‘Not a Target’, indicating that bullying and harassment would not be tolerated

towards staff. We were told the bullying and harassment hotline had been re-launched, and

there was ‘listening into action’ events in areas where high levels of reporting had been received

from. The trust had 400 mind and body champions, with quarterly events to improve mind and

body health.

The freedom to speak up guardian (FTSUG) role holder was also a director of nursing for one of

the divisions. They had one day per week formally designated for the role, but their substantive

role allowed reflexibility to undertake the role, usually spending four-six hours per week on

freedom to speak up. They had been in the role for two years and felt at times that the senior

level of her post could be an advantage as she knew who to contact and had easy access to

senior staff. At other times they were aware it could be a disadvantage being a woman, and in a

senior position, but were sensitive to this and potential conflict.

Following a board paper presented by the FTSUG the trust recognised the need for a second

FTSUG at the PRUH. This post was filled following expression of interests being submitted.

There were 19 ambassadors who supported the guardians, and their role was to signpost staff to

the correct person. The ambassadors came from all staff groups and had a range of experience

from student nurse to administrative staff. On review the ambassadors had brought 11 issues to

the FTSUG. To raise the ambassador’s profiles their photographs and contact details were on the

screen saver and on new leaflets, that had just been printed.

The ambassadors met with the FTSUG every eight weeks to go through the sub-group meeting

minutes (reports to board directly), which was chaired by a NED and had representatives from

other directors. The group had a standard agenda plus other items such as case reviews from

other trusts. Recommendations were reviewed to identify any learning for the trust.

A review of the six-eight concerns raised monthly with the FTSUG indicated they had stayed the

same, with bullying a high concern, behavioural relations and patient safety as themes.

There was a designated guardian for safe working (GFSWO) hours who covered the whole trust.

They attended the corporate induction, and trainee doctors were sent a newsletter from them

telling them who he was. New trainees were seen six-eight weeks after they start their rotation.

Challenges were the number of senior specialities, so to address this, they went to speciality

groups. The reporting lines were to the subgroup of the board. A quarterly report was made


available for the junior doctor’s forum, and from April 2019 a quarterly report to the board was

expected to be in place. Currently the board had a report six-monthly.

Twice a year the GFSWO sent out guidance to consultants regarding their role. Consultant were

expected to model the rotas to make sure they were compliant. However, the rota compliance on

the system did not always comply to reality. Reporting was by exception, mainly in relation to

working hours because of rota gaps and education opportunities being missed, the latter being

infrequent. The trusts profile was said to be like other large teaching hospitals, at an average of

70 reports per month. Larger proportion of reports came from the PRUH due to doctor vacancies.

Most reports were about service pressures, which could trigger a work service review or a

meeting with the speciality.

The GFSWO had links with three levels of networks, which they said was helpful, as there was

no overarching co-ordination nationally.

Junior doctor’s forums were held every quarter, chaired by the GFSWO. This was regularly

attended by non-doctor’s but not so well by doctor’s themselves. The day prior to our discussion

there had been no junior doctors in attendance at the forum, but six had attended the one prior to

that. The non-junior Drs who attended were consultants, service managers, rota co-ordinators.

Education department representatives, and education fellows.

There were arrangements for managing breaches in junior doctors working hours. If

compensation was agreed the doctor may get time off in lieu, (TOIL) or additional payment. But

TOIL was much more difficult to take at the PRUH because of rota gaps, although the trust was

working to reduce the vacancy rates there.

We saw the junior doctors welcome pack and induction information. We reviewed information

around the contract for Dr’s training, safe working and exception reporting minutes. The board

report for September 2018 included exception reports. An analysis of exception reporting for the

period January to December 2018 showed 94% were closed.

The executive team were aware of historical cultural issues at the PRUH, which we were told

made it difficult to progress and embed good practices. This was very evident in the PRUH

emergency department, where cultural issues were driving negative behaviours. Much of this we

were told, was around clinicians not seeing the value of being part of ‘King’s. We were told an

external agency was working with the trust to try and address this and to ensure the right

processes were in place, with a focus on an Emergency Department recovery plan for both sites.

There was strong recognition of the need to define the right models, make tough decisions and to

hold people to account.

We were told by staff there was no capacity to complete training due to pressure of work. Some

departments including the emergency department on both sites, had not received appraisals in

the last year or 1:1s on a regular basis.

A range of management/leadership programmes were available for pharmacists: Band 6

diplomas programme; band 7 leadership programme, in house development programme, and

CPPE a leadership programme. Band 8bs had specialist groups with managing services within

context of trust. Band 8c x 4 consultant pharmacist posts. For pharmacy technicians there was a

competency development and apprenticeship programme in place.


Pharmacy services had good exposure to various senior posts and feedback from other senior

leaders within the trust.

Our core service inspection findings suggested staff were aware of the importance of reporting

adverse events or near misses, and staff were confident to do so. They received feedback and

learning from the investigations. Staff were also aware of the trust’s responsibilities under the

duty of candour regulation. We saw information which indicated training in this subject was

provided by several means, including the corporate induction as part of the patient safety

presentation. In 2018, the patient safety team were granted a charitable bid by King’s Charity to

make a duty of candour video. The video, ‘Trust in Transparency’ was now being shown at

corporate induction. We saw too that information on duty of candour compliance was reported

through the patient safety committee and the Clinical Quality and Risk Group.

We had the opportunity to attend Serious Incident Committee meetings in the months leading up

to inspection. These were well attended and were chaired by the director of quality when the

medical director was absent. A representative from the clinical commissioning group (CCG) was

present. Staff attended to present their review and findings from serious incidents, or to give a

three month follow up on their action plans. Of note, staff very often did not recognise harm to

patients. Three reports were challenged because they had rated no harm to patient when the

committee felt there had been.

Staff across services we inspected understood the complaints process, and there was access to

guidance with this regard. There were complaints teams on both main sites, the trust having

increased the resource to one whole-time equivalent (WTE) at PRUH and south sites.

Responsibilities had been clearly defined for managing the process. Regular meetings with risk

managers were held to identify at an early stage, any adverse incidents arising out of complaints.

Staff Diversity

The trust provided the following breakdowns of medical and dental, nursing and midwifery staff

and allied health professionals by Ethnic group.

Ethnic group Nursing and

midwifery staff Medical staff

Allied health

professionals

White –

British/Irish/Any other

white background 17.0% 8.6% 4.0%

BME - British 13.7% 5.7% 0.8%

BME - Non-British 3.7% 1.9% 0.3%

Not stated 1.4% 1.4% 0.1%

N.B the figures are percentages of total staffing number

(Source: Routine Provider Information Request (RPIR) – Diversity tab)

During 2018 the trust had launched its diversity and inclusion strategy. They had also appointed


a diversity lead and prioritised action on race and disability equality. The strategy set out the

trust’s objectives up to 2020. The content described how the trust planned to fulfil its duty under

the Public-Sector Equality Duty, Workforce Race Equality Scheme, and the Equality Delivery

System. The trust had been using the NHS Equality Delivery System (EDS2) to help them

comply with the requirements of the Equality Act 2010. They indicated within the strategy that

they would be assessing performance by using community and staff panels of experts,

community leaders and voluntary sector and staff representatives to provide an objective review.

Information on equality and diversity had been shared with staff through the ‘PULSE’ newsletter,

a copy of which we saw.

At the last inspection we were told about the work streams which had been set up after the 2017

staff survey results. Diversity and inclusion was one of the six work streams set up to drive

improvements in the staff survey results. Each work-stream was required to meet every month

and was chaired by the chief nurse and executive director of midwifery. We saw the terms of

reference for this group and its overall purpose clearly stated. Short and longer-term goals had

been set within the reference terms.

During 2018 the focus was on other protected groups, including, staff with disabilities, and

supporting leaders and managers to mainstream diversity into how staff work and think. There

was a commitment to launch a disability staff network during 2019.

The trust already had two established networks; The first being, Black, Asian and Minority Ethnic

(BAME) Network, which was chaired by one of the NEDs. The launch of this was attended by

more than 160 staff. The second network was the Lesbian, Gay and Bisexual Transgender

(LBGT) Forum. We saw information which showed Black History month was celebrated within the

trust.

Diversity and inclusion awareness training was provided for all new starters as part of Induction.

The trust was working on ensuring unconscious bias training was included in equality diversity and

inclusion training.

Within pharmacy the appraisal rate had seen improvement because of improved engagement with

the pharmacy workforce. The appraisal rate had increased to 81% current rate vs 75% last year.

Pharmacy held regular team meetings within each site and clinical services directorates. There

were quarterly meetings with the chief pharmacist, monthly meetings with deputies, and weekly

staff meetings. Notice boards, medicines newsletters and ‘direct learning’ pharmacists’ meetings

(without any agendas). This also allowed the chief pharmacist to do appraisals with others.

Staff spoken to during focus groups were mostly aware of the freedom to speak up guardian and

their role, but, the majority did not feel that complaints or concerns raised would be treated

confidentially.

We were told that replacing staff leavers had become a “bureaucratic nightmare”, with managers

having to justify the role and get approval from two committees before recruitment could

commence. The external agency who provided the payroll and employee checks, was discussed

at many of the focus groups held. Staff expressed problems with delays in getting the recruited

person’s references and losing paperwork on multiple occasions.


NHS Staff Survey 2018 results – Summary scores

The following illustration shows how this provider compares with other similar providers on ten key

themes from the survey. Possible scores range from one to ten – a higher score indicates a better

result.

(Source: NHS Staff Survey 2018)

Workforce race equality standard

The scores presented below are questions relating to bullying and harassment from the NHS

staff survey, they are question 17b and key findings 25, 26 and 21, split between white, black and

minority ethnic (BME) staff, as required for the Workforce Race Equality Standard.

Notes:

• These scores were un-weighted, or not adjusted.

• For question 17b, the percentage featured is that of ‘Yes’ responses to the question.

• Key finding and question numbers have changed since 2014.

• To preserve the anonymity of individual staff, a score is replaced with a dash if the staff group

in question contributed fewer than 11 responses to that score.


Of the four questions above, the following questions showed a statistically significant difference in

score between White and BME staff:

• KF26. Percentage of staff experiencing harassment, bullying or abuse from staff the last 12

months

• KF21. Percentage of staff believing that the trust provides equal opportunities for career

progression or promotion

• Q17b. In the last 12 months have you personally experienced discrimination at work from a

manager / team leader or other colleagues?

(Source: NHS Staff Survey 2017)

We spoke with the director for equality and diversity and BAME. They described the changes

since the last inspection. There had been lots of work around race equality, and they were

working on disability equality, which was to be launched later this year. The trust had looked at

marginalised and under-represented staff. A staff network with 15 members, including Board and

executive sponsors had been set up in April 2018. The group met monthly. A survey had been

run, which told them the access to work scheme, run by the Department of Work and Pensions

(DWP) was tricky to navigate, and access to occupational health (OH) was very slow in support

for managers.

An event had been held to addressed feedback from staff, which included four separate external

organisation presentations, who spoke about access to work. There had been discussion of

reasonable adjustments and how they could not just remove the adjustments without discussion

with OH.

We were told by the director for equality and diversity and BAME about recruitment and

progression opportunities. They said this was another big area of concern linked to the workforce

race equality standard (WRES) and was raised repeatedly as a staff concern. They did a

retrospective audit and looked at 20 appointments, which showed they were fair open and

transparent. However, this was not shared widely with staff.

The director for equality and diversity and BAME said sharing stories would help to change the

culture. Reverse mentoring, which was launched last year had seen 38 staff engage with this


process. This was targeted with BAME staff, and this year was to be opened to other staff.

We asked if any qualitative or quantitative data had been collecting since the reverse mentoring

started. The response was the mentors had fed-back ‘lots of positives’, but not much feedback

had been received from the mentees.

In response to our question; What still needs to be addressed that you need support with? We

were told it was very difficult to do the work without a budget, which they had communicated. An

investment case was going in to do some more work around their agenda. This included; funding

for the networks, inclusive leadership training, recognising change of culture needs to be role

modelled by the leaders, and an academic study about awards around gender pay gaps. The

case had been put forward and was going to the investment board on the 18 March.

We held several staff drop in sessions prior to inspection. The most noted feedback was low staff

morale. There was increased reporting of bullying and harassment from line managers that staff

did not feel was being tackled. During a focus group discussion, we heard examples of managers

employing family and friends, and of relatives being promoted over and above other more skilled

and experienced staff. Staff felt they could not speak out ‘without fear of character assassination’.

These comments were echoed by some of the staff side representatives we met with. There were

several reported issues related to what staff perceived as a lack of action on the part of

managers and HR, some relating to bullying and others where grievances had been raised but

had not been addressed in a timely manner.

We reviewed the trust’s relationship policy, the purpose of which was to provide guidance to all

employees regarding personal relationships within the context of avoiding any actual or potential

conflicts of interest or misuse of authority. Information which suggested an unfair advantage or

disadvantage to either of the parties to the relationship would be considered seriously by the trust

and may have included investigation in accordance with the trust’s disciplinary policy and

procedures.

The FTSUG felt confident concerns were investigated, for example six staff came forward with an

issue, and with their permission this was escalated. A listening event was held, and the

information used to inform the removal of a manager who had previously had interventions but

had not improved. This demonstrated staff were listened to and action taken to address issues.

There was an awareness of staff having raised issues to senior manager, but no action had been

taken or reason why no action fed back to staff. Some have re-raised these issues with the

FTSUG who said they had escalated these and fed-back to staff on actions taken or why no

action had been taken.

There was a level of general dissatisfaction amongst clerical and administrative staff who spoke

with us in a focus group. Issues were around work load, lack of staff, poor IT, lack of space, and

behaviours of managers. This included basics, such as the way staff were spoken to, which at

times was not considered to be respectful. There were some positive comments around training

and support from some managers. However, appraisals for some remained an issue. We were

given an example of one employee who had only had two appraisals in ten years, and no one-

one reviews.

We reviewed the WRES action plan for 2018. Actions were identified with target dates and

responsible individuals. Some actions were complete, and others were seen to be in progress.


Friends and Family test

The Friends and Family Test was launched in April 2013. It asks people who use services

whether they would recommend the services they have used, giving the opportunity to feedback

on their experiences of care and treatment.

The trust scored about the same as the England average for recommending the trust as a place

to receive care from December 2017 to November 2018. There were two months where no data

was submitted, April and May 2018.

(Source: Friends and Family Test)


Sickness absence rates

The trust’s sickness absence levels from October 2017 to September 2018 were lower than the

England average.

(Source: NHS Digital)

General Medical Council – National Training Scheme Survey

In the 2018 General Medical Council Survey the trust performed as expected for the remaining

each of the indicators.

Survey area RAG

Overall satisfaction Clinical Supervision Clinical Supervision out of hours Handover Induction Adequate Experience Supportive environment Work Load Educational Supervision Feedback Local Teaching


Regional Teaching Study Leave

(Source: General Medical Council National Training Scheme Survey)

Feedback from medical staff in training was the training was generally good, and there were huge

opportunities for progression. They felt well supported overall. The staff were friendly and

approachable, although there had been some understaffing on the rotas which was causing

challenges. There was no space to sit and write letters or reflect, and although clinical audit was

encouraged, not all attendees had been able to be involved due to workload. The general feeling

regarding the IT was that it was very poor. The systems were described as slow, at times it was

difficult to get patients past medical notes.

A representative for the junior Dr’s spoke with us about the experiences of working at the trust.

They were now in a registrar post working in medical education. Staffing was said to be an issue

which was frequently discussed in junior Dr forums. They told us the baseline level of staffing was

the best in south London; however, the PRUH was not as well staff with medics.

Where forums could not be attended there were opportunities to communicate via emails, and the

director of medical education was ‘very good’, ‘extremely open’. Medical education was said to be

protected. They were very aware of the work of the guardian for safe working hours. We were told

Drs rarely worked over expected hours, but the on-call rota was ‘not good’. This was covered by

locums and bank.

We were told there were good opportunities for junior Drs, with shadowing and good supervision,

with a ‘very good induction’. There was good access to consultant, and handover between shifts

was ‘pretty good’. The escalation process when a patient deteriorated was described as working

very well.

Governance

We were provided with information which described the trust-wide corporate governance

structures and operation meetings. This was not dated and indicated it was draft. We were

unsure if it was new or reflected what had been in practice since the last inspection.

The trust set out the three levels to its governance structure in the document; level one included

the main board, reporting to the governors. Sub-committees of the board, chaired by non-

executive directors, the executive body, and sub-committees of King’s executives. This level

included such committees as: education and workforce development; finance and performance,

freedom to speak up guardian, quality assurance and research committee, and the audit

committee.

Level two governance structure included the trust planning and delivery board; the clinical

transformation steering board, quality executive board and efficiency board. Beneath these sat

various groups, committees and boards representing such as areas as mental health, cancer,

children, trauma, outpatients, patient safety, research and development, amongst others.

Clinical trust wide governance structure was reflected at level three. Sub-committees for patient

safety, patient outcomes, patient experience and organisational safety. Reporting into each of

these were various committees, including but not limited to; serious incident, medication safety,

transfusion, radiation exposure, mortality monitoring, end of life, and older persons.


The Finance and Performance Committee was chaired by a non-executive director. This

committee monitored the financial and operational performance of the organisation, including any

risks. They sought assurance where information suggested performance was trending downward.

Activities included a review of the monthly performance submissions to

NHS Improvement and monthly monitoring against the Single Oversight Framework. (This is how

NHS Improvement oversee NHS trusts and NHS foundation trusts in determining the type and

level of support needed to meet their requirements). The committee also had oversight of its

financial areas and the capital investment programme.

We saw information which showed audits by clinical division groups were carried out to check for

consistency. This included: Having terms of reference for committees, attendance at meetings,

the frequency of these, inclusion of agenda items and quality. Findings for development and

recommendations arose from the audits. For example, the need for action trackers and recording

all those in attendance.

The executive meeting attendance was described in the governance structure. We noted monthly

the attendance hours ranged from 35 up to 45 for the medical director and chief nurse/executive

director for midwifery.

The non-executive chair of the Quality/Audit and Risk Committee chaired the quality, research

and governance committee, (QARC). All the audit and quality assurance committee across the

trust reported into this committee and then to the board. We were told QARC did a deep dive at

each meeting and they would ensure the directorates attend to present. Clinical director and the

manager of the service present. Decisions about what is presented goes through the divisions.

Where there are worries, such as emergency department it is brought forward for review.

The director for quality governance had been in the post for three-months. In the short time they

had been with the trust they reflected a positive feeling that the governance agenda has been

represented at the layers below the executives. They said by way of example, the patient safety

committee had a good agenda, and the safeguarding committee pulled things through. What he

had experienced so far was that the agenda around governance was not a tick box. They added,

the divisions and care groups were doing well with some areas needing support.

The director for equality and diversity told us, all the different networks had chairs. BAME was the

largest and was chaired by a NED. The group fed into the working committee which fed into the

board. The director for equality and diversity was invited to the board once per year. In addition,

the quarterly board meetings informed equality and diversity, and the workforce committee was a

subcommittee of the board, which they attended quarterly.

In our discussion with the non-executive director chair for the quality/governance committee, we

were told meetings were held nine times per year. Membership included the interim trust chair,

interim CEO, medical director, two NEDs, and the chief nurse. There was no representation from

the three divisions, unless by invite. It was not clear what information came to the committee as

standard items. Therefore, there was a lack of clarity around the purpose and focus of meetings,

and priorities for quality. We were told if there were concerns the NED chair of this committee

would meet the trust’s interim chair for a working lunch to discuss. For example, Emergency

Department performance.

We attended a few of the trust’s governance meetings in the months leading up to the inspection.


This included attending the Executive Quality Board meeting on two occasions. These meetings

were lengthy and noted to be very well attended. Chaired by the chief nurse, the meetings

included a review of action logs and progress on the actions. There were formal presentations

and discussion on some key areas. This included: monitoring and reporting on complications of

surgery; patient outcomes report, imaging performance, and inpatient diabetes audit. We heard

and saw presentation by a range of staff groups from divisions on various areas of work, e.g.

palliative care, clinical handover, older people in ED and PRUH endoscopy. Divisional and care

group audit findings, risk and governance were discussed. Staff had the opportunity to ask

questions and offer challenge.

We attended five trust board meetings in the year preceding the inspection. The public part of

these meetings lasted for up to three hours. The meeting always commenced with a patient story,

which provided feedback for board members regarding patient experience. The board meetings

were held on both the King’s College Hospital and PRUH sites. We found that the board papers

were very detailed and data heavy. It was at times hard to pick out relevant data from the volume

of information provided. The board conducted a second part of the meeting which was not done

in public.

We reviewed three divisional quality committee minutes for each division. We found a great deal

of work was evident in terms of standardising care group reporting into the established

governance structures. However, as we found at our last inspection, the minutes continued to

show a mismatch in approach to reporting across the three clinical divisions. In addition,

attendance at these committee meetings did not always reflect membership or attendance from

the triumvirate of: divisional director of nursing, director of operations and divisional clinical

director. We found risks and safety were not consistent across the three divisions. Alignment with

the new operational structure had not been applied with consistency; three different templates

were in use during the same meeting timeframe. It was not always easy to identify what the

objective or meeting discussion related to in relation to reporting, providing assurance or

escalation. Further work would need to be done to align risk and governance reporting to ensure

enough scrutiny.

Medicines optimisation integrated into the trust’s governance structure, with reporting into a

variety of different teams. Combined audit results were given to all divisions and managed

ultimately through executive quality board. Each directorate pharmacist input into their own

governance meeting. The chief pharmacist was a member of the Clinical Directors meetings and

said they could raise issues of prescribing practice (e.g. unlicensed medicines, CDs). They felt

the MD always responded, and they were happy with communications. Pharmacy also reported

into all the other usual committees, such as; the Drugs and Therapeutic Committee, Drug Safety,

and Medical Gases.

The Education & Workforce Development Committee (EWDC) was the trust board sub-

committee with overall responsibility for workforce and assuring diversity and inclusion plans in

the trust. The EWDC was chaired by a NED and was attended by the chief nurse and executive

director of midwifery, who took the lead for diversity and inclusion. Meetings were also attended

by the executive director of workforce, the executive medical director, key workforce leads and a

nominated staff governor.

Safeguarding leads had revised the committee structure as they recognised the need to integrate

safeguarding services. The new committee structure started in February 2019 and included both


adult and children representation. Meeting were expected to be quarterly for two and a half

hours, which was a reduction of 50% in committee hours from the previous arrangements.

The governance arrangements around safeguarding needed to be strengthened. Although team

work with safeguarding partners and relationships were improving with safeguarding boards,

progress on some matters was slow. There was a backlog of safeguarding investigations of one

year plus, and little evidence of oversight of these or proactive following up. Our review of the

electronic data base for safeguarding showed 24 section 42 safeguarding investigations, which

were overseen by the local authority, had not been signed off. One of these dated back to 4

February 2018. This had not been escalated, and as a result we had limited assurance that

investigations met statutory requirements. We found limited analysis of risks or raising concerns

with respect to safeguarding with the trust board. Some information was not described in the

annual report.

Review of safeguarding minutes for safeguarding adults and children committee indicated

membership from the clinical directorates was very poor. It was not clear how any issues arising

from investigations were closed off. There was no clear structure which outlined where the

minutes from such meetings were escalated. Further, we noted there was a lack of analysis of

data around safeguarding referrals.

The trust provided information following our inspection which indicated actions they were taking

to improve the oversight of safeguarding. They also provided summarised feedback from the

various representatives concerned with safeguarding for Lambeth and Southwark. Their

comments were favourable regarding the level of engagement and responsiveness between the

trust and themselves.

Board Assurance Framework

The trust provided their Board Assurance Framework, which details five strategic objectives

within each and accompanying risks. A summary of these is below.

• Best quality of care

• Excellent teaching and research

• Skilled can-do teams

• Top productivity

• Firm foundations

(Source: Trust Board Assurance Framework – July 2018)

There were two Board Assurance Framework (BAF). The BAF for 2018/19 had several risks (6)

identified in 2012, and others identified in December 2017 and April 2018. Of those noted for 2012

all stated no gaps in control and no gaps in assurance. However, four had scores of 16 or above,

one had a score of nine, and one a score of 12. None of these six were recorded on the corporate

risk register, and there was no risk appetite score for these.

Our review of the second BAF showed a lack of date, header and footer to the document. This

was in a different format with more detail than the 2018/19 BAF. However, almost all the target

dates were set at 2019/20 and we were unsure if this BAF had been board approved. In addition,


there were no target scores, risk improvement scores or assurance scores. Seven of the risks had

no red, amber or green (RAG) status. If this was the BAF being prepared for 2019/20, then some

RAG scores were not scored appropriately, e.g. Objective 4.5, scored red and not applicable.

The interim chair told us there was insufficient depth to the BAF. This was being looked at by the

governance lead, and they would need to alert the executive team to the problem. The trusts

company secretary reported to us that the BAF was not the best document, which sometimes kept

them awake at night. Specifically, the BAF did not marry with the corporate risk register and had

not been to sub-committees as much as it ought to. They confirmed the BAF was looked at during

every other board meeting.

Management of risk, issues and performance

Finances Overview

Historical data Projections

Financial metrics

Previous

financial year

(2 years ago)

Last financial

year

This financial

year

Next financial

year

Income £1.11bn £1.12bn £1.12bn N/A

Surplus (deficit) (£49.8m) (£139m) (£146m) N/A

Full Costs £1.17bn £1.25bn £1.01bn N/A

Budget (or budget

deficit) (£28.5m) (£38.5m) (£146m) N/A

(Source: Routine Provider Information Request (RPIR) – Finances Overview tab)

Trust corporate risk register

The trust provided a document detailing their eight highest profile risks. Each of these have a

current risk score of 16 or higher.

Date risk

opened ID Description

Gross risk

score

(current)

Last review

date

November

2012 Risk 1

Failure to deliver financial

sustainability 25

Under regular

review

November

2012 Risk 2

Integrated care initiatives fail to

deliver reduced admissions, eliminate

delayed discharges or improve care

outside the

hospital

20 Under regular

review

November

2012 Risk 3

Failure to deliver workforce capacity

and capability 20 June 2018

November

2012 Risk 4 Failure to deliver benefits from KHP 20 June 2018

November

2012 Risk 5

Demand and capacity leads to target

failure 20 June 2018


November

2012 Risk 6

Failure to achieve operational

performance and maintain quality 20

Under regular

review

December

2017 Risk 7

Failure to comply with IG and GDPR

regulation 16

Under regular

review

April 2018 Risk 8

Risk to operational performance and

patient care as a result of estate and

equipment maintenance backlog

25* Under regular

review

(Source: Board assurance framework)

We reviewed the risk register for King’s College Hospital and found there were 367 risks recorded.

There were three risks attracting a score of 25. The top three risks being; carbon dioxide in the

ED, the second ITU medical staffing, and thirdly outdated CT. There was no indication as to how

long these had been on the risk register. The most recent reviews had been August 2018 and

September 2018. Eight risks had a score of 20, with the last review date being the same as the

above. We noted risk number 2426 for acute medicine related to recruitment of nurses to medical

wards had a score of nine. This was last reviewed in August 2018, and it was not known if the risk

remained.

Our review of the Princess Royal University and south sites register showed there were 149 risks.

The top risk was for the decontamination facilities not being fit for purpose, with a score of 25.

There was no indication as to how long this had been on the risk register, and the most recent

review had been in July 2018. Ten risks had scores of 20, with last review dates of July,

September and October 2018.

The corporate risk register had listed 154 risks, five of which had scores of 20. Review dates

ranged from May to October 2018, with nothing more recent. There were no financial risks

recorded, despite the trust being in financial special measures.

There were several IT risks on the respective risk registered. They were formally reviewed by the

ICT team monthly. Quite a few of these were expected to stay on the register permanently, such

as; cyber security, kit risk, and old technology kit. There was an unsupported software subgroup

to review this risk. Information governance risks and mitigations has been considered during the

year with training and mapping data flows from this work. Highest risks were recognised, and

some were migrated by digitising their system and not passing papers between sites.

The trust was non-compliant with the targets for PREVENT training. This was set at 85% at level

three, to be met by April 2018, but at the time was less than 60%. This was not on the risk register,

and there was no trajectory to achieve compliance. Child protection information sharing (C-PIS)

was not in place and should have been completed by December 2018. This was not on the risk

register and had not been escalated to the board. Within the annual safeguarding report there was

limited analysis of key risks. We did not identify any specific information around safeguarding

priorities for the coming year.

In our discussion with the interim CEO he was aware there was room for improvement in the risk

register, particularly divisional ones. The basic framework was said to be fine but application of

scores was not quite right, and there was a need to refine to serious risks. At the time of our

inspection there was no specific risk committee at board level, although we were told risks were

covered off in respective committees. In response to our question around NED challenge of the

risks, we were told this varied.

The chief pharmacist spoke about the two risk registers which related to their services, the

pharmacy risk register, and medicines risk register. They identified the risks in each respect, for


example; Air handling units at capacity, and space constraints within the dispensary. Medicines

risks included; Chemotherapy and cancer e-prescribing, Shortage of drugs (especially specialist

biosimilars), EPMA and ICU prescribing, now resolved by consultants writing scripts. The CD

policy, which they felt was not clear enough, and was currently being modified. There was a risk

around storage of medicines, with multiple systems in place. This was a priority on the upcoming

medicines management plan.

We saw benchmarking data, including Model Hospital, TIPS for antimicrobial stewardship and

Royal Pharmaceutical Society Standards for Hospital Pharmacy. The chief pharmacist was

particularly proud of collaborating with NHSI who had come to Kings to help them define

parameters for use nationally on the Model Hospital dashboard metrics tracker. An example of the

work was modification of biosimilar data, to include reporting of the subcutaneous route, which

then delivered £11.4m savings to organisation.

There were well established arrangements for managing infection prevention and control risks,

overseen by the director for infection prevention and control. Designated responsibilities had been

given to other key staff, including the infection control team, supported by link representatives.

There had been considerable focus on improving the management of risks on the PRUH site,

which related to Norovirus. As a result, and since the previous inspection practices had been

developed and improved there. Some of the changes related to the environment, and others to

training and support, as well as on-site testing for Norovirus, with 96% of results being available

within a day.

We reviewed four quality and performance reports, which went to the Quality, Risk and Assurance

Committee (QARC). These ranged across the dates May, October and November 2018, and

January 2019. The papers did not have a consistent structure and lacked some depth. For

example, the January 2019 paper had a section on performance against constitutional targets, but

the others did not

We were told following the inspection that the QARC agendas were prepared by the Board

secretariat, quality team and NED chairman.

The chair of the audit committee told us how they had reached out to other audit committees as a

means of improving the trusts previous approach to audit. Meetings had been restructured as a

result, with meetings now held six times a year but for a longer duration. We were told there

previously had not been a strong connection with the clinical body. The loss of control over pay

costs because of previous restructuring had not been swiftly identified. There had been a delay in

reviewing what could have been done differently.

There was recognition that more formal engagement was required, including at the non-executive

director level. An action plan had started to be implemented in May 2018, and there was now a

clear process linked to financial objectives.

We spoke with the chair of the quality, audit and risk committee. They identified three priorities; the

Emergency Department, 52-week waits and finance. Committee meeting agendas were said to be

prepared by the trust’s quality team. They were not aware of the recent ward review process and

how this integrated with the quality and governance agenda. There had been a lack of information

sharing, which meant they did not know about findings from the core service inspection.

Information management

The director of improvement, informatics and ICT did not have a standard board role. They were

responsible for three teams, and covered informatics, digital technology, telecommunications, and


information governance. Coding and medical records sat within their responsibilities, and they held

the senior information risk owner (SIRO) role for the trust.

The ICT and digital strategy, which had four specific purposes, (consistency in access to health

records, supporting clinical safety and operational efficiency, supporting audit, analytics and

research, and creating innovations in patient care). This had been approved by the board in

September 2018 and was reviewed monthly. King’s digital and technology highlight reports were

presented to the board. We saw information for the January meeting which included an update on

achievements, such as electronic inpatient discharge summaries, the rollout of EPR functionality,

and other patient facing digital functions.

Leaders told us digital processes were important, and the ICT roadmap had been used to inform

the strategy. It was noted in our discussion with the director of strategy of the need to have

effective system working and how important the king’s digital team were.

We were told there was good connectivity between sites, and all electronic health records were

aligned across locations. Electronic noting was set up and order communications were provided

for radiology and pathology. Discharge notice and electronic prescribing was fully established on

all sites. The number of electronic prescriptions were measured daily, and were reported to the

finance committee, and up to the board.

We noted there were quarterly audit reports for patient record requests. The subject access

quarterly audit report for the period July to September 2018 presented results for King’s College

Hospital and separately for the PRUH. For KCH, 1216 requests had been received, of which 215

were not completed within the expected turnaround time. For the PRUH, 89 out of 297 requests

had not been completed in the required timeframe. Action plans to address this were not included

within the reports.

Work was soon to be completed on national early warning score 2 (NEWS2) and nursing

assessments roll out and was expected to be complete by end of March. This had been discussed

at the King’s digital and technological programme board on 1 February 2019. Minutes of these

meetings showed the wide range of matters discussed and presented. This included updates on

any project work. Action trackers recoded the status work.

There had been a lot of work around cyber security and digital maturity had been undertaken since

our last inspection. Although the trust was not affected by the malware attack, they had removed

general administration rights, leaving only the ICT with access. The team undertook penetration

testing, the last one of which was in January, and they held a monthly cyber security meeting.

Information governance steering group reports, which included ICT security updates fed into the

QARC, and there was monthly reporting to the audit committee. Data security updates were

routinely provided, and the board was cited on compliance with General Data Protection

Regulation (GDPR), and the information security and protection toolkit.

The chief pharmacist explained how information technology systems were used effectively to

monitor and improve the quality of care. They advised us the current issue was too many systems

in different areas. The informatics team were using electronic prescribing and medicines

administration (EPMA) data to get prescribing reports to see if they could make better use of the

systems. Changes included taking two clicks to get a medicines reconciliation onto system vs nine

clicks previously.

A further advantage was the trust could see visibility on primary care prescribing, that is, all blood

tests results from other trusts and GPs. This would aid better prescribing for therapeutic drugs

that required monitoring.


The pharmacy system had been changed to Ascribe®. The aim was to have a ‘closed end to end

loop system’ for tracking medicines. The service was trying to organise different providers to

amalgamate and communicate with each other to aid communication of medicines flow through

the system.

Engagement

With regards to staff engagement, the chief nurse said the trust could never do enough

communication, and that it was really important to listen and really hear what people were saying

and be able to evidence that. The chief nurse felt the executive team really valued staff their

commitment and their contributions to the trust, and recognising the staff was a key element of

motivating the workforce. The trust had launched ‘King’s Stars’, and over 300 staff attended the

annual awards event, held in November 2018. A thousand-staff had also received London theatre

tickets.

Directorate managers spoke to us about staff engagement. They said there was a senior leader’s

group, to which 100 people in the trust were a part of. Members attend King’s engagement and

feedback was provided at team meetings. There were drop in sessions open to all staff, and

representatives could raise questions or focus on specific issue, for example, recent focus had

been on leadership and apprenticeship.

Divisional monthly management meetings took place, with representatives from all professions

and HR and communications also joined these. These meeting provided an opportunity for high

level, divisional issues and performance discussion. Each care group reported back to the whole

group, which developed relationships and shared learning, ensuring all had overview of what was

happening across the divisions.

The chief pharmacist told us department engagement with staff happened through visits to a

variety of services, with a focus on getting local views. There was a dedicated ‘Carter pharmacy

team’, who sense checked projects that could be implemented because of getting these views.

For example, there was a recent exercise, which involved further procurement of pharmacy

services because of staff feedback through the ‘Use of Resources’ meetings. Consultant

pharmacists and technicians worked alongside the chief pharmacist to ensure the normal day to

day operations were considered in plans for further pharmacy services.

In our discussion with staff side representatives some fed back that there was little engagement of

senior executives at meetings, with few attending. We reviewed minutes from five meetings which

did not reflect this. We saw attendance from at least one senior staff member at each, and the

attendance of the interim CEO, interim chair, at three, plus the chief financial officer in one.

The trust had a meeting in December 2018, where it set out its proposal to change the terms of

reference of the Patient Experience Committee from 2019. This was to strengthen patient

experience monitoring and action planning, and to ensure patient feedback led to sustainable

improvements in patient, family and carer experience.

The non-executive directors were clear on the importance of patient engagement, and they spoke

about the value of having patients present their experiences at board meetings. The chief nurse

was proud of the engagement with local communities. The trust had representation on all the

boards. Healthwatch had associate members of the FT. Charity members were working with the

elderly and social isolation. The local Dementia Alliance were now associate members, supporting

improvements in dementia care with staff linking into local dementia hubs.

When the trust held events patients were invited to these. The director for equality and diversity

said that although their role was primarily in workforce so first and foremost he was working with


staff. They had however, been working with the patient engagement team to involve patients on

accessibility information standard, and what type of experience patients have with regards to lifts

and toilets for example. A company had been brought in to do an accessibility audit at the PRUH.

This resulted in information being added to the trust website, so patients had access.

The trust was the first one to have links to the Prince’s Trust, supporting young patients to enter

their ‘Achieve’ programme. There had been engagement work with local school children regarding

what a fantastic children’s hospital would be like. Thirteen young ambassadors carried out mini

inspection of the children’s services, feeding back their findings to the respective team.

We were told there were several active members of Bromley governors at PRUH, and staff

engagement was improving.

We reviewed the trusts engagement and experience strategy, 2017-2020. This included a

commitment to deliver safe, kind and compassionate care resulting in a positive patient

experience. The trust’s values underpinned this, along with ‘My Promise’, which have been

created by the people of King’s, staff, patients and their carers - out of their experiences. We saw

and heard evidence during our engagement activities and the inspection of actions the trust had

taken to meet the strategic aims. This included patient stories being shared at monthly Board of

Directors meetings and the Governor’s Patient Experience and Safety Committee. A programme

of listening events such as ‘Whose Shoes?” for maternity service users, amongst other activities.

The Patient Experience Committee had operational responsibility for ensuring implementation of

the strategy and the associated work plan. This was monitored quarterly by the Trust Patient

Experience Committee and the Governors Membership and Community Engagement Committee.

The Patient Experience Committee reported through to the Board via the Executive Quality

Committee, which reported directly to the Quality and Research Governance Committee.

People’s views and experiences were gathered by pharmacy through Outpatient data collection,

the Drugs and Therapeutics Committee, and satisfaction surveys through Friends and Family test.

As a result, more ward-based technicians were deployed to speed up discharge based on

feedback. The chief pharmacist told us the re-validation of pharmacy staff (newly implemented)

would help, as this was more patient focussed.

The trust continued to use a much-valued team of volunteers, with more than 700 members. They

gave their time in various ways to support patients and staff to improve the patient experience on

the wards, in Outpatient clinics and the Emergency Departments. Data collected by the trust

showed patient contact with volunteers, made them between 2% and 4% more likely to

recommend King’s as a place to be cared for.

Funding had been secured to develop a bespoke volunteer scheme for young people, aged 16-25

to support patients in three roles; feeding, boredom and fundraising. An end of life companion

service had been launched in October 2018, with volunteers providing support and companionship

to patients at the end of their life.

The trust had a home hamper service and had given out more than 150 food parcels to vulnerable

patients on discharge.

Learning, continuous improvement and innovation

Leaders and staff in general understood the importance of learning from adverse events and

situations. The reporting processes in the trust enabled investigation and sharing of learning from


the findings.

During the past few months we had the opportunity to attend the Serious Incident Committee

meetings. These were well attended meetings, chaired by corporate MD for quality, and had

representation from the clinical commissioning group (CCG) leads. Staff representatives

presented feedback on incidents, including the root-cause analysis (RCA), recommendations and

actions arising from this. We noted information within the chronology of RCA did not always

translate into contributory factors. For example, nursing staff not escalating an elevated NEWS

score sufficiently early. The meeting enabled staff to question and challenge, for example,

challenge was made around the ownership of the problem in at least one case and action plans

not having dates.

We reviewed six serious incidents and found the level and detail in the information varied. Two

had timely identification of the incident and reporting, and the (RCA) was carried out in a timely

manner. Appropriate remedial actions were taken, and contributory factors were clearly stated.

The patient and family had been informed and duty of candour had been applied. The action plan

was consistent with the findings. At least one of the investigators had been trained in RCA. The

other four had some gaps, including a lack of clarity around identification of contributory factors,

whether the investigator was trained in RCA, and lack of sign off.

We followed up actions related to two incidents (2018-13352 and 2018 135-48). These related to

window restrictors on a ward. The information did not provide sufficient assurance of an

assessment of the windows and restrictors having been completed at King’s College Hospital. An

end to end review of the process for receipts, implementation, sign off and ongoing audit of

practices for safety alerts would help in strengthening this area.

The learning from deaths policy (August 2017) was reviewed. This described the approach to

reviewing deaths using the King’s College Hospital mortality review form. This provided a

structured review of the quality of care provided, the stage of care where problems were

identified, and whether there was any degree of avoidability associated with the death. In

addition, it identified if the deceased had any learning disability or severe mental health illness.

We noted the learning from deaths policy section five, supporting and involving families and

carers, provided links to other policies, which contained details on supporting and involving

families and carers. This included the trust’s being open and duty of candour policy, and

bereavement care guidelines. The latter contained one section covering case reviews, patient

safety incidents and investigations.

Our specialist advisors were unable to undertake a full review of learning from deaths from the

six files requested. We received the serious investigation report for each of the patients; however,

these did not reflect a structured judgement review or mortality review to inform learning.

However, we fed this back to the trust on our final day and subsequently were provided with data

for patient deaths by location for the period January to December 2018. We noted from this the

stage one review and case identification included consideration of the death certificate, and

factors such as whether the deceased had a learning disability, or severe mental health illness.

Mortality review was carried out along with a structured judgement, from this an avoidability of

death judgement score was assigned. Avoidability of deaths results for KCH for the period 1

October 2017 to 31 September 2018 showed 80% were unavoidable, 7% showed slight evidence

of avoidability, and 0.6% strong evidence of avoidability. There were 1% of deaths which showed

a strong probability, >50:50 of being avoidable, and 5% with a possibility of not being very likely


(<50:50).

We saw clear methods for sharing learning from deaths through various committees, news-

letters, debriefs and ‘SafetyNet’. The SafetyNet comprised of sharing anonymous information and

key learning points about incidents where there was organisational learning. These were issued

every couple of weeks to staff across the trust by the head of patient safety and were available

on the intranet page also.

The trust had a detailed training plan in progress to consider the new intercollegiate guidance

around safeguarding. They had a safeguarding children workplan, which was good practice. The

trust had agreed to review learning disabilities work via the safeguarding committee, and it was

recognised there was a need for more resources required to support this agenda.

It was clear from our discussion with the chief nurse that quality and patient care was central to

the services provided. Work had been done to reduce the use of agency and bank staff. Other

work had been done around improving clinical handovers, and we saw information demonstrating

discussion at meetings, actions, and the development of a new policy.

In 2017/18 there were 88 cases of C. difficile across the trust, which was higher than the target

set by the Department of Health of 72 cases and higher than the previous year when there were

69 cases. We heard about the work done in relation to infection prevention and control at the

PRUH, and how learning from previous outbreaks had been addressed in a positive manner.

Mandatory cross site infection control meetings, which included the medical director, director for

infection prevention and control, and infection control leads helped to promote a consistent and

joined up approach across sites.

Complaints process overview

The trust was asked to comment on their targets for responding to complaints and current

performance against these targets for the last 12 months.

Question In days Current

performance

What is your internal target for responding to complaints? 3 100%

What is your target for completing a complaint 25 70%

If you have a slightly longer target for complex complaints

please indicate what that is here N/A N/A

Total Date range

Number of complaints resolved without formal process in the

last 12 months? 10,000

October 2017 –

October 2018

(Source: Routine Provider Information Request (RPIR) – Complaints Process Overview tab)

Number of complaints made to the trust

The trust received 1,039 complaints from October 2017 to September 2018. Outpatients received

the most complaints with 277.


Core Service Number of

complaints

Percentage

of total

Outpatients 277 27%

Surgery 222 21%

Medical care (including older people's care) 173 17%

Urgent and emergency 147 14%

Maternity 97 9%

Diagnostics 44 4%

Services for children 35 3%

Critical care 15 1%

Gynaecology 3 0%

Other 3 0%

Provider wide 1 0%

No core service recorded 22 2%

(Source: Routine Provider Information Request (RPIR) – Complaints tab)

Patient complaints, learning themes and actions were said to be shared through a quarterly

report to QARC; Quarterly feeder report to the Patient Safety Committee, the annual report, trust

scorecards, the Finance and Performance Committee, and Executive Quality Committee. A six-

monthly divisional report was also produced for local governance meetings.

Complaints were categorised, and we saw information which indicated the top issue reported

related to clinical treatment by a doctor or dentist (37%). Communications and values and

behaviours accounted for 13% each. Admission, discharge and transfer (9%), and nurse-led

patient care, 8%.

The trust informed us over 70% of complaints were responded to within 25 days. We were made

aware that delays could be caused by more complex investigations arising from the complaint. In

addition, there were some delays where letters needed to be approved at executive level.

Sometimes response letters were drafted numerous times, which delayed the process.

The patient’s complaint annual report showed that in 2017/18, 956 complaints were received by

the trust – King’s College Hospital (KCH) 596, and Bromley sites 360. Overall, an organisational

decrease of 7% compared to 2016/17 (1026). This represented 8% reduction in complaints at,

KCH and 4% reduction on the Bromley sites. Compared to patient activity within the trust, this

was measured to 0.6 complaints per 1000 attendances. There had been 12,214 patient advice

and liaison service (PALS) contacts recorded - 6% increase from 2016/17.

The end of year performance of 51% in responding to complaints within 25 working days (45%

KCH Hill and 59% Bromley sites) did not reflect the information provided to us in the trust’s

presentation. Fourteen (1.5%) complaints had been referred to the Parliamentary and Health

Service Ombudsman for further independent investigation.


An improvement in response to complaints was noted since January 2018. The trust

acknowledged this was because of the initiatives taken to drive performance, which included

regular meetings with divisional staff and case tracking to highlight and prevent breaches to the

working timeframe.

Our discussion with a representative of the complaints handling team suggested improvements

had been made in the team’s ability to complete the complaints process. They told us a

complaints team had been established at the PRUH site, and much work had been done to

reduce ‘silo’ working, through the establishment of links, including legal and patient safety.

Weekly meetings were held, and patient care groups had time to present. There was recognition

of what was being done well, such as the improvement in three-day targets for complaint

acknowledgement; however, they said the sign off for letters related to medium or high risk

matters could take two to three weeks.

Compliments

The trust annual report on complaints included information related to compliments. These were

received through positive patient experience stories via patient opinion websites, HRWD, through

social media networks, Twitter and Facebook. Since January 2017, 209 compliments had been

recorded.

Accreditations

NHS trusts participated in several accreditation schemes whereby the services they provide were

reviewed and a decision was made whether to award the service with an accreditation. A service

will be accredited if they are able to demonstrate they meet a certain standard of best practice in

the given area. An accreditation usually carries an end date (or review date) whereby the service

will need to be re-assessed to continue to be accredited.

The table below shows which of the trust’s services have been awarded an accreditation.

Accreditation scheme name Service accredited

Joint Advisory Group on Endoscopy (JAG) DH Endoscopy 2017

Clinical Pathology Accreditation and its successor Medical

Laboratories ISO 15189 Yes, through Viapath

MacMillan Quality Environment Award (MQEM)

MacMillan Information &

Support Centre

Denmark Hill 2018

Psychiatric Liaison Accreditation Network (PLAN)

Excellent in 2015. Re-

inspected in July 2018 -

awaiting panel result

(Source: Routine Provider Information Request (RPIR) – Accreditations tab)

The corporate transformation plan had four areas of focus; continuous improvement, training,

delivery of projects and governance. The challenges of delivering quality improvement had been

identified, including; not having an aligned executive vision for transformation, or a central


governance structure to steer all projects and oversee risks, and the loss of expert staff following

restructuring amongst other factors. Despite these in the last year the trust reported its

achievements arising from the focus areas. For example; more than 2,300 staff had completed

white, yellow or green belt training, the colours representing different levels of training. The

content covered such areas as; improvement theories, launching projects, gathering data and

analysing this, making recommendations, planning and implementing. A rapid improvement

programme was being piloted with the emergency orthopaedic team, and workstreams were in

progress to improve the patient experience. This was an example of work arising from staff who

had completed green belt level training.

The trust had set up an advanced leadership programme, (ALP), which was to run through 2019

and 2020. The programme was expected to last nine months and consisted of seven modules,

providing opportunities to focus on strategic skills, team development, organisational

understanding and capacity to lead services. This was intended for senior functional heads in

leadership positions, with significant responsibility for strategic decision-making.

Opportunities were provided for development through the trust’s Leadership and Management

Pathway, which offered four levels of development. This included; delivering the strategy,

managing the service, managing the team and, developing self. The pathway had been designed

on a “blended” learning approach – learning was offered via online toolkits, e-learning and face-to-

face training, offering both flexibility and structure. Over 40 leadership and management e-learning

and video training packages had been designed and selected and available to access through the

learning management system (LEAP)

An enhanced recovery programme for trauma and orthopaedic patients at Orpington Hospital had

been put in place. This was part of the ‘Getting It Right First Time’ (GIRFT) and had resulted in

improvements in theatre activity at the location and reduction in cancellation rates.

In outpatients, work had been done to pilot the digital delivery of patient appointments, with roll out

of ‘In-Touch’ for some clinics. This gave patient improved visibility of appointments and waiting

times. Charitable funding had been secured to place ‘In-Touch’ kiosks and mobile check in units

across outpatients during 2019/20.

The PRUH had piloted a new multidisciplinary frailty pathway for patients over 75. This was aimed

at decreasing length of stay for these patients and helped to discharge patients’ home with

“discharge to assess” support care in place or referral to community rehabilitation services.

The trust had invested in the perfect ward app. This had enabled the trust on a weekly and

monthly basis to look at the safety in 105 clinical areas on all five sites. They were now able to

recognise any issue with staffing quickly through this system, as it gave an early warning. A ‘red’

shift policy had been introduced, which meant staff were shared out to red and amber areas from

less challenged areas of acuity.

Over 10,000 audits had been carried out on the perfect ward system, with immediate feedback on

results. They had done a specific audit on OPD, using the key lines of enquiry (KLOEs) and

speaking with patients. The trust was not aware of any other similar activities.

Divisional directors told us the perfect ward work had been very valuable in measuring specific

areas and involved a wide group of staff, opened conversations between all members of the team,

which had improved how they interacted. Further, ‘It was a useful tool becoming embedded into

practice.


The trust was introducing advance nurse practitioners in the outpatient department, and training

nurse assistants. Electronic patient records had been rolled out since our last inspection, and

there had been a local care record initiative.

A total of 40 wards out of 70 had gone through the ‘King’s way for wards’. This was focused on

five areas of standardisation, including; patient care, flow, environment, standards and

improvement. Each ward had undergone at least one accreditation, except for maternity.

Electronic patient records (EPR) had rolled out to the PRUH since our last inspection. EPR quality

indicators fed into the improved safety scorecard. Electronic prescribing was now all sites. Alerts

for safety issues such as venous thromboembolism were included in these.

We heard about the range of work which had been taking place around mental health and

challenging behaviour. This had included close working with other trusts, including twinning of

wards with one, and the intention of doing the same at another. There was a jointly appointed

senior nurse lead for mental/physical health, and mental health teaching had started in high risk

areas. King’s had also led work in south east London to reduce the length of stay for patients with

mental health conditions in crisis in the ED.

The trust commenced a two-year Advanced Critical Care Practitioner (ACCP) course in

September 2017. The course had 12 students, both from internal and external positions and from

a range of backgrounds including- critical care nurse, physiotherapists and two critical care

paramedics. The course was conceived as a new way of working and aimed to improve the flow

and care of patients, develop a more resistant staff team who could provide a consistent high-

quality service, which previously may have been lacking due to frequent changes of medical staff.

The ACCP were already able to look after intubated/ventilated patients and were developing their

ICU knowledge to ensure on qualifying they would be able to provide a 24/7 service that supports

staff including ED, which had significant patient flow issues, improving the quality and timeliness of

patient care. There were plans to evaluate the impact of the programme on the delivery of

consistent, high quality patient care, reduced delays and improved flow through the trust.

Pharmacy were proud of the innovative work, which included for example; collaboration on aseptic

services, driving forward on what it should look like for the trust, and wider in south east London,

based on commercial capacity. A stagey for clinical trials for genetic medicine had been developed

nationally. There was a procurement piece to merge the medicines supply chain within south east

London, whereby a central hub would deliver the medicines supply, thus ensuring stock holdings

were removed locally from hospitals and procurement occurs centrally. £14m funding has been

given to make this work across the STP. The savings would primarily be in space and cashflow

from not stockpiling medicines.

Work was happening to integrate pharmacists into joint pathways with regards to outcomes in

medicines optimisation, using a specific outcomes toolkit to direct patients to the correct

practitioner. At the time, respiratory, cardiac and paediatrics were the main areas piloted, and this

has been identified based on clinical need and speciality of pharmacists in this sector.

There was a pilot funding for one based automation drug cabinet in the Cardiac ward, which would

map the flow of nurses to medicines carts/cabinets. This would inform how medicines were used

within wards, with the resultant roll-out of that model across the trust. This was expected to be put

in place in March 2019.

The trust executive team were proud to report the training of 2000 staff in LEAN quality

improvement methodology. We attended an open day for staff at the PRUH, which provided

information on training and qualification opportunities for staff, advice and support around career


planning. Representatives from different clinical areas enabled interested parties to gain

information and consider the range of opportunities available to them.

The interim chair was proud the trust was getting to the bottom of the numbers and underlying

drivers of financial performance. He was proud of the level of engagement with clinicians and had

spent regular time in operating theatres to this end.

There was good recognition amongst the leadership team of the range of activities which

contributed to improvements. This included the LEAP training system and the number of staff who

had been taken through this programme (2000), the integrated care system, haematology

programme and productivity, and the partnership arrangements. In addition, it was recognised and

acknowledged the positive impact the nurse recruitment work had achieved, along with the trust

being a strong recruiter into its research programmes.

The trust continued to lead on many areas of research and was in the top five in the country for

clinical trials. Several leading clinical units and research centres were based at the trust, including;

the Clinical Age Research Unit, the HIV Research Centre, and the Harris Birthright Centre.

Developments had started on building a new leading-edge Haematology Institute. The NEDs told

us research activities were discussed in the QARC, and they were sited on innovative practices

around such areas as bone marrow transplant. They told us palliative care was world leading, and

more research was continuing in this area.


Acute services

Kings College Hospital NHS Foundation Trust Denmark Hill,

London,

SE5 9RS

Tel:020 3299 9000

www.kch.nhs.uk

Urgent and emergency care

Facts and data about this service

Details of emergency departments and other urgent and emergency care services

The Emergency Department at King’s College Hospital is a Major emergency centre for the south

east. It is a major trauma centre, hyper acute stroke unit, cardiac arrhythmia and cardiac arrest

centre. It also fulfils its obligations as a type 1 emergency department for it’s local population.

There are over 350 staff, including 80 doctors and 180 nurses.

The emergency department continues to make strides in novel ways of working including rapid

assessment and treatment and early mental health assessment and co-working, and

strengthening links with GP providers.

(Source: Acute Routine Provider Information Request (RPIR) – Context tab)

Activity and patient throughput

tel:020


Total number of urgent and emergency care attendances at King's College Hospital NHS

Foundation Trust compared to all acute trusts in England, August 2017 to July 2018

From August 2017 to July 2018 there were 230,385 attendances at the trust’s urgent and

emergency care services as indicated in the chart above.

(Source: Hospital Episode Statistics)

Urgent and emergency care attendances resulting in an admission

The percentage of A&E attendances at this trust that resulted in an admission remained similar

in 2017/18 compared to 2016/17. In both years, the proportions were similar to the England

averages.

(Source: NHS England)


Urgent and emergency care attendances by disposal method, from August 2017 to July

2018

* Discharged includes: no follow-up needed and follow-up treatment by GP

^ Referred includes: to A&E clinic, fracture clinic, other OP, other professional

# Left department includes: left before treatment or having refused treatment


Is the service safe?

Mandatory training

The service provided mandatory training in key skills to all staff but did not make sure

everyone had completed it.

We spoke to staff regarding access to training. They told us the online system they were currently

using was much easier to navigate than a previous mandatory training system. However, all staff

we spoke with told us they were not given adequate time to complete training. They added, there

was an ‘unwritten’ expectation that mandatory training would be completed in their own time,

outside of normal working hours.

The Emergency Department (ED) practice education team provided mandatory training for staff

within the department. The lead practice educator was responsible for ensuring nursing staff were

up to date on mandatory training. We saw evidence that not all staff had completed their

mandatory training and the practice educator told us this was mostly due to long term sickness

and maternity leave.

Staff working with children had additional training to ensure children and young people were kept

safe. Nursing staff working in the paediatric department undertook paediatric basic life support and

additional competencies relating to children’s health. Staff were trained in paediatric life support.

We were concerned with staff knowledge around some of the mandatory training modules. We

spoke with staff who had completed many mandatory training modules. They openly told us they

could not remember what they had learnt because the online module was not interactive and did

not fit their learning style. There was general feeling amongst staff we spoke with that mandatory

training was a ‘tick box exercise’.

Mandatory training completion rates

The trust set a target of 80% for completion of mandatory training.


Trust level

A breakdown of compliance for mandatory training courses as of October 2018 at trust level for

qualified nursing staff in urgent and emergency care is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met

Dementia [Once] 137 137 100% Yes

End of Life [Once] 209 209 100% Yes

Equality & Diversity [Once] 372 359 97% Yes

Health & Safety [Once] 372 360 97% Yes

Venous Thromboembolism [Once] 350 331 95% N/A

Aseptic Non-Touch Technique Level 1 [Once] 183 169 92% Yes

Fire [2 Years] 372 343 92% Yes

Conflict Resolution [5 Years] 274 249 91% Yes

Blood Transfusion [2 Years] 183 164 90% Yes

Infection Control (Clinical) [2 Years] 372 324 87% Yes

Manual Handling (Clinical) [2 Years] 372 302 81% Yes

Data Security Awareness (Information

Governance) [ 1 Year] 372 293 79% No

Slips, Trips and Falls [3 Years] 372 295 79% No

Resuscitation 370 283 76% No

In urgent and emergency care the 80% target was met for 10 of the 14 mandatory training

modules for which qualified nursing staff were eligible.


medical staff in urgent and emergency care is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met



Blood Transfusion [2 Years] 60 39 65% No

Equality & Diversity [Once] 165 104 63% No

Manual Handling (Non-Clinical) [Once] 165 101 61% No

Fire [2 Years] 165 97 59% No

Health & Safety [Once] 165 98 59% No

Infection Control (Clinical) [2 Years] 165 94 57% No

Data Security Awareness (Information Governance)

[ 1 Year] 165 74 45% No

Conflict Resolution [5 Years] 49 22 45% No

Aseptic Non-Touch Technique Level 1 [Once] 133 58 44% No


Mental Capacity and Consent [Once] 60 19 32% No


In urgent and emergency care the 80% target was met for one of the 14 mandatory training


modules for which medical staff were eligible.

(Source: Routine Provider Information Request (RPIR) – Training tab)

We spoke with the lead consultant for the ED whose responsibility it was to ensure mandatory

training had been completed for medical staff. They could show us different data which suggested

most medical staff were compliant with their mandatory training; contrary to the data supplied by

the trust through the routine provider information request. At the time of this report, the trust had

been unable to supply us with updated information to show any further compliance. We remained

concerned regarding the low figures.

Medical staff we spoke with were unable to tell us when they last completed any mandatory

training and told us they would be too busy to be able to complete it during works time and they

did not feel it was a priority.

Safeguarding

Staff understood how to protect patients from abuse and the service worked well with other

agencies to do so. Staff had training on how to recognise and report abuse and they knew how

to apply it.

There was an adult and child safeguarding policy, as well as a child protection policy and

procedure to guide staff. These policies explained individual responsibilities and the trusts

approach to reporting processes.

Despite training concerns for medical staff, staff understood their responsibilities to protect

patients from avoidable harm. The trust worked well with other agencies to ensure maximum

learning took place. Staff we spoke with could recognise, report and knew how to seek advice

regarding safeguarding concerns.

Staff working in the department had undergone a Disclosure and Baring Service (DBS) check as

part of the trust’s recruitment process. This ensured all members of staff were safe to be working

with vulnerable adults and children. The trusts DBS policy stated offers of employment were

withdrawn if any DBS check showed any criminal activity.

Updates to any safeguarding processes were cascaded through staff meetings, governance

meetings, newsletters and staff appraisals. Safeguarding policies were updated regularly, and

version controlled.

Children and young people were sufficiently safeguarded whilst in the children’s waiting area with

nursing and reception staff visibly able to see all patients.

Safeguarding training completion rates

The trust set a target of 85% for completion of safeguarding training.

Trust level

A breakdown of compliance for safeguarding training courses as of October 2018 at trust level for


Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met

Safeguarding Adults Level 2 [3 Years] 372 348 94% Yes


Safeguarding Children Level 3 [3 Years] 69 61 88% Yes

In urgent and emergency care the 85% target was met for both safeguarding training modules

for which qualified nursing staff were eligible.



Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met

Safeguarding Adults Level 2 [3 Years] 165 101 61% No

Safeguarding Children Level 3 [3 Years] 15 1 7% No

Safeguarding Adults Level 1 [Once] 1 0 0% No

In urgent and emergency care the 85% target was not met for the three safeguarding training



With regards to safeguarding children, there was low compliance for level two and level three

training for medical staff. However, medical staff could demonstrate a good understanding of

safeguarding and were able to tell us the process for reporting safeguarding concerns.

Cleanliness, infection control and hygiene

The service controlled infection risks well. Staff kept themselves, equipment and the

premises clean. They used control measures to prevent the spread of infection.

Staff kept themselves, equipment and premises clean. Policies such as hand hygiene, infection

control, personal protective equipment (PPE) and sharp objects were in place. However, these

policies were not always kept updated and not version controlled.

Standards of cleanliness were found within the department and maintained throughout the

inspection. Staff were observed washing their hands after each patient contact, donning gloves

and aprons and disposing of bodily fluids in line with National Institute for Health and Care

Excellence quality statement three – Hand Decontamination. Staff were also observed to be bare

below the elbows in line with trust policy.

The sluice room was kept tidy and free from clutter. Sharps boxes were correctly labelled and

were not over spilling. There was a dedicated cleaning team within the department which attended

requests by nursing staff for adhoc cleaning. There were cleaning schedules in place and we saw

completed paperwork confirming cleaning had been carried out. These were signed and dated.

The environment was visibly clean, free from dust and clutter. Soiled linen was placed in the

correct disposal bin and any linen which was heavily soiled was place in a bag and placed in the

correct bin.

There was sufficiently available PPE, including aprons, gloves and masks. We routinely observed

staff using these according to infection control policy and best practice guidance.


Environment and equipment

The service did not have suitable premises and equipment was not always looked after

well.

The design and layout of the emergency department did not always ensure patient confidentiality.

The main walk-in entrance did not cater for large queues of people and we observed patients

being asked for clinical detail in an area which could be overheard by waiting patients.

Consulting, assessment and treatment rooms were available; however, we observed patients

having clinical observations recorded in a communal area with other patients near. Nursing staff

told us this was due to a lack of space and availability of rooms.

We checked the stock of each resuscitation trolley within the department and found out of date

single use equipment. One vial of medicine was one year out of date. We noted the daily checks

had not been completed on any of the resuscitation equipment throughout the department contrary

to trust policy. There was a period of six consecutive days which had not had a check completed.

All rooms had emergency pull cords, although we noted that some pull cords were inaccessible to

patients during inspection.

The waiting areas used by patients was spacious with seating for patients and relatives. During

busy periods patients were unable to find available seating and congregated within the corridors of

the emergency department. This made it difficult for staff to locate patients and to ensure a clear

entry and exit from the department.

There was a separate secure area suitable for children and young people. It was decorated in a

child friendly way. This area was separate from the main emergency department and was not

overlooked by adult patients and visitors. The waiting area was observed by the nurse’s station.

The children’s emergency department did not meet all quality standards described by the Royal

College of Emergency Medicine’s mental health in emergency departments 2017. A room used for

assessment of a child or young person’s mental health had ligature points and was generally

unsuitable for patients with deteriorating mental health symptoms. Staff told us that for more

complex mental health needs, children would be placed in the resuscitation area in a side room.

Staff told us this was an identified risk but said they were unaware of any mitigation or actions the

trust was taking to provide a more suitable environment.

During the inspection, we made senior staff aware of our concerns around the paediatric mental

health assessment room. We were told this room would not be used for this purpose with

immediate effect.

There were two adult mental health assessment rooms located within the emergency department.

These rooms could be easily observed by nursing staff and had CCTV installed for the protection

of staff and patient. However, these rooms had movable furniture which could be used as a

weapon.

Assessing and responding to patient risk

Staff did not always complete and update risk assessments for each patient. They did not

always keep clear records and ask for support when necessary.

The trust had experienced a high number of black breaches. These peaked in January 2018 when

287 patients waited longer 60 minutes before being handed over to hospital staff. Delayed

handover poses a risk to patients who usually must wait in corridors or in an ambulance. Delayed


handover also means ambulances must wait with a patient, meaning they are unable to respond to

other calls.

Patients presented to the department either by walking into the reception area, by ambulance or

by the Helicopter Emergency Medical Service (HEMS). Those needing immediate treatment were

taken to the resuscitation area. The ambulance service telephoned through to the ‘red phone’

based in the resuscitation area to alert staff to a critically unwell patient’s imminent arrival. This

ensured staff could provide a specialist team ready for when the patient arrived.

The department utilised a system called ‘Rapid Assessment and Treatment’ (RAT) for patients

arriving by ambulance. This aimed to address delays in time to initial assessment, reduce

handover delay and minimise black breaches. This area allowed staff to undertake an initial

assessment of the patient and early treatment before streaming them onto a more appropriate

area of the department. Due to the limited size of this area and at times of peak demand this area

became overcrowded with ambulance crews queuing to get into the department. Patient handover,

from ambulance crew to receiving hospital staff member, was often conducted within earshot of

other patients and relatives within the department.

During inspection we spot checked initial assessment times displayed in the department and these

were consistently longer than 15 minutes. The Royal College of Emergency Medicine

recommends that patients should be assessed by a healthcare professional within 15 minutes of

arrival.

There were systems in place for the monitoring of risks to patients in the emergency department

so that staff could identify seriously ill and deteriorating patients. However, the department was

failing to ensure these processes were followed consistently. Some adult patients were not having

clinical observations taken in a timely way. Due to the inconsistency in recording clinical

observations correctly in the patient’s record, it was difficult to determine when a patient had

observations taken and when they were next due.

We checked the frequency of clinical observations within the paediatric department and noted

these were completely correctly and in accordance with the clinical recommendations for their

symptoms.

The department used MEWS (modified early warning score) for adults and PEWS (paediatric early

warning score) to assess how unwell patients were. In general, the higher the score the sicker the

patient. MEWS and PEWS should be monitored regularly and the sicker the patient, the more

frequent the observations should be. When we looked at the clinical records of patients, we found

that these scores were not completed, not reviewed or not reviewed as frequently as they should

be. We reviewed 20 patient records, adult and paediatric, and noticed 15 of these records had

incomplete or completely missing scores. Only the records from the resus area had fully

completed scores.

The department had a paediatric sepsis screening and action tool. This tool was to be applied to

all children over 12 years old who had suspected infection or clinical observations outside normal

ranges. We viewed a set of six care records for patients suspected of being septic and all six had

completed screening tools.

During busy periods there was not suitable observation of patients who were either confused, or at

risk of falls. We observed one patient walking around the majors’ department who was confused,

partially dressed and had nobody with them. Nursing staff did eventually attend to this patient but

after a prolonged period.


Staff said they worked closely with the drug and alcohol liaison team with patients referred to the

service where alcohol problems were identified. The department also had a good working

relationship with a local NHS trust that provided many psychiatric liaison staff to assess the needs

of patients presenting with acute mental health concerns. There were two dedicated mental health

assessment rooms based within the majors’ department.

Emergency Department Survey 2016

The trust scored about the same as other trusts for each of the five Emergency Department

Survey questions relevant to safety.

Question Score RAG

Q5. Once you arrived at the hospital, how long did you wait with the

ambulance crew before your care was handed over to the

emergency department staff?

8.2 About the same

as other trusts

Q8. How long did you wait before you first spoke to a nurse or

doctor?

5.7 About the same

as other trusts

Q9. Sometimes, people will first talk to a nurse or doctor and be

examined later. From the time you arrived, how long did you wait

before being examined by a doctor or nurse?

5.9 About the same

as other trusts

Q33. In your opinion, how clean was the emergency department? 8.1 About the same

as other trusts

Q34. While you were in the emergency department, did you feel

threatened by other patients or visitors?

9.4 About the same

as other trusts

(Source: Emergency Department Survey (October 2016 to March 2017; published October 2017)

Median time from arrival to initial assessment (emergency ambulance cases only)

The median time from arrival to initial assessment was zero minutes for the 12-month period from

October 2017 to September 2018. Initial assessment means the first time a patient is seen and

assessed by a nurse or doctor in the department.

(Source: NHS Digital - A&E quality indicators)

Percentage of ambulance journeys with turnaround times over 30 minutes for this trust


Kings College

From November 2017 to October 2018 there was a stable trend in the monthly percentage of

ambulance journeys with turnaround times over 30 minutes at King’s College Hospital.

Ambulance: Percentage of journeys with turnaround times over 30 minutes – King’s

College Hospital

Ambulance: Number of journeys with turnaround times over 30 minutes – King’s College

Hospital

(Source: National Ambulance Information Group)

Number of black breaches for this trust

A “black breach” occurs when a patient waits over an hour from ambulance arrival at the

emergency department until they are handed over to the emergency department staff. From

September 2017 to September 2018 the trust reported 1,288 “black breaches”.


(Source: Routine Provider Information Request (RPIR) - Black Breaches tab)

Nurse staffing

The service did not always have enough nursing staff, with the right mix of qualification

and skills, to keep patients safe and provide the right care and treatment.

During the inspection we observed nursing shifts being filled by members of staff of differing

grades. For example, we observed two band seven shifts being filled by two band six members

of staff. Staff told us this was due to insufficient staff within the department, making it necessary

to move lower grade staff into more senior shift vacancies. A member of staff with rostering

responsibilities told us this was a consistent problem within the department and juggling shift

vacancies was an increasing concern. Members of the senior nursing team were unaware of

exactly how many staff were required within the ED and how many full-time vacancies were

required. We were not fully assured the senior nursing staff had a full understanding of the

nursing requirements for ED.

The clinical lead for the department told us they were fully staffed; however, the rota showed the

band seven shifts were often filled by band six members of staff. Staff we spoke with confirmed

that this happened regularly.

We spoke with staff in the adult and paediatric ED who told us they were concerned about

staffing levels being low. They told us bank and agency staff were used where possible, but they

were not always successful in securing these on short notice. Staff told us that when bank and

agency staff were used it caused some problems because they often do not have the skills and

competencies the ED requires.

Staff told us that when the department was under pressure, some senior nurses came to the

department to help. However, staff felt the senior nurse’s cherry picked their duties and left the

department at the soonest opportunity.


Staff told us it was necessary to send nursing staff to help in the paediatric department at times

of increased patient activity. However, this meant that the paediatric ED was not always staffed

by nurses with specialist paediatric training. Paediatric nurses told us they would also help in the

adult area when required.

We spoke with staff in the clinical decision unit (CDU) who told us they felt they had enough

nursing staff to carry out their duties sufficiently. This was corroborated with the check of the

rota during inspection.

We observed one nurse handover during a shift change. There was a morning and evening

nursing handover which discussed each patient, their symptoms and where they were in their

treatment pathway. We observed nursing staff introducing themselves to patients and taking

note of their clinical presentation.

The trust reported the following qualified nursing staff numbers as of August 2017 and August

2018 for urgent and emergency care by site:

August 2017 August 2018

Staffing group

Planned

staff –

WTE

Actual

staff –

WTE

Fill

rate

Planned

staff –

WTE

Actual

staff –

WTE

Fill

Rate

Qualified nursing & health

visiting staff (Qualified nurses) 72 46.5 64.5% 400.3 346.4 86.5%

Fill rate had increased by over 20% and there were 300 more WTE in post in 2018 than there

was in 2017.

Site breakdown can be seen below:

• King’s College hospital: 200.6 WTE in post (86.9% fill rate)

(Source: Routine Provider Information Request (RPIR) – Total staffing tab)

Vacancy rates

From September 2017 to August 2018, the trust reported a vacancy rate of 15.1% for nursing

staff in urgent and emergency care. This was higher than the trust target of 8%.

The breakdown by site was as follows:

• King’s College emergency department: 13.6%

(Source: Routine Provider Information Request (RPIR) – Vacancy tab)

Turnover rates

From September 2017 to August 2018, the trust reported a turnover rate of 18.8% for qualified

nursing staff in urgent and emergency care. This was higher than the trust target of 10%.



• King’s college emergency department: 19.6%

(Source: Routine Provider Information Request (RPIR) – Turnover tab)

Sickness rates

From September 2017 to August 2018, the trust reported a sickness rate of 2.8% for qualified

nursing staff in urgent and emergency care. This was lower than the trust target of 3%.



(Source: Routine Provider Information Request (RPIR) – Sickness tab)

Bank and agency staff usage

From September 2017 to August 2018, the trust reported that 49.1% of qualified nursing shifts in

urgent and emergency care were filled by bank staff and 31.5% of shifts were filled by agency

staff. In addition, 19.4% of shifts were not filled by bank and agency staff to cover staff absence.

These figures are based on available shifts for bank and agency staff. They do not include shifts

filled by substantive staff.

(Source: Routine Provider Information Request (RPIR) – Bank and Agency tab)

Medical staffing

The service did not always have enough medical staff, with the right mix of qualification

and skills, to keep patients safe and provide the right care and treatment.

The department was meeting the Royal College of Emergency Medicine (RCEM)

recommendations that consultants should provide 24 hour 7 days a week cover as the ED was a

major trauma centre.

Doctors staffed the department 24 hours a day seven day a week. ED consultant presence was on

sight 24 hours a day seven day a week. However, ED consultants were required to work a ‘trauma

shift’ which consisted of a single 25-hour shift once per month. Two consultants we spoke with felt

this was too long and due to the busy nature of the department, it was an increasing concern that

staff burnout could happen. The clinical lead for the ED told us this was being reviewed and they

were hoping to do 12-hour shifts in future. However, at the time of the inspection this had not

taken place and there had been no senior approval for this.

The ED risk register showed a potential risk of harm to paediatric patients due to lack of

experienced paediatric medical staff. Operational staff we spoke with did not find this to be the

case and felt there was enough appropriately trained medical staff working within the department.

The ED was staffed by 24 consultants. 17 of the ED consultants participated in the trauma rota.

The trust had recently appointed a paediatric consultant who will oversee the medical teams in the


paediatric area. However, at the time of inspection they were not yet in post. At the time of

inspection there was six paediatric junior clinical fellows employed in the ED.

The trust reported the following medical staffing numbers as of August 2017 and August 2018

for urgent and emergency care by site:


Staffing group

Planned

staff –

WTE

Actual

staff –

WTE

Fill

rate

Planned

staff –

WTE

Actual

staff –

WTE

Fill

Rate

Medical & Dental staff - Hospital 269.9 232.9 86.3% 159 146.7 92.3%

Fill rate has increased to over 90%, although there are over 80 less WTE in post in 2018.


• King’s College hospital – 101.2 WTE in post (105% fill rate)


Vacancy rates

From September 2017 to August 2018, the trust reported a vacancy rate of 4.5% for medical

staff in urgent and emergency care. This was lower than the trust target of 8%.


• King’s College emergency department: -3.6%

The negative figure indicates there were more WTE in post than originally scheduled.


Turnover rates

From September 2017 to August 2018, the trust reported a turnover rate of 12.1% for medical





Sickness rates

From September 2017 to August 2018, the trust reported a sickness rate of 0.1% for medical






Bank and locum staff usage

From September 2017 to August 2018, the trust reported that 3% of medical shifts in urgent and

emergency care were filled by bank staff and 44% of shifts were filled by locum staff. In addition,

53% of shifts were not filled by bank and locum staff to cover staff absence.

These figures are based on available shifts for bank and locum staff. They do not include shifts


(Source: Routine Provider Information Request (RPIR) - Medical agency locum tab)

Staffing skill mix

In July 2018, the proportion of consultant staff reported to be working at the trust were higher

than the England average and the proportion of junior (foundation year 1-2) staff was also higher.

Staffing skill mix for the 114 whole time equivalent staff working in urgent and emergency

care at King's College Hospital NHS Foundation Trust.

This

Trust

England

average

Consultant 31% 29%

Middle career^ 9% 15%

Registrar group~ 29% 32%

Junior* 31% 24%

^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty

~ Registrar Group = Specialist Registrar (StR) 1-6

* Junior = Foundation Year 1-2

(Source: NHS Digital Workforce Statistics)

Records

Staff did not always keep detailed records of patients’ care and treatment. Records were

not always clear and up-to-date.


We reviewed 20 sets of medical records from adult and paediatric patients including patients who

had been admitted into the department with mental health needs. The medical records were not

completed consistently, and we found gaps in documentation, missing clinical observations and

illegible writing. We found the records did not always accurately record times when medicines was

given to a patient. We found adult sepsis screening tools were not always fully completed and

records of clinical observations were not always recorded.

Staff used paper and electronic records to record patient information. The electronic record system

had the ability to alert staff about specific needs of a patient, such as allergies, recent diagnosis,

those living with dementia and patients with learning disabilities. The computer screens used

within the department did not always protect sensitive patient information as they were easily

viewed by members of the public.

We observed paper records left open and unattended in-patient areas. These records were not in

use and members of the public were able to see confidential information. We observed this in the

adult’s major’s area.

Staff we spoke with were unaware of the process to follow once a patient had been discharged.

Staff told us they were aware the patients GP was sent a copy of the patient’s record but were

unaware whose responsibility this was. Admin staff we spoke with told us they scanned copies

onto a computer system and filed paper copies in a folder which was accessible to all staff. They

were also unaware of the process that followed once a patient was discharged.

We were not satisfied the standard of record keeping was enough to keep patients safe and

protect them from errors or harm.

Medicines

The service did not follow best practice when prescribing, giving, recording and storing

medicines. We could not be assured patients received the right medicine at the right dose

at the right time.

We found medicine fridges unlocked in the resuscitation area and open access to medicines

placed on the top counter with no member of staff present. The unlocked medicine fridge

contained Rapid Sequence Induction (RSI) drugs used for paralysis of a patient with life-

threatening symptoms. The drug preparation area was not locked by a door and relatives of

patients within the department could gain access if no member of staff was manning this area.

Staff told us there was CCTV in this area; however, when we spoke with security staff, they could

not assure us the CCTV was manned 24/7.

We observed two members of nursing staff undertaking controlled drugs sign-out. NICE guideline

[NG46] Controlled drugs: safe use and management states where possible two members of staff

should oversee the sign out of controlled drugs. Trust policy also stipulates this approach.

However, we witnessed two members of staff handing over the signing out of controlled drugs to

another two members of staff and not completing the sign out process. This leaves room for error

in the signing out of controlled drugs and increases the risk of the wrong dosage being signed out

for a patient.

There was pharmacy support and staff could access medicines supplies and advice throughout the

day and out of hours. Nurse were authorised to use Patient Group Directions (PGDs). These are

written instructions for the supply or administration of medicines to groups of patients who may not

be individually identified before presentation for treatment. These were available on the intranet and

could only be administered by trained and permanent nurse employed at the hospital. We saw that


the PGDs had been recently reviewed and were up to date. We saw the management team was in

the process of getting all the nursing staff to read the updates and sign the PGDs.

A medicines audit carried out within the ED showed significant concerns in many areas. For

example, ‘fridge temperature recordings in range’ showed as 64% compliant and ‘are all

refrigerated medicines in date’ as 57% compliant.

Arrangements were in place to ensure there were adequate supplies of emergency medicines and

equipment especially out of hours via emergency medicine cupboard and on-call pharmacist.

Incidents

The service managed patient safety incidents well. Staff recognised incidents and reported

them appropriately. Managers investigated incidents but sharing lessons learned with the

whole team and the wider service was limited. When things went wrong, staff apologised and

gave patients honest information and suitable support.

Serious incidents (SI) were discussed as part of the ED monthly clinical governance meeting. SI’s

were investigated, themes identified and learning outcomes discussed as part of the clinical

governance meeting. However, operational staff were unable to tell us any learning they had

received regarding any of the serious incidents which had taken place in the last 12 months within

the department.

The trust used an electronic reporting system which is widely used in the NHS. Staff used this

system to report incidents and near misses. Staff we spoke with were aware of how to use this

system and said they found the system easy to use. However, some staff reported they were not

always given the time to report incidents due to patient demand and work pressures.

From November 2014, NHS providers were required to comply with the duty of candour

Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The duty of candour is a regulatory duty that relates to openness and transparency and requires

providers of health and social care services to notify patients (or other relevant persons) of certain

‘notifiable safety incidents’ and provide reasonable support to that person.

The trust had a duty of candour policy in place and staff we spoke with were aware of this policy

and how to locate it. Senior staff took responsibility for the formal duty of candour process.

Morbidity and mortality meetings were held monthly which reported on all deaths in the ED. These

meetings were attended by consultant staff and senior nurses.

Management staff told us that all staff groups were responsible for reporting incidents using the

online incident reporting system. These would then be investigated by a nominated member of

staff and any learning disseminated during staff meetings.

Never Events

Never events are serious patient safety incidents that should not happen if healthcare providers

follow national guidance on how to prevent them. Each never event type has the potential to

cause serious patient harm or death but neither need have happened for an incident to be a

never event.

From October 2017 to September 2018, the trust reported one incident classified as a never

event for urgent and emergency care. This was a medicines incident, meeting SI criteria in


January 2018.

(Source: Strategic Executive Information System (STEIS))

Breakdown of serious incidents reported to STEIS

In accordance with the Serious Incident Framework 2015, the trust reported 23 serious incidents

(SIs) in urgent and emergency care which met the reporting criteria set by NHS England from

October 2017 to September 2018.

They were:

Incident type King’s

college

Princess

Royal

Total

incidents

Treatment delay meeting SI criteria 3 5 8

Sub-optimal care of the deteriorating patient meeting

SI criteria

4 4

Pending review (a category must be selected before

incident is closed)

1 2 3

Slips/trips/falls meeting SI criteria 2 2

Diagnostic incident including delay meeting SI criteria

(including failure to act on test results)

1 1 2

Abuse/alleged abuse of adult patient by staff 1 1

Unauthorised absence meeting SI criteria 1 1

Medication incident meeting SI criteria 1 1

VTE meeting SI criteria 1 1


Safety thermometer

The Safety Thermometer is used to record the prevalence of patient harms and to provide

immediate information and analysis for frontline teams to monitor their performance in delivering

harm free care. Measurement at the frontline is intended to focus attention on patient harms and

their elimination.

Data collection takes place one day each month. A suggested date for data collection is given but

wards can change this. Data must be submitted within 10 days of the suggested data collection

date.

Data from the Patient Safety Thermometer showed that the trust reported no new pressure

ulcers, no falls with harm and no new urinary tract infections in patients with a catheter from

October 2017 to October 2018 within urgent and emergency care.

(Source: NHS Digital - Safety Thermometer)


Is the service effective?

Evidence-based care and treatment

The service provided care and treatment based on national guidance and evidence of its

effectiveness. Managers checked to make sure staff followed guidance.

Staff working in the ED had access to the latest evidence-based treatment through the trusts

intranet site. We observed staff checking NICE guidelines and accessing the trusts own policy on

treating suspected sepsis patients. Trust policy referred to the Royal College of Emergency

Medicine (RCEM) and other guidelines where relevant. Junior members of staff also told us they

found the trusts policies easy to find through the intranet.

New NICE guidelines were reviewed, discussed and approved during the clinical governance

meetings and changes to practice disseminated to staff via the noticeboard, team meetings and

email.

Patient safety and medication alerts were brought to staff attention through team meetings and

email notification. Posters and notices were also pinned to notice boards in each area of ED.

There was a monthly trauma board which met for two hours including trauma consultants, nurse

specialists and department leads. New trauma evidence and guidelines were discussed and any

changes to practice disseminated to staff.

The trust had a service level agreement (SLA) with a local mental health trust to support staff in

treating patients with a mental health illness. Specialist staff were asked to attend and assess

patients who potentially required sectioning under the Mental Health Act. The trust had a policy in

place to help staff meet the needs of patients with a mental health need and the process of

contacting a specialist. Staff spoke highly of the mental health support staff that could give patients

with mental health illness more time and specialist skills.

We observed patients being given appropriate medical advice in line with latest evidence. We also

saw members of the medical team informing a patient when it was appropriate to seek further help

with their condition and what to do if their condition deteriorated. We observed the consultant in

charge checking NICE guidelines before giving the advice.

Nutrition and hydration

Staff gave patients enough food and drink to meet their needs and improve their health.

They used special feeding and hydration techniques when necessary.

We spoke with eight patients and their relatives about nutritional and hydration needs. There was

a mixture in response with four patients telling us they had not been offered a drink. However, this

may have been because nursing staff were not yet aware if the patient required an operation and

needed to be nil by mouth (not allowed to eat). The other four patients and relatives we spoke with

had been offered a drink or had been advised where to get a drink from if they required one.

There were shops on site and vending machines located throughout the hospital. We saw water

machines available for patient use.

Patients were asked if they had any special dietary needs and this was recorded by the nursing

staff. There was choice of food suitable for children.

Intravenous fluids were given where indicated and was noted in the patient’s records.



In the CQC Emergency Department Survey, the trust scored 6.3 for the question “Were you able

to get suitable food or drinks when you were in the emergency department?” This was about the

same as other trusts.


Pain relief

It was unclear if patient’s pain had been properly assessed and treated due to the inconsistencies

in recording pain information in a patient’s medical record.

We viewed 20 patient records of both adult and paediatric patients; there were general

inconsistencies in the recording of pain relief within the records. It was not always clear if pain

relief had been given, what had been given and when it was given.

We saw that patient pain scores were not always recorded so it was difficult to know if a patient

had been asked their pain score. We did however, observe members of staff in the resuscitation

area asking patients for their pain score and documenting these in a timely manner.

The departments had systems and processes in place to support staff in assessing pain in

patients who had difficulty communicating. However, staff we spoke with were unable to tell us

what processes were in place. Staff told us they generally looked at the patient’s appearance to

tell if the patient was experiencing pain.

We spoke with eight patients, all of them told us they been offered pain relief on arrival into the

ED.


In the CQC Emergency Department Survey, the trust scored 5.8 for the question “How many

minutes after you requested pain relief medication did it take before you got it?” This was about

the same as other trusts.

The trust scored 7.7 for the question “Do you think the hospital staff did everything they could to

help control your pain?” This was about the same as other trusts.


Patient outcomes

RCEM Audit: Moderate and acute severe asthma 2016/17

In the 2016/17 Royal College of Emergency Medicine (RCEM) Moderate and acute severe

asthma audit, King’s College Hospital emergency department failed to meet any of the national

standards.

The department was in the upper UK quartile for two standards:

• Standard 1a (fundamental): O2 should be given on arrival to maintain sats 94-98%. This

department: 96%; UK: 19%.

• Standard 5a (fundamental): within 60 minutes of arrival (acute severe). This department:


44.4%; UK: 19%.

The department was in the lower UK quartile for one standard:

• Standard 3 (fundamental): High dose nebulised β2 agonist bronchodilator should be given

within 10 minutes of arrival at the emergency department. This department: 12%; UK: 25%.

The department’s results for the remaining four standards were all within the middle 50% of

results.


asthma audit, Princess Royal hospital emergency department failed to meet any of the national

standards.





48.3%; UK: 19%.

The department’s results for the remaining five standards were all within the middle 50% of

results.

(Source: Royal College of Emergency Medicine)

RCEM Audit: Consultant sign-off 2016/17

In the 2016/17 Consultant sign-off audit, King’s College Hospital emergency department failed to

meet any of the national standards.

The department was in the upper UK quartile for one standard:

• Standard 3 (fundamental): Consultant reviewed: patients making an unscheduled return to the

emergency department with the same condition within 72 hours of discharge. This department:

25%; UK: 12%.

The department was in the lower UK quartile for the remaining three standards:

• Standard 1 (developmental): Consultant reviewed: atraumatic chest pain in patients aged 30

years and over. This department: 0%; UK: 11%.

• Standard 2 (developmental): Consultant reviewed: fever in children under 1 year of age. This

department: 0%; UK: 8%.

• Standard 4 (developmental): Consultant reviewed: abdominal pain in patients aged 70 years


and over. This department: 0%; UK: 10%.

The department’s results for the remaining two standards were all within the middle 50% of

results.

The site did not report any data for Standard 2.


RCEM Audit: Severe sepsis and septic shock 2016/17

In the 2016/17 severe sepsis and septic shock audit, King’s College Hospital Emergency

Department failed to meet seven of the eight national standards.

The department was in the upper UK quartile for three standards:

• Standard 1: Respiratory rate, oxygen saturations (SaO2), supplemental oxygen requirement,

temperature, blood pressure, heart rate, level of consciousness (AVPU or GCS) and capillary

blood glucose recorded on arrival. This department: 100%; UK: 69.1%.

• Standard 2: Review by a senior (ST4+ or equivalent) emergency department medic or

involvement of critical care medic (including the outreach team or equivalent) before leaving

the emergency department. This department: 98%; UK: 64.6%.

• Standard 8: Urine output measurement/fluid balance chart instituted within four hours of arrival.

This department: 40%; UK: 18.4%.


results.


results.


Unplanned re-attendance rate within seven days

From October 2017 and September 2018, the trust’s unplanned re-attendance rate to A&E within

seven days was worse than the national standard of 5% and about the same as the England

average.


Unplanned re-attendance rate within seven days - King's College Hospital NHS Foundation

Trust


We saw staff had access to a sepsis screening tool and a pathway to support them in identifying

and managing a patient with sepsis. Information about sepsis was readily available to staff via the

intranet. The trust had sepsis policies for adults and children.

Competent staff

The service made sure staff were competent for their roles. Managers appraised staff’s

work performance and held supervision meetings with them to provide support and

monitor the effectiveness of the service.

There was a trust induction programme for all new members of staff as well as an induction into

the ED. The induction programme consisted of checking competencies, such as, airway

management, breathing, ventilation and oxygenation. It also included an orientation of the

department. New staff we spoke with felt the local induction was useful and felt well supported by

their peers and mentor.

The department had a clinical nurse educator to ensure staff increased their knowledge base and

kept up to date on key skills. The education programme consisted of life support training,

management of the sick child and support in recording vital signs. The clinical educator told us it

was often difficult to find time for staff to complete educational programmes due to the increased

activity within the ED.

The department carried out simulation training for staff to ensure skills were kept up to date and

confidence was maintained in certain scenarios. This included chemical, biological, radiological

and nuclear (CBRN) training and scenarios, dealing with potential Ebola patients and

management of the critically unwell individual. Staff told us these training sessions were useful

and helped maintain a degree of competence.

Staff we spoke with told us they had been given the opportunity to carry out additional competency

training such as a master’s degree or advanced clinical training.

Staff were competent in recognising vulnerable patients and patients with complex social needs.

Staff were aware of how to refer patients for specialist advice, such as from the psychiatric liaison

team and the drugs and alcohol service.


Junior medical staff we spoke with told us they had a lot of opportunity to learn new skills within

the department. Junior and middle grade medical staff spoke highly of their senior colleagues and

told us they would often do adhoc refresher training with the consultants in the department.

Medical staff we spoke with said there was a great ethos in the department of asking senior

colleagues to show them how to carry out certain skills and not feel penalised or inadequate for

asking to be shown. Junior medical staff told us that senior colleagues were more than willing to

help them gain further clinical skills. We observed many senior colleagues talking junior staff

through scenarios and showing them how to carry out certain skills in a friendly and supportive

manner.

Senior nursing staff told us the monitoring of competencies within the department was undertaken

by the clinical nurse educator. For medical staff, the consultant in charge of ED was responsible

for ensuring medical staff competencies.

Appraisal rates

From September 2017 to August 2018, 74% of staff within urgent and emergency care at the

trust received an appraisal compared to a trust target of 90%.

Staffing group Appraisals

required

Appraisals

complete

Completion %

Healthcare Scientists 1 1 100%

Add Prof Scientific and Technic 6 5 83%

Nursing and Midwifery Registered 287 235 82%

Medical & Dental Staff - Hospital 123 87 71%

Administrative and Clerical 74 50 68%

Additional Clinical Services 56 37 66%

NHS infrastructure support 3 1 33%

Qualified Nursing and Health Visiting Staff 11 2 18%

Estates and Ancillary 1 0 0%

(Source: Routine Provider Information Request (RPIR) - Appraisal tab)

Both medical and nursing staff told us they did not always receive an appraisal. Staff told us they

felt they were able to talk to their managers frequently, but this did not always follow the formal

appraisal process. New staff told us they felt adequately supervised and were given opportunity to

talk to their mentors and line manager whenever required.

Multidisciplinary working

Staff from different disciplines worked together as a team to benefit patients. Doctors,

nurses and other healthcare professionals supported each other to provide good care.

The ED operated 24 hours a day, seven days per week and worked closely with many other

departments within the trust, such as pathology and diagnostics.

Staff confirmed they had 24-hour access to diagnostic services such as x-rays or computerised

tomography (CT), which was situated next to the ED.

Pathology support, such as blood testing was available 24/7 and staff we spoke with reported no

problems with the accessibility of this service.

ED staff also worked closely with frailty specialists to support patients who had additional health

and social care needs. We saw a number of interactions between ED and physiotherapy staff. We


saw a nurse and a physiotherapist helping a patient get used to their new walking aid whilst

provided advice for relatives.

ED staff also worked in collaboration with the psychiatric support liaison service and the child and

adolescent mental health service (CAMHS). Staff we spoke with said they had a good working

relationship together and worked well to provide best patient care.

We spoke with several local ambulance crews who told us they worked well with ED staff. The

ambulance crews we spoke with told us this was their preferred ED due to the tentative and

respectful nature of the staff working there.

Seven-day services

The psychiatric liaison service was available seven days per week and 24 hours a day to people

aged 18 and above. The diagnostic imaging department was co-located next to the ED and

provided a 24-hour seven- day a week service which included rapid access to CT scanner

facilities.

Occupational health services were also available seven days a week, these included speak and

language therapist, frailty specialists and diabetic services.

The trust had an agreement with a local trust who provided mental health liaison service 24 hours

a day, seven days a week.

Health promotion

We observed staff offering health promotion advice to patients relating to smoking, exercise and

diet and healthy lifestyles. We observed advice being given on how to manage specific patient

conditions.

There was a range of patient information leaflets available in the department and posters advising

patients how to access drug and alcohol services.

We observed paediatric members of staff giving written information to parents on how to deal with

conditions such as eczema, fever and headaches in their children. We observed verbal advice

being given to promote a healthier lifestyle.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards

Staff understood how and when to assess whether a patient had the capacity to make

decisions about their care. They followed the trust policy and procedures when a patient

could not give consent.

Staff understood the importance of consent when delivering care to patients and displayed a good

understanding of the requirements of the Mental Capacity Act (2005) or how to gain expert advice

from the psychiatric liaison team.

We observed staff gaining consent from patients prior to examination and treatment. We observed

implied consent taking place as well as formal and written consent. We saw in records staff had

completed capacity assessments and followed the correct process for consenting patients who

were unable to consent themselves. Staff understood who could give consent on behalf of a

patient when an advocate or best interest decision should be made.

The trust had consent to treatment policy, which was available through the intranet, version

controlled and in date. Staff we spoke with could tell us how to locate this policy.

Despite the low mandatory training rates for Mental Capacity and Consent, staff could tell us about

the process for gaining consent and there was good knowledge around the Deprivation of Liberty


Safeguards (DoLS). The Deprivation of Liberty Safeguards (DoLS) provide legal protection for

those vulnerable people aged 18 and over who are, or who may become, deprived of their liberty.

The safeguards exist to provide a proper legal process and suitable protection in circumstances

where deprivation of liberty appears to be unavoidable, in a person’s own best interests.

Data supplied to us by the trust showed nursing staff were not compliant in completing mandatory

mental capacity and consent training.

Mental Capacity Act and Deprivation of Liberty training completion

The trust reported that as of October 2018 Mental Capacity Act (MCA) training was completed by

32% of staff in urgent and emergency care compared to the trust target of 80%.

There was no separate course for Deprivation of Liberty Safeguards training.

(Source: Routine Provider Information Request (RPIR) – Statutory and Mandatory Training tab)

Is the service caring?

Compassionate care

Staff provided treatment and care in a kind and compassionate way and treated people with

dignity and respect. We observed staff were working very hard and were dedicated to looking after

patients throughout their journey. Staff were empathetic and considerate to patients and provided

sensitive care.

We observed curtains being drawn around patient’s beds when staff delivered care and treatment;

this ensured the patient’s dignity was respected.

We observed staff in the resuscitation area providing friendly, supportive and comforting care. We

observed several patients within this area being spoken to with dignity and respect and staff could

dedicate time to understanding the needs of each individual patient. One relative we spoke with

told us they were ‘blown away’ by the level of support and care given to them by the nursing and

medical staff. Other relatives of patients within the resuscitation area also spoke very highly of the

care their loved ones received. We observed all patients being informed of their treatment and

reassured where appropriate. Staff were aware of all the needs of patients and took the time to

understand the type of services which could be offered to a patient once they were in a more

stable condition.

However, during busy periods we were concerned the major’s area and walk-in patients were

given substandard care. We observed one patient booking in at the walk-in reception area and

being asked personal and sensitive information in front of a waiting queue of people. The nurse

did not appear to pick up on the sensitive nature of the patient’s symptoms and proceeded to ask

for clinical detail within earshot of the public.

We observed members of staff taking clinical observations in the waiting area in front of other

patients. We then heard staff discussing the results of these observations in front of other patients

and relatives. Staff told us they had access to private treatment/consultation rooms; however,

during busy periods these were often unavailable and in use.

Friends and Family test performance

The trust’s urgent and emergency care Friends and Family Test performance (% recommended)


was worse than the England average from October 2017 to September 2018. There was no data

submitted for April or May 2018.

In the most recent month, September 2018, the trust’s performance was 82% compared to

England average of 86.5%.

A&E Friends and Family Test performance - King's College Hospital NHS Foundation Trust

(Source: NHS England Friends and Family Test)

Emotional support

Staff provided emotional support to patients and relatives. We saw several members of staff

offering emotional support to relatives of patients who were at the end of their life. This included

talking sensitively and informatively about the patient’s condition to the relative, asking if there was

anything the staff could do for them and signposting them to additional services such as

counselling and bereavement services.

There was a multi-faith chaplain available within the hospital and other representatives from

various faith groups could be contacted. One relative told us the staff in ED had been ‘tremendous’

and explained things fully.

Staff told us they sometimes found it difficult to support people as much as they wanted when the

ED was busy.

Understanding and involvement of patients and those close to them

We observed staff introducing themselves, explaining procedures and obtaining consent before

conducting them. We observed staff involving young people in the paediatric department in their

care and giving them treatment options, which were easy to understand.

Patients and relatives, we spoke with across the ED told us they had been included in the decision

making of their own care. People’s emotional and social needs were considered by staff.


Patients were given information in a language they could understand without complicated medical

terminology.


The trust scored about the same as other trusts for each of the 24 Emergency Department

Survey questions relevant to the caring domain.

Question Trust 2016 2016 RAG

Q10. Were you told how long you would have to wait to be

examined?

3.8 About the

same as

other trusts

Q12. Did you have enough time to discuss your health or

medical problem with the doctor or nurse?

8.3 About the

same as

other trusts

Q13. While you were in the emergency department, did a doctor

or nurse explain your condition and treatment in a way you could

understand?

8.2 About the

same as

other trusts

Q14. Did the doctors and nurses listen to what you had to say?

9.1 About the

same as

other trusts

Q16. Did you have confidence and trust in the doctors and

nurses examing and treating you?

8.7 About the

same as

other trusts

Q17. Did doctors or nurses talk to each other about you as if you

weren't there?

8.7 About the

same as

other trusts

Q18. If your family or someone else close to you wanted to talk

to a doctor, did they have enough opportunity to do so?

7.5 About the

same as

other trusts

Q19. While you were in the emergency department, how much

information about your condition or treatment was given to you?

8.8 About the

same as

other trusts

Q21. If you needed attention, were you able to get a member of

medical or nursing staff to help you?

7.8 About the

same as

other trusts

Q22. Sometimes in a hospital, a member of staff will say one

thing and another will say something quite different. Did this

happen to you in the emergency department?

8.6 About the

same as

other trusts

Q23. Were you involved as much as you wanted to be in

decisions about your care and treatment?

7.3 About the

same as

other trusts

Q44. Overall, did you feel you were treated with respect and

dignity while you were in the emergency department?

9.0 About the

same as

other trusts

Q15. If you had any anxieties or fears about your condition or

treatment, did a doctor or nurse discuss them with you?

7.3 About the

same as

other trusts

Q24. If you were feeling distressed while you were in the 6.3 About the



emergency department, did a member of staff help to reassure

you?

same as

other trusts

Q26. Did a member of staff explain why you needed these

test(s) in a way you could understand?

8.5 About the

same as

other trusts

Q27. Before you left the emergency department, did you get the

results of your tests?

8.1 About the

same as

other trusts

Q28. Did a member of staff explain the results of the tests in a

way you could understand?

9.0 About the

same as

other trusts

Q38. Did a member of staff explain the purpose of the

medications you were to take at home in a way you could

understand?

9.5 About the

same as

other trusts

Q39. Did a member of staff tell you about medication side effects

to watch out for?

5.1 About the

same as

other trusts

Q40. Did a member of staff tell you when you could resume your

usual activities, such as when to go back to work or drive a car?

4.9 About the

same as

other trusts

Q41. Did hospital staff take your family or home situation into

account when you were leaving the emergency department?

4.3 About the

same as

other trusts

Q42. Did a member of staff tell you about what danger signals

regarding your illness or treatment to watch for after you went

home?

5.3 About the

same as

other trusts

Q43. Did hospital staff tell you who to contact if you were worried

about your condition or treatment after you left the emergency

department?

7.4 About the

same as

other trusts

Q45. Overall... (please circle a number)

7.8 About the

same as

other trusts


Is the service responsive?

Service delivery to meet the needs of local people

The trust planned and provided services in a way that met the needs of local people.

The ED is lead trauma centre for south east UK. This meant patients would often be taken to this

ED from anywhere in south eastern counties. The department was staffed by consultants 24 hours

a day and other medical staff who specialised in trauma. At the time of inspection, the ED was

accepting a wide range of patients including those suffering stroke, trauma, cardiac arrest, medical

and surgical emergencies and obstetrics and gynaecology emergencies.


The ED had a paediatric area which accepted babies, children and young people. There were

separate waiting areas for adult and child patients. The paediatric ED worked well with the

children’s ward to ensure children were in the most appropriate location.

Staff recognised there had been a steady increase in the number of patients presenting to ED with

mental health needs. Patients had access to mental health support on site via the psychiatric

liaison team and the children and adolescent mental health services (CAMHS) team.

There were daily performance meetings and Hunter Review Meetings (breaches) held within the

ED. These meetings included the site management team, bed managers, ward senior staff and

the ED leadership team. It was clear there was a focus on patient safety and staff worked

cohesively to improve flow through the ED. There was also once daily resuscitation and paediatric

safety huddles to discuss challenges of the department for that day.

The ED had patient pathways in place to stream patients to primary care services which reduced

the burden on the ED. This included signposting patients to a GP service, a sexual health clinic or

community walk-in service.

The ED had a clinical decision unit (CDU) where patients could stay for 24-48 hours. Patients

located here were under the care of the ED consultants.

Meeting people’s individual needs

The service took account of patients’ individual needs.

There was limited seating for walk-in patients and patients were not protected from the weather

when queuing outside the hospital. The waiting area was accessible for patients in a wheel chair

and trolleys were available for bariatric patients.

Translation services, such as, telephone interpreter and British sign language (BSL) lip speakers

were available 24 hours per day seven- days a week by an external provider. Staff understood

how to access these services.

There was a ‘family’s room’ available for relatives to use during times of bereavement or upsetting

news. This was a pleasant environment with literature and advice leaflet available. Adjacent to this

room was a viewing area where relatives could view their loved ones who had passed away.

Staff showed an awareness of the cultural and religious differences within the local community.

They were sensitive to the needs of families, relatives and patients.

We observed staff treating patients living with dementia with dignity and included family and carers

in the discussion of treatment choices. Relatives we spoke with of a female patient living with a

learning disability, told us they were grateful and happy with the treatment their relative had

received.

Patients could access addiction services and there were clear pathways for patients requiring

withdrawal from drugs and alcohol.

Staff in the ED had 24-hour seven- day per week access to psychiatric liaison support. Young

people requiring support from CAMHS often had to wait to be seen. Anyone with a mental health

condition was seen by one of these teams.

The service had a speciality frailty team who carried out assessments of frail and elderly patients

within the department. The team was based outside of the department and attended patients on

request.



The trust scored about the same as other trusts for each of the three Emergency Department

Survey questions relevant to the responsive domain.

Question – Responsive Score RAG

Q7. Were you given enough privacy when discussing your

condition with the receptionist?

7.0 About the same

as other trusts

Q11. Overall, how long did your visit to the emergency

department last?

6.2 About the same

as other trusts

Q20. Were you given enough privacy when being

examined or treated?

8.9 About the same

as other trusts


Access and flow

People could not always access the service when they needed it. Waiting times from

referral to treatment and arrangements to admit treat and discharge patients were not in

line with good practice.

The ED was operational 24 hours per day seven-days a week and patients could self-present to

the ED, be referred by their GP or 111 services, via ambulance or by the Helicopter Emergency

Medical Service (HEMS). Walk in patients were often streamed to the urgent care centre (UCC) or

to a local GP service operating outside of the ED. During inspection, the queue of walk-in patients

extended to the door and outside of the building during busy times. Some patients we spoke with

had been queuing outside for more than 20 minutes to book in and waited a further 40 minutes to

have an initial assessment. We heard patients complaining about the length of time taken to be

seen.

Staff we spoke with told us their biggest challenge and frustration was flow through the

department. They were concerned about the length of time some patients had to wait to be seen

by a clinician and the wait to transfer a patient from ED to a ward was increasing. Staff told us they

had a number of patients in the ED who had waited an extended period to be transferred to a ward

bed. Staff told us they had previously had a patient who waited 5 days to be transferred to a ward.

During the inspection we observed a number of patients who needed to be admitted onto a ward

but was unable to leave the ED due to lack of bed capacity within the hospital. This meant patients

often experienced a delay in treatment and specialist staff had to come to ED to assess a patient.

For example, we saw a liver specialist come to see a patient in the resuscitation area who required

admission onto a specialist medical ward, but the specialist was unable to start treatment because

the patient was not in the correct clinical area.

Staff told us they felt some pressure could be alleviated by having an ambulatory care unit close to

the ED. Ambulatory Care is a service which offers same day emergency care to patients at the

hospital. This means that patients are assessed, diagnosed, treated and are able to go home the

same day, without being admitted into a hospital bed overnight wherever possible. Currently, all

patients attended as walk-in patients regardless of whether they had been referred by a GP or

self-presented. The clinical lead in the department had put forward a business case for this but the

trust had not agreed to this plan. It was unclear if the trust was going to support the proposal of an

ambulatory care unit.


Safety huddles were held daily at multiple set times and as required dependant on department

activity. The purpose of the safety huddle was to assess which patients could be moved out of the

department to hold with patient flow. We joined several safety huddles and were concerned that

staff were more tasks oriented than patient oriented. We observed staff referring to patients by

their cubicle number and talking in a manner which was not conducive to good patient care. One

senior member of staff was heard speaking in a derogatory way to another member of staff and

gave staff deadlines of when to move patients out of the ED and to another department with no

clinical oversight or discussion of the patient’s needs.

Staff told us they had good links with the intensive care unit, anaesthetists and intensivists who

came to the department when needed.

Median time from arrival to treatment (all patients)

The Royal College of Emergency Medicine recommends that the time patients should wait from

time of arrival to receiving treatment should be no more than one hour. The trust did not meet the

standard for 11 months over the 12-month period from October 2017 to September 2018.

In the most recent month the trust’s median time to treatment was 76 minutes compared to the

England average of 61 minutes.

Median time from arrival to treatment from October 2017 to September 2018 at King's

College Hospital NHS Foundation Trust


Percentage of patients admitted, transferred or discharged within four hours (all

emergency department types)

The Department of Health’s standard for emergency departments is that 95% of patients should

be admitted, transferred or discharged within four hours of arrival in the emergency department.

From November 2017 to October 2018 the trust failed to meet the standard and performed worse

than the England average.

In the most recent month, October 2018, the trust admitted, transferred or discharged 78% of

patients within four hours of arrival in the emergency department compared to the England

average of 89%.


Four-hour target performance - King's College Hospital NHS Foundation Trust

(Source: NHS England - A&E waiting times)

Percentage of patients waiting more than four hours from the decision to admit until being

admitted

From November 2017 to October 2018 the trust’s monthly percentage of patients waiting more

than four hours from the decision to admit until being admitted was similar to the England

average.

From November 2017 to May 2018 performance against this metric was higher than the national

average however since May it has been like the England average.


admitted - King's College Hospital NHS Foundation Trust

(Source: NHS England - A&E SitReps).


Number of patients waiting more than 12 hours from the decision to admit until being

admitted

Over the 12 months from November 2017 to October 2018, 186 patients waited more than 12

hours from the decision to admit until being admitted. The highest numbers of patients waiting

over 12 hours were in August 2018 (29), March 2018 (26) and April 2018 (24).

Month Number of patients waiting

more than 12 hours to

admission

November 2017 8

December 2017 0

January 2018 9

February 2018 10

March 2018 26

April 2018 24

May 2018 16

June 2018 21

July 2018 13

August 2018 29

September 2018 20

October 2018 10

(Source: NHS England - A&E Waiting times)

Percentage of patients that left the trust’s urgent and emergency care services before

being seen for treatment

From October 2017 to November 2017 the trust performance was worse than the England

average; however, since then there has been no data reported for this metric.

Percentage of patient that left the trust’s urgent and emergency care services without being

seen - King's College Hospital NHS Foundation Trust



Median total time in A&E per patient (all patients)

From November 2017 to October 2018 the trust’s monthly median total time in A&E for all

patients was higher than the England average.

In the most recent month, September 2018, the trust’s monthly median total time in A&E for all

patients was 202 minutes compared to the England average of 154 minutes.

Median total time in A&E per patient - King's College Hospital NHS Foundation Trust


Learning from complaints and concerns

The service treated concerns and complaints seriously, investigated them and learned

lessons from the results, and shared these with all staff.

Summary of complaints

From October 2017 to September 2018 there were 147 complaints about urgent and emergency

care services. The trust took an average of 29 working days to investigate and close complaints.

This was not in line with their complaints policy, which states complaints should be closed within

25 working days.

The breakdown of the subjects of complaints are shown in the table below:

Subjects No. of complaints

Clinical Treatment 67

Values & Behaviours (Staff) 22

Communications 15


Patient Care including Nutrition / Hydration 10

Waiting Times 10

Other 7

Admissions, discharge, transfers and transport excluding delayed

discharge due to absence of care package 5

Consent to treatment 3

Trust Administration 3

Privacy, dignity and wellbeing (including care with compassion, respect,

diversity, patients' property and expenses); 2

Access to treatment or drugs (including decisions made by

Commissioners); 1

Prescribing errors 1

Facilities Services (Inc. access for people with disability, cleanliness,

food, maintenance, parking, portering) 1


Number of compliments made to the trust

The trust did not provide any compliments data.

(Source: Routine Provider Information Request (RPIR) – Compliments tab)

Patients and relatives, we spoke with were aware of how to make a complaint to the trust and we

saw leaflets available within ED which explained the process of making a complaint.

Staff could tell us the action they would take if a patient of relative was to make a complaint to

them. They told us they would try to resolve this complaint immediately or escalate to a more

senior member of staff. Staff also told us they gave patients and relatives a leaflet on how to make

a formal complaint.

Staff told us they received individual feedback from complaints if the nature of the complaint

involved that member of staff. Wider learning from complaints took place during monthly team

meetings. Additional training was offered to staff if a complaint related to the competency of an

individual.

Is the service well-led?

Leadership

Not all managers in the trust had the right skills and abilities to run a service providing

high-quality sustainable care.

There was a clear leadership presence in the department and it was easy for staff to access/locate

the consultant in charge of the shift. Their visibility was maintained throughout the inspection.

Medical staff we spoke with told us they felt supported by management and there was stability in

the department leadership team. Staff spoke fondly of the medical teams and there were clear

lines of accountability. Consultants we spoke with told us they felt it was essential to embed an

open and transparent culture in the department and felt this was necessary for staff retention.


Medical staff also told us they felt supported by senior colleagues and management. Opportunities

for career progression and training were provided through mentorship and educational

supervisors.

Nursing staff we spoke with were mixed in their response to the nursing leadership team. Some

staff felt that ideas and suggestions were not always heard whilst other management staff took

ideas on board and tried to implement them. Staff told us there was not always a leadership

presence on the ground and some of the leadership team were more concerned with data, figures

and numbers than morale or general staff concerns. We saw evidence of this during a daily

‘safety huddle’ when patients were referred to as bed numbers and there was a heavy emphasis

on data interpretation and meeting targets.

Staff told us there was a disconnect between the department leadership team and the executive

team because some senior members of the organisation did not appear to understand the

seriousness of some of the issues the department faced.

Staff told us they did not always feel kept up to date with developments and changes within the

department. Staff told us new ideas and suggestions were often disregarded without consideration

and staff concerns were not always addressed.

The department had senior nurse coordinators who oversaw the daily management and

requirements of the department on each shift. We found they were focused on the challenges

within the department and worked well with other colleagues from different departments to ensure

patient flow through the department was the best it could be. The senior nurse co-ordinators we

spoke with felt senior management did not appear to fully understand the challenges the

department faced.

Vision and strategy

The trust had a vision for what it wanted to achieve, however staff were unaware of this vision

and any workable plans to turn it into action.

Staff we spoke with were unaware of the vision and strategy for the ED. Staff were unaware of the

trusts values and mission statement and had no understanding of the local strategy for ED. Staff

were aware there were trust values but were unable to recall what these were.

Paediatric staff also told us the same; they had no clear understanding of the trust wide or local

vision and strategy.

Culture

Managers across the trust did not always promote a positive culture that supported and valued

staff, creating a sense of common purpose based on shared values.

Staff we spoke with felt proud to work in the department and spoke highly of their role despite the

pressures. We saw evidence of good team working and peer support. New staff we spoke with

said they felt supported by staff and nurtured into their role.

Junior medical staff we spoke with told us they felt the department had a learning culture that

supported them to progress in their career.

Nursing staff told us they did not always agree with managerial decisions but were empathetic of

the reasons why particular decisions needed to be made. Staff generally had a good

understanding of the challenges within the department but felt the trust had no solution to resolve

some of these.


Staff we spoke with said they had been affected negatively by some of the emotional events and

traumatic injuries seen within the department over the past few years. Staff spoke of resilience and

the importance of looking out for colleague’s wellbeing and ensuring staff took the opportunity to

discuss traumatic events. However, most staff members we spoke with felt the trust could do more

to help with the emotional wellbeing of staff within the department.

Staff we spoke with told us they felt confident to suggest new ways of working or to try new things

to improve patient experience but felt some managers automatically rejected new ideas. Staff we

spoke with felt there were some managers who were ‘old school’ and did not like to try ideas which

were not their own.

Governance

The trust did not always use a systematic approach to continually improving the quality of its

services and safeguarding high standards of care.

We reviewed minutes from monthly clinical governance meetings. The minutes demonstrated

incidents, complaints, performance and risks were discussed. There was time set aside to discuss

learning from specific incidents and complaints. However, we could not be assured that this

learning was cascaded to staff who did not attend the meeting. Staff we spoke with had limited

understanding of the department risks, learning from incidents and near misses.

The trust had arrangements in place for patients with mental health needs including a service level

agreement (SLA) with the local mental health trust to provide the department with a registered

mental health nurse (RMN) when required. However, staff told us that there was a lack of

confidence and understanding of how to care for people with mental health needs within the

department.


The trust did not have effective systems for identifying risks, planning to eliminate or reduce

them, and coping with both the expected and unexpected.

We viewed the emergency department (ED) risk register which was maintained electronically for

ease of access and update. The risk register was also available on a staff notice board located in

a staff only area. There were currently nine risks identified on the risk register.

A review of the local ED risk register identified a number of risks which had been on there since

2009. We saw no plans to eliminate the risk or what the department was doing to complete it.

The ED had an informatics dashboard which was used to monitor flow in relation to key

performance indicators. The dashboard was available throughout the department and showed how

the department was performing in relation. Coloured sections of the dashboard indicated how the

department was performing, it also gave staff an understand of how many patients were within the

department.


The trust collected, analysed, managed and used information well to support all its

activities, using secure electronic systems with security safeguards.

The trust had electronic copies of governance policies and procedures in place to ensure

information was stored securely and protected patient’s privacy and security. The department


collected information which was used to monitor performance against local and national indicators.

This performance data was overseen by a general manager for the department. We saw evidence

that information collected accurately reflected the performance of the department.

The department used collected information on many IT systems which included x-ray results,

admission and discharge times, ambulance handover times, breached patients and patient

records. These systems were password protected and we observed screens being locked when a

member of staff moved away from the computer.

Staff were aware of their responsibilities in relation to data protection and we observed staff using

locked confidential waste disposal bins to dispose of used paperwork.

Staff had access to the trust intranet which provided access to policies and procedures, trust wide

news, training, personal development records and performance data.

Engagement

The trust did not always engage well with patients, staff, the public and local organisations

to plan and manage appropriate services.

During our inspection we observed a local school class participating in learning within the

paediatric assessment unit. Staff told us that every week, different local school children would

come to the hospital to be taught safety, health and medical subjects. We observed children being

taught basic first aid techniques. This took place early on a weekday morning when the

department was at its least busy, to minimise any disruption to patient care.

We observed a child friendly feedback leaflet visible in the paediatric department. Staff told us this

was a new implementation and they had not yet collated and identified any themes from the

feedback. Staff said they had seen completed feedback leaflets but not yet looked through them.

The child friendly feedback leaflets contained pictures, easy to understand wording and colours to

make it appeal to children.

During our inspection we observed no feedback forms for adult patients receiving care in the

department. Staff told us there were feedback forms but was unable to find any for observation.

We saw no posters or signage which highlighted how a patient could leave feedback.

Staff told us they were given little information regarding recruitment updates and general changes

within the department. However, we did see evidence of staff newsletters and general information

being communicated to staff via email.


The trust was committed to improving services by learning from when things went well and

when they went wrong, promoting training, research and innovation.

The rapid assessment and triage (RAT) pathway had been recently introduced. Initial data was

showing a decrease in ambulance handover times. The department also had an urgent care

centre (UCC) which combined primary care services and emergency care services traditionally

provided by an ED. This allowed patients to be seen in the right department and by a clinician with

a suitable skill mix for the patient’s symptoms. This included GP’s, nurse practitioners and minor

injury specialists. The aim is that patients receive the right treatment at the right time by the most

suitable clinician.

The department had gone through several structural changes to make patient flow smoother. This

included knocking down walls to make the majors area larger. However, flow remained a problem

for the department despite these changes.


The trust had completed a pilot of volunteering in ED, which was funded by the innovation charity,

NESTA. Over 30 volunteers had been trained to support patients and staff in both ED’s. This had

been evaluated as a successful activity, and 11 new volunteers had been trained in Feb 2019.

Surgery


Surgical services at Kings College Hospital NHS Foundation Trust comprised of general, tertiary

neurosurgery cardiothoracic surgery, paediatric, cardiac and liver surgery. The hospital carries out

major trauma surgical treatment for the south east of England. The trust had 63,084 surgical

admissions from June 2018 to May 2018. Emergency admissions accounted for 11,554 (18.3 %),

41,763 (66.2%) were day case, and the remaining 9,767 (15.5%) were elective.

Surgical services are divided up according to general and specialities, as follows:

General Surgery:

There are currently 95 acute, and 24 elective beds in Surgery. The elective beds are described

as 'clean' and are on Coptcoat ward, taking patients under all surgical specialities except

orthopaedics. Elective orthopaedic patients are admitted to the newly created “clean” nine

bedded elective orthopaedic unit. A further three “clean” orthopaedic beds are available on

Murray Falconer ward (neurosurgery).

The acute surgical unit has 20 beds, including the surgical assessment unit. The current

emergency capacity consists of one ward dedicated for patients with hip fractures, one

emergency surgical ward, and a major trauma ward. There is a dedicated women’s surgical unit

which comprises a combination of short stay trolleys and beds. All wards are able to take ITU

step-down patients.

Tertiary neurosurgery:

There are three emergency and one elective neurosurgical wards, (78 beds) providing state of

the art interventional care and a 11 bedded Neuroscience High Dependency Unit (HDU). There is

a neuroscience admissions lounge and neurosurgical Out Patient Department (OPD), as well as

a 35-bed neurorehabilitation unit.

Cardiothoracic surgery (CTS):

There is a total of 34 beds: which includes six level three, immediately post CTS beds, 10 level

two HDU and 18 ward beds.

The trust does elective and non-elective cases including coronary artery bypass grafts, aortic and

mitral valve repair and replacement as well as supporting the trauma and abdominal aortic

dissection rota for south London. They also do some thoracic - non-cancer work.

Vascular surgery:

There are 12 beds on Cotton ward and a joint service where elective aortic vascular work is


performed. Non-elective aortic work and diabetic foot work, at King’s College Hospital. Carotid

endarterectomy and major amputations are also performed, with high success rate / low

complication rates. The vascular service supports the trauma, stroke, renal and cardiac services.

(Source: Acute Routine Provider Information Request (RPIR) – Context tab)


Mandatory training

The service provided mandatory training in key skills to all staff but did not make sure

everyone had completed it. Compliance rates for medical staff were poor.



Trust level


qualified nursing staff in surgery is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met



Health & Safety [Once] 1,243 1,214 98% Yes

Equality & Diversity [Once] 1,243 1,211 97% Yes

Venous Thromboembolism [Once] 1,161 1,100 95% Yes

Infection Control (Clinical) [2 Years] 1,243 1,159 93% Yes


Fire [2 Years] 1,243 1,136 91% Yes


Resuscitation 1,240 1,035 83% Yes

Manual Handling (Clinical) [2 Years] 1,243 1,000 80% Yes


[ 1 Year] 1,243 949 76% No

Slips, Trips and Falls [3 Years] 1,243 916 74% No


In surgery the 80% target was met for 11 of the 14 mandatory training modules for which

qualified nursing staff were eligible. Staff received e-mail alerts for those mandatory training

topics they had not fully completed. Most ward managers had oversight of staff mandatory

training and staff were supported by their line managers to complete training.


medical staff in surgery is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met



Manual Handling (Clinical) [2 Years] 47 37 79% No


Venous Thromboembolism [Once] 629 442 70% No







Fire [2 Years] 702 420 60% No




[ 1 Year] 702 344 49% No




In surgery the 80% target was met for one of the 17 mandatory training modules for which

medical staff were eligible.

Mandatory training compliance rates amongst medical staff were poor. There was a lack of

oversight from senior management for the monitoring of medical staff mandatory training. Since

the inspection we requested more up to date compliance figures and found medical staff were

compliant for one module only. Key mandatory topics such as mental capacity and consent,

infection control and resuscitation fell far below the expected compliance rate. For example,

across the four surgical specialities only 41% of medical staff had completed mandatory training

for mental capacity and consent. This meant 48 medical staff out of 118 had completed this

training. For infection control training, 46% of medical staff had completed the module. For

resuscitation only 38% of staff had competed the training. Medical staff we spoke with told us

they did not have the time to complete mandatory training. Staff were given no protected time to

complete such training. We found mandatory training for medical staff was not a risk on the

surgery risk register.


Safeguarding

Staff understood how to protect patients from abuse and the service worked well with

other agencies to do so. However medical staff had failed to complete the necessary

mandatory training.



Trust level



qualified nursing staff in surgery is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met


Safeguarding Adults Level 1 [Once] 1 1 100% Yes

Safeguarding Adults Level 2 [3 Years] 1,243 1,188 96% Yes

In surgery the 85% target was met for each of the safeguarding training modules for which

qualified nursing staff were eligible.


medical staff in surgery is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met



In surgery the 85% target was met for neither of the safeguarding training modules for which


Since the inspection we received further up to date information from the trust and this still

showed that medical staff had not competed the relevant mandatory training.

However, staff we spoke with across different skill mixes had a good knowledge on

safeguarding. They knew how to recognise and report abuse. Staff told us safeguarding

referrals were completed through the trusts electronic system or via e-mail to the safeguarding

team. The safeguarding team visited wards if a safeguarding referral had been made. Any

urgent safeguarding concern was referred to the senior nursing team. Social workers were

included in multidisciplinary team meetings for the more vulnerable patient.

Staff had access to safeguarding information through the trust’s policies and procedural

guidelines. There was access to safeguarding leads as we found at our previous inspection.



The service did not always control infection risks well. Staff did not always keep premises

and equipment clean. They did not always use control measures to prevent the spread of

infection.

On the whole we found cleanliness in the surgical wards was good; however, there were pockets

of concerns in the main theatres. We found high surface dust in several theatres and the recovery

area. Several pieces of equipment within the theatre department were dusty and some pieces of

equipment in the shared anaesthetic room, such as the diathermy machine and antiseptic

dispenser were rusting. Curtains within the recovery area were not dated, so there was no

indication of when they needed replacing. This was not in line with the Department of Health’s


code of practice on the prevention and control of infections. The code of practice sets out 10

criteria against which a registered provider should be judged. We found the trust did not comply

with criteria which states a provider should provide and maintain a clean and appropriate

environment in managed premises that facilitates the prevention and control of infections.

Staff raised concerns on Copcoat surgical admission lounge that on occasions patients who had

not been screened for meticillin resistant Staphylococcus Aureus (MRSA) and had attended for

theatre lists and communal clinical areas, when they were in fact MRSA positive. This posed an

infection risk to other patients. Staff told us this usually happened due to last minute changes to

the theatre lists, and admission of patients into the lounge who were in fact emergency patients.

During the inspection we found that due to a lack of beds, maxilla-facial elective patients had been

cancelled to fully utilise theatres emergency cases and these were being admitted for surgery

without appropriate screening.

During our observations of care, staff routinely washed their hands between patients and entering

or leaving wards. Staff used personal protective equipment (PPE) in accordance with hospital

policy.

There was one incident we observed whereby the surgeon’s shoes had blood and iodine solution

on them at the start of a new procedure, but this was an isolated incident. Hand gel was available

throughout the surgical areas and point of care. Staff were ‘bare below the elbows’ which allowed

for good infection control practices. Hand hygiene audits were conducted monthly and results

were displayed throughout wards. These audits showed that overall, surgical services were

compliant with scores averaging over 90%.

A number of patients were in isolation in side rooms to prevent the spread of infection. Staff made

use of appropriate advanced PPE and kept the doors shut. Signs on the outside of the doors gave

warnings around access and precautions.

During our last inspection we observed theatre doors being left open, which was not best practice

for controlling the environment safely. At this inspection, we found there was no change in this. We

found an anaesthetic room door and theatre door open to the front corridor of the theatre

department while staff were working.

There were arrangements for the safe handling, storage and disposal of clinical waste within the

patient bays and ward areas we visited. However, there was a lack of foot operated domestic bins

in theatres and we found open clear plastic sacks for domestic waste were stuck on the walls in

some theatres.

We observed cleaning staff carrying out regular ward rounds. Cleaning staff had access to

appropriate cleaning equipment and had been made aware of the required standards of cleaning.

There were IPC link nurses for each ward and they had received additional training to support staff

within the surgical division.


The service did not always have suitable premises and equipment; however, staff did look

after equipment well.

Surgical wards in the newer parts of the hospital were spacious and clutter free. However, some of

the wards in the older part of the building were restricted in size and lacked storage space. In

Lister ward, the clinical room was cramped and very warm. Stock was stored in patient walkways

due to the limited space, but the stock was placed on shelves and staff did the best they could

within the limitations.


At our last inspection we found theatres to be cluttered with equipment. During this inspection,

despite some improvements in storage in main theatres, on the whole storage space was still

limited, and therefore, large equipment was stored in corridors. There was limited space to store

all disposables and equipment. We found items such as printers and sharps bins stored on the

floors within theatres.

Fire exits on Trundle and Brunel Ward were identified as risks on the corporate risk register. We

visited both wards and found new fire doors had been fitted in Trundle Ward along with slide mats

to help aid of evacuating patients should they need to use the fire stairs. In Brunel Ward the fire

exit was clear of stock and readily accessible to all patients and staff in the event of a fire.

We found bariatric equipment was available throughout surgical services. Copcoat Ward was

spacious to provide access for larger equipment, and we saw the availability of a bariatric chair in

one of the surgical wards.

Overall, we found resuscitation trolleys within surgical services were well equipped and daily

checks had been completed. In theatres we found gaps on the daily check lists for one of the

anaesthetic machines, the refrigerator and the freezer in the preoperative room.

Reusable surgical instruments were sterilised off site by an external company. Staff told us the

system generally worked well and although there had been a few issues with equipment, on the

whole, the service was good. There were regular quality meetings between the hospital and the

service and any issues could be raised during these meetings.

During our last inspection, we found patients were administered local anaesthetic in corridors

within the day surgery unit. During this inspection, we found this was not happening. This was an

improvement since our last inspection.


Staff did not always complete an updated risk assessment for each patient. The completion

of Malnutrition Universal Screening Tool scores still did not reach the trust target of 100%

At pre-assessment, patients were assessed for their suitability for surgery. A pre-operative

assessment tool was used to assess the patients’ medical and social circumstances. The

department liaised closely with anaesthetists and consultants on patient concerns.

Risk assessment tools were used in patient records and these included falls risks, cognitive

assessment tools and pressure ulcer risks. Records we reviewed showed the assessments had

been completed. However, The Perfect Ward Audit score for January 2019 showed Malnutrition

Universal Screening Tool (MUST) was not fully compliant with a score of 87% for surgical wards.

We attended a team meeting on Lister Ward, whereby the new ward manager emphasised the

importance of completing the MUST and observations and how they would be monitoring this

more closely in the future through regular audits.

Staff used the National Early Warning Score (NEWS) to identify deteriorating patients. We found

the NEWS scores were correctly used by staff on all electronic records we reviewed. Staff we

spoke with had a good understanding of when they should escalate patient risk and were

complimentary on the accessibility and reaction of the immobile critical care outreach team when

concerns were raised.


In theatres we observed staff using the World Health Organisation (WHO) surgical checklist well.

The WHO checklist is a set of checks staff complete to increase the safety of patients undergoing

surgery. From audits we reviewed, overall compliance averaged 90% and above.

Medical and consultant care was accessible 24 hours a day seven days a week. However medical

staff told us, due to surgical beds not being ring fenced, this meant surgical patients were placed

on other wards around the hospital, making the management of the acute surgical patient more of

a challenge. Ward rounds sometimes took more than four hours to complete due to the outlier

placement of surgical patients.

We attended the directorate’s morning “safety huddle” at which all patients at particular risk were

discussed. Senior nurses had an opportunity to raise concerns or request additional support in

caring for individual patients in the discussion. We observed a nurse bedside handover where the

patient’s condition and observational checks were discussed along with any additional support

they required.

Staff received sepsis training and were allocated days for training on managing the acute unwell

patient. Staff told of us a teaching for sepsis training which was run during lunchtime and had been

well attended. Staff had access to the iMobile outreach team 24 hours, seven days a week if they

needed to escalate an acutely unwell patient.

We saw a post spinal surgery mobility tool was used by staff to determine if physiotherapy was

required post spinal surgery.

Nurse staffing

The service had enough nursing staff with the right qualuifications, skills, training and

experience to keep people safe from avoidable harm and to provide the right care and

treatment.

The trust has reported their staffing numbers below for the August 2017 and August 2018. Fill

rate had increased over the 12 months and was above 90%. Total WTE has increased by over

1,000.


Staffing group

Planned

staff –

WTE

Actual

staff –

WTE

Fill

rate

Planned

staff –

WTE

Actual

staff –

WTE

Fill

Rate

Qualified nursing & health visiting

staff (Qualified nurses) 129.5 101.7 78.5% 1305.3 1186.5 90.9%


• King’s College hospital – 814.1 WTE in post (89.9% fill rate)

(Source: Routine Provider Information Request (RPIR) –Total staff tab)

Vacancy rates

From September 2017 to August 2018, the trust reported a vacancy rate of 13.5% in surgery.


This was higher than the trust target of 8%.

A site breakdown can be seen below;

• King’s College surgery department: 12.9%


Turnover rates

From September 2017 to August 2018, the trust reported a turnover rate of 14% in surgery. This

was higher than the trust target of 10%.




Sickness rates

From September 2017 to August 2018, the trust reported a sickness rate of 3.1% in surgery

which was higher than the trust target of 3%.

Site breakdown can be seen below;




From September 2017 to August 2018, the trust reported a bank usage rate of 72.9% and

agency usage rate of 15.7% in surgery. This left 11.4% of available hours unfilled.



We found a good level of nursing cover across all surgical wards and for the different staff groups

within theatres. Although operational demands still meant nursing staff were placed under

increased pressure, the number of nurses on each ward was appropriate to provide safe care for

patients. Some senior staff told us they had been asked to reduce the number of nursing staff on

some of the wards and were concerned about the impact this would have on patient care and

operational demands.

The good level of nursing cover allowed the surgical wards to conduct six weekly ward meetings.

Staff from other wards covered for an hour and this allowed good attendance for constructive

discussions where patient care and quality improvements were discussed.


However, we found the nurse in charge of main theatres and cardiothoracic theatres were

completing exceptionally long hours to ensure the smooth running of theatres. One reported they

often completed hours from 06.45 to 19.00 and another 08.00 to 21.00.

(Source: Routine Provider Information Request (RPIR) - Nursing bank agency tab)

Medical staffing

The trust had enough medical staff with the right qualifications, skills, training and


treatment.


rate had increased over the 12 months and was above 90% although the total number of WTE

had decreased.


Staffing group

Planned

staff –

WTE

Actual

staff –

WTE

Fill

rate

Planned

staff –

WTE

Actual

staff –

WTE

Fill

Rate

Medical & Dental staff - Hospital 898.8 793.6 88.3% 732.9 660.6 90.1%

A breakdown by site can be seen below:

• King’s College hospital – 463 WTE in post (95.3% fill rate)

(Source: Routine Provider Information Request (RPIR) –Total staffing tab)

Vacancy rates






Turnover rates

From September 2017 to August 2018, the trust reported a turnover rate of 5.5% in surgery. This

was lower than the trust target of 10%.



• King’s college surgery department: 4.9%


Sickness rates

From September 2017 to August 2018, the trust reported a sickness rate of 1.3% in surgery.




From September 2017 to August 2018, the trust reported a bank usage rate of 16% and locum

usage rate of 54% in surgery. This left 30% of available hours unfilled.

These figures were based on available shifts for bank and agency staff. They did not include

shifts filled by substantive staff.


Staffing skill mix

In July 2018, the proportion of consultant staff reported to be working at the trust was similar to

the England average and the proportion of junior (foundation year 1-2) staff was lower.

Staffing skill mix for the whole-time equivalent staff working at King's College Hospital

NHS Foundation Trust

This

Trust

England

average

Consultant 50% 48%


Registrar Group~ 34% 27%

Junior* 8% 13%




There were no rota gaps for junior doctors and the current staffing levels were good. Junior

doctors we spoke with were happy with their current rota of two months of being on call as they


said this improved team work. However, a foundation year 1 doctor told us when covering the

acute surgical unit, if a colleague took leave, no prospective cover was arranged which meant the

doctor had to cover all surgical patients.

There was a shortage of staff within the anaesthetist sector and although the risk had recently

been downgraded on the risk register, the trust was still in the process of recruiting more staff.


Records

Staff kept detailed records of patients’ care and treatment. Records were clear, up to date

and easily available to all staff providing care.

The trust made use of both electronic paper records (EPR) and paper records, with nursing notes

being recorded on paper. Records were appropriately and securely stored in locked cabinets and

trolleys. Access to the EPR was password protected.

We checked 12 sets of patient records. These included EPR notes, paper notes and nurse

bedside notes. We generally found them well completed with appropriate observations recorded

and risk assessments completed. Patient consent was found in all records we reviewed.

On Lister ward, a documentation of bedside notes audit showed Lister Ward only met a

compliance rate of 47%. However, the new ward manager had taken robust action and more

scrutiny of records saw an improvement in the space of a couple of weeks to 67%. During Lister

Ward team meeting we observed the ward manager stressing to nursing staff the importance of

accurate recording and how they would be closely monitoring and conducting more audits. We

were assured that appropriate action was being taken. The manager had also arranged for more

moveable EPR stations to be available for staff, so they could use them when monitoring patient’s

observations.

Medicines

The service followed best practice when prescribing, giving, recording and storing

medicines. Patients received the right medication at the right dose at the right time.

Medicines were stored securely and disposed of appropriately. Medicines were stored in line with

trust policy and when temperatures went out of range, staff took remedial action. Medicines and

equipment for use in emergencies were readily accessible to staff and were checked regularly, and

tamper evident seals were in use to ensure medicines were secure in accordance with trust

guidance.

The trust had implemented a system to provide assurance that blood glucose testing kits were

calibrated before use. Staff could access medicines supplies and advice throughout the day and out

of hours. Staff had access to the on-call pharmacist out of hours and access to emergency

medicines, however, staff said that more pharmacy support was required on weekends to ensure

timely discharge.

The ward pharmacists conducted medicines reconciliation, discharge prescriptions and handled any

medicines related concerns. (Medicines reconciliation is the process of identifying an accurate list

of a person's current medicines and comparing it with the current list in use.) Patients we spoke to

on the day of inspection, told us that they had all spoken to a member of the pharmacy team about


their medicines. The pharmacy team topped up the stock medicines for each ward once to twice a

week. Ward staff could order additional items when needed. Nurses were authorised to dispense

some medicines for people ‘to take away’ and there was a record of this. This reduced the time

people had to wait to be discharged.

We checked a sample of medicine charts and saw they were completed fully with no missing

administrations. Allergy statuses of people and Venous thromboembolism (VTE) risk assessment

outcomes were routinely recorded on the electronic records and drug charts. We saw the pharmacy

team carried out regular audits on the management of medicines and CDs to ensure improvements

were being made where necessary. Findings were reported to the senior staff on the ward. We saw

these were discussed at hand over to all staff and staff implemented any actions.

However, daily fridge and room temperatures were not being recorded consistently. For fridge

temperatures there were 11 missing entries in January 2019 and for 12 days the room

temperature was above 25 degrees in Lister Ward. The action taken was recorded as: ‘open

clinical room door’. This meant unauthorised people would have access to medicines in the clinical

room. The ward manager said they had identified this as an area of improvement and would

address the team about it the following day on her safety meeting.

Incidents


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.

Never Events




never event.

From October 2017 to September 2018, the trust reported four incidents classified as a never

event for surgery.

They were:

• Surgical/invasive procedure incident meeting SI criteria in January 2018

• Surgical/invasive procedure incident meeting SI criteria in March 2018

• Surgical/invasive procedure incident meeting SI criteria in April 2018

• Medication incident meeting SI criteria in April 2018




(SIs) in surgery which met the reporting criteria set by NHS England from October 2017 to

September 2018.


These were:

Incident type Number of

incidents

Pressure ulcer meeting SI criteria 15

Surgical/invasive procedure incident meeting SI criteria 12

Slips/trips/falls meeting SI criteria 9

Treatment delay meeting SI criteria 5

Medication incident meeting SI criteria 2

Sub-optimal care of the deteriorating patient meeting SI criteria 2

Overall the incident reporting culture was strong. Staff we spoke with knew what constituted and

incident and how to report them. Feedback was provided through e-mails and regular team

meetings. Incidents at a local level were displayed in each ward on the staff performance board,

with actions taken and lessons learnt. These were displayed for all patients, visiting relatives and

staff to view. For example, we saw an incident of a patient fall and the actions taken, which

included ensuring all patients had an enhanced care risk undertaken. Displaying incidents which

had happened, and actions taken demonstrated an open and transparent approach by surgical

services.

The trust investigated serious incidents and never events by conducting root-cause analysis

(RCA) investigations and we saw duty of candour had been initiated for each serious incident we

reviewed. Duty of candour is a process of open and honest practice when something goes wrong.

Matrons and above level of staff had received in house human factors training for RCA and

incidents.

Incidents were discussed in all meeting minutes we reviewed ranging from surgical clinical

governance meetings, theatre and ward team meetings and daily staff huddles. We saw a good

example of a collaborative group discussion on an incident, where the contributory factors, such

as patient factors, task factors, team factors, individual staff factors, work environment and

organisation and management were discussed. Improvements and actions were discussed

against each contributory factor. This showed a holistic approach was taken when investigating

incidents.

There were monthly mortality and morbidity meetings held by the mortality monitoring committee.

The purpose of the meetings was to share and review adverse patient outcomes with a view to

identify themes and trends and clinical safe practice. We reviewed recent meeting minutes which

showed a good attendance and shared learning. According to the Kings annual report of

2017/2018, as a trust their mortality as assessed by the NHS Digital Summary Hospital – level

indicator (SHMI), placed the hospital in the top quartile of all acute trusts in England and Wales.


Safety thermometer

The service used safety monitoring results well. Staff collected safety information and

shared it with staff, patients, and visitors. Managers used this to improve the service.





their elimination.

Data collection takes place one day each month – a suggested date for data collection is given

but wards can change this. Data must be submitted within 10 days of suggested data collection

date.


ulcers, no falls with harm and no new catheter urinary tract infections from October 2017 to

October 2018 for surgery.






Policies, procedures and guidelines were easily accessible on the staff’s intranet. However, when

staff guided us to policies on the system, the latest ones did not always show first. For example, a

staff member showed us the controlled drugs policy, but we noticed this was not the latest version.

This happened several times during our visit, which meant staff were not always accessing the

latest guidance.

We reviewed several policies and procedures and found they had been developed in line with

relevant national guidelines and best practice from bodies which included National Institute for

Health and Care Excellence (NICE), Royal College of Surgeons and Royal College of Nursing.

Guidelines were reviewed in each surgical specialty governance meetings. Anaesthetists followed

safety guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and

copies of the guidelines were kept within the theatre department.

There were good examples of evidence based effective procedures in place. For example, there

was a good cross-specialty joint care pathway for pelvic pain patients encompassing the

gynaecological and acute surgical team. This allowed for prompt diagnosis and management,

rather than an extended length of stay for these patients.




Staff used a five-step malnutrition universal screening tool (MUST) to monitor patient’s nutrition.

Fluid charts to measure a patient’s hydration were also in use and we found these had been

completed appropriately from the records we reviewed. However, the Perfect Ward audit scores

showed the MUST had not been fully completed for all patients records with a score of 86.7%.

This was an issue at our last inspection.

There were protected meal times in each surgical ward during which visiting was restricted. Those

patients requiring support during meal times were suitably cared for by the nursing staff. Patients

told us the food was good and the selection was varied. All patients we visited had full water jugs

at their bedside table.

Dietitians and the swallow assessment team were called upon for those patients requiring support

and there was cover at the weekends. In Trundle ward there were dysphasia (a condition that


affects your ability to produce and understand spoken language) trained nurses, and most nurses

had completed a study day so they were able to complete bedside swallow assessments for those

patients who required them.

Pain relief

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.

Patients pain was managed well. Patients told us they were assessed regularly for pain and were

provided with suitable pain relief when they needed it. Pre-operative assessments included

discussions about the patient’s current pain management.

Effective processes were used by staff to measure pain and this was in the form of a pain tool,

which was a scoring mechanism to show how much pain patients felt. Nursing staff were able to

refer patients who required additional support to manage their pain to a pain management team.

Staff told us they were easy to access and get support.

Perfect ward audits for January 2019 scored high 90% above for checks such as, do staff know

how to assess and document patient’s pain.

Patient outcomes

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.

Trust level

From July 2017 to June 2018, all patients at the trust had a lower expected risk of readmission

for elective admissions when compared to the England average.

Of the top three specialties by number of admissions;

• General surgery patients at the trust had a lower expected risk of readmission for elective

admissions when compared to the England average.

• Ophthalmology patients at the trust had a lower expected risk of readmission for elective


• Urology patients at the trust had a similar expected risk of readmission for elective


Elective Admissions – Trust Level

Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive

finding, as this means there were fewer observed readmissions than expected. A value above 100 represents the opposite. Top

three specialties for specific trust based on count of activity

All patients at the trust had a lower expected risk of readmission for non-elective admissions


when compared to the England average.

Of the top three specialties by number of admission:

• General surgery patients at the trust had a lower expected risk of readmission for non-

elective admissions when compared to the England average.

• Trauma and orthopaedics patients at the trust had a lower expected risk of readmission for

non-elective admissions when compared to the England average.

• Urology patients at the trust had a lower expected risk of readmission for non-elective


Non-Elective Admissions – Trust Level



three specialties for specific trust based on count of activity

(Source: Hospital Episode Statistics - HES - Readmissions (01/07/2017 - 30/06/2018))

King's College Hospital

From July 2017 to June 2018, all patients at King's College Hospital had a lower expected risk of

readmission for elective admissions when compared to the England average.


• General surgery patients at King's College Hospital had a lower expected risk of


• Neurosurgery patients at King's College Hospital had a lower expected risk of readmission

for elective admissions when compared to the England average.

• Urology patients at King's College Hospital had a higher expected risk of readmission for

elective admissions when compared to the England average.

Elective Admissions - King's College Hospital



three specialties for specific site based on count of activity


All patients at King's College Hospital had a lower expected risk of readmission for non-elective


Of the top three specialties by number of admission:

• General surgery patients at King's College Hospital had a lower expected risk of

readmission for non-elective admissions when compared to the England average.

• Trauma and orthopaedics patients at King's College Hospital had a lower expected risk of


• Neurosurgery patients at King's College Hospital had a lower expected risk of readmission

for non-elective admissions when compared to the England average.

Non-Elective Admissions - King's College Hospital




King’s College hospital

In the 2017 National Hip Fracture Database, the risk-adjusted 30-day mortality rate was 6.4%

which was within the expected range. The 2016 figure was 7.8%.

The proportion of patients having surgery on the day of or day after admission was 75%, which

failed to meet the national standard of 85%. This was within the middle 50% of trusts. The 2016

figure was 68.6%. Although this figure had slightly improved since the last inspection, this still

failed to meet the national benchmark

The perioperative medical assessment rate was 93%, which failed to meet the national standard

of 100%. This was within the middle 50% of trusts. The 2016 figure was 94.8%.

The proportion of patients not developing pressure ulcers was 93.6%, which failed to meet the

national standard of 100%. This was within the bottom 25% of trusts. The 2016 figure was

92.3%.

The length of stay was 25.9 days, which falls within the bottom 25% of trusts. The 2016 figure

was 30.2 days.

Updated data provided by the trust showed 54.8% of patients had surgery on the day of, or day

after, admission, compared to 71.2% for England. The figure was not, however, risk-adjusted

and many of the patients seen at Denmark Hill had complex comorbidities. Work had been

undertaken through the GIRFT programme to reduce delays to theatre and there has been an

improvement in hours to operation within Denmark Hill achieving better than national for four out


of the past six months.

We reviewed the trusts comments on the audit and this showed that a business case to recruit

more staff to support the Falls and Fragility Fracture Audit programme (FFFAP) had not

advanced since it was discussed in January 2018.

(Source: National Hip Fracture Database 2017)

Bowel Cancer Audit


In the 2017 Bowel Cancer Audit, 75.8% of patients undergoing a major resection had a post-

operative length of stay greater than five days. This was worse than the national aggregate. The

2016 figure was 70.9%.

The risk-adjusted 90-day post-operative mortality rate was 1.9% which was within the expected

range. The 2016 figure was 1.3%.

The risk-adjusted 2-year post-operative mortality rate was 40.2% which was a negative outlier.

The 2016 figure was 21.6%. Further information from the trust showed the hospital was no longer

an outlier and the 2018 report showed the adjusted mortality rate had decreased from 40.2% to

12.8%

The risk-adjusted 30-day unplanned readmission rate was 6% which was within the expected


The risk-adjusted 18-month temporary stoma rate in rectal cancer patients undergoing major

resection was 52.7% which was within the expected range. The 2016 figure was 49.2%.

We asked the trust for their action plans but only received the national clinical audit, which

provided information on recommendations but did not show what actions the trust was taking.

(Source: National Bowel Cancer Audit)

National Vascular Registry

In the 2017 National Vascular Registry (NVR) audit, the trust achieved a risk-adjusted post-

operative in-hospital mortality rate of 0% for Abdominal Aortic Aneurysms. The 2016 figure was

0%.

Within Carotid Endarterectomy, the median time from symptom to surgery was 10 days, which

was better than the audit aspirational standard of 14 days.

The 30-day risk-adjusted mortality and stroke rate was 2.8%, which was within the expected

range.

(Source: National Vascular Registry)

Oesophago-Gastric Cancer National Audit


In the 2016 National Oesophago-Gastric Cancer Audit (NOGCA), the age and sex adjusted

proportion of patients diagnosed after an emergency admission was 20.5%. Patients diagnosed

after an emergency admission are significantly less likely to be managed with curative intent. The

audit recommends that overall rates over 15% could warrant investigation. The 2015 figure was

23%.

The 90-day post-operative mortality rate was not reported.

The proportion of patients treated with curative intent in the Strategic Clinical Network was

42.2%. This was similar to the national aggregate. This metric is defined at strategic clinical

network level; the network can represent several cancer units and specialist centres); the result

can therefore be used a marker for the effectiveness of care at network level; better co-operation

between hospitals within a network would be expected to produce better results.

The trust was not identified as an outlier for any indicators identified within the 2017 National

Oesphago-Gastric Cancer Audit.

(Source: National Oesophago-Gastric Cancer Audit 2016)

National Emergency Laparotomy Audit


In the 2016 National Emergency Laparotomy Audit (NELA), the King’s College hospital achieved

a green rating for the crude proportion of cases with pre-operative documentation of risk of death.

This was based on 88 cases.

The site achieved an amber rating for the crude proportion of cases with access to theatres within

clinically appropriate time frames. This was based on 70 cases.

The site achieved an amber rating for the crude proportion of high-risk cases with a consultant

surgeon and anaesthetist present in the theatre. This was based on 45 cases.

The site achieved a green rating for the crude proportion of highest-risk cases admitted to critical

care post-operatively. This was based on 34 cases.

The risk-adjusted 30-day mortality for the site was within the expected range based on 88 cases.

(Source: National Emergency Laparotomy Audit)

Patient Reported Outcome Measures

In the Patient Reported Outcomes Measures (PROMS) survey, patients are asked whether they

feel better or worse after receiving the following operations:

• Groin hernias

• Varicose veins


• Hip replacements

• Knee replacements

Proportions of patients who reported an improvement after each procedure can be seen on the

right of the graph, whereas proportions of patients reporting that they feel worse can be viewed

on the left.

In 2016/17 performance on groin hernias was about the same as the England average. On the

EQ VAS indicator, the trust had less patients report they felt worse but also less patients report

they felt improved too.

For varicose veins, performance was worse than the England average.

For hip replacements, performance was about the same as the England average.

For knee replacements was about the same as the England average.

During the inspection medical staff told us that despite evidence provided to the senior team by

clinicians regarding delay to emergency surgery, no changes to the theatre structure to allow for

a separate CEPOD theatre list had been made. Medical staff reported that patients were waiting

too long for emergency surgery which was having a detrimental effect on patient outcomes. We

were told certain cases got excessively delayed, for example appendicitis cases could wait for

more than 24 hours for surgery and for small bowel obstructions more than 76 hours and those

cases were ‘bumped’ for more urgent cases.

The trust were involved in best practice tariff for neck of femur (NOF), which is a national

measure. The time to surgery was slightly below the national average but due to the trust being a

major trauma centre they had to prioritise cases.


Competent staff





Appraisal rates

From September 2017 to August 2018, 86% of staff within urgent and surgery care at the trust

received an appraisal compared to a trust target of 90%.


required

Appraisals

complete

Completion

%

NHS Infrastructure Support Staff 2 2 100%

Other Qualified Scientific, Therapeutic,

Technician Staff 1 1 100%








Support to doctors and nursing staff 15 5 33%

Qualified Nursing Midwifery Staff 1 0 0%

At our last inspection appraisal rates fell below the trust target. At this inspection we saw an

improvement in the appraisal rates. Although some staffing groups had not reached the trust set

target they were much improved since our last inspection. There was a varied response to the

effectiveness of personal appraisals. Some staff felt they were a ‘tick box’ session while others

said the appraisals gave them direction and built their confidence.

There were excellent opportunities for training and development within the trust. Courses

attended, and training staff had received, included human factors training, simulation training and

staff had received dementia training from the Alzheimer’s Society. Staff told us the hospital had

approved funding for staff to receive training from a local mental health trust for training on people

with challenging behaviours.

The trust ran several respected courses in neurology and cardiology. Nurses working within the

neurosurgical unit were rotated on a three-month basis through the varied specialities within the

unit to gain experience in these areas.

Funding had recently been approved so staff could receive training from a local mental health

hospital for training on people with challenging behaviours.

Band 5 nurses told us there were lots of opportunities for progression and most nursing staff we

spoke with had progressed and developed through the trust. Within Neuroscience, there was a

Band 6 development programme to develop and encourage junior sisters.

(Source: Routine Provider Information Request (RPIR) – Appraisal tab)


Staff from different roles worked together as a team to benefit patients. Doctors, nurses,

and other healthcare professionals supported each other to provide good care.

There was strong collaborative team working across surgical services. We saw many good

examples of multidisciplinary team (MDT) working to ensure patients received good care.


Patients care plans were discussed in MDT meetings, where there was involvement from all

members which included doctors, nurses and allied healthcare professionals. We observed

several “huddle” meetings ranging from more senior meetings, where an overview of all patients

within the surgical wards were discussed, theatre team briefings and nursing handovers. We

observed a good bedside nursing handover. Two nurses allowed a student nurse the opportunity

to verbally handover and guided her and taught her as she went along.

The orthopaedic team had twice weekly meetings and a medical doctor attended the orthopaedic

ward to give a medical point of view so there was a holistic review of the patients care plan.

We observed good team working in theatre. The consultant and surgeon provided positive

feedback that working with the same colleagues regularly was an improvement, allowed close

working relationship, particularly when needing to discuss complex patients pre-operatively to

ensure surgery proceeded safely.

Seven-day services

There was suitable provision of services at all times to ensure care and treatment delivery

and to support the achievement of the best outcomes for patients.

Junior doctors cover at the weekend was sometimes a challenge as they had to cross over

numerous surgical specialities across many wards. Sometimes the doctors felt overstretched to do

all the tasks, particularly if there were unwell patients in geographically separate locations within

the hospital.

Trauma and acute surgery operated 24 hours a day seven day a week, however their support

services were at times a challenge. The availability of services such as ultrasound scanning

services were limited and posed difficulties particularly for diagnosis.

The iMobile outreach team was available seven days a week 24 hours a day to assess and

provide support for deteriorating patients on wards. Staff provided positive feedback on their swift

and effective response.

Occupational therapist and physiotherapists were available seven days a week. However, support

services were a challenge at weekends, for example, the availability of ultrasound scanning was

limited, and this meant patient diagnosis was sometimes delayed.

Health promotion

Patients were supported and encouraged by staff to take ownership of their recovery which

helped to improve patient outcomes.

The trust had many enhanced recovery programmes running throughout surgery services. We saw

the enhanced recovery after spinal recovery programme. This booklet gave patients an

understanding about their surgery and how important it was for them to play an active part in their

recovery. Advice supplied included risks and complications of the surgery, how long they were

expected to stay in hospital, discharge planning and how they could prepare themselves beforehand

for surgery. For example, patients were advised to stop smoking, exercise and make arrangements

for shopping and cleaning after the surgery.








61% of staff in surgical care compared to the trust target of 80%.

There was no separate course for Deprivation of Liberty Safeguards (DoLs) training.

Although mandatory training for medical staff for mental capacity and consent was poor, we

found staff had a good understanding and knowledge of MCA and DoLs. They knew how to

escalate and get support when required. An onsite mental health liaison team were available to

staff through a bleep system. Staff told us the team were very good. DoLs applications were dealt

with by the safeguarding team, who staff told us were very responsive and acted quickly.

From records we reviewed consent forms were fully completed and risks were identified. Patients

we spoke with said they had been given good information and complications had been explained.

Staff we spoke with had a good understanding of consent and the principle that a patient must

give permission before they receive any type of medical treatment, test or examination.



Compassionate care

Staff cared for patients with compassion. Feedback from patients confirmed that staff

treated them well and with kindness.

We saw good examples of patients being treated with respect throughout the inspection. Staff

were kind attentive and showed compassion. Patients were positive with their feedback and the

standard of care they had received. One patient commented “It’s the people that make the

hospital, they are kind, helpful, going above and beyond to make sure I am cared for”.

Several patients we spoke with said they preferred to wait longer for procedures, to have

treatment at the hospital because of the excellent staff, as opposed to having treatment at another

hospital.

Some patients had travelled a significant distance to be treated at the hospital. A patient gave an

example of the care they had received when at a previous admission the nurse took them

personally to the main entrance prior to discharge to make sure they were safe.


The Friends and Family Test response rate for surgery at King's College Hospital NHS

Foundation Trust was 15% which was worse than the England average of 21% from October

2017 to September 2018.

Friends and family test response rate at King's College Hospital NHS Foundation Trust, by

ward.


1. The total responses exclude all responses in months where there were less than five responses at a particular ward

(shown as gaps in the data above), as well as wards where there were less than 100 responses in total over the

12-month period.

2. Sorted by total response.

3. The formatting above is conditional formatting which colours cells on a grading from highest to lowest, to aid in

seeing quickly where scores are high or low. Colours do not imply the passing or failing of any national standard.


Emotional support

Staff provided emotional support to patients to minimise their distress.

There was a chaplaincy service that provided spiritual and religious care for patients. The service

was available throughout the night and day. We saw information available to patients on how to

contact the service. Multi-faith prayer rooms were available at the hospital which provided a quiet

and private space for patients and visitors.

We observed staff being kind and gentle to a patient who was distressed. They were able to

provide reassurance and calmed the patient. Patients we spoke with told us staff were kind and

provided support when they were unsure of anything.

At handover meetings, staff discussed the patient’s wellbeing and emotional support they required.

A psychiatric liaison service was available and easy to access for urgent referrals.

A hospital-based charity was able to provide support to young adults who had been hospitalised

due to violence. This charitable group consisted of youth workers and social workers.


Staff involved patients and those close to them in decisions about their care and treatment.

The majority of patients told us they had been involved in all aspects of their care and kept up-to-

date regarding changes to their care plans. Patients we spoke with told us they were given clear

information regarding the benefits and risks of their treatment and were given the opportunity to

ask questions.

A patient was able to describe how their spouse and family members were involved in all aspects

of their discharge following surgery, and the nursing staff made sure they were going to manage


appropriately at home, ensuring family members were happy prior to discharge. Care plans we

viewed showed discussion had taken place around patient care and discharge.



The trust did not always plan and provide services in a way that met the needs of local

people.

The hospital was the major trauma centre for south east London, Kent and Medway. Therefore,

they treated a range of people from local and surrounding areas. Many people who attended the

hospital did not live in the local surrounding area.

There was a centralised pre-assessment unit which was a one stop service for patients (unless

they required an x-ray). This meant patients assessments were completed in the same unit and

patients were not directed to different parts of the hospital. A telephone pre-assessments service

for day surgery patients had been introduced to reduce the need for patients making unnecessary

hospital attendances.

The trust now had a five-day physiotherapist service for neck of femur (NOF) patients. This helped

with discharge arrangements as there were now more multiple contacts per day. This was

introduced due to help reduce the extended length of stay for most of these patients. However,

discharge arrangements for NOF patients were dependent on individual local boroughs discharge

arrangements. For example, one local authority did not have a bed-based community hospital so

this made discharge arrangements more complicated for the hospital.

There were no dedicated surgical speciality wards, for example no dedicated urology ward.

Inpatients were placed throughout wards, with a different mix of nursing staff and skill sets. Staff

told us patients were often difficult to find following admission and there were delays in patient

care as patients were on outlying wards.

At our last inspection there was no orthoplastics list for patients and this was a risk on their risk

register. At this inspection we saw an improvement as a business case was passed and the

transition had started, and we were told it would be fully functional by June 2019.



A dementia team service was provided by the hospital. The “Forget me not” scheme was used by

the hospital. This meant patients living with dementia were able to document personal

preferences, which allowed the hospital to respond to their personal needs. Nurses we spoke with

had received dementia training, some of which included involvement from The Alzheimer’s

Society. In Trundle Ward, those more vulnerable patients living with dementia were placed in a

bay positioned in view of the nursing station, so additional support could be provided.

In Trundle Ward sensor impairment signs were used and we saw yellow signs behind patient’s

beds which indicated those patients were unable to eat solid foods. Translated and Braille menus

were available for patients.

Initiatives to help the more vulnerable patients included visits by therapy dogs and the trust were in

the process of arranging regular school children visits to some of the wards to help patients with

therapeutic engagement and stimulation.

Access and flow



referral to treatment and arrangements to admit, treat and discharge patients were not

always in line with good practice.

Average length of stay (Remove trust level if this is a one site trust)

Trust Level – elective patients

From August 2017 to July 2018, the average length of stay for all elective patients at the trust

was 4.8 days, which was higher than the England average of 3.9 days.

Of the top three specialties by number of admissions, the average length of stay for;

• Trauma and orthopaedics elective patients at the trust was 4.1 days, which was higher

than the England average of 3.8 days.

• Neurosurgery elective patients at the trust was 6.2 days, which was higher than the

England average of 4.9 days.

• General surgery elective patients at the trust was 3.1 days, which was lower than the


Elective Average Length of Stay – Trust Level

Note: Top three specialties for specific trust based on count of activity.

Trust Level – non-elective patients

The average length of stay for all non-elective patients at the trust was 7.4 days, which was

higher than the England average of 4.9 days.


• General surgery non-elective patients at the trust was 6.3 days, which was higher than the


• Trauma and orthopaedics non-elective patients at the trust was 9.3 days, higher than the


• Urology non-elective patients at the trust was 4.4 days, which was higher than the England

average of 2.8 days.

Non-Elective Average Length of Stay – Trust Level


Note: Top three specialties for specific trust based on count of activity.

King's College Hospital - elective patients

From August 2017 to July 2018 the average length of stay for all elective patients at King's

College Hospital was 5.6 days, which was higher than the England average of 3.9 days.


• Neurosurgery elective patients at King's College Hospital was 5.4 days, which was higher


• General surgery elective patients at King's College Hospital was 3.0 days, which was lower


• Hepatobiliary & pancreatic surgery elective patients at King's College Hospital was 7.9

days, higher than the England average of 6.8 days.

Elective Average Length of Stay - King's College Hospital

Note: Top three specialties for specific site based on count of activity.

King's College Hospital - non-elective patients

The average length of stay for all non-elective patients at King's College Hospital was 8.8 days,

which was higher than the England average of 4.9 days.


• General surgery non-elective patients at King's College Hospital was 7.4 days, which was


• Trauma and orthopaedics non-elective patients at King's College Hospital was 10.7 days,


• Neurosurgery non-elective patients at King's College Hospital was 14.7 days, which was



Non-Elective Average Length of Stay - King's College Hospital


Referral to treatment (percentage within 18 weeks) - admitted performance

From October 2017 to September 2018 the trust’s referral to treatment time (RTT) for admitted

pathways for surgery was worse than the England average.

In the most recent month, September 2018, the trust scored 52.2% compared to the England

average of 66.6%.

During the last inspection RTT targets were below the England average. During this inspection

we found there had been no improvement, results had in fact got progressively worse.


Referral to treatment (percentage within 18 weeks) – by specialty

One specialty was above the England average for RTT rates (percentage within 18 weeks) for

admitted pathways within surgery.

Specialty grouping Result England average

Oral surgery 59.5% 59.1%

Eight specialties were below the England average for RTT rates (percentage within 18 weeks) for




Cardiothoracic surgery 61.4% 79.4%

Neurosurgery 61.3% 69.8%

Ophthalmology 60.7% 67.8%

Urology 54.4% 76.7%

Trauma & orthopaedics 34.0% 59.8%

General surgery 30.5% 72.6%

ENT 26.8% 63.5%

Plastic surgery 26.3% 80.9%

We saw action plans to tackle RTT for orthopaedics, day case colorectal, bariatrics and non-

admitted pathways. Such plans included using external support from other hospitals and adding

additional cases at the weekend. However, RTT remained problematic for the trust.

Cancelled operations

A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was

due to arrive, after they have arrived in hospital or on the day of their operation. If a patient has

not been treated within 28 days of a last-minute cancellation, then this is recorded as a breach of

the standard and the patient should be offered treatment at the time and hospital of their choice

Over the two years, the percentage of operations cancelled at the trust and patients not treated

within 28 days have been worse than the England average.

Percentage of patients whose operation was cancelled and were not treated within 28 days

- King's College Hospital NHS Foundation Trust

Cancelled Operations as a percentage of elective admissions - King's College Hospital



Over the two years, the percentage of cancelled operations at the trust has been similar to the

England average. Cancelled operations as a percentage of elective admissions only includes short

notice cancellations.

We received data for on the day cancellation for the months of October 2018 to December 2018.

There was a total of 580 on the day cancellations. For day surgery the main reason for

cancellation was that patients did not attend and for main surgery the main reason was lack of

ward beds. Patients we spoke with during the inspection revealed they had often been cancelled

numerous times prior to admission. One patient reported the following: “Kings is a good hospital

when you get in. My operation has been cancelled five times. I saw my consultant in March 2018

who said I needed an operation. My operation had been cancelled in June, August, November and

twice in December. I am finally here today, and I hope it goes ahead”. Two further patients we

spoke with also confirmed they had previously been cancelled on more than one occasion.

Theatre utilisation ran at an average of 80%. This average was the same as the last inspection.

There were difficulties within the admissions team with staffing levels and not filling in lists far

ahead. Within day surgery filling in day lists was a struggle due to the changes to rules that

support minor surgery. For example, carpel tunnel and cyst treatments had stopped, however

these types of treatment filled small gaps in the lists that could not be filled by more complex

surgery. Staff told us pooled lists would be beneficial, but this required a culture of change within

the medic’s team to achieve this.

There were delays in theatre recovery due to the lack of patient beds. Patients did stay overnight

in recovery, approximately two patients per month. This was not appropriate as there were no

bathroom facilities in the recovery area.

Late discharges impacted on access and flow through the hospital. Nurses told us there were very

few care homes on the Discharge 2 Assess scheme. Different discharge arrangements within

different local authorities meant delays in getting the right package of care for each patient. We

attended a surgical huddle meeting. Discharges were discussed with a view of gaining insight into

how many beds would be available at a later part of the day for incoming patients. Support with

more complex discharge arrangements were discussed.






From October 2017 to September 2018 there were 222 complaints about surgical care. The trust

took an average of 30 days to investigate and close complaints. This was not in line with their

complaints policy, which states complaints should be closed within 25 working days.

A breakdown of subject can be seen below:

Subject No. of complaints






Communications 25


Facilities Services (inc. access for people with disability, cleanliness,


Appointments including delays and cancellations 5

Other 4



Waiting Times 4


Restraint 1



Commissioners); 1


Of the complaints, 139 (63%) were regarding King’s College Hospital.

At our last inspection we found complaints were not investigated and replied to within the trusts

recommended time frame of 25 days. At this inspection, although complaints were still not being

closed within the recommended 25 days we had seen an improvement in the timeliness of

responding. We discussed complaints with nursing staff. They were able to tell us, wherever

possible they would attempt to resolve a complaint on a face to face basis and try to diffuse the

problem. If they were unable to, then they would escalate to their line manager. There was a

patient Liaison Service (PALS) within the hospital and leaflets were available throughout the

wards we visited.

Patient complaints were discussed at regular ward and surgical governance meetings.






Leadership

Most managers at all levels in the surgical division had the right skills and abilities to run a

service providing high-quality sustainable care. However, there was a disconnect between

the executive team and clinical leaders within surgery services.

There was good strong local leadership within the surgical division. Staff were complimentary on

their clinical leads and head of nursing. They told us they were supportive, and patient driven.

Staff were happy with their immediate line managers which included ward managers and matrons.

We frequently heard staff describe their team as a family. The local leadership team were


experienced and had a good understanding of their risks and performance issues within the

service.

However, there was staff criticism with the senior executive team around their disconnect, and

their lack of involving clinical leads in important decisions that had been made within the surgical

division. For example, in Katharine Monk Ward, the change of bed capacity to accommodate the

intensive care unit (ITU) had not been communicated well, as well as the move of the surgical

assessment unit. Some clinical leads told us they did not think the executive team fully understood

the challenges they faced. Most staff we spoke with said that due to the frequent changes within

the executive team, they were not sure of who they were.

Vision and strategy

The trust had a vision for what it wanted to achieve, however there was a lack of

engagement with staff to turn it into action.

There was a lack of executive level strategic engagement with clinical staff to help improve the

service. Clinical decisions which directly impacted on surgical staff had often been made without

clinical staff input. Although staff we spoke with were committed to delivering good quality care,

the unstable and often frequent changes at board level, meant strategic decisions within the

surgical division were often changed or staff had to revisit them with a new team. Staff wanted a

more stable workforce at executive level to lead the service forward.

Culture

Managers across the trust promoted a positive culture that supported and valued staff,

creating a sense of common purpose based on shared values.

All staff we spoke with enjoyed working at the trust. Many staff had been working for the trust for a

number of years and had developed through a variety of roles. Staff were complimentary about the

training opportunities within the trust. Nurses told us the teams they worked in felt like being in a

family unit.

Staff said although the workload was pressurised, there was a good spirit amongst all teams. Staff

were proud to work for the trust and that it was a good place to work. We saw good teamwork

within the division. There was respect amongst staff within the different specialities.

Governance

The trust used a systematic approach to continually improve the quality of its services and

safeguarding high standards of care by creating an environment in which excellence in

clinical care would flourish.

Surgical services came under the umbrella of both the urgent care and allied clinical services and

network care. Acute surgery, trauma and planned surgery, theatres, anaesthetic and

ophthalmology sat under urgent care and clinical services and cardiovascular, critical care,

neurosciences, liver and renal sat under network care. Each speciality was led by a clinical

director. There were clear governance structures across each surgical speciality. Each division

conducted their own governance meetings, where standard set agenda items were discussed,

such as incidents and safety alerts.

We reviewed the cardiovascular care group quality governance and governance committee

meeting minutes. These were well attended by the clinical director, senior nursing representatives,

allied health professionals, a pharmacy representative and care group consultants. There were

terms of reference which provided the scope of each meeting and what should be discussed. The


January 2019 meeting showed discussion took place on a safety alert from NHS Improvement

(December 2018) on the risk of inappropriate placement of pulse oximeter probes.

There was a monthly clinical governance meeting for all of surgery. This was a meeting of all

surgical specialities and the sharing of information, risks and quality improvements from each

division. Incidents were discussed, and trends were identified from within theatres and

anaesthetists. For example, due to incidents reported of a shortage of glide scopes stylets

(instruments to help facilitate quick placement of an endotracheal tube and reduce patient trauma)

new equipment had been bought.


The trust had effective systems for identifying risks, planning to eliminate or reduce them,

and coping with both the expected and unexpected.

There was a monthly risk and governance meeting and for surgery this comprised of all the

surgical specialities. Topics of discussion included incidents, root-cause analysis and reports. We

reviewed meeting minutes and found they were well attended by a variety of different skilled staff.

A monthly clinical scorecard was shared with surgical specialities and this provided an overview of

current performance for surgical clinical indicators. Comparisons on previous months results could

be made so an overall picture was captured. Themes and trends could be identified from the

scorecard.

There was a surgical risk register which was reviewed and updated regularly. We noted several

risks had been on ongoing for a considerable length of time with no indication that the risks could

be mitigated. Top risks included the risk of injury to staff, patients and visiting relatives from violent

and aggressive patients. Most staff on the surgical wards we visited said the top risks were patient

and public violence and aggression. Some staff told us they did not feel the trust as a whole were

tackling the ever-increasing violence they faced on a regular basis or taking enough action to

minimise the risk. Staff told us violence and aggression were becoming an accepted part of their

daily working shift.

At a local level we found risks were assessed and mitigated. For example, on Trundle Ward we

saw a risk of a breach of single sex toilet facility (both males and females using the toilet) had

been mitigated by recommunicating to patients the correct toilets to use, ensuring the

housekeeper was aware and adding the risk to the risk register at the next review.




Access to patient’s individual records was password protected and restricted to authorised staff.

Information technology systems were used to monitor and improve care. Data was submitted to

external auditors to benchmark against quality standard. Surgical services used information

obtained through quality audits and performance reports to get a holistic view of performance.

Engagement

The trust ensured that patients, and their relatives and carers, the public, staff and external

partners were actively engaged and involved in identifying and driving improvements in

services.


People using the service were encouraged to give their views on the quality of the service. People

could comment through the Friends and Family test and PALS.

The trust worked with local parties in the public and voluntary sectors to support improvements.

For example, a dementia charity supported staff training for those patients living with dementia.

Staff told us they felt engaged with the daily function of the service, through regular meetings

where information was shared to staff, such as incidents, complaints and quality improvements.

Staff were recognised for their work through monthly team meetings. Some wards held ‘staff of the

month’ where other staff were able to vote for their contribution to the ward. The hospital had a

GREATIX report which was shared in clinical governance meetings. This was a report where staff

reported positive feedback on other staff (similar to the way they reported incidents).

Newsletters were issued regularly for information sharing.


There were robust systems and processes for learning, continuous improvement an

innovation.

There were many innovative projects for learning and continuous improvement. In Trundle Ward a

project which involved looking at ways to improve food choices and pain assessments for neck of

femur (NOF) patients with cognitive impairment ways, meant patients were now given picture

material and food preference charts to help them make decisions. The ward had placed laminate

pain assessment picture charts into everyone’s bedside notes. The assessment charts included

assessment of movement, facial expression, change in body language, physiological changes,

and behavioural changes. The ward had introduced a dignity champion, who provided a network

to support patients with impairment. And try to find initiatives through a steering group.

Within the neurosurgery unit innovations included the hospital completing the largest series of

paediatric deep brain simulations in the world and were the only paediatric spinal trauma service in

London.

There were improvements in the general anaesthetic MRI service, due to an overhaul in the

booking process and improvements in how patients were communicated. Patients could now have

video consultation, and this meant a reduction in the waiting time, from months to two to three

weeks.

A new Theatre Performance Dashboard had been implemented, giving clinicians and operational

managers a more holistic view of theatre performance. This enabled data driven prioritisation of

key areas to improve theatre productivity.

Eight planned care specialty inpatient pre-assessment services had been integrated into a

centralised inpatient pre-assessment clinic. This has helped improved the consistency & quality of

patient pre-assessment.

Maternity


King’s maternity service is divided on two sites King’s College Hospital (KCH) site and the

Princess Royal University Hospital (PRUH) site; both sites provide full range of maternity

services. In addition, KCH site is a tertiary unit taking referrals for fetal medicine, women with


abnormally invasive placenta, hypertension, liver disease, renal disease and other co-morbidities.

Women have a wide range of choices for each part of their maternity pathway- antenatal, post-

natal and intrapartum care. Women can choose their place of birth from a homebirth, alongside

birth centre at the Oasis birth centre, PRUH site and alongside birthing rooms at the KCH

venue.

The midwifery team provide midwifery services in a wide range of community settings and has

specialist staff supporting women with issues with such as perinatal mental health, migrant

women, safeguarding and substance misuse. Other initiatives include a successful continuity of

carer caseload model for women, with 17% of women receiving this model of care.

The trust is a teaching centre for both medical and midwifery students.

(Source: Trust Acute Provider Information Request – Context tab)

From July 2017 to June 2018 there were 9,134 deliveries at the trust.

A comparison from the number of deliveries at the trust and the national totals during this period

is shown below.

Number of babies delivered at King's College Hospital NHS Foundation Trust –

Comparison with other trusts in England.

A profile of all deliveries and gestation periods from April 2017 to March 2018 can be seen in the

tables below.


(Source: Hospital Episodes Statistics (HES) – Provided by CQC Outliers team)

The number of deliveries at the trust by quarter for the last two years can be seen in the graph

below.

Number of deliveries at King's College Hospital NHS Foundation Trust by quarter.

(Source: Hospital Episode Statistics - HES Deliveries (July 2017 - June 2018)


Profile of all deliveries (April 2017 to March 2018)

England

Deliveries (n) Deliveries (%) Deliveries (%)

Single or multiple births

Single 9,127 98.3% 98.6%

Multiple 160 1.7% 1.4%

Mother’s age

Under 20 131 1.4% 3.1%

20-34 6,012 64.7% 74.9%

35-39 2,506 27.0% 18.1%

40+ 638 6.9% 4.0%

Total number of deliveries

Total 596,828

Source: Hospital Episode Statistics, April 2017 to March 2018

KING'S COLLEGE HOSPITAL

NHS FOUNDATION TRUST

9,287

Notes: A single b irth includes any delivery where there is no indication of a multiple b irth. This tab le does not include

deliveries where delivery method is 'other' or 'unrecorded'.


Mandatory training

The service provided mandatory training in key skills to all staff. However, mandatory

training indicators were not being met.

Staff were given four training days a year to complete mandatory training. Training was by e-

learning or booked training courses. The practice development midwife (PDM) had responsibility

and oversight of staff mandatory training. The PDM told us they responsible for the supervision of

312 staff at Kings College Hospital (KCH). There was a further practice development facilitator role

that was a secondment role. The practice development facilitator role had been vacant since

January 2019 and was being advertised.

At KCH, we found mandatory training indicators were still not being met. The trust set a

compliance standard of 80% for all mandatory training. Following our inspection, the trust

provided us with a staff mandatory training spreadsheet that identified 19 mandatory courses. Staff

had not met the trust’s compliance indicator of 80% for any of the 19 mandatory courses. The

spreadsheet did not split staff training compliance into staff groups. We were therefore unable to

comment on specific staff group compliance. However, the data provided by the trust indicated a

decline in compliance with mandatory training since our previous report, which was published on

30 August 2015.

The highest rate of compliance in February 2019 was 72% for venous-thromboembolism (VTE)

training, (this is a condition in which a blood clot forms most often in the deep veins of the leg,

groin or arm), this equated to 52 of the 71 staff. The lowest rate of compliance was 4% for the

prevention of falls module, this equated to three of 71 staff. This meant the trust could not be

assured that staff had received appropriate training to enable them to carry out the duties they

were employed to perform in a safe manner.

Staff received mandatory training in specific maternity safety systems, including responding to

childbirth emergencies such as post-partum haemorrhage (excessive bleeding following delivery)

and cardiotocography (CTG) interpretation, (this is a technical means of recording the fetal

heartbeat and the uterine contractions during pregnancy), as well as normal birth and infant

feeding. We viewed the midwives mandatory training (MMT) report 2018. This recorded a 97.4%

compliance rate in subjects such as obstetric emergencies and CTG. However, this data was

based upon there being 301 midwives. Information provided by the trust in the provider information

return (PIR) set the establishment figure for qualified midwives/nursing at 375. This meant that not

all midwives mandatory training compliance had been accounted for in the midwives specific

mandatory training data.

Staff were given advance warning of training days via the trust’s electronic training records

system. We were told that if staff did not complete mandatory training in a timely way this would be

reported to their manager and would be brought up at annual appraisals.

The trust set an indicator of 80% for completion of mandatory training.

Trust level


qualified nursing staff in maternity is shown below:


Name of Course

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met


Aseptic Non Touch Technique Level 1 [Once] 246 246 100% Yes







Fire [2 Years] 472 339 72% No





In maternity the 80% indicator was met for five of the 12 mandatory training modules for which


The trust did not provide specific data for medical staff mandatory training compliance rates.

However, data returned by the trust indicated that Kings College Hospital (KCH) was below the

trust indicator with the level of maternity staff compliance in February 2019. For example, the

compliance rate for resuscitation training in January 2019 this was worse than the trust’s 80%

indicator.


Please note that the analysis in this section excludes training in safeguarding, Mental Capacity

Act (MCA) and Deprivation of Liberty Safeguards (DoLS), which are covered in separate sections

of this report.

Safeguarding

All staff did not have up to date training in safeguarding. Although staff did not have the

required training in safeguarding they were aware of the reporting procedures.

A team of specialist safeguarding midwives worked across both Kings College Hospital (KCH) and

Princess Royal University Hospital (PRUH) from 9am to 5pm, with dedicated time to address

safeguarding issues. Outside of this time midwifery staff would contact the local authority duty

social worker. Staff we spoke with were aware of how to contact the safeguarding midwives and

social work team, if they needed any support with regards to safeguarding issues.

A search of the trust’s intranet automatically provided the contact details of the trust’s

safeguarding team, in response to safeguarding being entered as a search item.

A matron acted as safeguarding lead midwife and provided safeguarding supervision. This

supported staff to develop and maintain their competence when caring for both women and babies

particularly those who may require safeguarding.

The trust’s electronic patient records (EPR) system flagged any women where there were

safeguarding issues. This ensured staff were aware of any safeguarding risks to women or babies.


We saw information behind nursing stations with a clear flow chart of processes for reporting

safeguarding acting as a reminder to staff.

The trust had a safeguarding adult’s policy, which included reference to Prevent, one part of the

government counter terrorism strategy. The trust had an abduction policy for maternity. This meant

staff had guidance on how to respond in the event of an infant or child abduction, or suspected

abduction.

Since September 2014, it has been mandatory for all acute trusts to provide a monthly report to

the Department of Health on the number of patients who have had Female Genital Mutilation

(FGM) or who have a family history of FGM. In addition, where FGM was identified in NHS

patients, it was mandatory to record this in the patient’s health record. We saw a clear process in

place to facilitate this reporting requirement, and clear guidelines on FGM, including recognising

and supporting women who may have experienced FGM. Staff we asked told us women that had

been subject to FGM would be identified antenatally and referred to the trust’s safeguarding team.

Staff could access the hospital’s independent domestic violence advocate (IDVA) to support

women at risk of domestic abuse. We saw details of the IDVA displayed on the antenatal and

postnatal wards.

The safeguarding team had rolled out training to midwifery staff in child sexual exploitation, human

trafficking, domestic abuse and migrant women in 2018. Figures for Kings College Hospital

maternity showed that in February 2019 level three safeguarding children training had been

completed by 63% of staff this was below the trust’s indicator of 85%. Safeguarding adults’ level

two training had been completed by 70% of staff this was also below the trust’s indicator of 85%.

It is worth noting that the figures for safeguarding training at KCH were below the trust’s required

compliance indicator for all mandatory safeguarding training modules in February 2019. The data

returned by the trust following our inspection did not identify the compliance rates for specific staff

groups, we are therefore unable to comment on safeguarding training data for specific staff

groups, such as medical or midwifery staff.

The trust set a indicator of 85% for completion of safeguarding training.

Trust level


qualified nursing staff in maternity is shown below:

Name of Course

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met



In maternity the 85% indicator was met for one of the two safeguarding training modules for

which qualified nursing staff were eligible.





premises clean. They used control measures to prevent the spread of infection.

In accordance with the trust’s indicator of zero, there were no reported cases of meticillin-resistant

Staphylococcus aureus (MRSA) from December 2017 to December 2018 in maternity. In the same

period there had been no cases of clostridium difficile (C Diff), one case of meticillin-susceptible

Staphylococcus aureus (MSSA) in February 2018, and one case of Escherichia coli (E-coli) in

June 2018.

All departments within maternity were considered high risk or very high risk for infection control.

However, the maternity quality of care audit recorded that the department was compliant with the

Department of Health (DoH) guidance recommending: ‘All patients admitted to high risk units and

all patients previously identified as colonised with or infected by MRSA, should be screened for

MRSA. In addition, local risk assessment should be used to define other potential high MRSA risk.’

Maternity were meeting the trust’s 100% indicator for time to isolation and time to decolonisation.

However, the maternity quality of care audit dated from January to December 2018 recorded that

between January and December 2018 screening of emergency patients for MRSA was worse than

the trust’s 100% indicator at 64%.

Cleaning rotas were not displayed in the wards. However, housekeepers had copies of cleaning

rotas, and checklists were completed daily, and monitored by the cleaning supervisor. This

ensured no areas were missed or cleaned twice. The maternity quality of care audit found 97%

compliance with housekeeping environment cleaning audits, this was close to the trust’s 98%

compliance standard. The audit also found 96% compliance with nurse cleaning in the same

period, this was close to the trust’s 98% compliance standard.

We saw all housekeeping staff wore disposable aprons and followed the correct procedures for

preventing the unnecessary spread of germs.

Clinical staff were required to comply with the ‘Five moments for hand hygiene’, as set out by the

World Health Organisation (2009) and with the trust’s own hand hygiene policy following National

Institute for Health and Care Excellence (NICE) guidelines. The maternity quality of care audit

found that maternity met the trust’s 90% standard for hand hygiene. However, we noted results

were not recorded on the obstetrics scorecard in January, July and December 2018.

We saw alcohol-based hand sanitizer available on the wards and units in maternity at the hospital.

We observed good use of these in all areas we visited.

Personal protective equipment (PPE) was available in all clinical areas. Staff followed correct use

of PPE. We saw staff members following trust policy and NICE guidance, QS61 statement 3:

‘People receive healthcare from healthcare workers who decontaminate their hands immediately

before and after every episode of direct contact or care.’

We saw all staff had bare skin below the elbows and staff with long hair had this tied back.

Sharps bins were available in treatment areas where sharps may be used, the bins automatically

shut when full to prevent overfilling. This was in accordance with Health and Safety Regulations

2013 (The Sharps Regulations), 5(1) d. This requires staff to place secure containers and

instructions for safe disposal of medical sharps close to the work area. We saw that labels on

sharps bins had signatures of staff, recorded the date it was constructed, by whom and on what

date.

Specific hand washing sinks were available in all rooms and at the entrance to bays on wards. All

sinks we saw were compliant with lever handles and taps positioned to cause the least amount of


splash. The maternity department had hand washing technique posters displayed to ensure staff

used the correct technique.

The labour ward had an infection control board which provided staff with information on infection

prevention and control. For example, there were guidelines, ‘What can I do to prevent Sepsis,’ and

diagrams for the ‘5 moments of hand hygiene’ technique. There were also guidelines on the use of

aseptic non-touch technique (ANNT) in catheter care and intravenous (IV) lines and safe glove

removal.

Information on the trust intranet indicated local induction included making staff aware of infection

prevention and control (IPC) policies and procedures. Staff with a clinical responsibility undertook

annual IPC recall training, either face to face or via an IPC team member, or by e-learning. There

was a range of IPC training available to staff via a multi-media library.


The service had suitable premises and equipment and looked after them well.

During our previous inspection we observed that some lifts were out of order with people waiting in

the lobby, and staff were using public lifts to transfer soiled linen. During this inspection we found

the hospital had addressed this with two of the four lifts in the Golden Jubilee wing being allocated

for staff use only, and only accessible with a swipe card. There was signage on the staff lifts to

make the public aware that these lifts were for staff use only. We found all lifts were working and

we did not see staff or members of the public having prolonged waits for lifts.

During our previous inspection we found processes for checking equipment and stock were not

robust in inpatient areas or in the community midwifery centre. However, during this inspection we

checked 12 pieces of electrical equipment throughout the hospital and community maternity

services. All the equipment we looked at had a servicing maintenance sticker attached to show

when the equipment was serviced, as well the date when the next service was due. All the

equipment we checked had been serviced and the service records were in accordance with

servicing schedules. Maintenance schedules and servicing records were held by the trust’s

estates department. Staff told us the estates team arranged servicing, and reminded staff when

equipment was due for servicing. Clean equipment had green ‘I am clean’ stickers attached which

included the date and time they were cleaned.

The maternity department consisted of antenatal clinic rooms, maternal assessment unit (MAU),

fetal medicine unit (FMU), labour ward, maternity theatres, obstetric antenatal/postnatal ward,

and birth centre.

The department-maintained security in accordance with Royal College of Gynaecology (RCOG)

2008 recommendations. We found the hospital had good systems to ensure the security of the

maternity unit. This included swipe card access to all maternity areas. The public and non-

maternity staff were only permitted access to maternity areas by using an intercom to speak with

staff. There was always a receptionist on the labour ward. The receptionist on the post-natal ward

worked from 9am to 5pm. Outside these hours, ward staff would check the identity of visitors to

the ward. Women who were being discharged were given a printed paper slip to present to the

receptionist if they were taking a baby home. We were asked by reception staff to show our

identification when first entering both the labour and post-natal wards. These measures ensured

staff and visitors were monitored when arriving and departing the wards.


There was a lack of tail gating notices on all wards and departments. These are notices at the

entrance to wards and departments that remind staff and the public not to allow other people

access to the ward by entering when the doors are opened. The lack of notices meant there was a

risk that people who had not been granted access could get into the areas.

Antenatal and post-natal wards were open planned, with enough space to manoeuvre beds

between bays and other areas if needed.

We checked resuscitation trolleys on all levels and found they contained the correct equipment

and all consumables were in date. We saw equipment and content checklists were completed.

There were fetal blood sampling, postpartum hemorrhage (PPH) and pre-eclampsia trolleys and

an epidural trolley available on the labour ward. These were well organised, and checklists were

carried out daily to ensure all the necessary equipment was available and in date.

In theatres we saw specific packs for caesarean section (CS) and third-degree tears. The packs

contained sterile equipment that was specific to the surgery with the aim of helping surgeons and

theatre staff by speeding up the process.

Staff told us they had adequate access to equipment needed to deliver safe care. We saw

adequate numbers of cardiotocograph (CTG) machines, (these are machines that record the fetal

heartbeat and the uterine contractions during pregnancy), resuscitation equipment, fetal blood

analysers and fetal heart rate monitors.


Staff completed and updated most risk assessments for women and their babies. They kept

clear records and asked for support when necessary.

Women were assessed in the medical assessment unit (MAU) or in triage before they were

admitted to the wards. We found there had been action to improve assessment of risks to women

and their babies since our previous inspection. For example, women at risk of hypertension (high

blood pressure) were identified at the antenatal clinic and case-loaded. The department had two

0.5 whole-time equivalent (WTE) specialist midwives for hypertension. Women that were

hypertensive, (these were women with having a blood pressure greater than 140/90 mm Hg) or

diabetic were reviewed daily during the consultant ward round.

The labour ward matron did a daily matron’s audit. This included checks on womens modified

early obstetric warning score (MEOWS); Venous thromboembolism (VTE); cannula and catheter

care. We viewed the matrons audit for the labour ward dated 31 January 2019 and found this

was complete.

Women were continuously risk assessed using the MEOWS scoring tool. We found most women’s

MEOWS scores across maternity were up to date. Electronic patient records (EPR) automatically

totalled MEOWS scores, this enabled staff decision making for women’s care and treatment.

However, we noted the MEOWS score for a woman on the high dependency unit (HDU) had gaps

in the records on 30 January 2019 from 5pm to 11pm, and on 31 January 2019 from 8.30pm. This

meant staff could not be assured of early identification had the woman deteriorated.

Women were assessed for VTE. There was a VTE lead midwife and VTE assessments were

audited as part of the matron’s daily audit. We viewed 10 women’s EPR and found VTE

assessments were complete.

The high dependency unit (HDU) used a situation, background, assessment, recommendation

(SBAR) tool at shift handovers. This is a technique that can be used to facilitate and prompt


appropriate communication. The technique provided focused and easy communication by

transferring relevant and critical information between staff, especially during transition of patient

care from one shift to another. However, we reviewed 10 SBAR records and found they were not

always recorded consistently.

There were emergency response teams for babies and women. There were clear procedures for

staff to follow to summon emergency help, and staff told us the teams responded quickly when

called.

We viewed the women’s health speciality outcomes report dated 29 January 2019. This reported

that puerperal sepsis and other puerperal infections, (infections occurring following child birth),

rate was higher than expected. There was no action identified in the report, but the report recorded

that an action plan was due in March 2019.

All midwifery staff had received training in sepsis awareness from the trust’s critical care outreach

team, i-Mobile, during the trust’s sepsis awareness week in 2018. Staff told us they would refer

any woman thought to be at risk of developing sepsis to the i-Mobile team for further assessment

without delay.

The service followed the ‘Five Steps to Safer Surgery’ World Health Organisation (WHO) checklist.

The perioperative team took the lead on WHO audits in theatres. Responsibility for audits of

practice, safety checks and swab count in delivery rooms remained with the midwifery team. We

viewed WHO audit results dated from October to December 2018. The audits found over 90%

compliance with ‘sign in’, ‘time out’, and ‘sign out’ in the period.

Women had a copy of the 'Five Steps to Safer Surgery' WHO checklist recorded in their notes. We

viewed eight women’s WHO checklist notes and found in one set of notes the checklist was

incomplete. We observed a WHO checklist being completed on 31 January 2019 and found staff

did not pay full attention during the sign in process.

There was a clear criterion for women that needed a paediatrician to be present at birth. This

included guidelines on the management of multiple pregnancy, the management of breech

presentation and a pathway which outlined when staff should call a paediatrician.

There was a daily consultant led multidisciplinary ward round on labour ward at 8am. This

continued to the postnatal ward where higher risk women were seen as part of this round. Women

involved on the postnatal ward rounds were highlighted by the midwife in charge depending on

their needs.

There was a daily safety huddle on the labour ward and post-natal ward which gave staff the

opportunity to discuss women’s who may require extra care and update staff on the progress of

women throughout the service. This was attended by multidisciplinary staff members including

consultants and registrars.

Hypoxic Ischemic Encephalopathy (HIE), is a type of brain damage that occurs when an infant’s

brain doesn’t receive enough oxygen and blood. From January to December 2018 there had been

27 cases of HIE, this was worse that the trust’s indicator of zero. It was also significantly worse

than January to December 2017 when there had been 10 cases of HIE. The trust had conducted a

‘therapeutic hypothermia’ audit in 2018. This audit looked at outcomes for babies that required

cooling of the baby’s brain or body to reverse brain hypoxia, (oxygen deprivation), caused by high

temperatures. This is one of the treatments for HIE. The audit contained recommendations which

had been recently implemented, including improvements in the documenting of HIE on the

electronic patient record system.


The department used a system of ‘fresh eyes’ on all CTG monitoring. This is a system where a

review of the CTG printout is undertaken by two members of staff, either another midwife or

medical staff, to check there is agreement in its interpretation. The system helps to reduce the risk

of possible misinterpretation.

Medical staff and midwives received monthly practical obstetric multi-professional (PROMPT)

emergency training. This provided staff with evidence-based tools combining teaching with

effective teamworking and collaborative clinical management in care of critically ill women and

babies.

Maternity offered six training places a month on advanced neonatal life support. On 1 February

2019, maternity had 63 staff who had completed this training.

Community midwives were aware of the trust’s ‘hypertension in pregnancy guideline’. Women with

a previous history of pre-eclampsia or pregnancy induced hypertension, chronic hypertension or

renal disease were referred to the antenatal hypertension clinic.

Staff told us women with a new diagnosis of renal dysfunction were being identified earlier as a

result of the hospital having an early intervention team. Women with renal disease were case-

loaded and received follow up from the specialist renal and obstetric team.

There was a weekly perinatal meeting that reviewed incidents or issues involving women and

babies directly before and after birth. There was also a weekly CTG meeting which reviewed

incidents or issues involving fetal monitoring during labour.

Midwifery and nurse staffing

The service had enough staff with the right qualifications, skills, training and experience to

keep people safe from avoidable harm and to provide the right care and treatment.

Staff told us midwifery staffing had improved since our previous inspection in 2015. From January

to December 2018 the average staffing fill rate, (this is the number of shifts which were staffed in

accordance with assessed levels of staffing needs), was 97.5% during the day. This was better

than the trust indicator of 97%. The rate at night was 104%, this was better than the trust indicator

of 103%.

The hospital had introduced three matrons, with a split in their role of 70% clinical and 30%

managerial since our previous inspection in 2015.

The hospital had six case-loading teams with six midwives allocated to each team.

Maternity services used the ‘safer staffing’ tool to assess the nursing capacity required on each

shift. Staffing by band was displayed on each ward with the planned and actual numbers shown.

This was updated daily.

We found establishment staffing level for midwives was one midwife to 26 women. This was in

accordance with the recommendations of a nationally recognised acuity tool called Birthrate plus.

Birthrate Plus is a planning tool for midwives which provides managers with a means to measure

the work and time involved in providing high quality maternity services and translating this into

staffing numbers. The tool was used to calculate the required number of midwives to maintain one

to one care for women in labour.

We were shown evidence that the department staffing was reviewed annually to ensure the needs

of women were met and the ratio of midwives to women was correct. Although some staff reported

feeling overworked.


Recovery nurses staffed the theatres general recovery unit from 9am to 5pm. Between 5pm and

9am the recovery unit was staffed by midwives who were assessed as competent in the role. Both

recovery nursing staff and midwives told us they had no concerns with the arrangement. This was

in accordance with royal colleges recommendations in ‘Staffing of obstetric theatres – a

consensus statement’ (2009).

Maternity used agency workers and staff from the trust’s bank to cover shifts. Staff told us agency

workers were regular agency staff who knew the common processes and procedures on the

wards. However, some staff told us shifts on the antenatal and postnatal wards were not always

covered.

Staff told us a staffing restructure in 2018 resulted in the role of band 3 maternity support workers

(MSW) being replaced with band 2 health care assistants (HCA). Both midwifery and HCA staff

raised concerns about the change. Staff told us the HCA role placed more pressure on midwifery

staff as HCA did not have the same skill set as MSW. Staff told us MSW were able to do some

women and baby observations, as well as offering breast feeding support and tests. Staff told us

HCA were not trained to assist in these tasks and it was not in their job description to perform

these tasks.

Maternity had introduced band 4 breast feeding support workers as part of the staffing restructure.

However, staff told us there were insufficient numbers of breast-feeding support workers. For

example, staff told us in the week preceding our inspection there was one breast feeding support

worker on the postnatal ward roster at night. However, the breast-feeding support worker had

been absent due to sickness and their shifts had not been covered. This meant midwives had to

cover women’s breast feeding needs during these shifts.

There were six community midwives’ teams working across the KCH catchment area. The

community midwifes worked set shifts. Community midwifery teams told us they were rarely asked

to provide support for hospital-based services, but they could provide support if there were staffing

shortages in the hospital.

The trust provided specialist midwives including: a practice development midwife, perinatal mental

health midwife, a midwife specialising in migrant women, infant nutrition midwife, breastfeeding

lead, bereavement midwife and safeguarding midwife.

The trust has reported their staffing numbers in August 2018 as follows:

Staffing group Planned staff

Actual

staff

Fill

Rate

Qualified nursing & health visiting staff (Qualified nurses) 37.5 32 85.3%

Qualified nursing midwifery staff (Qualified nurses) 375.4 400 106.6%

The staffing fill rate was 101.4% fill rate (244.6 WTE) in August 2018.


The midwifery training report 2018 recorded that in December 2018 the total number of midwives

was 301, of which 11 were on maternity leave and 13 were on secondment or a career break.

From September 2017 to August 2018, the trust reported a vacancy rate of -2.9% in maternity.

The rate for KCH was -0.4%. The negative figure indicates that there were more WTE in post

than originally scheduled. However, we discussed this with staff. They told us the acuity tool did


not take into consideration women and babies “continuity of care.” Staff told us the tool used for

assessing midwifery needs was misleading and did not reflect the actual staffing needs in

maternity when continuity of care was factored in.

From September 2017 to August 2018, the trust reported a turnover rate of 9.7% in maternity.

This was lower than the trust indicator of 10% and the trust average for nursing staff of 12.4%.

The rate for KCH was –13.1%


From September 2017 to August 2018, the trust reported a sickness rate of 4.4% in maternity.

This was higher than the trust indicator of 3% and the trust average for nursing staff of 3.3%. The

KCH rate was the same as the trust rate at 4.4%


From September 2017 to August 2018, the trust reported a bank usage rate of 67.6% in

maternity, and an agency usage rate of 20.5%. This left 11.8% of available hours unfilled.



(Source: Routine Provider Information Request (RPIR) - Nursing bank agency)

From April 2017 to March 2018 the trust had a ratio of one midwife to every 22.67 births. This

was better than the England average of one midwife to every 25.68 births.

(Source: Electronic Staff Records – EST Data Warehouse)

Medical staffing

There was 94 hours labour ward cover. Staff told us the trust had increased consultant staffing

hours and had reviewed staffing in response to recommendations of the Royal College of

Obstetricians and Gynaecologists (RCOG), ‘Providing quality care for women: obstetrics and

gynaecology workforce, 2016’. All women had a named consultant (for high-risk pregnancies) or a

named midwife (for low risk pregnancies).

There was a registrar on call for the labour ward 24 hours a day seven days a week (shift time).

This was in-line with recommended Safer Childbirth and RCOG guidelines of 60 hours of

consultant presence. Consultants were present on the maternity unit from 7am to 9pm Monday to

Friday and from 9am to 9pm at weekends. Outside these hours’ consultants were on call from

home. Staff told us consultants were responsive when called out of hours, and there had not been

any issues with consultants responding to an out of hours call.

A copy of the consultants on call rota could be found at the nurse’s station. There were no

reported problems getting hold of an on-call consultant.

The obstetric theatres were managed by the maternity service with full anaesthetic support. A

consultant anaesthetist did a joint ward round daily with a maternity consultant Monday to Friday

and an anaesthetic registrar completed ward rounds at the weekend.


Five consultants covered both obstetrics and gynaecology on a 16-day rota. There were eight

obstetricians on a 16-day rota. There were elective caesarean section (CS) lists from Monday to

Friday. However, in our previous report we reported that there was no dedicated cover for

consultant leave and this was covered by registrars. We found this was still the case with

consultant leave being covered by registrars.

Antenatal ward rounds were covered by a different consultant each day in accordance with the

consultant rota. However, there was no cover for consultant leave. Staff told us when a consultant

was on leave ward rounds would be covered by a registrar and their findings would be discussed

with the labour ward consultant.

There were twice daily medical handovers. There was a room available for handovers within each

unit. This ensured confidential discussion about patients. Neonatal consultants were involved in

meetings with the maternity department. We were told that neonatal doctors were available if

needed and there was a good relationship between the maternity and neonatal departments.

Two consultants shared cases in the termination of pregnancy clinic. There was also back-up

consultant cover in place to cover staff absence and ensure that late gestation women could

always be accommodated.

In July 2018, the proportion of consultant staff reported to be working at the trust was about the

same as the England average and there were no junior (foundation year 1-2) staff.

Staffing skill mix for the 84.6 whole time equivalent staff working in maternity at King's

College Hospital NHS Foundation Trust.

This

Trust

England

average

Consultant 42% 41%



Junior* 0% 6%





Records

Staff kept detailed records of women and babies care and treatment. Records were clear,

up-to-date and easily available to all staff providing care.

Women and babies had an electronic patient record (EPR). These were used to hold information

on antenatal appointments, blood test results, scan results and the delivery of babies. Staff told us


the EPR scheduled care plan was used as a coverall and allowed staff to individualise women’s

appointments. The EPR also flagged any safeguarding risks to women or new-born infants.

Women held their own paper maternity records, and these were used throughout the pregnancy

and recorded information from appointments. These were in addition to the hospital recording

system. Women’s paper notes included useful information about pregnancy, screening, pain relief

and birth choices.

Women were given a ‘red book’ on discharge to keep records of their baby’s growth and

development, and for use in the community and transfer between services. We saw midwives

check with women prior to discharge that they had this book before they left.

We saw a variety of different forms were completed prior to discharge, including referrals to the

community midwives, social workers, and GP surgeries. This ensured continuity of care for women

and babies post discharge.

Medical records were stored securely on the wards in unlocked trolleys behind nursing stations.

We did not see any unattended trolleys or unattended nursing stations during our visit. We also

checked a medical records trolley in a corridor on the antenatal ward and found this was locked.

We reviewed 10 sets of women’s notes at KCH across the maternity departments and saw they

were comprehensive and well documented. Women’s records included diagnosis and

management plans, consent forms, evidence of multidisciplinary input and evidence of discussion

with women and families. Notes were generally compliant with guidance issued by the General

Medical Council (GMC) and the Nursing and Midwifery Council (NMC), (these are the professional

regulatory bodies for doctors and nurses). Women’s records were easily accessible to staff who

needed them.

The maternity quality of care audit dated from January to December 2018 recorded that maternity

were not meeting the trust’s 95% indicator for the documentation of intravenous (IV) lines care,

with an average of 67% compliance over the period.

Community midwifery staff had been provided with tablet computers. Staff told us this eliminated

the risk of carrying women’s records in their cars, as women’s information could be accessed

securely from the EPR on the tablet computers.

Medicines


medicines. Women received the right medication at the right dose at the right time.

During our previous inspection in April 2015 we found fridge temperatures in community midwifery

were not regularly checked and medicines stored there were not checked to see if they were in

date. During this inspection we found medicines that needed to be stored in fridges were in date.

Fridges were checked daily and the minimum and maximum temperatures recorded. Staff signed

to say these had been checked and we saw a protocol which should be followed if the fridges

were not in the correct limits. This was in line with best practice guidelines.

Antimicrobial stewardship is the systematic effort to educate and persuade prescribers of

antimicrobials to follow evidence-based prescribing, in order to stem antibiotic overuse, and thus

antimicrobial resistance. The maternity quality of care audit demonstrated that maternity met or

exceeded the trust’s indicator of 95% for recording of clinical indicators (95%), stopping and

reviewing antimicrobials (99%), switching patients from intravenous (IV) to oral antibiotics (100%),

and working in accordance with the trust’s antimicrobial stewardship guidelines (100%).


We looked at the arrangements for storing medicines on the postnatal ward. We found the ward

followed best practice and had a locked controlled drug cupboard, inside another cupboard, and

all the drugs we looked at were in date. We looked at controlled drugs (CD’s) (medicines liable to

be misused and requiring special management). Checks of controlled drugs were completed daily.

Staff told us that the pharmacist visited daily and checked drugs and charts.

In theatres the theatre practitioner held the keys to the drug cupboards to ensure they were safely

stored.

Incidents

Staff recognised incidents and reported them appropriately. Managers investigated

incidents. However, lessons learned were not always shared with the whole team and the

wider service.

During our previous inspection in April 2015 we reported there was no systematic approach to

ensure staff were offered a debrief following a serious incident. During this inspection senior

managers told us there was no formal policy on staff debriefing. At the time of this inspection

managers told us staff were debriefed immediately following a serious incident and matrons would

always meet with staff in response to a serious incident. However, following our inspection we

were provided with a formal procedure ‘Supporting staff following an adverse incident.’ This meant

a systematic approach had been introduced, but that managers we spoke with were unaware of

the policy. The procedure did not specify the timescales for debriefing staff.

The trust used an electronic incident reporting system. Incident reports were reviewed daily by the

risk lead midwife and assigned to a staff member for conclusion. Staff told us there was a culture

of reporting incidents, but, some staff said receiving feedback about incidents they had submitted

was variable and, “Could be improved.”

In April 2015 we reported medical and consultant staff in maternity services did not routinely report

incidents on the electronic reporting system. The incidents we reviewed sometimes indicated a

midwife had reported an incident at the request of a consultant. However, the director of midwifery

told us all staff were responsible for reporting incidents. The head of midwifery (HOM) said they

had not received any recent reports of medical staff asking matrons to report incidents for them.

Matrons reviewed incidents and assigned them a grade. The severity of an incident was graded

using the National Patient Safety Agency (NPSA) framework, these were: no harm (impact

prevented (near miss), impact not prevented), low, moderate, severe and catastrophic.

Incidents were red, amber, green (RAG) rated. All incidents were reviewed at the weekly incident

review meeting (IRM). Amber and red rated incidents were investigated by the patient safety

manager.

We viewed the trust’s incident reports for the period 1 July to 31 December 2018. KCH reported

708 incidents during the period. We found there had been one ‘red’ rated incident in the period

and 37 ‘amber’ rated incidents. These were referred for root-cause analysis (RCA) investigation.

Staff told us the incident review system was, “Under strain,” because of resources and incident

reviews were not always timely. We noted eight of the ‘amber’ rated incidents had been closed.

Other open ‘amber’ incidents did not always have chronological dates of actions or reviews

recorded on the incident report, when an investigation was in progress.

The trust’s risk lead midwife reviewed all incidents. All low or no harm incidents were reviewed and

logged for trend analysis. Matrons and clinical leads were responsible for investigating incidents,


recording actions and signing them off when complete. This included any immediate actions that

needed to be undertaken to ensure women and babies safety. If it was decided after a further risk

review by the IRM, that an incident was classified as a serious incident (SI), it was passed on to

senior managers and an RCA investigation was conducted. Once the RCA report had been

completed, and approved by the trust corporate SI committee, it was sent to the Clinical

Commissioning Groups (CCG) in accordance with national policy for approval.

Incidents were fed back to clinical leads by the risk lead midwife and risk lead consultant. This

meeting provided appropriate oversight to senior clinicians within the department of incident

themes and trends.

Staff could access any Serious Incident (SI) reports, however, there was no record of who had

read these, therefore no assurance that lessons learnt had been seen by all staff members. Staff

we spoke to gave mixed accounts of their awareness of these reports.

During our inspection all staff we spoke to were aware of their responsibilities relating to Duty of

Candour under the Health and Social Care Act (Regulated Activities Regulations) 2014. The Duty

of Candour is a regulatory duty that relates to openness and transparency and requires providers

of health and social care services to notify patients (or other relevant persons) of “certain notifiable

safety incidents” and provide them with reasonable support.

Duty of candour was included as part of induction training for new starters across the maternity

services.

We reviewed incident data for the service and actions staff took following incidents and saw

evidence staff applied duty of candour appropriately. We saw the duty of candour was discussed

in several meeting minutes, SI and RCA reports.

There were quarterly joint mortality and morbidity meetings with staff from the special care baby

unit (SCBU). The meetings looked at mortality and morbidity data for women and babies as well

as reviews of the quality of care provision. The meetings monitored themes and trends and areas

for learning.




never event.

From October 2017 to September 2018, there had been no never events at KCH.



(SIs) in maternity which met the reporting criteria set by NHS England from October 2017 to

September 2018.

The different types of incident were:

Incident type No. of incidents

Maternity/Obstetric incident meeting SI criteria: baby only (this include

foetus, neonate and infant)

7

Maternity/Obstetric incident meeting SI criteria: mother only 2




We viewed three SI investigation reports and action plans in response. These indicated

multidisciplinary meetings were held and cases were reviewed at several staff meetings and a root

cause analysis (RCA) had been completed. Clear and specific recommendations and action plans

were in place and monitored to completion.

Safety thermometer

The trust did not use the maternity safety thermometer or submit data to the NHS safety

thermometer in maternity.




effectiveness. Although some policies and procedures had exceeded their review dates.

During our previous inspection in April 2015 we found the trust was not following the Royal

College of Obstetricians and Gynaecologists (RCOG) guidelines on antenatal tests for low-risk

women. The trust had made a decision to delay the implementation of recent NICE guidelines on

blood sugar testing and glucose tolerance tests at early stages of pregnancy, until the service had

been reorganised because of the demands this would place on the service (a high percentage of

women using the service were diabetic). However, during this inspection we found the trust had

addressed this by introducing and implementing a guideline for diabetes based on NICE (NG5

CG33, 2015) guidelines.

During our previous inspection we found It was not clear that midwives understood how to respond

to the test to identify jaundice. During this inspection we found the trust had addressed this and

introduced a guideline and pathway for jaundiced babies which staff were aware of and

implemented.

Staff told us guidelines were accessible on the trust intranet but said the system could be difficult

to navigate. We found that during a search for safeguarding information in maternity there was a

wide range of policies and procedures, including previous versions of policies. This made finding

the most up to date guidance difficult to locate. A member of staff told us the policies, “Need a

cleanse.”

We viewed three guidelines on the intranet that had exceeded their review dates. For example,

induction of labour, waterbirth and pain in labour guidelines were due for review in April 2018.

We found from our observations and discussions with staff and women that care was being

provided in accordance with the National Institute for Health and Care Excellence (NICE) quality

standard 22. This standard covers the care of all women up to 42 weeks of pregnancy. It covers all

areas of antenatal care including community and hospital settings.

Women who needed a caesarean section (CS), whether planned or not also received care in

accordance with the NICE recommendations (Quality standard 32). For example, Quality

statement 1: Vaginal birth after a caesarean section (VBAC).

There was evidence to indicate that NICE Quality Standard 37 was being adhered to in respect to

postnatal care. Examples included staff discharging women and babies with appropriate checks


and with correct medicines. All women we spoke with had been given breastfeeding advice and

support.

The trust was following recommendations from NICE Quality Standard 190: Intrapartum care.

Women were offered a choice of birthing locations and choice of care throughout labour. Women

we spoke with told us this was discussed at antenatal appointments and staff discussed how they

could accommodate women’s choices.

Growth was monitored from 24 weeks by measuring and recording the symphysis fundal height in

mothers and babies, (this relates to the McDonald's rule, and is a measure of the size of the

woman’s uterus, it is used to assess fetal growth and development during pregnancy): Reducing

risk through audits and confidential enquiries (MBBRACE) UK (2015) and in accordance with

NICE guidelines (NG3, 2015).

From evidence we reviewed and from talking to staff, the service adhered to The Abortion Act

1967 and the Abortion Regulations 1991. There was correct completion of HSA1 forms which

were signed by two doctors before admission. An audit of HSA1 forms in November 2018 found

100% compliance with completion of the HSA1. The correct procedure was also followed for the

HAS4 form which was sent to the Department of Health (DoH) after completion.

We reviewed the ‘invasive procedures protocol’ this met RCOG guideline 6.7 this included the

procedure for feticide and procedure for fetal anomaly over 21 weeks prior to induction of labour.

We saw areas of evidence-based antenatal practice. For example, the trust offered fetal anomaly

screening in accordance with current UK National Screening Committee programmes. This was in

accordance with NICE quality standard QS22: Antenatal care.

We saw evidence of a policy/guidance on the use of nets for emergency pool evacuation. Staff

told us they recently had an unannounced ‘skills drill’ on pool evacuation to ensure staff were

aware of the policy and procedure for pool evacuation.

We were told new NICE/RCOG guidelines would be disseminated to staff by obstetricians or the

practice development midwife.

A new-born infant physical examination (NIPE) system had been introduced to ensure neonatal

screening and referral pathways were in place and included a mechanism that meant that babies

not screened within 72 hours of birth would be identified.

The department had a NIPE lead midwife and some staff had undergone training to aid the

screening of newly born babies before they left hospital. This demonstrated the trust had taken

action to improve the NIPE screening of babies prior to discharge.

The trust was working towards level 1 UNICEF ‘Baby Friendly’ accreditation. Baby Friendly

accreditation is based on a set of standards to promote breast feeding and mother and infant

interaction.


Staff gave women and babies enough food and drink to meet their needs and improve their

health.

Women were offered a choice of menu options and dietary requirements were taken into

consideration. Women we spoke with reported the food was edible and options were available.

Women were supplied with a jug of water in the morning on the antenatal and postnatal wards and

there were regular hot drink rounds six times a day. However, one woman we spoke with told us

their water jug had not been refilled when it was empty and they had to ask staff to refill the jug.


We found the water dispenser in the postnatal ward reception area was empty. Staff told us two

water refills were on order, but they did not know when they would be delivered. Reception staff

told us they would call the health care assistants if a person requested water in the reception area.

There was no signage to inform people they could request water.

The trust’s obstetric scorecard dated from December 2017 to December 2018 recorded that

maternity were meeting the trust’s 85% indicator for: breast feeding at delivery (first feed) with an

average rate of 88%; the breast feeding when discharged from hospital rate was 88%; the breast-

feeding rate when discharged from community care was 92%.

The department offered a breastfeeding room and had a specialist breastfeeding midwife to

support women. Breast feeding support workers were trained to support women with feeding their

babies. However, some staff told us there were insufficient numbers of breast-feeding support

workers to meet all women’s support needs.

The midwife station on the postnatal ward had a neonatal care and assessment board. This had a

flowchart to guide staff in ‘caring for healthy babies who are reluctant to breast feed’, as well as

information on ‘mastitis and breast feeding’.

Workshops were available to support women struggling to breastfeed.

All the women we spoke with on the postnatal wards said they had received support to breastfeed

soon after birth, and that this had continued on the postnatal ward.

Printed information of breastfeeding support was available in the maternity department.

There was a breastfeeding room for women to use with a fridge to store breastmilk. Women who

preferred to bottle feed their baby found sterilisers were readily available.

Pain relief

Staff assessed and monitored women regularly to see if they were in pain.

Women had access to a range of pain relief methods following NICE guidance CG190. This

included Entonox (gas and air) and Pethidine (a morphine-based injection) for medical pain relief

during labour.

The anaesthetic department provided by the anaesthetic cover 24 hours a day, seven days a

week.

The rate for women receiving general anaesthesia for elective caesarean section (CS) was 3%.

The rate for emergency CS was 9%. Combined spinal and epidural anaesthesia (CSE), (this is a

pain control technique which combines the benefits of both spinal anaesthesia and epidural

anaesthesia), was 4% of elective CS and 2% of emergency CS. Most women, 90%, having

elective CS had spinal anaesthesia. The rate for emergency CS spinal analgesia was 46%.

Epidural rates for women receiving elective CS were 1%. The epidural rate for emergency CS was

50%.

Epidurals were available 24 hours seven days a week. Women generally received epidurals within

30 minutes of request.

We found that pain scores were recorded in the care records we looked at. This meant women’s

pain could be appropriately identified and managed in a timely way.

Staff told us they had access to the trust’s pain team for advice and guidance on pain

management. Staff also told us they could ask the theatre’s 24-hour anaesthetic team about pain

relief as well as contacting the i-Mobile team for advice on pain relief.


A woman we spoke with told us she was due to be discharged, but staff had delayed her

discharge whilst the midwife checked her pain management arrangements prior to her discharge.

This meant staff could be assured women were leaving with pain management arranged.

Patient outcomes

Managers monitored the effectiveness of care and treatment. However, there were a range

of outcome indicators that were not meeting the trust’s standards and actions in response

were not always timely.

The trust used an obstetric scorecard to monitor outcomes and measure how maternity services

were meeting the trust’s key performance indicators (KPI). We viewed the obstetric scorecard

dated from December 2017 to December 2018.

The obstetric scorecard indicated that maternity was not meeting the trust’s 40% KPI for normal

births. The average rate from December 2017 to December 2018 was 32.4%.

Maternity were not meeting the trust’s 22% KPI for induced labour. Between December 2017 and

December 2018, the KCH average was 31.8%. Maternity had not met the 22% KPI in any month

during the period.

The trust’s KPI for ventouse and forceps delivery was 15%, (these are assisted births using

forceps or a ventouse suction cup). Between December 2017 to December 2018 maternity were

not meeting the trust’s KPI, with the average rate of assisted births in the period being 21.7%.

We viewed the women’s health speciality outcomes report dated 29 January 2019. This reported

that actions were required in response to the data. There was no action identified as the report

recorded that instrumental delivery was under investigation at the time of inspection. An action

plan in response was recorded as due in March 2019.

Maternity were not meeting the trust’s KPI for deliveries complicated by major postpartum

haemorrhage (PPH), (this is major bleeding following birth). The obstetrics scorecard recorded

between December 2017 and December 2018 there had been 127 episodes. The trust’s KPI was

10 cases per month. Maternity had not met the trust’s KPI in any month in the period. The highest

rate of PPH was 22 in January 2018 and the lowest rate was 11 in March and August 2018. We

requested from the trust audit data and action plans relating to PPH. The trust sent a ‘massive

obstetric haemorrage’ audit dating from 2016. Actions and recommendations from the 2016 audit

had been implemented. However, PPH rates from December 2017 to December 2018 were not

meeting the trust’s KPI indicators.

Between December 2017 and December 2018 KCH were not meeting the trust’s 1.5% KPI for

women experiencing third- or fourth-degree tears. The trust’s obstetrics scorecard recorded that

the average rate in the period was 2.9%. The trust’s KPI had not been met in any month during the

period, with the highest rate being 4.7% in August 2018; and the lowest rate being 1.6% in

November 2018. However, from September to December 2018 the trend in third- and fourth-

degree tears was improving with the average in these months being 2.1%. We requested audit

data and action plans in response on tears from the trust. We received audit data. However, we

did not receive information on any actions the trust was taking in response to the audit data.

Between January and May 2018 KCH had 13 babies born with meconium aspiration against a KPI

of 0. (Meconium aspiration syndrome (MAS), also known as neonatal aspiration of meconium, is a

medical condition affecting new-born infants). However, it should be noted that the obstetric


scorecard was blank and did not record whether there had been any cases from June 2018 to

December 2018.

Maternity were meeting the trust’s KPI for women suffering eclamptic fits, (Eclampsia is the onset

of seizures (convulsions) in a woman with pre-eclampsia. Pre-eclampsia is a disorder of

pregnancy in which there is high blood pressure and either large amounts of protein in the urine or

other organ dysfunction). Between January and December 2013 there had been one case of a

woman suffering an eclamptic fit, this had occurred in November 2018.

We viewed the maternity audit schedule 2018 to 2019. Audits were undertaken in accordance with

national strategic directives and correlated to NICE Quality Standards. These included core audits

from ‘Clinical Negligence Scheme for Trusts’ (CNST) standards. For example, at the time of

inspection an audit was in progress on immediate skin to skin contact for babies born in the

operating theatre.

In the 2017 National Neonatal Audit the hospital’s performance in the two measures relevant to

maternity services was as follows:

• Are all mothers who deliver babies from 24 to 34 weeks gestation inclusive given any

dose of antenatal steroids?

There were 146 eligible cases identified for inclusion, 92.4% of mothers were given a complete

or incomplete course of antenatal steroids.

This was better than expected when compared to the national aggregate where 86.1% of

mothers were given at least one dose of antenatal steroids.

The hospital met the audit’s recommended standard of 85% for this measure.

• Are mothers who deliver babies below 30 weeks gestation given magnesium sulphate in

the 24 hours prior to delivery?

There were 45 eligible cases identified for inclusion, 57.8% of mothers were given magnesium

sulphate in the 24 hours prior to delivery.

This was higher than the national aggregate of 43.5% and put the hospital in the top 25% of all

units.

The trust KPI for all caesarean section (CS), including elective and emergency, was 26 %. The

CS total rate from January to December 2018 was above the trust’s KPI at 29.6%. Between

January and December 2018 KCH maternity had not met the 26% KPI with the exception of April

2018 when the rate had been 25.3%. The highest rate of total CS in the period was 33.9% in

November 2018.

The CS rates improved for elective CS where the trust KPI was 10%. The maternity department

had achieved the trust KPI in five months during the period. These were: December 2017 (10%),

February 2018 (9.9%), March 2018 (8.8%), April 2018 (7.9%), July 2018 (9.7%), September 2018

(8.2%).

In relation to modes of delivery from April 2017 to March 2018 the table below shows the

proportions of deliveries recorded by method in comparison to the England average:


(Source: Hospital Episodes Statistics (HES) – provided by CQC Outliers team)

As of September 2018, the trust reported no active maternity outliers.

(Source: Hospital Evidence Statistics (HES) – provided by CQC Outliers team)

The trust took part in the 2017 MBRRACE audit and their stabilised and risk-adjusted extended

perinatal mortality rate (per 1,000 births) was 6.64. This is up to 10% lower than the average for

the comparator group rate of 6.71.

(Source: MBRRACE UK)

Competent staff

The service made sure staff were competent for their roles. Managers appraised staffs work

performance and held supervision meetings with them to provide support and monitor the

effectiveness of the service.

Appraisal rates had improved since our previous inspection in April 2015 when only a quarter of

midwifery staff had received an appraisal. However, in February 2019, 76.5% of midwifery staff

had received an appraisal this was worse than the trust standard of 90%.

Staff told us they received both a local departmental induction and a corporate induction.

In response to changes in the regulation of midwives and the regulation of supervision in 2017, the

trust had introduced a new model of midwifery supervision. The trust had one professional

midwifery advisor (PMA) to roll out the new model of midwifery supervision ‘A-EQUIP’ (advocating

for education and quality improvement). A-EQUIP is a continuous improvement process that aims

to build personal and professional resilience, enhance quality of care for women and babies and to

support midwives preparedness for professional revalidation.

Profile of all deliveries (April 2017 to March 2018)

England

Deliveries (n) Deliveries (%) Deliveries (%)

Single or multiple births

Single 9,127 98.3% 98.6%

Multiple 160 1.7% 1.4%

Mother’s age

Under 20 131 1.4% 3.1%

20-34 6,012 64.7% 74.9%

35-39 2,506 27.0% 18.1%

40+ 638 6.9% 4.0%

Total number of deliveries

Total 596,828

Source: Hospital Episode Statistics, April 2017 to March 2018

KING'S COLLEGE HOSPITAL

NHS FOUNDATION TRUST

9,287

Notes: A single b irth includes any delivery where there is no indication of a multiple b irth. This tab le does not include

deliveries where delivery method is 'other' or 'unrecorded'.


Midwifery staff told us they received regular quarterly supervision from the PMA and ad hoc

supervision from the director of midwifery and women’s health and head of midwifery (HOM). Staff

told us there were regular team meetings. During our inspection we saw a member of staff come

to work on their day off to attend a team meeting on the labour ward. The staff member told us,

“We will come to team meetings when we are not working. It’s a busy unit and it’s the only way

they can bring most of the staff together.” The PMA staff offered reflective supervision to midwifery

staff upon requests.

New midwives joining the trust completed a comprehensive preceptorship programme. This

included completing a midwife development handbook, where evidence of competency was

documented and awarded.

The trust employed a dedicated practice development team for midwifery. This included practice

development midwife (PDM) who met with midwives throughout their employment. They helped

with the training development of students and newly qualified midwives. The PDM told us they had

responsibility for the learning and development of 312 staff in maternity. Although a second role of

practice learning facilitator was being advertised as a secondment opportunity, there were

insufficient numbers of learning and development staff for the numbers of staff employed in

midwifery across the trust.

Matrons, the PDM and a clinical facilitator supported band 7s clinical competence. This included a

detailed list of competencies including administration of oral medication, administration of

intravenous (IV) medication, epidural infusions, and CTG interpretation.

Staff had access to an online learning peri-natal training programme (PTP). This included an

interactive e-learning tool covering a comprehensive array of topics in fetal monitoring and

maternity crisis management, including competency assessments covering all modules

Maternity had clinical nurse specialists for migrant women, substance misuse and safeguarding.

Staff told us they were supported with revalidation with their professional bodies. For example, the

NMC or the Health and Care Professionals Council (HCPC). Staff we spoke with told us

mandatory training compliance and revalidation was always discussed as part of their annual

appraisal.

There were regular ‘skills/drills’ training sessions. Staff told us about training they had recently

received as part of the ‘skills/drills’ in evacuating a woman from the birth pool in the event of an

emergency. These enabled staff in receiving instant feedback and reflection on required skills.

Maternity had introduced practical obstetric multi-professional training (PROMPT). This is an

evidence-based training package that teaches healthcare professionals how to respond to

obstetric emergencies. All obstetric, anaesthetic and midwifery staff received a PROMPT manual

which they were required to complete prior to undertaking PROMPT training.

Work was in progress on developing a high dependency course based upon PROMPT. The

course content would cover care of the critically ill woman.

Staff told us funds were available from the trust for external courses if they were service critical

and relevant to their role. For example, eight staff had completed a high dependency course and

eight staff had completed examination of the new-born in 2018.

Consultant appraisals were managed centrally by the trust. Staff told us the college tutor was

engaged with the learning and development of junior doctors.


Doctors had job plans which set out what work they would complete and hours they worked. Job

plans were reviewed as part of doctors CPD this ensured doctors job plans met the needs of the

service.

From April 2018 to September 2018, 83% of staff within maternity care at the trust received an

appraisal compared to a trust indicator of 90%.


required

Appraisals

complete

Completion

rate








Staff of different kinds worked together as a team to benefit women and babies. Doctors,

midwives and other healthcare professionals supported each other to provide good care.

We saw several examples of multidisciplinary working. The daily huddle meetings were well

attended by staff across the women and children’s division including anaesthetists, junior doctors,

lead clinicians, midwives and department leaders. We saw a huddle on the labour ward and found

it followed a set structure and was well attended. We were told the timing of huddles was flexible

as they had to be held at a time that was suitable for most staff.

Midwives told us they could contact consultants if they needed advice, for example, around risk

assessments. Midwives said junior medical staff were approachable. Medical staff told us

relationships between medical staff across maternity and neonatal care were good.

The monthly incident report meeting (IRM) was attended by obstetric consultants, junior doctors,

the head of midwifery (HOM) and matrons.

There was a weekly perinatal meeting which was attended by staff from the neonatal unit (NNU),

obstetrics and midwifery staff. Neonatal staff told us they worked closely with maternity and

obstetric staff. There was a monthly meeting between maternity staff and neonatal staff where

transitional care and perinatal care was discussed.

There was a join monthly risk multidisciplinary meeting between KCH and PRUH. This involved a

member of staff from every maternity team attending a video conference to review maternity risks.

We were given an example of multidisciplinary training. This involved simulation training planned

for 12 February 2019 between the community midwives and London Ambulance Service (LAS).

The training would involve a scenario in a patient’s home.

Staff told us there was effective working between mental health teams, social services, local GPs

and the midwifery team when dealing with women with mental health issues.

We were told working relationship between allied health professionals (AHP) physiotherapists and

staff within the maternity department were good by both AHP and maternity staff.

Community midwives worked with Lambeth Early Action Partnership (LEAP). This was a 10 year

programme with a focus on improving breastfeeding rates, reducing childhood and maternal


obesity and domestic violence, and improving social, emotional, communication and language

development of babies and young children.

Seven-day services

All women could report to the hospital in an emergency through the accident and emergency

(A&E) department. The labour ward, Harris Birthright Centre and Nightingale Birth Centre

operated 24 hours a day, seven days a week service.

Community midwifery care and clinics ran between 9am and 5pm, Monday to Friday, outside of

these hours an on-call service was provided.

The maternity unit had ultrasound scanners available that could be used out of hours if necessary.

There were two dedicated obstetric theatres which offered 24-hour caesarean sections (CS).

Consultants and anaesthetists were available on site from 8:30am to 9pm and on call outside of

these times on a rotation basis. This ensured women had access to consultant advice at all times.

Staff had access to the i-Mobile critical care support team 24 hours a day, seven days a week.

Paediatricians based on the special care baby unit (SCBU) provided 24-hour, seven day a week

cover for complex deliveries.

Health promotion

The trust had introduced the ‘saving babies lives care bundle.’ This was an initiative from NHS

England (NHSE) to reduce stillbirths and early neonatal deaths. It brought together four elements

of care based on: reducing smoking in pregnancy, risk assessment and surveillance for fetal

growth restriction; raising awareness of reduced fetal movement, and effective fetal monitoring

during labour.

The obstetric scorecard dated from December 2017 to December 2018 recorded that maternity

were meeting the trust’s KPI of 5% or below for women smoking by the time their baby was

delivered. The actual rate of women smoking at the time of delivery was better than the trust’s KPI

at 3.4%.

The women’s health ‘speciality patient outcomes report’ dated 29 January 2019 found: 73% of

women received alcohol screening, 75% of women received smoking screening and 75% of

women were given brief smoking advice. This was lower than the trust indicator of 90%.

Discharge planning included information packs for women outlining medication needs, doctor’s

appointment and follow up, and women’s contraception methods. This was discussed with women

prior to departure. Women were given advice on the risk of cot death, including smoking and

sleeping positions for baby.


Although staff understood how and when to assess whether a woman had the capacity to

make decisions about their care. Training rates for the Mental Capacity Act 2005 and

Deprivation of Liberty Safeguards were low. As a result, the trust could not be assured that

staff followed the trust policy and procedures when a woman lacked capacity to consent.

We were told Mental Capacity Act 2015 (MCA) and Deprivation of Liberty Safeguards (DoLS)

training comprised one stand-alone training module and staff did not complete any further updates

of mandatory MCA and DoLS training.


Although staff we spoke with were aware of the principles of the MCA and DoLS, we found MCA

and consent training completion rates did not meet the trust’s training indicator. The trust sent us a

spreadsheet in February 2019 which recorded MCA and consent training as 44%, this was much

worse than the trust’s 85% indicator. This meant the trust could not be assured that all staff had

sufficient knowledge of MCA and DoLS to carry out duties related to the act.

We saw staff verbally gaining consent before commencing any treatment. We saw staff fully

explained procedures and associated risks of accepting treatment or not consenting to treatment.

Midwifery and medical staff we spoke with were aware of Gillick competence, this reflects that

parents cannot overrule the child’s consent when the child is judged to be competent to make a

decision. The understanding required for different interventions will vary considerably and

therefore a child under 16 may have the capacity to consent to some interventions but not to

others. Staff we spoke with understood their roles in relation to Gillick competence.

The trust, in accordance with the Department of Health Guidance (DoH), 2009, adapted the

previous DoH standard consent forms. There were different versions of the standard consent form.

A form for adults or competent children/young people and a form for parental consent for a child or

young person. The trust also had a form for assessing the capacity of adults found unable to

consent to investigation or treatment following an assessment of capacity.

Doors on the labour ward had notices attached informing staff that, “The lady in the room has fully

consented.” This meant new staff providing care would be aware that formal consent had been

sought and could focus on providing care to women in labour.


Compassionate care

Staff provided emotional support to women and those close to them to minimise their

distress.

The six women and relatives we spoke with all reported that they received good-quality care and

all staff were kind to them. We saw staff providing woman-centred care and responding

compassionately when a woman needed help. This was in accordance with NICE QS15

Statement 1.

Staff maintained women’s privacy and dignity by drawing curtains around women before

undertaking examinations or providing care. Typical comments about staff included: “I feel that I

now understand what a caring hospital is.” Another woman commented, “Great service and great

care.” A woman told us how a midwife had seen that the woman’s gown was undone and had

discreetly assisted the woman to fix the gown.

We saw staff introducing themselves to women and those close to them, and explaining their roles

within the department. This was in accordance with NICE guideline QS15, statement 3:

Patients are introduced to all healthcare professionals involved in their care, and are made aware

of the roles and responsibilities of the members of the healthcare team.

We saw staff taking time to interact with women and saw examples where staff demonstrated the

importance of gaining the trust of women they were providing care for.


Bereaved families had a symbol placed on the door of the room which all staff understood.

Bereaved families were also given postcards with the same symbol to present to staff. This meant

families would not have to explain their bereavement to staff, and staff would be aware and could

respond compassionately to them.

When asked, women were able to tell us the name of the midwife who was in charge of their care

on that day.

We saw photographs of staff displayed within the department. This helped women to identify staff

members during their stay. We had one negative comment from a woman that had requested a

bed pan from a member of staff and said the staff member had responded with, “It’s not my role.”

Friends and family test performance (antenatal), King's College Hospital NHS Foundation

Trust

From September 2017 to April 2018 the trust’s maternity Friends and Family Test (antenatal)

performance (% recommended) was generally similar to the England average. Since April 2018

however there had been a decline in responses with no month having more than two responses.

Friends and family test performance (birth), King's College Hospital NHS Foundation Trust

From September 2017 to September 2018 the trust’s maternity Friends and Family Test (birth)

performance (% recommended) was generally similar to the England average. In April, May, June

and September 2018 there were insufficient responses to create an average recommendation

rate.

Friends and family test performance (postnatal ward), King's College Hospital NHS

Foundation Trust


From September 2017 to September 2018 the trust’s maternity Friends and Family Test

(postnatal ward) performance (% recommended) was generally similar to the England average.

However, between April and June 2018 there were insufficient response to create an average

recommendation rate.

Friends and family test performance (postnatal community), King's College Hospital NHS

Foundation Trust

From September 2017 to April 2018 the trust’s maternity Friends and Family Test (postnatal

community) performance (% recommended) was generally similar to the England average. Since

then there had been insufficient responses to create an average recommendation rate.


The trust performed better than other trusts for one of the 15 questions in the CQC maternity

survey 2017

Area Question Score RAG

Labour and

birth

At the very start of your labour, did you feel that

you were given appropriate advice and support

when you contacted a midwife or the hospital?

8.81 About the

same

During your labour, were you able to move around

and choose the position that made you most

comfortable?

7.92 About the

same

If your partner or someone else close to you was

involved in your care during labour and birth, were

they able to be involved as much as they wanted?

9.87 Best

performing

trusts

Did you have skin to skin contact (baby naked,

directly on your chest or tummy) with your baby

shortly after the birth?

9.02 About the

same

Staff during

labour and

birth

Did the staff treating and examining you introduce

themselves?

9.38 About the

same

Were you and/or your partner or a companion left

alone by midwives or doctors at a time when it

7.80 About the

same


worried you?

If you raised a concern during labour and birth, did

you feel that it was taken seriously?

8.36 About the

same

Thinking about your care during labour and birth,

were you spoken to in a way you could

understand?

9.43 About the

same

If you used the call button how long did it usually

take before you got the help you needed?

8.51 About the

same


were you involved enough in decisions about your

care?

8.54 About the

same


were you treated with respect and dignity?

9.08 About the

same

Did you have confidence and trust in the staff

caring for you during your labour and birth?

8.75 About the

same

Care in

hospital

after the

birth

Looking back, do you feel that the length of your

stay in hospital after the birth was appropriate?

7.36 About the

same

Thinking about the care you received in hospital

after the birth of your baby, were you given the

information or explanations you needed?

7.57 About the

same

Thinking about your stay in hospital, how clean

was the hospital room or ward you were in?

8.37 About the

same

Thinking about the care you received in hospital

after the birth of your baby, were you treated with

kindness and understanding?

8.06 About the

same

(Source: CQC Survey of Women’s Experiences of Maternity Services 2017)

Emotional support

Staff provided emotional support to women to minimise their distress.

The hospital had two named bereavement midwives who supported women and their families

following stillbirth or neonatal death. All midwives undertook bereavement training as part of their

mandatory training.

The bereavement midwives provided 1:1 care. A local charity provided families with memory

boxes to enable parents to keep mementoes of their baby. The bereavement midwives provided

on-going support to families following discharge.

Staff told us bereaved families would be supported by the bereavement midwives for as long as

the family required support. Staff told us they could refer women and families to the hospital’s

chaplaincy team. The KCH chaplaincy team offered spiritual, religious or pastoral support to

people of all faiths and beliefs, religious and non-religious.

Midwifes told us they could signpost women or their partners to ‘talking therapies’ with the trust’s

counselling and mental health support services. Women were assessed for any extra care needs

they may require at booking with the community midwives. This included an assessment for

postnatal anxiety and depression.


Women experiencing anxiety or depression were identified antenatally and received on-going

advice, assessment, psychological treatment, parent-infant mental health interventions (PIMHS),

and onward transfer of care to other services.

Women were assessed for any extra care needs they may require at booking with the community

midwives. This included an assessment for postnatal anxiety and depression.

We saw staff supporting a woman in labour on the labour ward. We saw staff offering the woman

emotional support and validation. For example, staff told the woman, “You are doing amazing.”

Mothers we spoke with on the postnatal ward told us they received breastfeeding support

immediately and this continued on the ward.


Staff involved women and those close to them in decisions about their care and treatment.

Most women we spoke with told us they felt involved in planning and making decisions about their

care. Women we spoke with told us nurses and midwifery staff involved them in decisions about

their care and they were involved in their care planning. We spoke with nine women, partners and

relatives during our inspection. Most of them told us they were satisfied with the information and

advice they had been given; leading up to and during labour; following the birth of their baby; or

whilst receiving care and treatment. For example, a woman told us that she had required suction

during labour and staff had explained what they were doing during every step of the procedure.

The woman said she had found this reassuring.

The Head of Midwifery (HOM) told us they regularly walked around the maternity department and

spoke with women who had given birth and their families to gain insight into women’s and families

experiences.

Staff communicated with women and their families and care partners making sure they understood

the treatment they were to receive, and the risks associated with this. We saw consultants clearly

explaining to women the risks associated with their labour, giving women options and respecting

their decisions.

The antenatal unit was midwife led. Staff were committed to providing and promoting normal birth.

Staff offered women a choice of birthing options, and if women requested no consultant presence

this was adhered to as long as it was safe to do so.

Staff wore identity badges which enabled women to identify their names and roles. There were

also notices on the postnatal ward that identified staff uniforms and roles.

We reviewed the trust website which included a range of welcome information for women

accessing services. The website also had links to online self-referral forms for antenatal bookings,

an online booking form to enrol on antenatal classes or a tour of the unit, as well as information on

the labour ward, birth options such as pool births, and postnatal and neonatal care.





Kings College Hospital (KCH) maternity provided care for more than 6,000 mothers and babies

each year. The hospital provided for all aspects of obstetric and midwifery care, from before

conception and before birth (antenatal) to birth and after delivery (postnatal).

The maternity department was on the third and fourth floors of the Golden Jubilee Wing and

included the Nightingale Birth Centre. The Nightingale Birth Centre (labour ward) was on the fourth

floor of the Golden Jubilee Wing. The labour ward was staffed by midwives and an obstetric team.

The labour ward offered care for low and high-risk pregnancies during labour and birth. Facilities

included 10 rooms for women in labour; a four-bed area for women who needed extra monitoring

before birth; a two-bed high dependency unit (HDU); and a five-bed recovery area. The labour

ward was supported by two operating theatres for planned and emergency surgery.

During our previous inspection in April 2015 we found maternity services had high bed occupancy

levels at times of peak demand. The challenges of caring for women at these times were

exacerbated by the high acuity of some women using the service and the physical capacity of the

unit. During this inspection we found bed occupancy levels were still high. Staff told us the

demographic of the patient population at the hospital meant the hospital had high rates of women

with complex needs and high rates of safeguarding. However, senior managers told us there had

been improvements in managing capacity with the introduction of a system of flexing available

space. For example, two labour rooms could be flexed and used for postnatal care at times of

peak demand.

Maternity had introduced a triage area at the entrance to the Nightingale Birth Centre, this was

comprised of four single rooms, and a triage reception and waiting area. There was a designated

triage team allowing for better continuity of care and improved communication.

Women were triaged before arrival on the Nightingale Birth Centre. Women with additional needs

were flagged at the point of triage to ensure staff were aware pre-admission if any extra care

needed to be implemented.

The Nightingale Birth Centre had a birthing suite where staff provided care for women with low risk

pregnancies and natural birth. The maternity unit was midwifery led and staff were committed to

providing and promoting normal birth. Women were offered a choice of birthing options. Women

could choose whether to have their babies in the Nightingale Birth Centre or at home with the help

of community midwives, if they lived in KCH catchment area. Women from outside the KCH

catchment area would be referred to their local community midwifery team.

The birthing suite was led by a team of midwives that specialised in natural birth. The birthing suite

offered 1:1 midwifery care with access to medical assistance if needed. The birthing suite had two

rooms, Woodland and Beach. Birthing suite midwives encouraged women to stay upright and

move around whilst in labour using equipment such as birth balls, ceiling mounted slings,

mats and birthing pools. All rooms at the birthing suite had en-suite bathrooms and tea and coffee

making facilities. However, data provided by the trust indicated that the birthing suite was under-

utilised. Between December 2017 and December 2018, 243 women used the suite for the birth of

their babies. This was lower than the trust indicator of 60 women a month using the suite. The

trust’s indicator had not been met in any month during the period, with the highest usage rate

being in June 2018, when 33 women used the suite. The lowest rate was in January 2018, when

19 women used the suite. Staff told us women were offered use of the suite, but, often declined.

In response to the ‘Better Births’ national maternity review (NHS England 2016). The Nightingale

Birth Centre had introduced case-loading. This is a model of care where midwives carry their own

https://www.kch.nhs.uk/patientsvisitors/wards/m-o#Nightingale_Birth_Centre

https://www.kch.nhs.uk/patientsvisitors/wards/m-o#Nightingale_Birth_Centre


caseload of women to form trusting relationships and provide care throughout the woman’s

experience of pregnancy and childbirth up to 28 days’ following the birth of their baby.

Community midwifery services consisted of six teams based in two centres, the midwives house

and the community midwives centre, which were located close to the main hospital. The two bases

provided facilities for both low risk and high-risk antenatal clinics. Booking appointments and

routine antenatal care were provided at both centres.

The Harris Birthright Centre was a clinical unit and research centre for the assessment and

treatment of unborn babies. Women that were less than 16 weeks pregnant would be referred to

the early pregnancy assessment unit (EPAU). Women over 16 weeks pregnant would be referred

to the maternal assessment unit (MAU). Between January and December 2018, the MAU had

5,652 attendances.

The EPAU was open from 9am to 12 noon daily for clinics. Afternoons were reserved for booked

appointments.

Fetal anomaly screening and routine ultrasounds examinations were available in the Harris

Birthright Centre Monday to Friday from 8.15am, with the last appointments being booked at

6.45pm. Ultrasound scans were available on the labour ward at all times.

The antenatal unit was midwife led. Staff were committed to providing and promoting normal birth.

Antenatal care was provided by the midwifery team in collaboration with women’s GP or

obstetrician. Care included routine health checks such as blood tests and other screenings. The

screening enabled staff in early identification of infectious disease, including Hepatitis B, HIV or

syphilis. Women were encouraged to make a birth plan which included their wishes for labour and

birth.

Antenatal care, parent craft and postnatal clinics were provided in a variety of locations including

GP surgeries and health centres across the catchment area served by the trust. For example, we

saw antenatal classes for new expectant fathers were advertised in the antenatal ward.

Parents could attend classes if they were interested in having a home birth. These sessions were

also attended by parents who had recently had home births to share their experiences. The home

birth rate from December 2017 to December 2018 was 4.4%, this was lower than the trust’s 8%

indicator. The trust’s indicator had not been met in any month in the period, with the highest rate of

home birth being 5.6% in February 2018 and the lowest rate being 2.9% in May 2018.

The department had a bereavement midwife and an assistant bereavement midwife. Their role

included attending ‘Stillbirth and neonatal death’ (SANDS) meetings and working with the SANDS

guidelines to provide women with adequate support following the loss of a child. A perinatal mental

health specialist was employed within the department. This ensured a specialist midwife was

available to advise on women and help women who needed extra support.

The maternity unit did not have a dedicated bereavement suite at the time of inspection. However,

staff showed us a private room that was scheduled to become a bereavement room. Staff told us

some of the funding for the room had been agreed by SANDS.

The trust followed Human Tissue Authority (HTA) guidance (2015) of the disposal of pregnancy

remains following pregnancy loss or termination. All termination of pregnancy was for fetal

abnormality. Gestations over 16 weeks were offered the option of support from a bereavement

midwife.

https://www.gov.uk/government/publications/hepatitis-b-explaining-the-screening-result

https://www.gov.uk/government/publications/hiv-explaining-the-screening-result

https://www.gov.uk/government/publications/syphilis-explaining-the-screening-result


The special care baby unit (SCBU) and neonatal unit (NNU) were easily accessible across the

corridor from the labour ward. This meant neonatal staff could respond quickly to requests from

labour ward staff. It also meant babies could be transferred to SCBU and the NNU quickly.

From April 2017 to September 2018 the bed occupancy levels for maternity were generally higher


The chart below shows the occupancy levels compared to the England average over the period.




Safer childbirth standard 2.2.20 states ‘Women have the right to choose where to give birth. If a

woman chooses to give birth at home or in a midwifery unit contrary to advice from midwives and

obstetricians, there needs to be clear documentation of the information given’. We saw

documented evidence that this standard had been met in women’s notes.

The labour ward was a midwifery led unit the services were tailored to meet women’s needs

wherever possible. If women requested no consultant presence this could be adhered to, as long

as risk assessments were in place and women were aware if escalation was needed that a

consultant would be called.

Women were given a named midwife and contact number on booking, in accordance with NICE

guideline QS22 statement 2.

Community midwives identified women who would need language interpreting services at booking.

Staff at the hospital were made aware of women that required interpreters prior to admission and


interpreters were booked. These were either face to face, if face to face interpreters were not

available, telephone interpreting services could be accessed.

A Spanish speaking midwife offered antenatal classes for speakers of Spanish.

The hospital had a large West African population which had higher rates of kidney disease. The

hospital had developed a specialist midwife in acute kidney injury (AKI). All women identified as

having kidney disease would receive care from the AKI specialist midwife.

The midwife station in the postnatal ward office had a magnetic whiteboard that provided

information on women’s individual needs. For example, one woman had “Spanish speaking”

recorded on the board. The board could not be seen from the ward and maintained women’s

privacy, but, provided staff with an overview of women’s individual needs on the ward.

Staff told us bariatric equipment would be ordered from an external supplier, including chairs and

beds. Staff told us the trust’s chairs and beds could hold patients up to 220lbs, if a further weight

limit was needed suitable equipment could be requested.

The department had pathways of care for women with learning disabilities. Women were identified

at the booking stage and offered advice and extra support if needed. Women could also be

referred to the safeguarding team’s learning disability specialist; the safeguarding team would

liaise with the woman, the woman’s multi-disciplinary team (MDT) and family members regarding

the woman’s needs. This included attending outpatient appointments if necessary or home visits to

discuss individual needs.

The department had a strategy for women with mental health needs, ‘A road to better maternity

and mental health care.’ This involved the reorganisation of community and antenatal care to

provide equitable services for women that met the criteria for referral to the perinatal psychiatric

liaison team.

Women with mental health issues were placed on a care pathway and had regular contact with the

South London and Maudsley (SLAM) antenatal and postnatal mental health team. An alert was

placed on the system so anytime the woman contacted the department staff were aware of their

extra needs and care could be planned.

A teenage pregnancy specialist midwife was in post; her role was to offer extra support to young

people who were pregnant. Young women under the age of 18 years would be case-loaded by the

specialist young parent’s midwifery team.

Staff supported vulnerable women with complex social care needs to attend antenatal check-ups

at the hospital, and community midwives were mindful to allow these women to choose a time that

was suitable for them and where necessary provide transport to the hospital. This demonstrated

staff understanding of women in vulnerable situations in accordance with NICE CG 110:

‘Recommendations for pregnant women who have complex social factors.’

The service had two dedicated bereavement midwives which provided services to women in

gynaecology, pregnancy loss, medical termination of pregnancy, and theatre admission units. Staff

told us the bereavement midwife’s role was to ensure standardised care for women across

services. This helped to ensure women experiencing the loss of a baby received appropriate care.

Post mortem examination was offered in all cases of stillbirth and neonatal death. This was

following recommendation 4 of the MBRRACE UK to improve future pregnancy counselling of

parents. We saw the documentation related to this which was completed following stillbirth or

neonatal death.


Partners were able to stay on post-natal wards. Partners could visit at any time. General visitors

were limited to two. Women we spoke with generally thought visiting hours were reasonable.

Women were offered food options including religious choice, for example, halal and kosher

options. Staff could contact the hospital kitchen to make meal requests and cater for women’s

needs.

Babies had hearing screening on the postnatal ward, if this was not possible there was a clinic

available at the antenatal clinic and women were given an appointment before they left hospital.

The hospital had trained some staff to carry out the Newborn and Infant Physical Examination

(NIPE) check prior to discharge. Staff told us this had a positive effect on the flow through the

department and reduced delayed discharges.

Leaflets were readily available; we saw several relevant leaflets available throughout the maternity

wards and departments. We saw a notice in a range of languages informing women that printed

information was available in a wide range of languages upon request.

Access and flow

People could access the service when they needed it. There were arrangements to admit,

treat and discharge women and babies.

During our previous inspection we found the postnatal and antenatal ward was very busy, and we

observed midwives and maternity support workers asking women to wait until they had finished

another task before they responded to their request. However, during this inspection we found

these wards were calm and staff were generally responsive to women’s requests.

From January to December 2018 the rolling number of births in the previous 12 months was 4,944

births at KCH.

Women did not have to wait to see their GP before contacting the maternity department. Women

in the KCH catchment area could complete an antenatal self-referral form on the hospital’s

website. Women who lived outside the catchment area could also be considered for care from

KCH. The obstetric scorecard dated from December 2017 to December 2018 recorded that

maternity were meeting the trust’s 50% key performance indicator (KPI) for antenatal bookings

within 10 weeks, with 57% of women booked. The department were almost meeting the trust’s

90% KPI for antenatal appointments booked within 12 weeks with the 12-month average being

89%. In the same period 124 women had been booked later than 20 weeks into their pregnancy.

The maternity department had been closed on eight occasions between January and December

2018. These were all due to labour ward capacity. There had been two women diverted to other

hospitals as a result of these closures. There had been no closures of the neonatal unit (NNU) in

the same period.

During our previous inspection we found a of lack of capacity on the labour ward had resulted in at

least one birth in antenatal beds every month in the year up to January 2015.

Senior staff told us the introduction of a maternity triage had improved patient flow in the

department and reduced pressures on the labour ward. Although some antenatal staff told us they

had concerns that the labour ward would try to keep women on the antenatal ward and this

sometimes posed risks to women and babies. However, data provided by the trust showed some

improvement in the numbers of women giving birth on the antenatal ward. The obstetric balanced

scorecard dated between December 2017 and December 2018 recorded the trust’s KPI as zero

https://www.kch.nhs.uk/forms/kchantenatal


births on the antenatal ward. There were four births on the antenatal ward in the period, two of

these were in February 2018, there was one birth in March 2018 and one birth in November 2018.

The maternity triage reduced the number of women entering the labour ward as women attending

maternity services could be redirected to the maternity assessment unit (MAU). Staff told us triage

accepted elective admissions and emergency admissions directly from ambulances. Staff told us

ambulances transferred women directly to maternity triage and by passed the acute medical unit

(AMU) where patients usually received care when admitted via the emergency department. This

was said to be because of staffing shortages on the AMU.

A triage consultation form was completed for all calls coming into the unit. It included planned

place of birth, risk factors (for example: headaches, raised blood pressure), past history, medical

conditions, fetal movement, vaginal bleeding (PV), pain and blood loss.

Women had 24-hour access to the triage phone line for advice or if they were in labour or

experienced any immediate problems, such as bleeding. The triage system for all women went

through a dedicated triage midwife and depending on the women’s needs they were bought into

the maternity assessment unit (MAU), triage, or directly to labour ward.

Community midwives provided antenatal clinics in GP practices, health centres and the home.

They provided antenatal and, postnatal care from the first pregnancy appointment until discharge,

usually around 10 days after birth, when they handed over care to the health visiting team. Women

that did not attend antenatal appointments were followed up and an alert was put on the maternity

IT system.

Ultrasound (nuchal) scans took place in the Harris Birthright Centre, in the Fetal Medicine

Research Institute. There were also facilities for ultrasound scanning on the labour ward. Staff told

us this meant women in labour could have a scan 24 hours a day, seven days a week on the

labour ward, without having to leave the ward to visit the Harris Birthright Centre.

If everything had gone well women were encouraged to go home within a few hours of birth. If

women or their baby needed to stay in hospital, they would be transferred to a postnatal ward.

The hospital planned for three caesarean sections (CS) a day on weekdays. Occasionally four

women were booked in on one day, but staff told us that often they could move women to ensure

an even workload. Women who were booked for planned CS were given spinal and general

anaesthetics in theatre, and post-surgery were taken to the recovery unit and then to the post-

natal ward.

Women were given a discharge date when they were booked in for a planned CS. This enabled

women to plan discharge arrangements and family support if needed. We asked two patients post

operatively if they had a date for discharge and both were aware of their planned discharge date.

The trust had a specialist midwife to lead the planned CS pathway of care.

Women were discharged with a contact number to call if they had any issues after leaving

hospital. We saw midwives explaining to new mothers that they were available 24 hours a day and

to call if they had any concerns.

The midwife station on the postnatal ward included a whiteboard that identified women and babies

discharge status. This gave staff an at a glance overview of all women and babies on the ward.

The board was red, amber, green (RAG) rated to indicate whether women were due for discharge.

For example, a red rating indicated the woman and baby would not be discharged today, yellow

indicated an expected discharge by 6pm, and green indicated the woman and baby were ready for

discharge.

https://www.kch.nhs.uk/service/a-z/harris-birthright


Babies who needed special care were transferred to the neonatal unit (NNU) and looked after by a

specialist neonatal team.

The obstetric scorecard dated from December 2017 to December 2018 had a mixed picture for

discharges from the labour ward. On average the department were meeting the trust’s 15% KPI for

labour ward discharges. However, there were variations month on month. For example, in June

2018 the rate was better than the trust’s KPI at 21%, but the rate in April 2018 was worse than the

trust’s KPI at 9%. The KPI had been met for five separate months during the period December

2017 to December 2018.

The women’s health ‘speciality patient outcomes report’ dated 29 January 2019 reported that the

non-elective readmission within 42 days of delivery was higher than expected. However, the report

did not record the rates of readmission.


Although the service treated concerns and complaints seriously, investigated them and

learned lessons from the results, the time taken to respond to complaints was not in

accordance with the trust’s complaints policy.

The obstetric scorecard dated from December 2017 to December 2018 recorded that between

December 2017 and December 2018 there were 31 complaints about maternity. The time the trust

took to respond to complaints in a timely way was much worse than the trust’s 70% indicator. For

example, the rate varied in the period from the highest rate of 36% in January 2018 to the lowest

rate of 12.5% in October and November 2018.

We saw evidence of appropriate responses to complaints, including apologising to women and

meeting with them to review their notes and offer explanations. We saw evidence of learning from

complaints. We were told the staff would receive individual feedback on a complaint that

concerned them. Staff would be asked to complete a written reflection in the event of a complaint

being upheld as part of their learning.

There was a divisional complaints governance structure and flow chart to aid staff with managing

complaints. Complaints were discussed as part of the incident review meeting (IRM) and risk

meeting. We asked some staff members if they could give us examples of any learning from

complaints. We were told complaints were fed back to staff, but staff could not give us any specific

examples of change as a result of a complaint.

A matron we spoke with told us if possible they would try to resolve complaints immediately with

the complainant. The matron said where this was not possible they would signpost complainants

to the patient advice and liaison (PALS) team. The complaints department handled all formal

complaints.

We saw information was available on how to make a complaint across the maternity department.

When asked women were not aware how to make complaints but all said they would raise it with

the midwives.

From October 2017 to September 2018 there were 97 complaints about maternity. The trust took

an average of 27 days to investigate and close complaints. This was not in accordance with their


A breakdown of themes can be seen below:

https://www.kch.nhs.uk/service/a-z/neonatal





Communications 13



Waiting Times 2



62 complaints were made about Denmark Hill and 35 about Princess Royal University.



Leadership

Managers at all levels in the trust had the right skills and abilities to run a service providing

high-quality sustainable care.

Maternity was part of the women’s health directorate, which was part of the urgent care, planned

care and allied critical services division. The chief nurse was the named board level lead on

maternity.

The head of midwifery (HOM) reported to the non-executive director of midwifery and women’s

health. The clinical lead consultant reported to the clinical director of obstetrics.

Staff told us members of the directorate and local leadership teams were approachable and

visible. Staff told us there had been an improvement in the visibility of senior management since

the director of midwifery and women’s health had taken up their post six months earlier. The

maternity senior managers including the director of midwifery and women’s health, and the HOM

did a weekly walk about on the wards. However, community midwives told us senior managers

were not visible in community teams.

Hospital based staff told us consultation and communication with staff had improved since the

director of midwifery and women’s health had taken up their post.

There were appointed clinical leads in all maternity and obstetric departments, the role of the

clinical leads was spoken about positively by most staff.

Matrons were local leaders for community and hospital services. Midwives and healthcare

assistants and breast-feeding support workers reported to the ward matrons. The matrons

reported to the HOM.

Staff told us new matrons had been recruited for maternity in response to the previous CQC

inspection in 2015. Staff told us changes included a move from one matron from 9am to 5pm to

three matrons. Matrons were required to attend obstetric ward rounds and attend all emergencies.

Matrons had also been provided with bleeps to ensure they were responsive to situations on the

wards. Staff told us matrons had an ‘open door’ policy.


There were monthly midwifery matrons and band seven meetings. Staff told us the meetings

discussed incidents and complaints and were used as an opportunity to share learning.

Community midwives told us the consultant midwife was supportive and a useful resource to

community midwifery staff. Staff said the consultant midwife regularly facilitated meetings where

safeguarding and incidents were discussed.

There was a weekly CEO newsletter that was e-mailed to staff with trust news and updates.

Vision and strategy

The service did not have a defined vision and strategy for what it wanted to achieve and

workable plans to turn it into action

We saw that the trust’s values were displayed in the hospital and maternity department. These

were the ‘Kings values.’ The values were: ‘understanding you, inspiring confidence in our care,

working together, always aiming higher, making a difference in our community.’ All the staff we

spoke with were aware of the values and said they were aligned to staff appraisals.

Maternity services did not have a defined strategy. Senior managers told us the trust was in the

process of producing a new strategy. Senior staff told us a new maternity strategy would be

produced to align with the trust strategy once the trust strategy was complete.

Maternity services had a ‘Maternity safety improvement plan 2019/20.’ The plans aim was to

improve quality outcomes and experiences for women and babies by reducing unwarranted

variation through: improved patient safety, enhanced personalised care and improved patient

experience, and improved clinical effectiveness. This provided a comprehensive plan on how

maternity would meet national initiatives such as the national maternity review ‘Better Births.’ The

plan detailed how the plan’s progress would be monitored, for example, via the obstetric

scorecard.

Maternity had produced an action plan in April 2018 setting out how the department would meet

the, ‘Safer Maternity Care. Next steps towards the national maternity ambition’ (DoH, October

2016), and ‘Safer Maternity Care: The National Maternity Safety Strategy - Progress and Next

Steps’ (DoH, November 2017). However, the action plan we received from the trust did not specify

timescales for completion of the actions.

In October 2018, maternity had produced a strategy and action plan to improve communication

between KCH and Princess Royal University Hospital (PRUH).

Staff told us there had been a staffing restructure in 2018 that had resulted in midwifery support

workers (MSW) being replaced by health care assistants (HCA). Staff told us they thought this was

under review by senior managers, but, had not had confirmation that the MSW role would be re-

introduced.

Culture

Although managers promoted a positive culture that supported and valued staff, some staff

reported that the culture in maternity could be hierarchical.

Most of the staff we spoke with told us they were proud to work for KCH. Staff told us there had

been improvements since our previous inspection in April 2015. A member of staff told us, “We are

in a much better place than we were.”


Staff told us morale in maternity had improved. A number of staff cited the trust’s introduction of

‘Kings Flex’ this was flexible working for staff as one of the reasons for the improvement in staff

job satisfaction.

Health care assistants (HCA) and some lower grade nursing staff told us the culture in maternity

department could be hierarchical. Staff told us some band six and band seven midwives did not

like to be challenged by staff of lower grades. Staff told us this was most apparent when women

were moved from the labour ward to the postnatal ward. Staff told us labour ward nurses would

often transfer women to the postnatal ward as shifts were due to handover even though staff on

the postnatal ward had requested that labour ward staff transfer women prior to or following

handover.

Staff told us there was a ‘no blame’ culture in regard to reporting incidents. Staff told us there was

an open and honest culture where they were encouraged to report incidents.

We viewed the maternity staff survey results, dated July 2018. We found staff responses were

mixed. For example, 60% of staff responded that the service utilized input/suggestions from staff;

54% responded that the culture in this work setting makes it easy to learn from the errors of

others; 76% responded that they would feel safe being treated at KCH as a patient. The survey

found that staff responding that they felt burnt out was widespread. There was an action plan in

response to the staff survey with clear timescales for actions to be implemented. For example, the

action plan recorded that midwifery recruitment was ongoing to ensure that staffing levels were

kept at safe standards.

Governance

The service used a systematic approach to monitor the quality of its services and

safeguarding standards of care

There was a strategic governance structure in place from ward to board. The trust had a flowchart

which clearly detailed the trust’s key governance meetings and reporting structure. For example,

the community midwife meeting, safer maternity strategy meeting, and obstetrics scorecard

meeting reported to the midwifery governance meeting. This fed into the gynaecology core group

and maternity board meeting.

The trust had a range of quality performance committees and performance monitoring systems.

The maternity service’s clinical governance and risk management strategy described the roles and

accountabilities of committees and meetings.

There were cross-site monthly clinical governance meetings. These meetings reviewed reports

from the monthly maternity incident review meetings (IRM) and maternity risk committee meetings.

There were weekly perinatal meetings and weekly cardiotocography (CTG) meetings. The

outcomes of the meetings fed into the maternity governance meeting.

The directorate had perinatal morbidity and mortality meetings. These meetings were an

opportunity to review all perinatal deaths at the hospital to explore key themes and identify any

trends or themes. This could mean that any deaths in the service were reviewed by a

multidisciplinary team.

During the daily huddle meetings, we saw effective discussion around women’s needs and clear

indication of women who needed extra vigilance.



The systems for identifying risks, planning to eliminate or reduce them, and coping with

both the expected and unexpected were not always effective.

Performance management issues in maternity were managed by the director of maternity and

HOM. Staff told us there had been an improved focus on risk since the director of midwifery and

women’s health had taken up their role.

There was an obstetric clinical lead for risk, responsible for the management of obstetric risk.

There was a midwifery lead for risk, responsible for supporting staff with the assessment of risk.

There was close working between the obstetric clinical lead for risk, the governance midwife, the

director of nursing and midwifery, and the trust risk manager for women’s services in reviewing

incidents and identifying risk. When action plans were developed following incidents, we saw the

changes were tracked at department level.

We spoke to the obstetric consultant leading on patient risk and the midwifery risk lead. They

described the maternity risk management processes including systems for learning from incidents.

However, some staff told us the systems for feeding learning back to staff following incidents were

variable.

Maternity used an obstetrics scorecard, this was a dashboard that gave an overview of the

departments performance in relation to key performance indicators (KPI). The scorecard used a

traffic light red, amber, green (RAG) system to monitor KPI. We viewed the scorecard dated from

December 2017 to December 2018 and found the scorecard provided comprehensive, easily

accessible and useful data on the department’s performance.

The scorecard demonstrated mixed results in regard to KCH maternity meeting the trust’s KPI.

The dashboard recorded of the 44 areas the dashboard monitored, maternity had a ‘red’ rating for

the year to date in 19 KPI measures and an ‘amber’ rating in four. A red rating indicated that

maternity was not meeting the trust’s KPI for a specific area in the period. For example, the KPI

was not being met for ‘failed instrumental delivery’ of which there had been 14 from December

2017 to December 2018 when the trust’s KPI was zero.

We noted there were a few omissions in the data recorded on the obstetrics scorecard. We saw a

pattern with these omissions as they dated from the latter half of 2018. For example, there was no

data or RAG rating recorded on the scorecard in regards: to one to one care on the labour ward

from February 2018 onwards, there was no data recorded on cases of meconium aspiration from

June 2018 onwards, and there were gaps in the monthly data recorded for unit closures.

The divisional risk register identified 12 ‘open’ risks at KCH. The longest open risks related to a

risk that Anti-D (Immunoglobulin) may not being given to rhesus negative women causing

complications in future pregnancies. There was a record of review of the risk dated September

2018. However, the previous record on the register was May 2013, when the risk register recorded

that an e-learning module would be rolled out to staff. Although a review was recorded in

September 2018 it did not record whether the module had been rolled out or any other information

with regards to the management of the risk. We saw a risk on the risk register related to the

purchase of bilirubinometres, (these are devices for measuring the amount of bilirubin in the

blood), that was added on 19 November 2018. A review of the risk on the 16 January 2019 did not


contain an update on the progress and whether the devices had been ordered or delivered.

Incidents were red, amber, green (RAG) rated on the electronic incident report spreadsheet. Red

rated incidents were presented at monthly cross-site clinical governance meetings.

Staff told us the maternity patient safety and risk management and strategy was aligned to the

trust’s strategy. Work was in progress on terms of reference (TOR) and work plans for a maternity

risk management meeting.

Maternity services had introduced a procedure to capture all admissions to the neonatal intensive

care unit. This involved a midwife reviewing admissions on a weekly basis.

Some staff told us they had received dedicated training for a major incident. Although staff told us

maternity would remain in operation as business as usual if there was a major incident. Staff told

us they received updates on the trust’s major incident preparedness via trust newsletters.




Staff told us the trust’s IT systems were, “Reliable.” Maternity had two midwives who had received

training in supporting staff with the electronic patient records (EPR) system. We viewed a

maternity newsletter, dated January 2019, this provided staff with information on the EPR system

and planned reconfigurations of the system.

The trust had introduced tablet computers for the community team. Staff told us the tablet

computers meant staff did not have to transport women’s paper-based data in the community. The

computers also aided staff in accessing guidance from the trust intranet or via search engines.

Midwives sent discharge summaries to community midwives and GPs when a woman and baby

went home from hospital. This enabled ongoing care within the community.

The trust’s online antenatal self-referral form had been updated to ensure compliance with the

General Data Protection Regulation (GDPR).

Staff told us they could access policies, protocols and other information they needed to do their job

through the trust intranet. They also had internet access to evidence-based guidance from bodies

such as NICE and the Nursing and Midwifery Council (NMC). There were sufficient numbers of

computers available to allow staff to do this.

Women who used maternity services had hand-held antenatal records which they brought with

them to all appointments. This allowed multi-disciplinary staff to access to women’s up-to-date

records and enabled their ongoing care.

We saw the names, roles and contact details of the trust’s information governance team in the

third-floor staff room. This enabled staff in contacting the team should they require advice or

support with information governance.

Engagement

The trust engaged well with women and those close to them, staff, the public and local

organisations to plan and manage appropriate services.


Staff told us they received regular newsletters from the trust. Staff also told us about ‘Kings News’

this was a trust wide news update feed on the trust’s intranet. Staff told us both the newsletter and

the intranet feeds were informative.

The trust had networks for black and ethnic minority (BAME), staff disability, and lesbian, gay,

bisexual and transgendered (LGBT) staff. The networks gave staff from diverse groups

opportunities to raise concerns, share knowledge and offer support.

Senior managers told us there was a staff survey in 2018. However, maternity were waiting for the

results of the survey at the time of inspection.

Maternity had introduced ‘Freedom to Speak Up’ ambassadors in every department. This meant

there were speaking up arrangements to protect women and improve the experience of staff.

Maternity had launched its own ‘staff appreciation award’ scheme. Staff could nominate other staff

for an appreciation award. Award categories included ‘best midwife’ and ‘best support worker.’

Women were signposted to comprehensive information on hospital and community maternity

services through the trust’s website. Maternity had a social media account where women and

families could ask questions or provide feedback. The account was administered by the

department administrators. The social media account was also used by staff to provide updates on

services.

The service had introduced a maternity voices partnership in 2018. This was a forum for women

that used the service to meet with staff. The forum was hosted by maternity services but chaired

by service users or ex-service users.

The trust had a patient representative on the maternity services liaison committee (MSLC). The

committee had a remit of improving birthing services for women attending KCH. The committee

met bi-monthly and provided lunch for patient representatives and assistance with travel costs.

The committee had been involved in improving women’s access to breastfeeding support by

providing workshops and drop in sessions. The committee had also lobbied for improved access

to birthing pools.

Staff at the fetal medicine unit (FMU) and women using services were involved in a blood pressure

self-monitoring in pregnancy (BuMP) feasibility study. This was a qualitative analysis of women's

experiences of self-monitoring.




The trust had opened a 24hour maternity triage in 2018. The triage acted as a reception area for

the labour ward and reduced the number of people walking through the labour ward. The triage

also directed women to the service area they required.

Staff were engaged in a range of research projects. Recent research had included: breaking the

cycle of domestic abuse and a qualitative review of fist time father’s mental health and wellbeing.

Staff in the fetal medicine unit (FMU) were involved in research into acute kidney injury (AKI) in

pregnancy.


Maternity services advertised and participated in an umbilical cord blood donation scheme.

Women were encouraged to donate their umbilical cord blood for use in the treatment of people

with blood cancer.

The trust was engaged in Wave 2 of the Maternal and Neonatal Health Safety Collaborative. This

was a National Health Service Improvement (NHSI) initiative. The three-year programme aims to

support improvement in the quality and safety of maternity and neonatal units across England.

A research midwife had been allocated to the ‘NHS 70’ project. Their remit was to promote

research into high risk pregnancies. This work would be contributory to the NHS long-term plan.

Staff were nominated in three categories for the London Maternity and Midwifery Festival awards,

including: midwife achievement award, innovation award, and the high-risk community team had

been nominated for the team award.

Staff had been shortlisted in two categories for the Royal College of Midwives annual awards.

End of life care


End of life care at King's College Hospital is provided by the specialist Palliative care team (SPCT)

who work with a local Hospice, providing support to patients with complex symptoms at the end of

life. Palliative care consultant, the clinical director, clinical nurse specialists (CNS) and practice

development nurse (PDN) supported the generalist staff in the delivery of end of life care, as well

as the training and education of nursing and medical staff.

The SPCT was led by the lead palliative care consultant and the nursing matron. The team

consisted of clinicians, nurses, social workers, a service manager and team administrator. In

addition, the bereavement office staff provided bereavement support after death and the

chaplaincy team provided multi-faith support.

Staff providing end of life care included ward nurses and doctors, housekeeping staff, porters and

allied health professionals. End of life care is also provided by a hospital specialist palliative care

team and cancer nurse specialists for patients needing difficult symptom management.

An end of life care service is provided to support the management of pain and other symptoms

and provide psychological, social and spiritual support. The purpose of the end of life care is to

achieve the best quality of life for patients and those close to them, the support was provided to

help patients live as normal routine as possible until death and to offer support to help the family

cope during the patient’s illness and in their own bereavement.

The end of life service is provided five days a week, Monday to Friday from 9.00 am to 5.00 pm

only. The specialist palliative care team work closely alongside a local Hospice to provide

specialist end of life care to patients admitted to the hospital. Seven-day end of life telephone

advisory service at Kings College Hospital was provided by speciality registrars.

End of life care encompasses all care given to patients who are approaching the end of their life

and following death. It may be given on any ward or within any service in a trust. It includes

aspects of essential nursing care, specialist palliative care, and bereavement support and

mortuary services.


For this acute inspection we visited the following wards and departments: Oliver, Byron, Donne,

Marjory Warren, Annie Zunz, Lister, Mary Ray, the mortuary, St Luke’s chapel, and multi-faith or

quiet room.

We spoke with five patients who were receiving end of life care and three relatives. We reviewed

12 patient records. We spoke with 22 staff, including, ward nurses, and ward clerks, mortuary

technicians and doctors. We visited the chaplaincy and the bereavement office. Before and during

the inspection we reviewed data relating to end of life care at the hospital from the trust.

The trust had 2,370 deaths from August 2017 to July 2018.


Referrals for end of life care (EOLC) were made via the trust electronic patient record (EPR).

Registrar provide a 24-hour telephone advice service for end of life care patients at Denmark Hill

site, there was bereavement offices, chaplaincy and mortuary services that supported the end of

life care. There are link nurse forums on both sites & an established programme of medical,

nursing and Allied Health Professionals education.

(Source: Routine Provider Information Request (RPIR) – Context acute tab)


Mandatory training

The service provided mandatory training in key skills to all staff and monitored staff

compliance with completion of mandatory training.

The specialist palliative care team (SPCT) received and completed mandatory training. Some

mandatory training was delivered as face to face, but the majority was delivered by e-learning.

The mandatory training records of the SPCT were up to date. We saw the team had completed

their training in line with trust policy.

Mandatory training modules included: basic life support; conflict resolution; equality diversity and

Human Rights; first safety; health and safety; infection prevention and control; information

governance, PREVENT (preventing radicalisation); safeguarding adults and children; and manual

handling among others.

All the staff we spoke with within the SPCT said they felt they had access to appropriate and

timely mandatory training to enable them to perform their day-to-day roles.

End of life care training was not part of the mandatory training; however, the end of life training

was provided by the SPCT practice development nurse to the ward staff.

Staff we spoke with on the wards said that having the SPCT providing training and knowledge on

end of life care improved the quality of care for end of life patients. Staff gave examples of the

SPCT going onto the ward to provide training and advice to staff supporting end of life patients

and staff knew how to contact the SPCT if they needed training or additional guidance.



Trust level


qualified nursing staff in end of life care is shown below:


Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met








Manual Handling (Clinical) [2

Years] 14 14 100% Yes

Venous Thromboembolism [Once] 14 14 100%

No target

for this

module

Data Security Awareness

(Information Governance) [ 1 Year] 14 13 93% Yes

Resuscitation 14 13 93% Yes

Safeguarding Adults Level 2 [3

Years] 14 13 93% Yes

Aseptic Non-Touch Technique

Level 1 [Once] 10 8 80% Yes



In end of life care the 80% target was met for 12 of the 15 mandatory training modules for which



medical staff in end of life care is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met




Venous Thromboembolism [Once] 5 4 80%

No target

for this

module

Safeguarding Adults Level 2 [3

Years] 5 4 80% Yes


Manual Handling (Non-Clinical)

[Once] 5 4 80% Yes


Data Security Awareness

(Information Governance) [ 1 Year] 5 4 80% Yes

Aseptic Non-Touch Technique

Level 1 [Once] 4 3 75% No


Mental Capacity and Consent

[Once] 3 2 67% No



In end of life care the 80% target was met for eight of the 13 mandatory training modules for

which medical staff were eligible.


Safeguarding

Staff understood how to protect patients from avoidable harm and the service worked well

with other agencies to do so. Staff had training on how to recognise and report suspected

abuse and they knew how to apply the expected principles and actions.

All of the SPCT team knew the trust had a policy on safeguarding adults and children including

how to make a referral to the safeguarding team. The SPCT team demonstrated good awareness

of safeguarding procedures and how to recognise and report concerns if they felt a person was at

risk of abuse. Staff were also able to demonstrate an understanding of the types of concerns

which may alert them to a possible safeguarding concern. Staff knew who the safeguarding lead

was and knew how to find additional information on the trust’s intranet.

One member of the SPCT gave an example of making a referral to the safeguarding team at the

hospital due to concerns regarding a patient’s welfare. Staff sent the referral to the local authority

and the member of staff received feedback from the safeguarding team on the actions taken.

Clinical staff received training and regular updates in adult safeguarding and child protection. The

training included signs of abuse and female genital mutilation.

Nursing staff were aware of the signs of abuse and they told us they would report any concerns to

the person in charge of the shift or the ward manager. They were aware of the role of the social

worker and said the social worker followed through on concerns and ensured they were

addressed. A member of staff said they would not discharge a patient if there were concerns

which might affect the person at home, until actions to protect the person had been agreed.





Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met




The service controlled infection risks well. Staff kept followed trust policies and procedures

to keep equipment and the premises clean. They used control measures to prevent the

spread of infection.


Staff had access to policies on infection, prevention and control. For example, staff were bare

below the elbows in line with trust policy, used antibacterial hand gel between patient care, wore

personal protective equipment and disposed of waste correctly. This ensured that patients

receiving end of life care who could be more susceptible to infection were cared for as safely as

possible.

We observed staff in the mortuary wearing personal protective equipment when they were

involved in handling patients. We observed staff wearing the appropriate clothing and following

infection control protocols, for example, when entering or leaving the post-mortem areas. Staff in

the mortuary had access to hand washing facilities and protective clothing, this included gloves

and aprons.

Within the mortuary, monthly infection audits were completed by the manager and the results

shared with the team. Concerns could be discussed with the hospital-wide infection control team if

required. There were clear protocols for the staff to follow for cleaning the premises and

equipment.

Other areas we visited, such as the bereavement centre, the chapel and the wards, were visibly

clean and well maintained. We observed staff following infection control guidance and observing

the trust policy of staff being bare below the elbow to ensure handwashing techniques were

thorough and reduce the spread of infection.

We saw different coloured bags for different types of waste were being used. For example, the

disposal or handling of clinical and non-clinical waste on the wards and in the mortuary, which

was in line with trust policy. Most of the staff have been trained on IPC, there were link nurses on

all the wards we visited.


The service had suitable premises and equipment, but these were not always maintained

sufficiently to keep staff safe.

The environment and equipment associated with end of life care was well maintained. The trust

had an equipment store and staff said there was no problem in obtaining equipment in a timely

manner.

In the emergency department there was a room for relatives and a private room where they could

see their deceased relative. There was an entrance to this room where ambulance staff could

bring in a deceased patient without going through the main department.

The mortuary viewing room was visibly clean, tidy and appropriately located and furnished. The

bereavement office was easily accessible.

Processes were followed to safely maintain equipment. For example, all syringe driver pumps in

use were maintained and used in accordance with manufactures instructions. A syringe driver was

used to deliver consistent infusions of medication to support end of life patients with complex

symptoms. Two types of syringe driver were in use across all wards.

The use of two types of syringe drivers across the hospital had been risk assessed to prevent the

risk of potentially harmful errors and incidents. We observed the trust policy around the use of

syringe drivers was consistent across the hospital.

Syringe drivers were available on request from the equipment library. Nursing staff on the ward

told us the syringe drivers were routinely cleaned by ward staff and a date was put on them stating

when they were due for annual maintenance. The monitoring requirements for the syringe drivers

were on the electronic prescribing system in the patients’ electronic records.


Pressure-relieving equipment, including air mattresses, were available for patients requiring them.

We saw these mattresses in use in all the wards we visited where an end of life patient was being

care for.


Patient’s individual risks were assessed and monitored, and staff provided support to

maintain their safety. A formal treatment escalation plan was being developed to ensure

best practice when a patient’s condition deteriorated.

The SPCT triaged all the referrals into the service every day. Referrals were received

electronically and were categorised by need and risk.

The SPCT identified and responded to the changing risks of patients. The SPCT had a daily

meeting where they assessed the case load and prioritised visits to end of life patients. Staff

discussed and allocated visits to see patients to ensure continuity wherever possible. The SPCT

stated they saw newly referred patients as a priority and aimed to do this within 24 hours. Audit

data confirmed all referred patients were seen by the SPCT within 24 hours between Monday to

Friday. After each visit SPCT recorded a follow up date based on their assessment of the patients’

needs in the patient electronic record (EPR).

The hospital used an electronic patient record system which was accessible to staff via electronic

computer workstations on wheels and from fixed desktop computers on all wards and offices.

Patients identified as near the end of life had an electronic flag on their patient record.

Ward staff told us that specialist support was available from the SPCT and confirmed the team

responded promptly to referrals and requests for additional support with patient symptom

management.

Staff carried out risk assessments where appropriate for patients receiving end of life care. The

assessments formed part of the electronic care records and included water low scores (for

assessing risk of pressure ulcers) and the malnutrition universal screening tool (for assessing risk

of malnutrition) amongst others. All the nursing staff we spoke with on the wards and within the

SPCT said the electronic care record had improved the quality of record keeping and monitoring of

patients.

The electronic patient record system enabled staff to identify patients who had low or high risk in

terms of their care needs. This enabled staff to prioritise nursing care based on individuals need

and the last days of life rounding tool to increase or decrease observations where appropriate.

There was evidence in patients records that they were regularly reviewed by nursing and medical

staff. End of life care patients were seen by medical staff every day. This ensured that if patients

had increased needs this was identified. For example, change of medication for stronger pain

relief.

Nurse staffing

The staffing levels and skill mix of the nurses and other staff in the end of life care team

were reviewed and planned to support safe practice.

Overall staffing rates

The trust has reported their staffing numbers below for August 2018. The trust did not provide

figures for this staff group for 2017.


Staffing group Planned staff Actual staff Fill Rate

Qualified nursing & health visiting staff

(Qualified nurses) 16 13.9 87%


The specialist palliative care team acted as a link between specialist services and the staff from all

the clinical areas. The team helped to spread information and improve the awareness of policies

and procedures specific to specialist palliative and end of life care. The team visited and treated

end of life patients on the wards and took part in teaching sessions for staff.

The hospital’s SPCT consisted of a lead consultant/clinical director and a matron for care. There

were also clinical nurse specialists providing the end of life care. The team responded to all

referrals from clinicians throughout the hospital for adult patients who had complex support and/or

complex symptom management needs during end of life care. This included support to families of

patients referred.

The specialist palliative care team screened and allocated all new referrals daily. Current work and

new allocations were reviewed every morning by the team and work was allocated based on

patient need and urgency. The SPCT consultant worked across the trust, as part of a

multidisciplinary team.

The specialist palliative care team had four whole time equivalent (WTE) clinical nurse specialists

covering the inpatient wards on weekdays, between the hours of 9 am and 5 pm. There was a

matron and a practice education nurse in the team too.

Nursing handovers took place every morning. These were detailed and focused on the holistic

needs of each patient. There was discussion of their condition and comorbidities, but also ongoing

assessments of the patients’ needs as their condition changed, such as updating family members.

The nursing team used the handover to plan their visits for the day and anticipate any possible

discharges or new referrals.

Vacancy rates

From September 2017 to August 2018, the trust reported a vacancy rate of 17.9% in end of life

care. This was higher than the trust target of 8% and the trust average for nursing staff of 10.2%.


• King’s College Hospital – 11.6%


Turnover rates

From September 2017 to August 2018, the trust reported a turnover rate of 8.8% in end of life

care. This was lower than the trust target of 10%.




Sickness rates


From September 2017 to August 2018, the trust reported a sickness rate of 3.7% in end of life

care. This was higher than the trust target of 3% and the average for nursing staff of 3.3%.




Medical staffing

The service had medical staff with the right qualifications, skills, training and experience to

keep people safe from avoidable harm and to provide the right care and treatment.

The hospital medical staffing was well established, with five consultants in palliative medicine (3.4

WTE), two of whom were employed full-time, delivering hospital-based care and outpatient clinics.

The consultants were supported by two specialist registrars and a foundation year two (FY2) junior

doctor. The registrars supported the delivery of a seven-day, telephone advisory service and were

part of the King’s Health Partnership with four other NHS hospitals, providing on call cover during

out of hours.

Specialist palliative care consultants provided Monday to Friday, face-to-face reviews and

provided specialist advice during out of hours. The lead palliative care consultant was a clinical

director and played a senior role in running of the trust.

An on-call registrar was available 5pm to 9am seven days per week by phone as part of an

agreement with the local NHS trust. The registrar covered four trusts and could be available for

face to face review when required.

The trust have reported their staffing numbers below for August 2017 and August 2018.


Staffing group Planned staff

Actual

staff Fill rate

Planned

staff

Actual

staff

Fill

Rate

Medical & Dental staff -

Hospital 35.7 20.5 57% 10.8 3.9 36%

There has been a large decrease in both the planned and actual number of WTE at the trust.


Vacancy rates


care. This was higher than the trust target of 8% and the trust average vacancy rate for medical

staff of 10.2%.




Turnover rates

From September 2017 to August 2018, the trust reported a turnover rate of 16% in end of life care.

This was higher than the trust target of 10% and the trust average for medical staff of 12.4%.





Sickness rates

From September 2017 to August 2018, the trust reported a sickness rate of 0% in end of life care.

(Source: Routine Provider Information Request (RPIR) - Sickness tab)

Records

Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date


The hospital used electronic patient record (EPR) system. Records were held securely on the EPR

system which was accessed by authorised staff only through a protected password.

Staff kept appropriate records of patients’ care and treatment. Records were generally clear, up-

to-date, and available to all staff providing care.

Plans for interventions, observations, and investigations were recorded in EPR, so were the

medicines, hydration and nutrition plans.

Patients receiving end of life care had an individualised care plan, which included holistic

assessment of physical, spiritual, and psychological needs through the use of “ICare”. This was a

tool that was used to record intervention of patients receiving end of life care. Examples of SPCT

write ups on electronic patient record system were observed. They were found to be clear, specific

and of good quality.

All of the staff we spoke with commented on the use of the EPR, they stated that, the EPR had

improved the quality of care and support to patients. This was because the system saved time,

had all the records in one place for reference, for example allergies, flags for dementia, learning

disabilities, and ensured patients received holistic care.

Nursing staff checked syringe drivers as per the care plan, the syringe driver checks ranged from

hourly to four-hourly; this meant that any patient who was end of life would receive a symptom

review regularly.

The mortuary register recorded date of death, time received in the mortuary, name, ward, age, and

gender. Signing out checks were completed. The identity band check was completed jointly by the

funeral director collecting the body and a mortuary staff member. A release form was completed

that included identity number and coroner’s name if needed.

Medicines


medicines.

We reviewed ten of the electronic medication records for end of life care patients and found these

to be up to date and appropriately recorded.

Staff prescribed anticipatory medicines for patients receiving end of life care. Anticipatory

medicines are prescribed in anticipation of managing symptoms, such as pain, breathlessness,

nausea and vomiting, which are common near the end of a patient’s life. Ward based medical staff

and the specialist palliative care consultants prescribed medicines. Our review of 12 electronic

medicines record showed anticipatory medicines were prescribed and administered appropriately.


There were no concerns regarding the availability of anticipatory medicines. All wards were well

stocked, and staff had access to medicines on demand.

Medicines were stored safely and securely. All medicines storage cupboards were securely

locked, and regular audits were completed regarding the accuracy of controlled drug (CD)

documentation and medicines management.

Written prescribing guidelines were available for doctors to prescribe appropriate end of life

medicines to manage patient’s pain, breathlessness, anxiety and other symptoms.

Records showed that patients referred to the specialist palliative care team had their medicines

reviewed by the team. This was done in consultation with other medical staff involved with the

patients’ care.

Incidents

Never Events


follow national guidance on how to prevent them. Each never event type has the potential to cause

serious patient harm or death but neither need have happened for an incident to be a never event.

From October 2017 to September 2018, the trust reported no incidents classified as never events

within end of life care.



In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents

(SIs) in end of life care which met the reporting criteria set by NHS England from October 2017 to

September 2018.






There were systems and processes to report and investigate incidents, whereby a root-cause

analysis was completed and learning points identified, and staff told us they were encouraged to

report incident. Incidents were reported through the trust’s electronic reporting system. Any

incident relating to end of life care was referred to the End of Life Steering Group for discussion

and dissemination.

Ward staff we spoke with knew how to report incidents using the hospital electronic reporting

system. They were able to give examples of the type of incidents which required escalation and

reporting but could not recall any that related specifically to palliative care or end of life care.

Staff in all roles supporting end of life care services had a basic understanding of the duty of

candour requirement and they had received training.

The SPCT were aware of the duty of candour regulation. Regulation 20 of the Health and Social

Care Act 2008 (Regulated Activities) Regulations 2014 requires the trust to be open and

transparent with a patient when things go wrong in relation to their care and the patient suffers

harm or could suffer harm which falls into defined thresholds. Although staff were aware of the


duty of candour, there had not been any incidents within end of life care where this had been

implemented in the last 12 months.





End of life care was managed in accordance with NICE guidelines; NICE quality standard 13 and

NICE guideline 31 and were reflected in the trusts policies and end of life strategy.

The SPCT used guidelines from the National Institute of Health and Care Excellence (NICE), “End

of Life Care for Adults” (Quality Standard 13) and “Care of Dying Adults in the last days of life”

(NICE guidelines 31). They were also using “Strong Opioids for Pain Relief” (NICE guidelines

CG140) and the “Five priorities for care of the person- one chance to get it right” (June 2014)

Leadership Alliance. We found the service provided care and treatment which was usually in

keeping with national guidance.

Updates on NICE guidance were disseminated through the specialist care directorate meetings.

We saw that guidance had been updated in the care of the dying policy.

We found the policies, procedures and processes provided to staff complied with national

guidelines and good practice recommendations. The hospital had introduced “ICare”, this was an

end of life care plan based on the ‘five priorities for care of the dying person’ set out by the

priorities for care of the dying person from the Leadership Alliance for the Care of Dying People.

The aim of the end of life care plan was to promote a stronger culture of compassion in the NHS

and social care and put people and their families at the centre of decisions about their treatment

and care.

End of life care was provided in line with the principles of the Priorities for Care of the Dying

Person. For example, the possibility of dying had been recognised and talked about clearly with

the patient and those close to them. We saw in patients records when these conversations had

taken place and the people involved such as consultants and family members.

The trust submitted data to the 2018 National Audit of Care at the End of Life (NACEL), the

outcome of which is due to be published in May 2019. This national audit focuses on the quality

and outcomes of care experienced by those in their last admission in acute, community and

mental health hospitals throughout England and Wales.




In the patient records we looked at, we saw nutritional assessments had been completed and

were regularly updated. We saw patients were assessed using the Malnutrition Universal

Screening Tool, which was used to identify nutritional risks.

Staff were aware of the option of clinically assisted hydration in patients approaching the end of

their life, in line with guidance from the General Medical Council (2010) and the National Institute

for Health and Care Excellence: Care of dying adults in the last days of life (2015). Medical staff

described an individual approach for the provision of clinical assisted hydration, which they

discussed with the patients’ next of kin. Nursing staff were aware of the importance of providing


regular mouthcare for patients nearing the end of their life, to alleviate discomfort associated with

a dry mouth.

Our review of 12 electronic care records showed staff completed nutrition and hydration

assessments for each patient. We observed fluid monitoring was completed for patients, which

demonstrated daily fluid input and output totals. Staff confirmed they had access to dietitians and

could refer patient to them were necessary. This was reflected in the patient records we reviewed.

Pain relief




The service ensured appropriate pain relief was prescribed and administered to manage pain in

patients receiving end of life care. The service audited the use of additional measures to manage

pain. These audits included the use of syringe drivers (continuous delivery of medicines) and the

use of strong pain killers.

Wards were well stocked to ensure prescribed medicines were available. Staff had access to

syringe drivers to enable the continuous infusion of medicines when these were prescribed. There

were staff competencies to complete to ensure the safe delivery of medicine through a syringe

driver.

We saw anticipatory medicines were prescribed for patients in their last days or hours of life. Staff

felt confident in their use. The specialist palliative care team discussed patient symptoms

(including signs of pain) with staff, to ensure the prescribed medicines met the needs of patients to

ensure their comfort.

Our review of patient records showed that patients at risk of deteriorating, who may have required

additional medicines to alleviate their symptoms, had medicines prescribed in advance to minimise

patient waiting time and discomfort.

Patient outcomes


improve them. They collected and compared local results with those of other services to learn

from them.

End of life care Audit: Dying in Hospital

The trust participated in the end of life care audit: Dying in hospital 2016 and performed better

than the England average for each of the five clinical indicators.

The trust answered yes to five of the eight organisational indicators. The ones which they

answered no to were:

• Between 1 April 2014 and 31 March 2015, did formal in-house training include/cover

specifically communication skills training for care in the last hours or days of life for allied

health professional staff?

• Was there face-to-face access to specialist palliative care for at least 9am to 5pm, Monday to

Sunday?

• Does your trust have one or more end of life care facilitators as of 1 May 2015.

(Source: Royal College of Physicians)

The hospital completed a gap analysis to identify the actions required to address areas for


improvement identified in the local audit. We saw they had made considerable progress against

the action plan with most areas of work complete.

The trust participated in the End of life care Audit: Dying in Hospital 2016 and performed better

than the England aggregate for two of the three agreed indicators and worse than the national

aggregate for the remaining measure. The trust achieved an average score for the percentage of

patients having documented evidence of a holistic assessment of the patient’s needs in the last

24 hours of life, scoring 79.6% compared to the national aggregate of 83%.


The SPCT audited an aspect of the care of the dying every year and participated in the national

End of life care Audit. During our inspection, the end of life care leadership informed us the

national audit process was changing and they did not know when the new process would launch.

The trust had therefore implemented its own audits to audit local performance against the quality

standards set by NICE.

The SPCT followed The Leadership Alliance for Care of Dying People “Priorities for care of the

dying patient” (2014) when providing care and support to end of life patients and their families.

The hospital reviewed every patient death that occurred in the hospital as part of the trust

mortality review, and the SPCT participate in these reviews where necessary. The SPCT

specifically look for any issues that may have had a negative impact on the last days of life for

patients, to prevent issues in the future.

The electronic patient record system enabled staff to place an electronic flag on patients who

were end of life. This enabled staff to quickly identify end of life patients and meet their individual

needs and choices, for example the preferred place of death.

The service collected information about all patient deaths to monitor and evaluate care of patients

in their last phase of life. The SPCT, as part of their death audit reviewed the notes of patients

who had died in hospital. They had developed a system of key performance indicators to ensure

care and treatment met national guidance and evidence-based care. The information collected

included referral to the specialist care team, recognition that patients were in their last days of

their life, documented evidence that patients and their next of kin’s needs and wishes were

explored. The results demonstrated an improving trend.

Competent staff




Staff working in the specialist care team (SPCT) had the skills, knowledge and experience

required for their role.

Appraisal rates

From April 2018 to September 2018, 96% of staff within end of life care at the trust received an

appraisal compared to a trust target of 90%.

Staff group

Individuals

required (YTD)

Appraisals

complete

(YTD)

Completion

rate









We spoke with all the SPCT nurses who said they had annual appraisal with their respective line

manager. Staff felt that the appraisal process was positive and enabled staff to discuss their

training and career needs in a supportive manner.

The SPCT told us that one to one supervision and clinical supervision was available to all staff.

Clinical staff dealing with end of life care received a face-to-face training in end of life care as part

of their induction to the trust. The SPCT offered training sessions for all clinical staff to raise

standards of care and increase the awareness of end of life care amongst the wider staff teams.

The mortuary team provided training to all the porters including hoisting the deceased to maintain

their dignity and ensure no post-mortem injuries occurred. They also trained porters to transfer

the deceased from the wards in a respectful manner, quietly through corridors and not causing

any distress to patients on the wards.

Nurses attended syringe driver training and completed a competency assessment prior to

administering medicines in a syringe driver. The trust did not have a requirement for staff to

attend update or refresher training on syringe driver, however staff were able to attend the

training again if they wished. Nursing staff told us, as registered nurses they were considered to

be accountable to ensure they maintained their skills.

All staff including volunteers completed communication skills training specifically tailored to end of

life care.

Nursing staff told us they had access to training and could ask if they required additional training.

A student nurse said they had received a good induction, had attended study sessions on

essential symptom control and medicines management and were supported in achieving their

competencies for training. They felt there was excellent support and education for student

nurses.

Porters admitted bodies from the community and the hospital to the mortuary, both in and out of

normal working hours. All porters received mortuary training on starting their employment with the

hospital and were required to complete a set of competencies to admit bodies. Staff informed us

that porter training was renewed every two years.

The bereavement service spoke to clinical staff during their induction about the role of the

bereavement team. We observed staff being supportive and providing guidance to a junior doctor

completing a coroner’s referral. The chaplaincy team provided insight to their role in the trust to

staff during induction.


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.


We observed two handover meetings with the palliative care team and found them to be

structured, detailed and with a focus on personalised care. Staff received an overview of all

patients referred to the team. In addition, patients requiring specialist medical review where

highlighted to the palliative care consultant on duty. We observed input by an oncology clinical

nurse specialist who highlighted areas of concern with some patients.

Multidisciplinary staff (MDT) teams used the electronic patient record system to update patient

records and provide advice and guidance on patients. We noted the MDT staff routinely read and

updated guidance for patients who were end of life within the electronic patient records.

The SPCT team said MDT working was extremely positive across the trust and they worked

together to ensure end of life patient needs were holistically met.

The SPCT staff worked closely with the bereavement team, chaplaincy, and mortuary staff teams.

Staff within each team told us they had good working relationships with each other and this

benefitted the services offered to patients and their families. The mortuary team had recently held

an open day for the SPCT team to spend time in the mortuary and ask questions to understand

how they supported the deceased.

Ward staff we spoke with were aware of the chaplaincy and bereavement services and their roles

in supporting end of life care.

There was good multidisciplinary working between the chaplaincy and the specialist palliative care

team. There were processes for regular meetings throughout the working week. This helped

patients receive the emotional support that was required as well as serving to provide emotional

support to colleagues.

Seven-day services

End of life care services from the specialist palliative care team were provided Monday to Friday

9.00 am to 5.00pm. Outside those times, there was a 24-hour on-call telephone advice service.

A named palliative care consultant was available on-site Monday to Friday between 9am and 5pm.

The specialist palliative care team did not provide services seven days a week. However, the

hospital clinicians had access to specialist palliative advice during out of hours, seven days a

week from an on-call registrar.

Staff could access specialist advice between 5pm and 9am seven days a week via the on-call

registrar by phone as part of an agreement with the local hospice and another NHS trust. The

service of the on-call registrar was shared with neighbouring trusts. The on-call registrar provided

telephone advice to four neighbouring hospitals. Consultant medical cover was available by

telephone during out of hours, seven days a week and this can be accessed by the on-call

registrar when required.

The chaplaincy service was available every day of the year, 24 hours a day. The team had

arrangements with local faith leaders to provide an on-call out-of-hours service.

The mortuary also had an out of hour’s service for evenings and weekends. The mortuary

manager told us relatives were able to view their deceased relative outside of normal working

hours if needed.

Health promotion

The SPCT team explained how they provided support to a wide range of palliative care patients

and not just those in the last days of life. These included patients who had comorbidities that

affected their health and wellbeing who may need specific guidance on health promotion.


The practice education nurse carried out health promotion in relation to end of life care throughout

the hospital.

There was a focus on empowering patients to make choices about their care, and then decide for

themselves where possible, the course of their treatment. This included where active treatment

was to be withdrawn, as well as where limits to treatment were agreed.





Staff understood their roles and responsibilities under the Mental Capacity Act (2005). They knew

how to support patients those who lacked the capacity to make decisions about their care. All of

the SPCT we spoke with knew the trust policy on the Mental Capacity Act (MCA) and the

Deprivation of Liberty Safeguards (DoLS), including how to apply this in their role. The SPCT staff

knew the five core principles of the MCA and explained how to apply the principles in every day

practice to provide the least restrictive options to patients.

The hospital policy on MCA and DoLS gave staff clear guidance in relation to patients who were

end of life and how to record all decisions in relation to any restrictions and promote the least

restrictive methods of care in a patient’s last days of life. We reviewed patient care records which

showed that staff had taken a patient’s capacity to consent into account when having these

discussions. We saw that, where appropriate, mental capacity assessments were undertaken.

Medical staff were aware of the need to obtain consent for care and treatment and spoke with us

about the steps they took to seek patients’ views and discuss treatment options with them. Prior

to the decision that someone was to move to end of life care, they had discussions with patients

and provided information over a period of time to give the patient and their relatives time to

absorb the information and make decision about what they wanted.

We reviewed six Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms in relation to

end of life patients and found these included records of discussions with patients and relatives

regarding DNACPR decisions. The electronic flagging system enabled staff to immediately

identify a patient DNACPR patient and act accordingly. This was an improvement from our last

inspection in March 2016.

At the inspection in May 2015 we identified that, there were no standardised process for

completing mental capacity assessment in line with relevant guidance and legislation. There was

no unified do not attempt cardio-pulmonary resuscitation (DNACPR) policy and DNACPR orders

were not consistently completed in accordance with trust policy, national guidance and

legislation, however at this inspection these issues had been resolved. We noted a complete

record of discussion with family and completion of DNACPR records for end of life care patients.

The hospital used an electronic version of the DNACPR orders. Senior nurse told us, as part of the

admissions process, a box in the Electronic Patient Record was completed with the status of the

patient. This would be completed on admission or during the post take ward round (by a

consultant within 24 hours).


The trust reported that from October 2017 to September 2018 Mental Capacity Act (MCA) training

was completed by 0% of staff in end of life care compared to the trust target of 80%.




Compassionate care

Staff cared for patients with compassion. Feedback from patients confirmed that staff treated

them well and with kindness, dignity, and respect.

On the wards, staff displayed a culture of compassion and prioritised care to patients at the end of

life. We spoke with both patients and patient relatives who spoke positively of the care provided.

We observed staff dealing with patients and family members physical, psychological and

emotional needs in a timely and appropriate way.

Feedback from patients confirmed that staff treated them well and with kindness. Patients were

respected and valued as individuals. The evidence was universally positive about the way patients

were treated by staff. We observed compassionate care in the approach from all the staff we saw

on the wards.

Staff understood and respected the varied personal, cultural, social and religious needs of people.

They also demonstrated an understanding of how this related to care needs and took this into

account when delivering services.

Staff took the time to talk with people who received end of life care and those close to them in a

respectful and considerate way. We observed sensitive conversations taking place between staff

and the dying person, and those identified as important to them.

Feedback from patients and relatives on all the wards visited were mostly all positive. Patients and

their relatives said they were happy with the care received from both palliative care specialists and

ward staff. One patient was full of praise for staff and described the care as “great”

Emotional support

Staff provided emotional support to patients to minimise their distress. Spiritual and religious

support was offered to patients approaching the end of their life appropriate to their needs and

preferences. Families could access the bereavement team for support and follow up. The service

also referred patients and their families to a local charity within the hospital premises for emotional

support including counselling and advice.

The chaplaincy service was available to offer emotional and spiritual support to patients and their

relatives. This included a team of three chaplains and 15 hospital volunteers. The hospital

volunteers specifically trained in supporting patients and relatives through dying visited the wards.

The volunteers came from several different faiths.

Staff we spoke with understood the impact that a patients’ care, treatment or condition had on their

wellbeing and on those close to them, both emotionally and socially. Emotional support was

available for patients and relatives through the end of life care team, which included a clinical

psychologist, social workers, the chaplaincy team and bereavement services. Patients who were

receiving end of life care and those close to them received the support they needed to cope

emotionally with their care, treatment or condition.

The patient affairs office supported friends and relatives following a patient’s death by explaining

all the legal processes and what to expect after someone has died. An information pack included

the contact details for support and counselling groups. Bereavement officers in the patient affairs

office also liaised with doctors to complete the death certificate. They supported relatives or

friends wishing to see the deceased by accompanying them to the place of rest/viewing room.


We observed staff showing empathy and providing comfort to patients who were upset and in

distress. Staff immediately drew curtains around their beds to maintain their privacy and dignity. In

one instance, a chaplain arrived to provide emotional support to a patient. The patient was moved

to a side room the following day for a more serene and comfortable environment.



Most people approaching the end of life and their families felt sufficiently informed about what they

wished to know and supported to make decisions about their care.

Patients we spoke with confirmed staff introduced themselves, explained procedures, and

obtained their consent before carrying out procedures. Staff listened to patients and provided care

in line with their preferences. Relatives also confirmed that they were informed about patient care.

Our review of patient records showed staff documented discussions they had with patients and

their relatives.

Patients who received end of life care services were involved as partners in their care. We

reviewed care records and saw that staff delivering end of life care had recorded some

discussions with patients and relatives such as options to make the patient more comfortable.

These included discussions about care and treatments and their implications.

Staff spoke sensitively with patients and those people close to them so that they understood their

care, treatment and condition. Staff took the time to make sure that what was said to patients and

those close to them was taken in understood.

Staff had the knowledge about the services on offer to patients at end of life, this included both the

hospital and in the community. As a result, they were able to answer questions and make

arrangements for patients who wanted to go home or be discharged to their preferred place of

care.

A relative told us about the excellent relationships they and their relatives had with the specialist

palliative care team and clinical nurse specialist.




The hospital had an end of life care strategy, which set out plans to deliver end of life care for

patients admitted to the hospital. The strategy took into consideration the importance of

recognising people in their last days of life.

The hospital had no designated palliative care wards or beds. Patients were looked after on any of

the wards. A side room was allocated wherever possible. Patients with an infection risk would

need to be prioritised for the side rooms to prevent cross infection with other patients. Staff

explained when patients at the end of their life were cared for in a bay they used curtains to

promote their privacy and dignity. They also said they tried to make a room available on the ward

where those close to the patient could meet. Staff on the wards told us they provided patients

relatives with refreshments and free parking tickets.

The specialist palliative care team worked closely with the local hospice to discuss joint patients

and plan their care, support and treatment.


Patients were referred to the SPCT for symptom control, complex needs including emotional and

psychological needs, pain control and bereavement support for families. Advice on patient care

and management was given to ward teams and for treatment escalation. The SPCT did complex

discharges and fast track discharge.

There were clear processes for referral to the specialist palliative care team. Referrals were made

through an electronic system. Ward staff could also contact the specialist palliative care team

through bleeps and on phone if urgent. The specialist palliative care team received referrals from

hospital staff in all clinical areas.

Relatives had access to visitor’s rooms on the wards we visited. Bed side chairs were available to

enable relatives to stay close at night time. Ward staff informed us relatives were able to stay with

their loved ones until after they have passed on. There were private rooms available for staff to

have private conversations with patients and their relatives.



The trust had an end of life care strategy, which recognised that the end of life care was not just

the responsibility of the specialist palliative care team, but the responsibility of all the hospital. The

strategy clearly provided the foundation for improvements since the last inspection in May 2015.

Patients and relatives had access to the hospital’s chaplaincy, which was open to people of all

faiths and none. The chaplaincy team provided spiritual support for different faiths. The team

represented a variety of faith traditions and were also supported by several pastoral volunteers

and an out of hours on-call service. The chaplaincy team promoted an extensive network of

connections with faith leaders from other religious groups and denominations who visited patients

of varying religions if required.

Patient had access to variety of information leaflets regarding different topics including death and

dying, preferred place of death, chaplaincy, complaints and services they could access.

Patients had an individualised care plan tailored to their needs. We saw evidence of advance care

planning available in patients record. Staff discussed with patients and documented their preferred

place of death in the records reviewed.

Staff confirmed they could access interpreting services for patients through a help line. They could

also request for face-to-face interpreting services when required.

Relatives received a prompt and responsive service from the bereavement service. Viewings of

the deceased could be arranged, usually the same day, and be supported by the staff when

mortuary staff were not available. If required, evening and weekend viewings could be arranged,

but viewings were generally during the working week. If required, the clinical site managers would

arrange and support evening and weekend viewings. If the quick release of a deceased patient

was requested, provided all legal requirements were complied with, this was accommodated by

the service.

Information leaflets for families whose relatives were receiving end of life care were available and

they were given out by SPCT and the Macmillan Information centre.

The advanced renal team provided clinics locally and, if the patient became too frail, home visits

could be arranged. Links with the hospice and primary care through the ‘Coordinate My Care’

system ensured that patients and their families were supported, and their wishes and preferences

were met.


Relatives were offered bereavement counselling and provided with information leaflets highlighting

further resources and services available to them. The bereavement and mortuary services took

account of people’s religious and cultural needs and were flexible around people’s needs such as

releasing the body within 24 hours. Death certificates were issued within 24 hours if everything

was in order.

The mortuary had a dedicated viewing room for relatives/friends to view the deceased, a waiting

area and toilet facilities.

The Bereavement office carried out the administration of a deceased patient’s documents

including the Medical Certificate of Cause of Death (MCCD) and their belongings, as well as

providing practical advice and signposting relatives to registering the death and planning a funeral.

The centre contained a quiet room, which meant that interviews of the bereaved relatives took

place with the upmost privacy.

The SPCT had a bereavement multidisciplinary team, where patients who died were discussed

and any concerns around the needs of their families were highlighted and actions put in place to

support the families. Contact with the family was made two to three weeks after the death of their

relative, followed by a bereavement letter eight weeks later offering follow-up bereavement

support, including the need to discuss feelings or the need to have questions answered. Families

were offered immediate support and future support as well.

The Bereavement Centre staff told us that systems were in place for the quick release of

deceased patients, if required, for religious reasons. Out of hours, the site practitioner could

release the MCCD. We were told that the MCCD was available for relatives ideally within the next

24 hours, or the next working day, if the death happened over the weekend, except for those

patients who were referred to the coroner.

Access and flow

People could access the service when they needed it. Waiting times from referral to

treatment and arrangements to admit, treat and discharge patients were in line with good

practice.

The specialist palliative care team (SPCT) received referrals through an electronic referral system,

but ward staff could call the team with questions about end of life care at any time. The specialist

palliative care nurses were provided with bleeps, this medium of communication enabled them to

respond to calls and referrals without having to return to their office. Staff on inpatient wards told

us the SPCT were very responsive and visited the ward daily, and as and when required as well.

The SPCT triaged and reacted promptly to referrals made to them for the provision of end of life

care, usually within one working day. Ward staff demonstrated they understood how to make a

referral to the specialist team and reported that the team responded promptly. Palliative care staff

informed us they responded to urgent referrals within four hours, while non-urgent referrals were

responded to within 24 hours.

The SPCT provided a system of rapid discharge (fast track) for patients who wished to die at

home, in a hospice or nursing home. The team had worked to improve the discharge process of

EOLC patients by working internally with staff on the wards and externally with the local CCGs.

The SPCT facilitated the transfer of patients from the hospital to the community teams, the SPCT

and the discharge liaison nurses could describe the communication flows and systems that were

in place. This included the engagement with the district nursing team, GPs and the hospice, the

nursing home team to ensure the teams were well placed to deliver continuous end of life care.

We noted documentation was available to support the discharge of patients, including a standard


discharge summary and gold discharge summary. This ensured that streamline care was

communicated across care providers.

The end of life care team had a dedicated social worker who could fast track discharges for

patients who wanted to return home or to other places of care in the community.

For patients and relatives of patients affected by cancer, the MacMillan information centre, which

was opened Monday to Friday, 10am to 4pm (except Bank Holidays), offered emotional, financial

and practical support and information. The centre was able to direct patients/carers to local and

national support services and signpost them to self help and support groups. The centre provided

support in a quiet and calm environment, with a full range of patient support information both

online and in paper format. Staff told us that feedback was good around the service they provided,

however, we were unable to see evidence of this during the inspection.

The chaplaincy organised an annual remembrance service for the bereaved relatives. Bereaved

relatives were invited to the services via a card that was handed out when the family attended the

bereavement office after their relative had died.




The trust had a patient liaison and advisory service (PALS) who managed any concerns and

complaints received. Information was available to patients and their relatives about how to raise a

concern regarding the care they received. The PALS team reviewed all concerns raised in line

with their trust policy. When concerns were not answered to the satisfaction of patients or their

carers, staff advised them to make a formal complaint.

We reviewed key performance indicators which included compliant and concerns raised about end

of life care. Any complaints around the delivery of end of life care were reviewed by the End of Life

Strategy Group. We were told by a palliative care consultant that, in the last year, six complaints

had been made about the end of life care. Ward-based complaints about end of life care were also

discussed at the End of Life Strategy Group.

We reviewed the complaints received and saw actions were in place to mitigate the same

incidents that led to the complaints from happening again, including more staff training and the

attendance of the ward manager at the End of Life Strategy Group. The process undertaken when

the complaint was made demonstrated the systems followed enabled a timely response to the

complaints. We saw a good governance structure and learning from complaints.

Bereavement centre staff undertook interviews with families after the death of their relatives. Staff

told us that, when meeting families, if any issues arose around the care of their relatives, the staff

will contact the medical team involved and try and resolve the issue for the family.

We found leaflets throughout each ward telling patients and relatives about how to access Patient

Advice and Liaison Service (PALS) to make a formal complaint. None of the patients we spoke to

felt they had cause to complain. The trust website also has a section on how to complain.


Leadership

Managers at all levels of the service had the right skills and abilities to run a service

providing high-quality care. Since the previous inspection in May 2015, the trust had developed

an action plan to support the delivery of a specialist palliative care. There was good leadership of


the SPCT, led by the palliative care consultants and the nursing matrons. The SPCT team and

ward staff spoke about the positive impact the leadership was having on the service.

The specialist palliative care team worked closely with staff from other specialities including

medical, surgical wards and the emergency department. There were close working relationships

with staff in the bereavement office, the chaplaincy service and mortuary staff.

Leadership of end of life care had been strengthened since the last inspection. The end of life

clinical director and a non-executive director had responsibility for end of life care at board level.

Staff told us the end of life matron and the clinical director of end of life care understood the end of

life care issues within the organisation and were active and visible to staff.

Vision and strategy

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.

The specialist palliative care service had a strategy for the provision of end of life care. Each

member of the SPCT was aware of their service’s strategy and of the trust’s values known as

ICare. Each member of staff was committed to ICare through their work. The SPCT felt these were

reflected in the way in which staff carried out their work in line with national standards, as set out

in the ‘Ambitions for Palliative and End of Life Care’. There was a set of overarching ambitions as

building blocks for personal care provided to patients at the end of their life. These included seeing

each person as an individual, ensure equal access to care and delivering patient centred and

coordinated care.

The end of life care strategy referred to the outcomes of the previous Care Quality Commission

(CQC) inspection in 2015 and results from the National Care of the Dying Audit (2016). Service

improvement requirements and recommendations contributed to the foundations of the current

end of life strategy. The strategy was also driven by national programmes of work to enhance end

of life care. These included the ‘Ambitions for Palliative End of Life Care: A National framework for

local action 2015-2020’ and National institute for Health and Clinical Excellence quality standards.

There was a list of 16 key priorities, and a workplan setting out actions to achieve the aims of the

strategy. Progress was reviewed quarterly though the ‘end of life steering group’.

Culture

Managers across the trust promoted a positive culture that supported and valued staff,


The SPCT was positive about their role and felt empowered to deliver end of life care to patients

admitted to the hospital, who was approaching the end of their life. The SPCT was highly regarded

by ward staff we spoke with.

Ward based staff we spoke with regarded end of life care as a priority for dying patients. We saw

interactions between staff and patients nearing the end of their life, which demonstrated respect

and compassion. Ward-based nursing staff felt empowered to raise concerns with medical staff

including consultants. Nurses told us consultants were approachable and listened to them if they

raised any concerns about patient care.

The hospital had ‘freedom to speak up guardians’ and staff were aware of how to contact them if

required. Staff felt able to raise concerns without the fear of retribution.

The SPCT worked closely with the lead for the chaplaincy and pastoral care. This meant there

was an opportunity for staff to access support and debriefing when this was required. Staff told us


that end of life care was for everyone and was an important part of their job. They said they felt

supported to deliver good end of life care.

The bereavement team was clear about their role in supporting relatives during a difficult time.

Staff were supportive and gave appropriate information to the bereaved in a manner that allowed

them to ask questions. The bereavement team received regular supervision and one-to-one

support with their manager and stated they had good relationships with the SPCT and the

chaplaincy service.

It was evident that mortuary staff carried out their role with respect for each other, the deceased

and those close to them. Staff took pride in their job and were clear about their role in enabling

people to say their final goodbyes with the deceased, and the impact this may have on their

grieving process and ongoing life.

Staff told us they enjoyed and took great pride in caring for end of life patients. They said they

were aware of the end of life strategy.

We found the trust had processes and procedures to ensure they met the duty of candour through

training, support for staff, policy and audits. Staff felt involved and their opinions were valued in

shaping the team, service, strategy taking it forward.

Governance

The trust used a systematic approach to continually improve the quality of its services and

safeguarding high standards of care by creating an environment in which excellence in

clinical care would flourish.

Governance processes with the end of life service had been strengthened since our last inspection

in May 2015. This had included the end of life strategy group. The group had representation from

staff from a multidisciplinary audience and included members from the trust senior leadership

team and a named non-executive director. All members of the specialist palliative care team

attended the end of life steering group meeting. There was a clear line of communication from

‘ward to board’ meaning that views of staff were conveyed to the senior management team and

the board, and information was shared with the end of life team.

The service had developed audit tools to monitor and assess performance in line with national

guidance and standards. The service monitored a set of key performance indicators and reported

these to the end of life strategy group and the trust’s governance and quality assurance committee

quarterly. In addition, the service also provided information to the trust’s ethics committee of the

trust.

The SPCT used a systematic approach to the continual improvement of the quality of its services

and safeguarding high standards of care by creating an environment in which excellence in clinical

care would flourish.

The end of life care priorities included the development of robust governance arrangements for the

provision of end of life care. We saw that polices were developed across all organisations involved

in end of life care and then these polices went through the appropriate governance meetings for

sign off by each organisation involved in end of life care. The new syringe driver policy and care of

the dying policy had been developed in this way. We saw guidance had been updated in the care

of the dying policy.

There were weekly SPCT death and discharges meetings with the end of life clinical director,

information and outcome of these meetings were cascaded to all staff involved in the provision of


end of life care. Ward nurses said there were good lines of communication between the SPCT and

the ward staff.


The service had systems for identifying risks, planning to eliminate or reduce them, and

coping with both the expected and unexpected. The SPCT had taken sufficient actions to

identify and manage risks.

The service had their own risk register which gave them an oversight of risks and plans as to how

to mitigate against these risks. There was a scrutiny of incidents that related to the end of life care

by the end of life strategy group.

The mortuary had an incident plan, which set out arrangements to cope with unexpected demand.

There was a systematic work stream for the mortuary staff, of actions to take if admitting bodies

from a major incident. All staff in the mortuary were aware of the plan and how to escalate

concerns and of actions to take to increase capacity.

The SPCT held monthly meetings, these meetings were well attended and there was a fixed

agenda. Agenda items included incidents and feedback, a review of the risk register, complaints

and compliments, effective care, policy updates and updates on guidance from the National

Institute for Health and Care Excellence and medicines management. We saw the minutes of

meetings which confirmed these discussions took place at the meeting.




The SPCT used an integrated electronic care record for all patients receiving end of life care. Staff

had access to up-to-date, accurate and comprehensive information on patients’ care and

treatment.

Policies, procedures and protocols could be accessed through the trust’s intranet. Staff on in-

patient wards and from the SPCT had access to information they required to provide good end of

life patient care. All staff had access to the trust’s intranet which contained a wealth of information

and guidance for staff to carry out their duties. Staff we spoke with were familiar with the trust

intranet and knew where to find the information they needed.

Engagement

The trust engaged well with patients, staff, the public and local organisations to plan and

manage appropriate services and collaborated with partner organisations effectively.

The service sought the views of relatives following the death of patients. The service had

conducted a bereavement survey between December 2017 and June 2018. The service sent out

surveys to the next of kin who collected the death certificates for all deaths that occurred in that

period. The survey was sent out three months after the collection of the death certificate and the

service received 115 replies (35% response rate). Results demonstrated that in most of cases,

care was provided to a good standard. This included most relatives (86%) felt their next of kin had

received good personal care and nursing care (84%). Following the survey, the service used the

results and added actions to the strategic workplan to deliver service improvements in end of life

care.

The bereavement team met with relatives of deceased patients when collecting the medical

certificate cause of death, which was required to register the death with the Registrar of Births and


Deaths Office. During this meeting, relatives were handed a bereavement booklet which contained

practical advice and information about additional support such as the chaplaincy service.

Bereavement staff offered the opportunity for relatives to raise any questions or issues connected

to the care of their loved one. The bereavement staff asked for permission to share this feedback

with the specialist palliative care team and ward staff.

The SPCT had ward champions for end of life care. These were members of staff with a specialist

interest in end of life care and who had been provided with additional support and access to

training. Staff on some wards confirmed that they had end of life champions and other staff were

not aware of who the end of life champion on their ward was.

To ensure public and patient representation was established and maintained within the trust, a

layperson was appointed as part of the board to champion end of life care.

Staff awareness of the SPCT was raised by the annual ‘Dying Matters’ at King’s College Hospital,

a stall at the King’s College Hospital. Open day and road shows across the trust to raise

awareness around the care of the dying amongst staff. A palliative care consultant told us that

public awareness around end of life care was undertaken by St Christopher’s Hospice.




We observed many service improvement initiatives since our last inspection in May 2015. There

was a stronger leadership and delivery of end of life care at the trust had improved. The learning

from the CQC inspection and recommendations were built into an end of life work plan to support

the trust’s vision and strategy for end of life care. This was monitored by the end of life strategy

group and report on progress provided to the governance and quality assurance committee.

There was a pilot project run by the specialist palliative care team (SPCT) which offered shortened

one-day training on communication in end of life. The training offered participants an opportunity to

develop skills in having end of life care conversations with patients and relatives.

The SPCT developed ‘Kwiki’ information pages on the trust intranet to support trust staff with

easily accessible information on palliative care, end of life care, DNACPR, rapid discharge and

syringe pump use.

Outpatients


Kings College Hospitals have 1.3 million outpatient attendances a year across four main sites

and other community centres. Each of the trust three divisions are responsible for their own

outpatient service delivery and quality. The King’s College Hospital site has separate booking

function/teams for a variety of services across the divisions. The trust had an outpatient efficiency

programme underway which is led by a director of delivery and outpatients and two clinical leads.

The focus of the programme is to set in place standardised good best practice and systems for


outpatients across the trust and to improve the patient’s and staff experience.

During our inspection we visited clinics in the following specialities: clinical gerontology,

dermatology, ophthalmology, stoma care, diabetic foot care, gastroenterology, general surgery,

breast, cardiology, haematology, neurology, endocrinology and the pain clinic. We also visited

two satellite dialysis units – Dartford and Sydenham. We spoke to 54 members of staff including

nurses, healthcare assistants, doctors of all grades, administrators, technicians, therapists and

managers. We spoke to 16 patients and their relatives.

(Source: Acute Routine Provider Information Request – context tab)

Total number of first and follow up appointments compared to England

The trust had 1,484,801 first and follow up outpatient appointments from August 2017 to July

2018. The graph below represents how this compares to other trusts.

(Source: Hospital Episode Statistics - HES Outpatients)

Number of appointments by site

The following table shows the number of outpatient appointments by site, a total for the trust and

the total for England, from August 2017 to July 2018.

Site Name Number of spells

King's College Hospital 991,833

Princess Royal University Hospital 396,211

Kings College Dental Hospital 152,800

Queen Mary's Sidcup 143,086

Beckenham Beacon 92,779


This Trust 1,884,927

England 107,320,812


Type of appointments

The chart below shows the percentage breakdown of the type of outpatient appointments from

August 2017 to July 2018. The percentage of these appointments by type can be found in the

chart below:

Number of appointments at King's College Hospital NHS Foundation Trust from August 2017 to

July 2018 by site and type of appointment.



Mandatory training

The service provided mandatory training in key skills, but some staff had difficulty

accessing it. The service did not take robust steps to ensure all staff completed

mandatory training, and compliance rates amongst medical staff were poor.

Staff mostly received effective training in safety systems, processes and practices. Mandatory

training was provided through a combination of e-learning and face to face sessions. Staff told us

they received email alerts to remind them when they were due to complete mandatory training,

and managers monitored compliance. Training compliance dates were calculated for the

individual staff member, based on when they had joined the organisation.

We received mixed information as to whether staff received protected time to complete their

mandatory training. Staff in some clinics told us they were taken off the rota to complete their

training, whereas other staff particularly administrative staff told us they were expected to

complete their mandatory training during work time or breaks.

Furthermore, staff based in the satellite dialysis units we visited encountered issues with

completing their electronic mandatory training, due to slow running information technology


systems.



King’s College


qualified nursing staff in outpatients at King’s College is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met

Manual Handling (Non-Clinical) [Once] 2 2 100% Yes





Venous Thromboembolism [Once] 24 23 96% Yes










In outpatients at King’s College the 80% target was met for 11 of the 14 mandatory training

modules for which qualified nursing staff were eligible. Although this did not quite meet the trust

target, staff explained that mandatory training rates had been impacted by factors such as

maternity leave.


medical staff in outpatients at King’s College is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met







Fire [2 Years] 43 26 60% No








In outpatients the 80% target was met for two of the 12 mandatory training modules for which

medical staff were eligible. This meant that not all medical staff had received training essential to

providing safe patient care. However, we spoke to three medical staff who told us they were up to

date with all their mandatory training, and in some clinics, managers told us all staff, including

medical staff, were compliant.


Safeguarding


agencies to do so. Most nursing staff had training on how to recognise and report abuse

and they knew how to apply it.

Staff were competent and confident in their knowledge of safeguarding. Safeguarding information,

including contact numbers and details of the trust lead were easily available on clinic office

noticeboards, and most staff were aware of how to access support. Staff gave examples of

safeguarding concerns they had identified, and when they had made referrals. Staff we spoke with

could describe different types of abuse and were knowledgeable on what to look out for. Staff

were confident that they could access support and advice from safeguarding leads.





qualified nursing staff in outpatients is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met



In outpatients the 85% target was met for one of the two safeguarding training modules for

which qualified nursing staff were eligible. This meant that most nursing staff had received

training essential to protecting patients from abuse and neglect, although the target was not

quite met for the Safeguarding Children Level 2 module.


medical staff in outpatients is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met





In outpatients the 85% target was not met for any of the safeguarding training modules for which

medical staff were eligible. This meant that not all medical staff had received training essential to

protecting patients from abuse and neglect. By contrast, we spoke to three medical staff who

told us they were up to date with all their mandatory training, and in some clinics managers told

us all staff, including medical staff, were compliant.




premises visibly clean. They used control measures to prevent the spread of infection.

Most clinic areas we visited were visibly clean. However, clinic environments were often cluttered,

due to a lack of storage space. Staff’s ability to clean these areas was reduced because of this.

Hand sanitisers were available throughout clinics and at the point of entry. There were several

handwashing sinks in clinic and side rooms, and the main clinic areas. We observed staff washing

their hands prior to, during and after patient contact. There was easy access to personal protective

equipment (PPE), such as aprons and gloves, throughout the clinics, and at the entrance to side

rooms. We witnessed staff using PPE effectively. Staff adhered to the trust bare below the elbow

policy.

Staff took appropriate precautions when treating patients with communicable diseases. For

example, in the dialysis units, patients with blood-borne diseases received treatment in side

rooms, and were usually treated during the twilight session, to reduce the risk of transmission.

Clinics conducted monthly hand hygiene audits as part of the weekly or monthly ‘Perfect Ward’

audit. We requested a copy of these audits from the trust, but at the time of writing we had not

received them

Staff escalated any issues with cleaning to the contracted cleaning agency. Cleaning staff

recorded completion of cleaning tasks in a checklist document. We saw cleaning checklists in

most areas we inspected, although these were inconsistently complete.

Staff used ‘I am clean’ stickers to indicate whether items of equipment had been cleaned and

when the next clean was due. We saw that ‘I am clean’ stickers were present on most items of

equipment we looked at.

We saw there were appropriate arrangements for managing waste and clinical specimens. We

saw that sharps bins were signed and dated when brought in to use. The sharps bins we viewed

were not overflowing. We saw that when sharps bins were full, staff sealed the bin and alerted the

nurse in charge, who would arrange for it to be collected by the hospital’s estates team.


The service did not always have suitable premises or equipment and did not always look

after them well.

The environments of several of the outpatient clinic areas we visited were not fit for purpose. For

example, the dialysis units, ophthalmology, cardiology and diabetic foot clinics had limited space

which was affecting consultation rooms, storage and patient bed space. Staff told us this meant


patient privacy and dignity, and the space available for patient appointments, was sometimes

compromised.

Key leaders in outpatients were aware of this and admitted environment and equipment was a

challenge. Managers had been acting to address the issues, and they had been recorded on the

risk register. For example, there had recently been a Getting It Right First Time’ (GIRFT)

programme in ophthalmology, during which some equipment, such as field machines, had been

updated. There were also longer-term plans for the ophthalmology clinic to move in to the space

currently occupied by the dermatology clinic, to improve the setup. However, this had not yet been

confirmed, and staff felt that solutions were restricted by the financial issues affecting the trust.

We checked six resuscitation trolleys and found the daily checking of these was inconsistent and

some items were out of date. Of the six trolleys we looked at, staff had not consistently completed

daily checks of the content of five trolleys. Furthermore, two of the six trolleys we looked at

contained one or more out of date items of equipment or medication, with the most out of date

item being from December 2017. This was poor practice and meant there was a risk that staff may

not have the appropriate equipment or medication available to them in the event of an emergency.

At the time of our inspection we alerted staff to the out of date medication, and we saw they

disposed of it immediately.

In both Dartford and Sydenham Dialysis Units, the boiler had been broken for at least two months,

and staff were having to use temporary or workaround systems. This meant this equipment was

not always well maintained. However, staff told us there were arrangements to fix the boilers in the

weeks following our inspection.

Despite the challenges faced by the service, we found some aspects of environment and

equipment in clinics was suitable and managed well.

We looked at four sluice areas and found that these were clean and tidy.


Staff completed and updated risk assessments for each patient. They kept clear records

and asked for support when necessary.

There were clear pathways and processes for the assessment of people within outpatient clinics

who became unwell and needed hospital admission.

Patients’ clinical observations such as pulse, oxygen levels, blood pressure and temperature were

monitored in line with National Institute for Health and Care Excellence (NICE) guidance CG50

‘Acutely Ill-Patients in Hospital’ before during and after any interventional procedure. A scoring

system known as the national early warning score (NEWS) was used by staff to recognise “at risk”

patients and refer to medical staff, for intervention to help prevent deterioration. We saw NEWS

charts in some of the patient records we looked at. In the dialysis units we visited, staff closely

monitored patients’ observations such as blood pressure, throughout their treatment. The trust

provided information which stated all new starters received NEWS training on induction.

Staff could access the psychiatric liaison team if they became concerned about risks associated

with a patient’s mental health. There was a formalised escalation process for admitting patients

attending outpatient appointments, who were displaying mental ill health, to the Emergency

Department for treatment.

In some clinics, managers led daily ‘huddles’ with their teams, to identify any issues that might

impact upon patient care, such a staffing, and deal with them straight away. Managers were able

to identify recurrent themes from the ‘huddles’ which they were able to escalate for action.


Clinic administrative staff had access to panic buttons which they could press to call for urgent

assistance if a patient became ill in the waiting area.

In clinics where children were treated, staff could access a registered children’s nurse for advice.

In Sydenham Dialysis Unit, if patients became unwell staff told us they would dial 999 for an

emergency ambulance. In Dartford Dialysis Unit, staff had a service level agreement which stated

they could seek support to care for deteriorating patients from medical staff working for a different

trust, who were based on the same hospital site.

Nurse staffing

The service mostly had enough nursing staff with the right qualifications, skills, training

and experience to keep people safe from avoidable harm and to provide the right care and

treatment.

Managers used a ‘check and challenge’ methodology to determine their staffing requirements,

both for staffing numbers and skill mix. Ward sisters and lead nurses attended regular meetings to

review current staffing data and any issues that were having an impact on staffing requirements.

Managers reviewed staffing establishments using information such as the current budgeted

establishment, acuity and dependency data and professional judgement.

In some clinics, if staffing was reduced due to leave or sickness, managers helped out clinically.

However, staff told us this meant that managers struggled to complete their administrative duties.

Vacancy, turnover and sickness rates in outpatients were higher than the trust targets for these

specific measures, which meant there were fewer substantive nursing staff available to care for

patients. However, it should be noted at the time of our inspection, leaders reported that nursing

vacancies had been reduced, and some outpatient specialities did not have any nursing

vacancies.

The trust has reported their staffing numbers for outpatients below for the period August 2017

and August 2018. Although the fill rate has decreased, there are over 75 more WTE in post.


Staffing group

Planned

staff –

WTE

Actual

staff –

WTE

Fill

rate

Planned

staff –

WTE

Actual

staff –

WTE

Fill

Rate


(Qualified nurses) 1.5 3 202.7% 82.3 78.4 95.3%


• King’s College Hospital – 38.3 WTE in post (82.4% fill rate)


Vacancy rates

From September 2017 to August 2018, the trust reported a vacancy rate of 10.3% in outpatients.

This was higher than the trust target of 8%



• King’s College Hospital: 16.7%

Staff told us they used regular bank staff to fill rota gaps and mitigate the risks of decreased

staffing. Following our inspection, the trust provided information stating that the vacancy rate

across the trust was 3%. This should be taken in to account because outpatients was managed by

several divisions, therefore there was variation in vacancy rates in different clinical specialities.


Turnover rates

From September 2017 to August 2018, the trust reported a turnover rate of 15.9% in outpatients.

This is higher than the trust target of 10%.



This meant that levels of nursing staff retention were not always in line with the trust target.

Following our inspection, the trust provided information stating that the turnover rate across the

trust was 14%. This should be taken in to account because outpatients were managed by several

divisions, therefore there was variation in turnover rates in different clinical specialities.


Sickness rates

From September 2017 to August 2018, the trust reported a sickness rate of 3.6% in outpatients.




This meant that more nursing staff were off sick than the trust target, and fewer substantive

nursing staff were available to care for patients. Following our inspection, the trust provided

information stating that the sickness rate across the trust was 4%. This should be taken in to

account because outpatients were managed by several divisions, therefore there was variation in

sickness in different clinical specialities.




agency usage rate of 16.2% in outpatients. This left 20.5% of available hours unfilled.





Medical staffing

The service mostly had enough medical staff with the right qualifications, skills, training

and experience to keep people safe from avoidable harm and to provide the right care and

treatment.

Medical staff we spoke with told us the introduction of electronic job planning had resulted in

better visibility of working patterns and allocation of resources, which helped to ensure there were

enough medical staff to meet patient need. The consultant workforce had also been increased to

improve capacity in outpatients.

Where there were gaps in the rota, managers could book bank or locum medical staff. However,

some staff told us bank or locum medical staff did not always have the correct training or were

unable to access the bespoke IT software required to permit smooth running of the clinic.


and August 2018. Fill rate has increased nearly 10% however the total number of WTE had

decreased by 40.


Staffing group

Planned

staff –

WTE

Actual

staff –

WTE

Fill

rate

Planned

staff –

WTE

Actual

staff –

WTE

Fill

Rate

Medical & Dental staff - Hospital 107.6 83.3 78% 49.7 43.7 87.9%



This meant there were mostly sufficient levels of substantive medical staff to care for patients in

outpatients.


Vacancy rates


This is lower than the trust target of 10%.





This was good practice and meant there were sufficient levels of substantive medical staff to care

for patients in outpatients.

Turnover rates


This is higher than the trust target of 10%. All medical staff report to King’s College Hospital so

there is no site breakdown.


(Source: Routine Provider Information Request (RPIR) - Turnover tab)

Sickness rates

From September 2017 to August 2018, the trust reported a sickness rate of 0% in outpatients.

This was notably lower (better) than the trust target of 3%.



From September 2017 to August 2018, the trust reported a bank usage rate of 4.3% and locum

usage rate of 89.9% in outpatients. This left 5.8% of available hours unfilled.


filled by substantive staff, therefore we cannot make a judgement on what proportion of all shifts

were covered by bank or locum staff.

(Source: Routine Provider Information Request (RPIR) – Medical agency locum)

Records

Staff mostly kept detailed records of patients’ care and treatment. Records were mostly

clear, up-to-date and easily available to all staff providing care.

Patient’s individual care records, including clinical data were written and managed in a way that

kept patients safe.

Staff reported that patient records were mostly available for patient clinics in a timely manner.

There was a good system for ensuring medical records were available for clinics. Clinic staff

submitted clinic lists in advance to the on-site medical records team, who would retrieve the

records from the library or off-site storage, and then deliver them to the clinic. Medical records staff

carefully tracked records in and out of the library, to ensure they could be found easily. Medical

records staff tried to accommodate last minute requests for medical records wherever possible.

This was good practice and ensured records were easily available to staff providing care.

When medical records were not stored in the library, and were kept elsewhere, for example in

medical staff offices, the responsibility for finding them was then placed on administrative staff

working in the clinics.


If patient medical records were not available for clinics, administrative staff told us they created a

temporary set of notes, which were then joined up with the main record at a later date. However,

staff told us this only happened occasionally.

The OPD used a mixture of electronic and paper records, although there were plans for the

service to move to using only electronic records in the future. We looked at six sets of patient

records and saw these were complete, up to date, and entries were legibly signed and dated, in

line with national professional guidelines. However, two records we looked at had loose sheets of

paper, which meant there was a risk that confidential patient information could become lost.

We saw patient records were mostly stored securely away from patient areas when not in use.

This helped to ensure patient records were not accessible to unauthorised persons.

However, in Dartford Dialysis Unit, to prepare for the next session of dialysis patients, staff kept

patient treatment folders alongside packs of medicines specifically intended for that patient. The

treatment folders contained prescriptions, care plans and observation charts. These packs were

temporarily stored for fixed periods of the time in the main area where patients received dialysis

treatment, due to a lack of storage space. This meant there was a risk that these patient treatment

folders and medication packs were sometimes accessible to unauthorised persons. We asked

staff about this, and they told us they mitigated this risk by staff staying vigilant to patients looking

at these folders. The trust also told us the folders were essential for the regular treatment of

patients. Nevertheless, this was not a robust or long-term solution to the risk posed.

Medicines

The service mostly followed best practice when prescribing, giving, recording and storing

medicines, however some medication cupboards were disorganised.

Staff reported good access to the pharmacist who visited the clinics. Some specialist pharmacists

led their own outpatient clinics.

The trust offered an outpatient telephone medicines helpline from Monday to Friday, which

patients could access if they had queries about their medication.

We saw staff recorded the dates that liquid medicines were opened on, so they were not used

outside the safe period of time.

We looked at five medicines fridges and found that items in the fridges were in date, fridge

temperatures were recorded, and fridges were locked. This meant that refrigerated medicines

were stored securely and could only be accessed by authorised staff.

We looked at a sample of items of medication in four medication cupboards and found that these

were in date. However, medications were not always stored in an organised manner. For example,

in Sydenham Dialysis Unit and ophthalmology, we found the medications cupboard was cluttered

and disorganised, and staff were unable to provide a stock list.

Incidents





Staff understood their responsibilities to raise concerns, record incidents, concerns and near

misses. The trust used an electronic incident reporting system to report incidents and ‘near-miss’

situations.


There was a good culture of incident reporting. Staff told us they were encouraged to report

incidents and could give recent examples of incidents they had reported and the relevant learning.

Staff told us when incidents happened, managers focused on what could be learned, rather than

apportioning blame.

Staff and managers shared learning from incidents in several ways, including monthly meetings,

‘grand rounds’, and online through the trust intranet. Staff also told us they spent time learning

from incidents at other healthcare providers, through national websites and patient safety alerts.

The duty of candour is a regulatory duty that relates to openness and transparency and requires

providers of health and social care services to notify patients (or other relevant persons) of certain

‘notifiable safety incidents’ and provide reasonable support to that person. Staff we spoke with had

knowledge of duty of candour but did not have any recent examples where they had needed to

formally carry out the duty of candour.

Never Events




never event.

From October 2017 to September 2018, the trust reported no incidents classified as a never

event for outpatients.



In accordance with the Serious Incident Framework 2015, the trust reported eight serious

incidents (SIs) in outpatients which met the reporting criteria set by NHS England from October


These were:


incidents


Confidential information leak/information governance breach

meeting SI criteria 1

HCAI/Infection control incident meeting SI criteria 1




Safety thermometer

Safety thermometer data is not applicable in outpatients.


Services collected and monitored safety information. While this was not submitted to the NHS

Safety Thermometer, the service monitored information through operational performance reports.

We viewed operation performance scorecards which showed that the service regularly reported on

falls and infection control. We saw that outpatients at King’s College Hospital was consistently

above the 90% target for hand hygiene compliance, and the numbers of falls although small, had

remained steady.





The service used a range of evidence-based guidance, legislation, policies and procedures to

deliver care, treatment and support to patients.

The service followed relevant national guidelines and standards. Staff accessed policies and

corporate information on the trust’s intranet, which also contained links to national guidance.

Medical and nursing staff we spoke with gave examples of guidelines they had recently referred to

and told us they found them helpful. For example, in dermatology, staff frequently made use of

standards and guidelines from the British Association of Dermatology. Some medical staff in some

specialities, such as the diabetic foot clinic, told us they had also helped to author national

guidelines and standards.

There were protocols and standard operating procedures in some clinics, which staff said helped

to ensure they provided a consistently effective service. For example, staff used an anaphylaxis (a

severe and potentially life-threatening reaction to a trigger such as an allergy) protocol in the

infusion suite, to monitor patients for signs of adverse reactions. This was good practice.

Understanding of and adherence to National Institute of Health and Care Excellence (NICE)

guidelines was embedded in multidisciplinary working and evidenced using audit programmes to

benchmark practice. There were regular ‘Perfect Ward’ audits including monthly audits of hygiene

and infection control, medicines management, environment and equipment, and staffing, amongst

many others. Action plans were discussed at clinic team meetings to monitor improvement.

We reviewed six policies including those relating to medicines management and policies specific

to dialysis treatment. The policies we viewed referenced national guidelines from organisations

such as NICE and Royal Colleges. They contained guidance for screening, referrals, escalation,

specific interventions and further sources of advice and information.

However, not all the policies were up to date, which in turn meant the national guidance referred to

could have been out of date. Of the six policies we looked at, five were out of date at the time of

our inspection. For example, one of the policies expired in November 2014. This was not best

practice and meant staff may not always have used the most up to date information to guide care

and treatment of patients.



Staff identified, monitored and met patient’s nutrition and hydration needs.


In the dialysis units we visited, staff provided patients with water, hot drinks and biscuits during

their dialysis session, to ensure they were suitably nourished and hydrated. This was in line with

best practice.

Pain relief




Staff accessed appropriate pain relief for patients within outpatient clinics. Patients’ pain was

assessed and monitored. Staff told us they would use pain tools such as the one to ten pain scale.

For patients who had difficulty communicating, staff told us they would use a movement and facial

expression-based assessment tool to determine patients’ pain.

There was a pain clinic for patients experiencing pain. Staff gave patients advice on how to

manage their pain and who to contact if they had any problems with pain after a treatment.

Patient outcomes


improve them. They compared local results with those of other services to learn from

them.

The service routinely collected and monitored information about the outcomes of patient’s care

and treatment. The trust contributed to relevant local and national patient outcome and

performance audits, including benchmarking activities and peer review with other NHS hospital

trusts. For example, in the diabetic foot clinic, medical staff contributed to the National Diabetes

Foot Care Audit and were knowledgeable about their performance in the audit.

Medical staff we spoke with were knowledgeable about patient outcomes in their speciality and

participated in ongoing plans to improve outcomes. For example, in the gastroenterology clinic,

staff were actioning a 10-point plan to improve the service. Medical staff told us the department

had been successful in implementing most of strategies, in a bid to improve poor benchmark

data.

Some specialities, such as ophthalmology, conducted research on the hospital site, with the aim

of improving patient outcomes.

Follow-up to new rate

From August 2017 to July 2018,

• the follow-up to new rate for King's College Hospital was higher than the England average.

• the follow-up to new rate for Kings College Dental Hospital was similar to the England average.

Follow-up to new rate, King's College Hospital NHS Foundation Trust.



The follow-up to new rate measures how many follow-up appointments a patient has for each

new appointment. A higher number of follow-up appointments can indicate treatment taking

longer and therefore not being as effective.

Competent staff




Staff had the right skills and knowledge to meet the needs of patients. Managers arranged ad hoc

forums outside of mandatory training to meet the learning needs of staff. For example, some

clinics had local staff leads for specific subjects, such as safeguarding, and staff provided

learning sessions on those subjects to their peers.

Managers encouraged and gave staff opportunities to develop their professional skills and

knowledge. Most staff we spoke to, of all bands and disciplines, told us they felt they could

access development opportunities and their managers were supportive of this. For example,

some staff had been supported to study for qualifications in nursing or health and social care or

attend external study days.

Consultants provided regular teaching for junior doctors and students. Junior medical staff we

spoke with told us consultants were available for advice and discussion of complex cases and

were positive about the supervision they received.

All staff received a structured induction programme when they commenced their employment with

the trust. We spoke with three members of staff who had recently joined the trust and they had

received a corporate trust induction as well as a local induction to their area of work. Local

inductions included a period of shadowing. Staff were positive about the induction they had

received.

Staff received an annual appraisal, and review of their objectives every six months. Managers set

objectives for new starters. Most nursing staff told us they received an appraisal and it was


useful.

However, some medical and administrative staff we spoke to told us they felt appraisals were a

‘tick box’ exercise, they were time-consuming and lacked value. Furthermore, administrative staff

expressed concerns that they did not have the skills and knowledge to deal effectively with

difficult conversations with patients over the phone. Administrative staff felt there was a lack of

training and support from management on this subject.

Appraisal rates

From September 2017 to August 2018, 80% of staff within outpatient departments at the trust


King’s College

Staff group Appraisals

required

Appraisals

complete

Completion

%






Technician Staff

1 1 100%


Allied Health Professionals 65 58 89%





Qualified Allied Health Professionals 3 2 67%



The above data shows that most staff had received an appraisal in a timely manner. However,

medical and dental staff and administrative and clerical staff were notable exceptions. It should be

noted that staff told us there had been significant turnover in recent months amongst

administrative managers, which had caused delays in administrative staff receiving their

appraisals. At the time of our inspection, some new substantive managers had recently come in to

post, and they told us of their plans to ensure all administrative staff received an appraisal in a

timely manner.





Multidisciplinary working was embedded into practice in most outpatient clinics we visited. For

example, the liver clinic provided a one-stop service involving different disciplines of staff working

together.

Consultants worked closely with the matron in charge of each clinic and had daily discussions

including escalation of any immediate issues. Administrative staff worked closely alongside clinical

staff to monitor and interpret performance data.

There were also positive multidisciplinary interactions between clinic staff and the wider hospital.

For example, in the dermatology clinic, nursing staff would regularly attend medical ward rounds

on oncology wards or visited patients with skin disorders in critical care. Staff from the

haematology clinic visited the wards to provide teaching on sickle cell disease.

Seven-day services

Most clinics in the OPD operated five days per week between the hours of 9am to 5pm.

The trust offered Saturday clinics in some specialities. For example, in the cardiology clinic, staff

told us the echo team offered Saturday lists.

Health promotion

Staff supported patients to live healthier lives and identified patients who might need extra

support.

We saw evidence that the OPD provided information on several health promotion topics including

national priorities such as smoking cessation, living with dementia and cancer. There were

information leaflets available in all clinics which patients could take away.





Staff we spoke with understood the relevant consent and decision-making requirements of

legislation and guidance, including the Mental Capacity Act (MCA) 2005.

We saw staff taking consent from patients, for example, for dialysis treatment. This was recorded

on ‘intentional rounding charts’ in the patients notes. Consent was regularly audited as part of

monthly ‘perfect ward’ audits.

Staff we spoke with were aware of the requirements of their responsibilities as set out in the

MCA. Staff told us they would refer patients to the trust safeguarding team or on call psychiatry

liaison team, if they needed an MCA assessment, and were supported by their managers to do

so. Staff told us they knew who to contact for advice in cases where a patient may require

support, for example, some clinics had a visiting psychologist who could provide assistance. The

clinical staff we spoke with were knowledgeable about guidelines and competencies to help

assess whether a patient had capacity to consent or make decisions. Staff were aware that there

was a specific consent form that should be used if there were concerns about a patient’s capacity

to consent.




55% of staff in outpatient departments compared to the trust target of 80%. All were registered at

King’s College. Although staff we spoke with were aware of their responsibilities and relevant

guidelines, the low compliance rate meant there was a risk that not all staff would have the

knowledge and skills required to deal with issues concerning consent, and the MCA.




Compassionate care


them well and with kindness.

We saw staff took the time to interact with patients and their relatives in a respectful and

considerate way. Throughout our inspection we saw staff greet patients in a friendly manner, ask

how patients were feeling, and ensure they were comfortable.

Staff showed an encouraging, sensitive and supportive attitude to patients and their relatives.

Patients we spoke to were positive about the care they received from staff. For example, patients

told us “staff are so kind, I am always greeted with a smile”, “staff are so caring, it’s like a second

home here”, and “it’s been a very positive experience, I have been made to feel so welcome.”

Throughout clinic areas we visited, we saw cards from patients displayed, thanking staff for caring

for them.

Chaperones were available to reassure patients during intimate examinations or procedures.

Staff tried their best to make sure patient’s privacy and dignity needs were respected, however this

was not always possible due to the environments they were working in. For example, in

ophthalmology, due to the layout of the consulting and test rooms and lack of space, patients

could overhear conversations between other patients and clinicians providing care. Staff were

frustrated by this and were conscious of the need to mitigate the impact the environment had on

patient privacy and dignity. Staff tried to make patients feel more comfortable, by talking gently

with them to reassure them, and providing additional blankets for patients to cover themselves

with.

Emotional support


Staff at all levels understood the impact that a patient’s care, treatment or condition would have on

their wellbeing and those close to them.

Staff offered patients appropriate and timely support and information to cope emotionally with their

care and treatment. In several clinics we visited, such as the dermatology and breast clinics, there

were clinical nurse specialists (CNS) available to support patients. CNS staff provided patients

with their contact details and working hours, so patients and relatives were clear on when they

were available.


Some clinics also conducted Health Needs Assessments, which looked closely at patient’s

psychological needs and social circumstances, to ensure they were receiving appropriate support

throughout their care and treatment.

Staff advised patients on how to find other additional support services. Many clinics we visited held

regular patient peer support groups. For example, in ophthalmology and stoma care, staff had built

networks of ‘patient experts’ who could provide emotional support to a newly-diagnosed patient.

There was a Macmillan Information and Support Centre on site at the hospital, of which staff were

knowledgeable and could refer patients to. Staff also told us they could liaise with the hospital

bereavement team to organise support for bereaved families of patients, or patients coping with a

life changing diagnosis.



Staff communicated with patients in a way that they could understand, and patients confirmed this

was the case. Patients told us staff allowed them time to ask questions about their care and

treatment.

Where appropriate, staff involved patients’ relatives, carers and those close to them in planning

and making shared decisions about their care and treatment. Patients and relatives told us they

felt staff achieved a good balance between speaking directly to patients and including their

relatives and said “we all felt involved in the discussion”.

We saw that staff welcomed patient’s carers and treated them as important partners in the delivery

of patient care. For example, in some clinics, patients with specific needs attended their

appointment accompanied by a carer, and staff appreciated the need to involve them.



The trust was not always able to plan and provide services in a way that met the needs of

local people.

The outpatient services provided by the trust mostly reflected the needs of the population served.

However, they did not always ensure flexibility, choice and continuity of care for patients.

Patients we spoke to told us they did not always have a choice of appointment times, and patients

who worked full time told us this was particularly challenging for them.

The facilities in clinic areas we visited were not always appropriate and patient centred, due to

restrictions on space. For example, the ophthalmology waiting area often became crowded.

Patients told us there was not enough car parking available at the site. Many patients receiving

dialysis treatment experienced transport delays. The trust had a service level agreement with the

respective transport providers and was trying to monitor the quality of the service. For example, at

Sydenham Dialysis Unit, managers were reviewing the length of time spent cleaning dialysis

machines, and the unit’s opening hours, to mitigate the problems caused by transport arriving late.

Most OPD clinics were clearly signposted. We saw volunteers working in outpatients to help

patients and relatives find their way. However, in ophthalmology, staff told us not all the signage

was suitable for patients with restricted vision, and they were not aware of any immediate plans to

address this.


There were self-check in screens available at several clinics, but about half of those we saw were

broken. Staff told us they had reported this, but no action had been taken to fix them to date. This

meant that patients had to attend the reception to check in for their appointment, which we saw

could cause delays and queues. Staff told us this had been the case for some time and did not

know of any plans to address the issue.

We did not see clinic waiting times displayed in the clinic waiting areas we visited. Staff told us

they tried to keep patients informed about waiting times, but all patients we spoke to about waiting

times told us staff had not updated them on how long they would have to wait or whether clinics

were delayed.

Services did not always provide the right information to service users prior to their appointments.

For example, administrative staff told us that incorrect telephone numbers were often printed on

appointment letters, meaning patients would often call through to the wrong department. Staff told

us they had frequently raised the issue to management, and held meetings to discuss their

concerns, but managers had been unable to solve the problem. Call handlers in the outpatient

appointment centre (OPAC) frequently received calls for follow up appointments, which they then

had to divert to the clinic specialties. Staff told us this was frustrating for patients and was the

source of complaints. This was not responsive practice.

Where patient needs were not being met by the service offered, staff and managers tried to use

this to inform how services were developed and improved. However, staff felt these initiatives were

restricted by the financial pressures faced by the trust.

Nevertheless, the service was responsive to the needs of the local population in some ways. The

trust provided some specialist clinics for the local population. For example, the haematology clinic

provided specialist care for patients with sickle cell disease. Half of appointment slots were kept

open for walk-ins, and the other half were planned appointments. This meant the service could be

responsive to the needs of local people.

Some clinics, such as the liver clinic, ran ‘hot clinics’ where the patient’s GP could refer them for a

same or next day appointment. This was responsive practice.

In some clinic waiting areas we visited, there were some provisions for children, such as toys,

books and child-friendly décor.

We saw water was available in most clinics we visited. In main outpatient areas, there were cafes

and vending machines that patients could access for food and drink.

Did not attend rate


• the ‘did not attend’ rate for Kings College Dental Hospital was higher than the England average.

• the ‘did not attend’ rate for King's College Hospital was higher than the England average.

The chart below shows the ‘did not attend’ rate over time.

Proportion of patients who did not attend appointment, King's College Hospital NHS

Foundation Trust.


The service had introduced initiatives to reduce DNA rate, and this was adapted to meet the

needs of the specific patient. For example, staff in the clinical gerontology clinic recognised that

not all patients would have a mobile phone, and so would telephone their home instead to remind

them of their appointment.




Services were delivered and co-ordinated to take account of the needs of different people,

including those with protected characteristics under the Equality Act and those in vulnerable

circumstances.

There were interpreting services available for patients who did not speak English. Staff told us

they could visit the trust accessible information and communication intranet page which provided

information on how to access interpreters and communication aids. Translation services could be

booked for telephone and face to face interactions. In clinic areas, we saw information leaflets

were available in different languages. We the electronic self-check in screens that were working,

displayed information in a variety of languages.

The trust told us they had introduced a "This is me" document for patients with a cognitive

impairment, which contained specific information on the likes, dislikes and preferences of patients

with communication difficulties. Staff also told us they could seek advice from the dementia and

delirium team, to support patients living with dementia.

Staff told us patients with learning disabilities would usually attend their appointment with a carer,

and the trust provided patient passports and leaflets in an accessible format.

Staff also provided appropriate support to patients experiencing mental ill health. As part of the

clinic services operational policy there was an agreed psychology pathway, where staff in clinics

would ask screening questions to establish patient’s wellbeing and identify any symptoms of

mental ill health. Patients who required specific support could then be referred for psychological

support.

Access and flow


referral to treatment were not consistently in line with good practice. The capacity of the

service could not always meet demand and high levels of patient intake.


The service was taking action to try to minimise the length of time patients had to wait for care and

treatment and prioritise patients with the most urgent needs. There was a recovery programme to

address the waiting times, which included several measures such as providing additional clinics.

For example, some specialities provided virtual clinics as an alternative to face to face

appointments, to address waiting lists.

However, at the time of our inspection, many patients were experiencing lengthy waiting times for

appointments, particularly for those patients on 52-week pathways, and to be seen when they

arrived for their appointment. There were several reasons for this, including complex booking

systems, staff vacancies, and a lack of available clinical rooms and space. Staff told us that clinics

were frequently overbooked. The trust had a recovery programme to improve on this, but board

papers we looked at stated that they were failing to meet their recovery trajectory. Despite this,

leaders told us there was a harm review programme where consultants would review patients on

the waiting list, conduct risk assessments and prioritise bringing patient appointments forward

based on urgent clinical need.

Appointment systems and technology, including telephone systems, were complex and not always

easy for staff and patients to use. Appointments could be booked in a number of ways. Most new

appointments were dealt with by call handlers at the Outpatients Appointment Centre (OPAC).

Most follow up appointments were booked through the clinic specialities themselves. Staff who

booked appointments told us that they had to replicate data on to five different systems and this

was difficult. Staff were not always able to book patients in to appointments in a timely manner,

due to appointment slots not being released on the system. As a result, access and flow in to

outpatients could be delayed.

Outpatient services showed generally poor performance in referral to treatment (RTT) and cancer

waiting times. The trust was performing worse than the England average and national standard for

both the RTT incomplete pathway, where patients should be seen within 18 weeks, and for urgent

cancer referrals, where patients should be seen within two weeks. This meant the service was not

always responsive and could not always meet patient urgent clinical needs in a timely manner.

Referral to treatment (percentage within 18 weeks) – non-admitted pathways

From October 2017 to September 2018 the trust’s referral to treatment time (RTT) for non-

admitted pathways has been worse than the England overall performance. The latest figures for

September 2018, showed 85.6% of this group of patients were treated within 18 weeks versus

the England average of 86.7%.


Referral to treatment rates (percentage within 18 weeks) for non-admitted pathways,

King's College Hospital NHS Foundation Trust.


Referral to treatment (percentage within 18 weeks) non-admitted performance – by

specialty

Seven specialties were above the England average for non-admitted pathways RTT (percentage

within 18 weeks).


General medicine 94.6% 91.1%


Thoracic medicine 89.4% 86.7%

Rheumatology 88.5% 88.0%


Cardiology 86.4% 86.1%


Twelve specialties were below the England average for non-admitted pathways RTT (percentage

within 18 weeks).


Geriatric medicine 94.4% 95.4%

Other 86.6% 90.9%


Ear, nose & throat (ENT) 83.4% 84.7%

ENT 82.6% 86.4%


Urology 75.8% 86.9%


Dermatology 73.0% 89.1%


Neurology 72.9% 79.3%


Gastroenterology 68.0% 83.4%


Referral to treatment (percentage within 18 weeks) – incomplete pathways

From October 2017 to September 2018 the trust’s referral to treatment time (RTT) for incomplete

pathways has been worse than the England overall performance. The latest figures for


the England average of 86.2%. This was also worse than operational standard of 92%, which the

trust had failed to meet for the whole of the period.

Referral to treatment rates (percentage within 18 weeks) for incomplete pathways, King's



Referral to treatment (percentage within 18 weeks) incomplete pathways – by specialty

Three specialties were above the England average for incomplete pathways RTT (percentage

within 18 weeks).





16 specialties were below the England average for incomplete pathways RTT (percentage within


18 weeks).






Other 85.0% 89.9%






ENT 77.0% 86.5%

Urology 75.3% 86.4%






Cancer waiting times – Percentage of people seen by a specialist within 2 weeks of an

urgent GP referral (All cancers)

The trust is performing worse than the 93% operational standard for people being seen within two

weeks of an urgent GP referral. The performance over time is shown in the graph below.

Percentage of people seen by a specialist within 2 weeks of an urgent GP referral (All

cancers), King's College Hospital NHS Foundation Trust

(Source: NHS England – Cancer Waits)

Cancer waiting times – Percentage of people waiting less than 31 days from diagnosis to

first definitive treatment (All cancers)


Percentage of people waiting less than 31 days from diagnosis to first definitive treatment

(All cancers), King's College Hospital NHS Foundation Trust

The trust is performing better than the 96% operational standard for patients waiting less than 31

days before receiving their first treatment following a diagnosis (decision to treat). The

performance over time is shown in the graph below.


Cancer waiting times – Percentage of people waiting less than 62 days from urgent GP

referral to first definitive treatment

The trust is performing worse than the 85% operational standard for patients receiving their first

treatment within 62 days of an urgent GP referral. The performance over time is shown in the

graph below.

Percentage of people waiting less than 62 days from urgent GP referral to first definitive

treatment, King's College Hospital NHS Foundation Trust



The service treated concerns and complaints seriously, investigated them and learned lessons

from the results, and shared these with all staff.

Throughout the clinics we visited we saw information displayed for patients and relatives on how to

make a complaint. Patients we spoke to knew how to make a complaint and knew they could visit


the Patient Advice and Liaison Service (PALS) for support with making a complaint. Staff

described PALS as responsive.

Staff told us that they would try to resolve concerns and complaints informally when they arose, by

speaking with the complainant and addressing their concerns immediately where possible.

Staff discussed complaints and concerns during clinic meetings. Staff could give examples of

improvements they had made to services in response to complaints and concerns. For example, in

response to a series of patient complaints about communication from receptionist staff, the trust

implemented ‘receptionist standards’ which all receptionist staff were required to follow.

However, at the time of our inspection, staff told us they received many similar complaints,

including about communication and waiting times. Staff told us this meant the issues of access

and flow in to the OPD were not being addressed. During our inspection, three of the 16 patients

we spoke to complained about waiting times, both for receiving an appointment slot, and waiting

when they arrived in to the department.

We viewed the complaints policy which was clear and incorporated statutory requirements and

best practice from the Department of Health and Social Care and other government bodies.

However, the policy was out of date, as it was due to be updated in November 2017. This meant

there was a risk that staff could refer to information that was no longer applicable, and therefore

provide a less responsive service to patients.


From October 2017 to September 2018 there were 277 complaints about outpatients. The trust

took an average of 27 days to investigate and close complaints. This is not in line with their


A breakdown of subject can be seen below;



Communications 51





Waiting Times 12




Commissioners); 5




End of Life Care 1

Other 1




Commissioning Services 1

A breakdown of complaints by site is below:

Site No. of complaints

King’s College Hospital 165

Princess Royal University Hospital 56

Queen Mary's, Sidcup 38

Orpington Hospital 8

N.B there were a further 10 complaints split across the smaller sites.


The outpatients service received a higher number of complaints





Leadership

Managers at all levels in the trust had the right skills and abilities and were aiming to run a

service providing high-quality sustainable care.

Most leaders we spoke to understood the challenges to quality and sustainability that the OPD

faced. Leaders we spoke with were aware of where the issues in the department were and could

identify short-term actions needed to address them.

The daily operation of most clinics was managed by a band seven nurse, and overseen by a

matron, in partnership with the lead consultant for the clinic specialty and service managers. At a

more senior level, oversight was then devolved to directors within the care group that the clinic

specialty was attached to.

Leaders could access leadership development from the King’s Academy leadership and

management pathway. For example, staff with new or additional responsibilities attended a three-

day course on ‘stepping in to management’. We also spoke to several members of staff who had

been identified by managers as having the right skills and abilities and were supported to apply for

promotion.

Some staff, particularly those who had recently started in their roles or transitioned to new ones,

told us they had received a lot of support from their managers. Staff described managerial support

‘beyond my expectations’ and told us their managers had empowered them to make positive

changes.

Managers mostly described the executive team as supportive, particularly regarding business

cases.


Most staff we spoke with described local leadership as visible, supportive and approachable. Most

staff told us they felt able to raise concerns. We saw examples of where leaders had met with staff

who raised concerns to discuss the issues and work together to find solutions.

Despite this, staff told us there had been some considerable turnover amongst administrative

managers, particularly in the ophthalmology department. This had meant there had been a lack of

leadership for administrative staff, and there were no regular meetings. At the time of our

inspection, two new managers had recently come in to post and they told us of their plans to

improve the leadership of the service through regular meetings.

Vision and strategy

The trust had a vision for what it wanted to achieve and workable plans to turn it into

action, developed with some involvement from staff. However, this vision was mainly

focused on the immediate issues affecting the OPD.

The OPD had a strategy for the short term to improve upon the current clinic environments,

productivity and patient access and flow. Each service line had plans for development and

improvement, for example, to improve ‘Perfect Ward’ audit scores. Most staff we spoke with

understood that the trust was in financial special measures, which could impact the timeliness of

projects and slow down the approval process for business plans.

There was a team of key leaders who supported efficiency initiatives in some outpatient clinics, as

part of the ‘King’s Way for Outpatients Transformation Programme’, which was overseen by the

trust board. This was a comprehensive programme which covered many aspects of patient

experience, outpatient capacity and demand, and service design. The programme aimed to

standardise many outpatient processes, for a more consistent approach. The programme included

a defined vision around improving efficiency and digitalisation. The progress of the Transformation

Programme was measured through several key metrics, which were presented at trust board

meetings, where leaders discussed the current month’s improvements and the next steps.

The trust had carried out a ‘Getting it Right First Time’ (GIRFT) programme in some areas of

outpatients at the trust (such as ophthalmology), which was a national productivity programme, in

partnership with NHS Improvement.

There was an overall vision, mission and strategy for the trust built on four interconnected BEST

strategies: Best Quality Care; Excellent Teaching and Research; Skilled “Can Do” Teams and Top

Productivity. These were supported by a series of principles, the Trust’s ‘Firm Foundations’:

rigorous governance; sound finances; strong partnerships; compelling communications; robust IT

and information and fit for purpose infrastructure. We saw these principles displayed in clinic staff

areas, including in the dialysis units we visited.

There were some additional plans for the long-term future of the OPD, but these were not an

immediate priority due to the current challenges faced by the department, and the wider context of

the trust’s financial special measures. Staff we spoke with were aware of some of these plans,

although did not feel they had been directly involved in them. Not all of these plans’ had clear

timescales. For example, managers told us there was an estates plan to reconfigure the Golden

Jubilee Wing, and there were plans to increase the use of electronic patient records in the future.

Culture

Most managers in OPD promoted a positive culture that supported and valued staff,



All staff we spoke to spoke of a desire to put the patient first and provide the best quality care.

However, staff acknowledged that due to factors such as waiting times, and unsuitable

environments, they were not always able to provide a patient-centred service.

We saw posters advertising the Freedom to Speak Up Guardian (FTSUG) and most staff knew of

the role, although they could not always name the FTSUG by name.

Most staff generally felt supported, respected and valued. However, this was variable amongst

clinic area and staff group.

Some medical staff told us they felt under pressure, and described their work schedules as hectic,

with no dedicated time for professional development or job planning. Medical trainees we spoke

with reported staying late regularly, due to both workload issues and personal learning.

Consultants encouraged junior doctors and trainees to exception report these events, and report it

to the Guardian of Safe Working, although junior doctors we spoke with admitted they did not

always do so.

Morale amongst administrative staff across most services was low. In areas such as

ophthalmology, there had been a high turnover of managerial staff which had caused a lack of

stability. Furthermore, in the OPAC, calls regularly came in which were not for them, as they dealt

only with first outpatient appointments and follow-up appointments were handled by individual

clinics. This meant that OPAC administrators/call handlers were regularly the subject of frustration

from patients. Staff felt this could be resolved by ensuring the correct number for the correct

speciality was given to patients on their follow up appointment letter. Managers encouraged staff

to take breaks if they felt overwhelmed, but staff told us they were carrying a lot of stress and felt

“drained”. Staff said local managers had tried their best to resolve the issue, but they were not

supported by the executive team on this issue. Administrative staff told us they had not received

specific formal training to deal with these difficult conversations. Other administrative staff we

spoke to told us they did not always feel valued and supported by management.

Several staff told us recruitment and retention was problematic. Staff felt they were losing

colleagues to other trusts because of the better rates of pay and seniority, and this had contributed

to poor morale.

Governance

The trust used a mostly systematic approach to continually improving the quality of its

services. In some outpatient clinic areas, management and governance structures helped

to create an environment in which excellence in clinical care would flourish. However, this

was inconsistent and not all outpatient clinic areas were able to safeguard high standards

of care.

There was no formal central governance structure for outpatients at King’s College Hospital.

Governance was devolved to divisions comprised of clinical specialities making up ‘care groups’,

and each care group operated mostly independently. Most outpatient specialities were part of the

Post-Acute and Planned Medicine Care Group.

There was a clear reporting and escalation structure for each care group. Each month, at regular

risk and governance meetings the triumvirate of each speciality would present to the general

manager, clinical director and deputy director of operations of the care group.

Within the care groups, leaders conducted regular risk and governance meetings which was then

fed up to care group leaders. Care group meetings were chaired by the care group’s governance

lead. We requested and viewed a sample of minutes from these meetings and found they

contained fixed agenda items adverse incidents and the risk register. The remainder of minutes


then discussed a variety of services, which allowed for information to be shared across services.

However, the meetings did not have fixed agenda item to discuss the overall quality of outpatient

services. Leaders recognised this and told us that during 2019-2020 there were plans for a new

Outpatients Board led by operational directors, which would steer towards centralisation for

outpatients and have a stronger overview on the performance of outpatient clinics. However, this

was not yet in place at the time of our inspection.

The next step in the governance structure was for the care group governance lead to then pass

information and escalate issues to the patient safety committee and then to the executive team.

Most services and teams had regular team meetings, which meant that there were clear systems

for staff to receive the information and updates.

Alongside the governance structure for the respective specialities, there was a specific team of

leaders who met to monitor measures to improve performance in outpatients, through the

outpatient efficiency programme steering group. We viewed a sample of minutes from this group,

which showed the meeting facilitated discussion and information sharing on outpatient

performance measures across specialities. The minutes showed that points for action, who was

responsible and timescales for completion were clearly recorded. However, we saw the outpatient

efficiency programme steering group was not formally incorporated into the governance structure

chart the trust sent us, which meant there was a risk that accountability and management might

not always be clear.




All specialities that provided outpatient clinics had a risk register. Most managers we spoke to had

a good understanding of the performance of their service and described performance dashboards

as helpful for service planning and development.

We viewed the risk register provided by the trust, which was comprehensive. There were 69 risks

logged related to outpatients. All risks had controls in place, records of ongoing actions, assigned

to a specific staff member to deal with. There was an approval process for risks to be added to the

risk register. Risks did not have a specific review date. However, not all risks had been reviewed

recently, with the oldest review date being February 2018. There was not always a clear date

recorded of when the risk was placed on the risk register. It was therefore not clear if the risk

status was being regularly reviewed.

Staff we spoke to throughout the inspection told us they had been able to raise issues which were

logged on the risk register. We found risks on the risk register were mostly aligned with what staff

told us they were concerned about.

Performance was managed and overseen within care groups, and in more depth in the

Outpatients Efficiency Programme.




Managers appropriately processed, challenged and acted upon information. There was a business

intelligence unit system which offered a suite of reports on different measures. Staff told us they

felt this system offered streamlined, useful data which gave them a clear vision on how outpatients


was performing. Leaders remarked that visibility of information had much improved since our last

inspection.

There were mechanisms to ensure information was accurate. Staff conducted regular data

validation. There was a central RTT validation team who worked on Patient Tracking Lists, to

ensure data was accurate, and liaised with service managers closely. Service managers had

oversight of the cached-up clinics report which checked that all appointments in the service had an

outcome. This was processed through validation work carried out by the administrative staff within

the outpatient’s department, who liaised with the relevant medical secretaries to check any

unknown outcomes. This ensured that patients received the appropriate follow-up after their

appointment. For example, administrative staff in charge of the clinical gerontology clinic told us a

strong focus on validation work had a positive impact on RTT performance.

Staff shared information so that key leaders, such as service managers, had sight of it.

Leaders had offered data training to help administrative staff in some specialities understand the

importance of the tasks they completed, and how their work contributed to overall RTT

performance.

However, there were multiple systems for booking outpatient appointments. Staff told us that for

first appointments, staff were required to input information in to five systems manually. This was

difficult.

Furthermore, staff told us that sometimes IT systems were slow and caused problems with printers

when trying to print appointment letters. This meant admin staff had to make a note of the

appointment made and reminders to send the letter out at a later date. Staff both on the main

outpatient site and the dialysis units we visited told us they often had issues accessing mandatory

training.

Engagement

The trust engaged well with patients, staff, the public and local organisations to plan and

manage appropriate services and collaborated with partner organisations effectively.

The trust worked well with internal and external stakeholders. Leaders told us they regularly met

with Clinical Commissioning Groups (CCGs) and system partners, to work together to manage

demands on the OPD service.

For example, we saw in the Board minutes, leaders had met with local CCGs and a neighbouring

trust to learn about their OPD transformation programmes and promote collaborative working. In

some clinics, staff worked in partnership with staff from other neighbouring trusts, to provide a

patient-centred service.

Services engaged with staff locally in design and improvement, and staff we spoke with felt they

could offer suggestions for improvement locally. However, staff felt their suggestions were not

always implemented due to the financial and capacity pressures the trust faced. Staff could not

give examples of being involved in wider, longer-term trust projects. This contributed to a sense of

uncertainty about the long-term vision and strategy of the OPD.

Leaders expressed a desire to improve the uptake of patient feedback mechanisms, and this was

regularly monitored.





Leaders were committed to improving the outpatient service, particularly regarding waiting times

for patients. However, whilst there was work in progress there were still a number of issues that

remained outstanding, as detailed throughout this report.

The trust had a quality improvement (QI) programme which was open to all staff and through

which staff could develop QI skills while completing projects specific to their area of work.

Princess Royal University Hospital Farnborough Common

Orpington

Kent

BR6 8ND

Tel: 01689 863000

www.pruh.kch.nhs.uk

Urgent and emergency care


Details of emergency departments and other urgent and emergency care services

The emergency department (ED) at the Princess Royal University Hospital (PRUH) is open 24

hours a day, seven days a week. It sees approximately 5,500 patients per month with serious and

life-threatening emergencies and is also a Hyper Acute Stroke Unit (HASU).

The department includes a paediatric emergency department dealing with all emergency

attendances under the age of 18 years with approximately 900 attendances per month.

Patients present to the department either by walking into the reception area or arrive by

ambulance via a dedicated ambulance-only entrance. Patients transporting themselves to the

department are seen initially by a nurse from a co-located urgent care centre (UCC) and, if

determined suitable to be treated in the ED await triage (Triage is the process of determining the

priority of patients’ treatments based on the severity of their condition). The UCC is managed by a

different provider and was not part of the inspection.

The department has different areas where patients are treated depending on their needs, including

a resuscitation area, two major’s areas, and a ‘sub-acute’ area for patients with less serious

needs, and a clinical decision unit (CDU). A separate paediatric ED with its own waiting area,

cubicles and CDU is within the department.

We visited the ED over three days during our unannounced inspection and returned unannounced

during a weekend. We looked at all areas of the department and we observed care and treatment.

We looked at 30 sets of patient records. We spoke with 35 members of staff, including nurses,

doctors, allied health professionals, managers, support staff and ambulance crews. We also spoke

with 19 patients and eight relatives who were using the service at the time of our inspection. We

reviewed and used information provided by the organisation in making our decisions about the

service.


Activity and patient throughput

Total number of urgent and emergency care attendances at King's College Hospital NHS

Foundation Trust compared to all acute trusts in England, August 2017 to July 2018

From August 2017 to July 2018 there were 230,385 attendances at the trust’s urgent and

emergency care services as indicated in the chart above.


Total attendances to the Emergency Department – Princess Royal University Hospital.

January 2018 – January 2019

(Source: Data Request – Quality Indicator Scorecard, Princess Royal University Hospital,

January 2019)


Urgent and emergency care attendances resulting in an admission – trust wide data

The percentage of A&E attendances at this trust that resulted in an admission remained similar

in 2017/18 compared to 2016/17. In both years, the proportions were similar to the England

averages.


Urgent and emergency care attendances resulting in an admission – Princess Royal

University Hospital January 2018 – January 2019

(Source: Data Request – Quality Indicator Scorecard, Princess Royal University Hospital,

January 2019)


Urgent and emergency care attendances by disposal method, from August 2017 to July

2018

* Discharged includes: no follow-up needed and follow-up treatment by GP

^ Referred includes: to A&E clinic, fracture clinic, other OP, other professional

# Left department includes: left before treatment or having refused treatment



Mandatory training



Trust level



Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met








Conflict Resolution [5 Years] 274 249 91% Yes









In urgent and emergency care the 80% target was met for 11 of the 14 mandatory training




Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met






Fire [2 Years] 165 97 59% No




[ 1 Year] 165 74 45% No






In urgent and emergency care the 80% target was met for one of the 14 mandatory training



Mandatory training was either undertaken as face to face or e-learning. The face to face training

included Mental Health, safeguarding adults, fire safety, infection prevention and control, and

blood transfusions. All of these modules could be completed as e-learning if staff were unable to

attend the face to face sessions. Staff reported some frustration with only being able to access

some mandatory training from the King’s College Hospital site only; staff told us they felt there was

a bias towards staff at King’s College Hospital.

We asked the trust to provide us with the mandatory compliance rates as at the time of inspection.

The department attained compliance with at least 85% of departmental staff having completed

mandatory training in 11 of 29 modules.

When comparing the data provided by the trust as part of the provider information return and the

dataset provided following the inspection, there had been little progress made against 18 of the

mandatory modules staff were required to complete.

Safeguarding




Trust level



Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met



In urgent and emergency care the 85% target was met for both of the safeguarding training




Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met



Safeguarding Adults Level 1 [Once] 1 0 0% No

In urgent and emergency care the 85% target was met for none of the three safeguarding

training modules for which medical staff were eligible.


Staff we spoke with in the children’s ED were aware of their responsibilities to protect vulnerable

children. They were knowledgeable about safeguarding procedures. The children’s ED had a

safeguarding flag system in place. Patients were checked against the child protection –

information sharing portal to determine whether individual children were known vulnerable

children; subject to a vulnerable child or child protection plan; or who was a looked after child.

Staff were not able to discharge children from the ED on the electronic system until they had

completed a safeguarding prompt screen confirming there were no concerns about the child.

Staff working in the major’s department were able to describe the referral process they would

complete if they had concerns about an adult. Staff could describe the different types of abuse

including neglect, financial, sexual, exploitative and domestic violence. Five staff we spoke with

could not recall whether the electronic patient record contained any flags to alert staff if a patient

previously identified as vulnerable, arrived at the department. This meant staff may not always be

alerted if a patient had previously attended and had a recorded history of violence, abuse or other

safeguarding concerns.


The ED and clinical decision unit were visibly clean and tidy. We observed support staff cleaning

the department throughout the day. Stickers were used to show if equipment in store rooms was

clean. Nursing staff reported that regular staff were used which meant they were familiar with the

layout of the department and the cleaning requirements.


Clean linen and equipment was stored in covered trolleys within the department and a sluice room

provided a separate area for waste to be disposed of. Separate clinical and general waste bins

were located throughout the department.

Audit Criterion AMU Ambulatory ED

Hand Hygiene 97% 100% 95%

Infection Prevention 91 92 50 (Nov 76)

Care, treatment and

welfare

84 93 79 (Nov 86)

Medicines

Management

85 (Nov 92) 100 76 (Nov 83)

Environment 90 100 90

Documentation 83 75 (Nov 91) 86

Staffing 88 77 80

Equipment and

Supplies

90 100 70

Quality 68 88 38

Personal protective equipment was available across the department. During the inspection we

observed multiple occasions when staff did not routinely decontaminate their hands before and

after contact with patients. Whilst the trust provided us with data which suggested there was

generally good compliance with hand hygiene (as described in the table above), our observations

of general practice amongst health professionals was of a differing opinion. We noted the scores

of hand hygiene audits completed during the week of 14 January 2019; the result of this audit was

reported as 63.3%. Wider infection and prevention audit results for the week of 13 January 2019

was reported as 79.4%

We observed multiple occasions when two patients were nursed in cubicles designed for only one

patient. Whilst a screen was placed between the two patients, the spacing between each patient

did not meet national service specifications and posed a potential infection risk to patients

Preparation of intravenous antibiotics was observed to be poor. We observed nursing staff

preparing intravenous medicines on four separate occasions. On each occasion, nursing staff did

not wash their hands before donning gloves; preparation surfaces were not cleaned prior to the

commencement of medicine preparation. Staff were observed to not be using intravenous trays

when transporting prepared intravenous medicines from the preparation area to the patient

bedside. Instead, nurses scooped up infusion sets, paying little attention to ensuring the connector

of giving sets did not touch any non-sterile surfaces to reduce the risk of microbial contamination.

These practices were contrary to best practice guidelines including those specified in the British

National Formulary, which states that intravenous infusions should be prepared following strict

aseptic non-touch techniques to reduce the risk of microbial colonisation. We discussed our

observations with nursing staff at the time of the inspection to ensure medicines were prepared

correctly and in accordance with trust and national best practice polices.

There was a recognition amongst the local leadership team of a need to ensure there was greater

vigilance and compliance with the trusts infection prevention and control policy. This was

highlighted in the Emergency Departments newsletter “Tackling risk in the ED”, dated November-

December 2018. A note to staff in the newsletter said:

“Infection Control (a polite reminder re- Trust policy)


Can we have a focus on infection control, particularly the spread of norovirus within the hospital

and increased numbers seen of symptomatic hospital acquired inpatients. Need to ensure all

teams are following the below guidance.

EPIC & Specialty consultants / NIC & Senior nurses to lead by example and ensure this is

followed with their respective teams.

• No food and drink in clinical areas

• Bare below the elbow

• Watches removed

• Soap and water handwashing compliance must be adhered to

• Glove wearing must be indicated and removed immediately after all tasks and before leaving

side rooms and bays.

• Hands must be cleaned before and after wearing gloves”

Our observations during the inspection suggested this note to all staff had little impact in improving

compliance with hand hygiene practices and wider infection prevention practices. Notwithstanding

the poor practice we observed during the initial unannounced inspection, we also observed two

occasions during our second visit when staff did not comply with isolation protocols when exiting

side rooms which were being used for the management of enteric isolated patients. Nursing staff

were observed exiting the room whilst still wearing aprons and gloves after having provided

contact care to both patients

Cleaning checklists for the resuscitation bay suggested cleaning was not completed as per local

protocols. For example, for the week of 21 January 2019, bay 4 was checked and equipment

cleaned on 27 January only. Bays 1, 2 and 3 were reported as checked and cleaned on 26 and 27

January only


We previously reported one room in the ED was designated for patients with mental health needs

requiring assessment or treatment. At our previous inspection we were told and observed that this

room had been designed specifically with adjustments to prevent patients harming themselves or

others. There were two doors to the room that could not be locked from the inside or outside, a

strip alarm around all walls and a ligature free sink which followed guidance. However, we had

previously found the room was used to treat not only patients who presented with mental health

needs, but also for patients with medical needs. This meant the room had been equipped with

oxygen and suction points; a hospital trolley; and lightweight furniture. These items presented as

ligature points and therefore posed a risk to patients with suicidal tendencies or thoughts.

At this inspection we found the room continued to be used for both mental health patients and

medical patients. The varied use of rapid consultation room A as both a clinical treatment room and

a secure mental health room presented a risk to those patients with suicidal tendencies. Staff

reported the room was used to accommodate patients who presented in mental health crisis. The

room contained ligature points including high backed light weight chairs and oxygen and suction

flow meters which were attached to outlet points. We raised our concerns with the trust who

responded by stating:

“If a high-risk mental health patients are admitted into the Department then the ligature points

identified (oxygen tubing, suction tubing, high backed chair etc.) are removed ensuring that the

cubicle is ligature free.


A member of staff, either a security officer or a Health Care Assistant special, is assigned to monitor

the patient. This Standard Operational Policy is in place and all members of staff are aware of the

requirements. The nurse in charge of the shift would usually be responsible for ensuring this risk

assessment is completed when needed and appropriate actions are taken to ensure that any items

in the cubicle that could be used to self-harm are immediately removed.

There is already an established mental health working group reviewing the documentation (including

risk assessments) and the first PDSA cycle of documentation is about to be undertaken.

A designated mental health assessment cubicle has been factored in as part of the plans for the

new Emergency Department build, in liaison with our Oxleas Mental Health Trust colleagues.”

On 16 February 2019 we carried out a further unannounced inspection of the emergency

department to see whether the mitigations described above were embedded processes in the

department. We reviewed rapid consultation room A which continued to have the same oxygen

and suction points, hospital trolley and lightweight furniture in the room. We reviewed six sets of

notes for patients who had presented with acute mental health conditions. Of the six case records

reviewed, mental health risk assessments had only been completed for two patients. Of the four

patients without mental health risk assessments, medical notes for three patients reported those

patients had increasing suicidal thoughts

We were therefore not assured the mitigations initially proposed by the trust were sufficiently

robust due to poor compliance with their completion by staff. We raised our further concerns with

the trust who subsequently provided more detailed mitigations on 19 February 2019:

• “All mental health patients that present to the department must have a mental health triage

document completed within 15 minutes of being triaged;

• Patients to be nursed wherever possible in designated ligature free mental health cubicle, the

highest risk patients to be cared for in the cubicle;

• If this cubicle is not available, then we will ensure the lower risk mental health patients are

cared for in a minimal risk environment with an allocated Health Care Support Worker (HCSW);

• As a minimum, the Nurse in Charge (NIC) of each shift to allocate a Health Care Support

Worker to the mental health patients that require close monitoring. In addition, if required

following assessment a Psychiatric Liaison Nurse (PLN) or security guard is to be allocated to

ensure safety of the patient;

• The Health Care Support Worker or PLN allocated for the close monitoring must be included in

the handover of the patient between the two Registered Nurses (triage nurse to cubicle nurse);

• The close monitoring forms must be implemented immediately when the triage category/risk

has been identified;

• The close monitoring form must be clearly and fully completed at 15-minute intervals and any

variations to be documented as appropriate;

• At each 2 hourly ED safety huddle assurance will be provided that the mental health care

package assessment and close monitoring forms have been completed and there is ongoing

assessment of the evolving risks for each mental health patient in the ED;

• It is the responsibility of the NIC to ensure this process is completed;

• If the patient absconds then the missing patient form must be completed and escalated to NIC,

medical controller, site team, security and the police where appropriate (Appendix 4);

• There will be daily audits to monitor the implementation, the appropriateness and the correct

usage of the monitoring tool.

• On-going audit and feedback to the teams will be included in the department’s governance

programme to ensure good practice has been embedded.”


The department had a separate children’s ED. The department had four trolley bays, one cot

cubicle, one high dependency cubicle, a minor injury bay, triage room and a two bed CDU. There

was a separate children’s waiting area which had lots of play equipment for children attending.

A nine-bed clinical decision unit (CDU) was next to the department and staffed by the ED. This

provided a short stay ward facility for patients awaiting test results or requiring overnight

observation. This ward was also used to reduce late discharges home of elderly patients. In

addition to the nine beds there was a seated area for patients waiting for blood results prior to

discharge away from the ED.

At our previous inspection we reported the resuscitation area had four bays, one of which contained

equipment suitable for acutely unwell children. Staff told us there had been a number of times when

they had needed to expand the capacity of the resuscitation area to seven bays, due to the numbers

of critical patients. They showed us an area where an additional two beds were placed and a cubicle

opposite the resuscitation area provided the last space. At that inspection staff told us it could be

challenging to treat critical patients in a crowded environment, and senior staff in the department

told us they wanted to increase the capacity of the resuscitation department permanently. At this

most recent inspection, capacity challenges meant staff were still using non-clinical areas for the

management of seriously unwell patients. The first area was referred to as “Resus 5”. Resus 5 was

located directly next to resuscitation bed spaces 3 and 4. The space was allocated as a clean

medication area and included space for medicine preparation, hand washing and storage of

consumables. However, we saw there was no piped oxygen, suction or fixed patient monitoring

systems. There were no call bells available and the area lacked any facility to protect the privacy

and dignity of patients.

A sixth space was referred to as “Resus 6”. This was located adjacent to resus bed spaces 1 and 2

and was located directly in front of the doors used by ambulance teams to access the resuscitation

unit. Again, this was not a formal clinical bed space; it lacked any piped oxygen, suction or fixed

monitoring. Neither resus 5 or 6 were of sufficient size to allow for the effective management of the

acutely unwell patient.

Whilst a business case had been developed for the expansion of the resuscitation area, this had not

been progressed to a confirmed capital investment business case at the time of the inspection.

There was limited mitigation, with a general acceptance of the requirement to use Resus 5 and 6 as

necessary. We formally raised our concerns with the trust who reported the following actions:

1. Resuscitation areas 5 and 6 (non-clinical spaces) are no longer to be used for the assessment

of acutely unwell patients. These areas are not equipped properly to look after patients safely

(wall oxygen, suction, call bells) and do not provide the privacy to care for patients with dignity.

2. Ensure clinicians are aware of the clinical criteria set by the Royal College of Emergency

Medicine (RCEM) to determine which patients should be cared for in the Resuscitation Area

and which patients would be excluded. Ensure nursing staff are aware which patients meet

these criteria.

3. Ensure that any patient brought in by Blue Light ambulance or any patient that deteriorates in

the Emergency Department is robustly assessed to determine whether they meet the criteria

to be moved into the Resuscitation Area for immediate treatment.

4. Ensure that all patients are assessed on an individual basis when stepping down from the

Resuscitation Area into majors if there is no inpatient bed available and that the balance of

risk in the Department as a whole is considered when stepping patients down.


5. Ensure that patients in the Resuscitation Area are reviewed every hour to assess whether they

may be stepped down and out of the Resuscitation Area. Additionally, an assessment of all

patients will be made as soon as full capacity for the Resuscitation Area has been reached,

with a view to immediately stepping a patient down to provide capacity: escalation plan. Flow

in the context of all patients thought to need the care and monitoring provided in the Resus

area would require immediate discussion between Lead for ED on Shift and AMU consultant

in charge to assess whether any patients could be managed in the L1 area of AMU or cardiac

care area or a monitored area of Majors. Referrals to Critical Care Outreach would be

undertaken for any patient considered in need of Critical Care input / management as is our

standard practice.

6. Identify monitored cubicles within Majors B to be equipped as step down cubicles (Level 1.5

cubicles) from the Resuscitation Area. All members of staff to be made aware of this change.

7. Ensure that all members of staff are aware of the additional assessment cubicle and its use to

examine patients in a private and dignified manner.

8. Agree a process within the Stroke and Intensive Care Pathways to ensure that patients who

require a Hyper-acute Stroke bed or an Intensive care bed are moved to a specialty bed from

the Emergency Department within a 90-minute window. This requires appropriate actioning

of escalation protocols to ensure HASU and Critical Care always have one empty bed

identified and if this is not the case then there is a pathway that provides bed capacity in these

areas within 60 minutes (to allow a clean and decant from ED). Ensure that stroke patients

are identified post thrombolysis to be stepped down into the Majors B Level 1.5 area to be

nursed on a one to one (or 1: 2) basis by the specialty stroke nurse.

9. Ensure that the i-mobile (critical care outreach) team are aware of patients stepped down from

the Resuscitation Area who are still waiting for an inpatient bed if they have a NEWS greater

than 4 or are thought to be at risk of deterioration (link to I Mobile protocol for informing them

of ED patients going to ward who are at risk of deterioration)

10. Ensure that the Business Case for the expansion of the Emergency Department has been

approved by to the Executive Team for 2019/20 capital investment. It is important to note that

we have raised the urgency of this capital funding with the regulator and will do so again. The

Trust is also exploring financing the ED capital build through the PFI.

During our further unannounced inspection on 16 February 2019 we found capacity in the

resuscitation bay was being managed effectively. There continued to be delays in patients being

transferred to on-ward care setting including intensive care. However, patients who no longer

required to be treated in the resuscitation area were being identified and transferred to appropriate

areas within the major’s area of the emergency department. The trust had reported that prior to our

initial inspection, “One cubicle opposite the Resuscitation Area had been identified as an

assessment cubicle in which to examine patients with privacy and dignity.” During both our first and

second inspection, senior clinical staff in the department reported that this area was not appropriate

as it was not sufficiently equipped with piped oxygen or suction and was not co-located in the

resuscitation bay. Further, staff reported concerns over the impact of staffing the identified area as

it took one of two nurses away from the main resuscitation area. There clearly remained a disconnect

between the mitigation afforded by the trust executive team and their view the additional space

should be used for the assessment of patients, and the views and practices of clinicians working in

the department who refused to use the cubicle.

The design of the resuscitation bay meant there was a risk patient could be exposed to ionising

radiation. Bed spaces were small and were only protected partly by radiation blocking screens. We


discussed this with the trust Radiation Protection Supervisor. They reported local radiographers

would adopt standard procedures including ensuring staff and visitors were removed from the area

before an x-ray was taken. Radiographers were observed wearing protective lead aprons when

undertaking x-rays in the resuscitation bay. The radiation protection supervisor reported there was

no risk assessment in place for the resuscitation bay

We were able to gain easy access to the dirty utility area located in the major’s area. A range of

substance subject to COSHH (Control of Substances Hazardous to Health) requirements were

stored in unlocked cupboards

The clinical decision unit and resuscitation bay were both well equipped. However, we noted an

excess of equipment and trolleys in both areas which led to staff having to move multiple items

before hospital beds could be moved. Two cubicles in Majors A were poorly positioned which

hindered the easy movement of beds and trolleys; movement was further hampered by the

storage of linen bins and notes trolleys directly outside these two cubicles. We also noted a trolley

in resuscitation bay four being held together with tape

Checks of emergency equipment was sporadic. For example, the resuscitation trolley in the

clinical decision unit had the following gaps in daily checks:

Month Total number of days routine checks were

missed

November 2018 6 days missing

December 2018 3 days missing

January 2019 6 days missing

(Source: PRUH/AT/001)

The resuscitation trolley in Majors A had not had daily checks on 1, 2, 6, 7, 11, 15, 18, 19 22 and

26 January 2019. Environmental and equipment checklists in the resuscitation department were

inconsistently completed. For example, during the week of 4 February 2019, the “Resus checklist”

was only completed on 10 February 2019. During our inspection on 16 February 2019 we found a

range of consumable, single use equipment in the resuscitation bay which had expired. This

included a single use chest drain kit and an end tidal carbon dioxide monitor (this is used to

confirm the correct positioning of endotracheal tubes). We referred these items to the nurse in

charge at the time of their discovery in order they could be removed from the supply chain


Patients accessing the ED independently registered at the co-located Urgent Care Centre (UCC)

and were seen by a nurse who carried out an initial clinical assessment (streaming). Patients

assessed as requiring ED treatment then re-registered at the ED reception and were seen by a

triage nurse. The UCC was managed by a different provider and so did not form part of this

inspection.

We reviewed a total of thirty sets of notes for patients who received care in the resuscitation bay,

major’s bays and the paediatric emergency department. There was variation in the quality of the

records. For children, staff consistently used a recognised early warning tool to help them identify

the deteriorating child. Of the thirty records we reviewed, seven patients presented with signs of

sepsis. Compliance with the sepsis screening tool was varied with six screens not completed for

those patients. Although hourly rounding safety checklists had been introduced in to the

department, these were not consistently completed. This included, for example, a patient who had

presented with acute onset confusion and had been in the department for a period of seventeen


hours with no recorded safety checks and a second patient who had not had their second, third- or

fourth-hour safety checks recorded whilst in the resuscitation bay

We reviewed five sets of notes for patients receiving care and treatment in the clinical decision

unit. There was evidence of a good use of the national early warning system. Staff consistently

used the tool, calculated scores correctly and recorded any action required when scores were

high, or the patient had been recognised as being at risk of deterioration. Staff used appropriate

risk assessments across the five records we reviewed. This included falls risks, those at risk of

malnourishment, pressure ulcers and visual phlebitis infusion assessments

There were clear referral pathways for patients to be admitted to the clinical decision unit. Staff

reported only emergency department physicians had admitting rights to the CDU which prevented

the area from being used inappropriately. Admission pathways had been considered and included

only low risk patients including those with low risk chest pain, low risk of falls and those with low

risk mental health concerns. We reviewed five care records which confirmed those admissions

were in line with the CDU admission criteria

Compliance against falls risk assessments were audited monthly. A review of evidence suggested

general good compliance with falls risk assessments being completed as detailed below.

However, we reviewed six sets of notes during the inspection and found that three records had not

had a falls risk assessment completed. This was despite each patient presenting with a history of

falls at home. We further identified one elderly patient who had sustained a fracture as a result of a

fall. Whilst a falls risk and skin integrity assessment had been completed, the patient remained on

a non-pressure relieving trolley for over fourteen hours. We escalated this patient to the nurse in

charge who promptly took action to transfer the patient to a hospital bed whilst they waited for

further treatment

Majors – Falls Risk Assessments Compliance Audit (January 2019)

Criteria (duplicates removed) No. who met inclusion criteria No. of assessments

completed

<65 with associated condition

(PD, EOTH etc.) 2 1

>65 years old 8 8

Admitted with fall / history of 1 1

Confused 1 1

Total 12 11

(Source: Data request Falls Jan 2019)

Patients arriving by ambulance were greeted by a senior nurse at the ambulance triage window.

We observed three ambulance crews arrive; all were greeted, and patients triaged against a

nationally recognised triage tool within ten minutes. Once triaged, patients were then directed to

the most relevant clinical area. However, due to the department being over capacity during the

three days of inspection, ambulance crews and patients were left waiting in the “Ambulance

corridor” until a clinical space became available. During one observation, an ambulance crew

waited forty minutes before they could hand their patient over to hospital staff. Three ambulance

crews we spoke with reported it was not unusual to wait for over an hour before they could hand

their patient over to the hospital. During one daily operations huddle, staff reported the ambulance

offload time to be at 52 minutes and the current triage time for patients who self-presented was 42


minutes. It was unclear who retained the clinical responsibility for the patient whilst they were

waiting for handover. Although the patients had been triaged, there was no routine observations

carried out on patients whilst they were held in the ambulance corridor.

We observed variation in the quality of triage being carried out. In some observed cases, nurses

were thorough, spoke with patients, and explained the anticipated next steps. However, we also

observed occasions when the triage nurse had to be prompted by the ambulance crew to assess

the patient; there was a reliance on the triage nurse taking information from the ambulance crew

as compared to undertaking an independent assessment of the patient.

There were arrangements in place to refer patients who presented with mental health conditions to

a specialist psychiatric liaison team. A psychiatric liaison nurse (PLN) was available 24 hours a

day, seven days a week and was able to provide assessments in the emergency department.

PLN’s determined whether patients required support and supervision from registered mental

health nurses; if this was identified as necessary, shifts were placed to agency for an appropriately

qualified nurse to be source. If patients were considered high risk, members of the security team

were used to monitor the patient until a qualified nurse was available.

There were appropriate pathways and referral mechanisms for patients requiring rapid

tranquilisation, although we noted this guideline was not dated. Security staff reported all episodes

of physical restraint used against patients; these incidents were reviewed monthly to ensure the

physical restraint was appropriate and was carried out in accordance with legal frameworks. There

was a general acceptance amongst trust staff that the availability of specialist mental health beds

was an ongoing concern and challenge. Staff provided anecdotal evidence of patients remaining in

the emergency department for periods exceeding twenty-four hours because of a lack of specialist

beds.


The trust scored about the same as other trusts for each of the five Emergency Department

Survey questions relevant to safety.

Question Score RAG

Q5. Once you arrived at the hospital, how long did you wait with the

ambulance crew before your care was handed over to the

emergency department staff?

8.2 About the same

as other trusts

Q8. How long did you wait before you first spoke to a nurse or

doctor?

5.7 About the same

as other trusts

Q9. Sometimes, people will first talk to a nurse or doctor and be

examined later. From the time you arrived, how long did you wait

before being examined by a doctor or nurse?

5.9 About the same

as other trusts

Q33. In your opinion, how clean was the emergency department? 8.1 About the same

as other trusts

Q34. While you were in the emergency department, did you feel

threatened by other patients or visitors?

9.4 About the same

as other trusts


Median time from arrival to initial assessment (emergency ambulance cases only)

The median time from arrival to initial assessment was zero minutes for the 12-month period from




Percentage of ambulance journeys with turnaround times over 30 minutes for this trust

Kings College


ambulance journeys with turnaround times over 30 minutes at Kings College.

Ambulance: Percentage of journeys with turnaround times over 30 minutes - Kings

College

Ambulance: Number of journeys with turnaround times over 30 minutes - Kings College


Princess Royal, Farnborough



ambulance journeys with turnaround times over 30 minutes at Princess Royal, Farnborough.

Ambulance: Percentage of journeys with turnaround times over 30 minutes - Princess

Royal, Farnborough

Ambulance: Number of journeys with turnaround times over 30 minutes - Princess Royal,

Farnborough


Number of black breaches for this trust

A “black breach” occurs when a patient waits over an hour from ambulance arrival at the

emergency department until they are handed over to the emergency department staff. From

September 2017 to September 2018 the trust reported 1,288 “black breaches”.


(Source: Routine Provider Information Request (RPIR) - Black Breaches tab)

Nurse staffing

The Head of Nursing reported the department had been subject to a skills and establishment

review over the preceding 12 months. As a result, significant changes were due to be made

regarding the number of staff employed across each agenda for change banding for nursing and

support workers (detailed below). In addition to the increased establishment of band 2 support

workers and band 5 registered nurses, the department had also secured funding for three existing

staff to undertake a two-year training programme to become advanced clinical practitioners, with

their training scheduled to commence in 2019.

Band Establishment at time of

inspection (whole time

equivalent (WTE))

Vacancies at time of

inspection (WTE)

Head of Nursing (Band 8c) 1 0

Matron (Band 8a) 1.8 0

Senior Sister/Senior Charge

Nurse (band 7)

8 (Increasing to 9 in February

2019)

0

Sister/Charge Nurse (Band 6) 56 (reducing to 31.6 wte from

February 2019)

0

Registered Nurse (Band 5)

36 (Increasing to 53.7 wte

from February 2019)

Information requested but not

provided

Health support workers (Band

2)

4 (increasing to 19.2wte from

February 2019)

0

The clinical decision unit was staffed with one registered nurse and two support workers both day

and night. Staff reported that this staffing ratio was sufficient to meet the needs of patients as it

allowed for each staff member to provide direct care to three patients with support workers

adopting delegated tasks but overseen by the registered nurse.


Staffing was based on the standard activity of the department. For example, during the day, the

department was staffed with four nurses covering major’s A (one nurse was allocated as nurse in

charge so did not routinely take a patient load); three nurses in majors B, 2 nurses were allocated

to the resuscitation bay; one nurse assigned to the walk-in triage bay and one to the ambulance

triage bay; one nurse was assigned to the sub-acute area; and either one nurse and two support

workers or two nurses and a support worker to the clinical decision unit. An additional nurse was

sourced to provide twilight support and three nurses were allocated to the children’s emergency

department. In addition, the wider department was supported by a nurse-in-charge who oversaw

the running of the entire emergency department.

At night time, staffing remained the same except for the children’s emergency department which

operated with two registered nurses due to the reduced activity; a twilight nurse covered the

children’s emergency department to accommodate peaks in activity.

We attended a daily emergency department huddle during the inspection. Whilst staffing was

considered in terms of unfilled shifts, there was no discussion regarding the capacity of the

department. There was no consideration given to the fact the department was at full capacity, with

several cubicles being used to hold two patients therefore increasing departmental occupancy

exceeding 100% of its actual capacity. We noted that during periods of peak activity, there were

not always sufficient staff to meet the needs of patients. For example, the resuscitation bay was

staffed consistently with two registered nurses. During two of the three days of the inspection, six

patients were observed receiving care in the resuscitation bay; an area equipped to manage only

four patients. We observed one patient who deteriorated whilst in the ambulance queue. The

patient was quickly assessed by a consultant and was transferred to resuscitation bed space 5.

We observed that whilst the patient had been initially assessed, the patient was then observed to

be left unsupervised and unmonitored for 25 minutes before a nurse and doctor then commenced

a further assessment of the patient; the patient remained in resus 5 without any monitoring,

oxygen, suction or privacy screens.

There were periods when only one member of nursing staff was present in the resuscitation bay.

This was in part because one nurse was observed escorting patients to various parts of the

department including radiology. This was despite there being a further five patients in the

resuscitation area. Staff working in the resuscitation area reported it could be challenging to

continually monitor and record patient vital signs when the area was over capacity. We observed

this during the inspection, when one trauma patient had no recorded observations for over an hour

since arriving in to the resuscitation bay.

The challenges of staffing the resuscitation department was a known risk and was captured on the

urgent care risk register. A business plan for the expansion of the resuscitation department also

captured the need to increase the nursing establishment.

The trust reported the following qualified nursing staff numbers as of August 2017 and August

2018 for urgent and emergency care by site:


Staffing group

Planned

staff –

WTE

Actual

staff –

WTE

Fill

rate

Planned

staff –

WTE

Actual

staff –

WTE

Fill

Rate

Qualified nursing & health

visiting staff (Qualified nurses) 72 46.5 64.5% 400.3 346.4 86.5%

Fill rate has increased by over 20% and there are 300 more WTE in post in 2018 than there was


in 2017.


• Princess Royal University hospital – 145.8 WTE in post (86% fill rate)


Vacancy rates




• Princess Royal University emergency department: 17.1%


The Head of Nursing reported 18 nurses had left the department since the summer of 2018 and

the department was operating a vacancy rate of 20%; this conflicted with the workforce

establishment data provided by the Head of Nursing as described in the table above. We asked

the trust to provide us with the accurate workforce vacancy data as at the time of the inspection as

detailed below:

Staff Group Establishment

FTE

In-

Post

FTE

Vacancy

FTE

Vacancy

%

Nursing and Midwifery Registered 100.77 74.30 26.47 26.27%

Turnover rates

From September 2017 to August 2018, the trust reported a turnover rate of 18.8% for qualified

nursing staff in urgent and emergency care. This was higher than the trust target of 10%.


Princess Royal University emergency department: 17.8%


Sickness rates

From September 2017 to August 2018, the trust reported a sickness rate of 2.8% for qualified

nursing staff in urgent and emergency care. This was lower than the trust target of 3%.






From September 2017 to August 2018, the trust reported that 49.1% of qualified nursing shifts in

urgent and emergency care were filled by bank staff and 31.5% of shifts were filled by agency

staff. In addition, 19.4% of shifts were not filled by bank and agency staff to cover staff absence.



(Source: Routine Provider Information Request (RPIR) – Bank and Agency tab)

Medical staffing

The trust reported the following medical staffing numbers as of August 2017 and August 2018

for urgent and emergency care by site:


Staffing group

Planned

staff –

WTE

Actual

staff –

WTE

Fill

rate

Planned

staff –

WTE

Actual

staff –

WTE

Fill

Rate

Medical & Dental staff - Hospital 269.9 232.9 86.3% 159 146.7 92.3%

Fill rate had increased to over 90% although there are over 80 less WTE in post in 2018.


• King’s College hospital – 101.2 WTE in post (105% fill rate)

• Princess Royal University hospital – 45.5 WTE in post (72.7% fill rate)


Vacancy rates

From September 2017 to August 2018, the trust reported a vacancy rate of 4.5% for medical



• King’s College emergency department: -3.6%


The negative figure indicates there were more WTE in post than originally scheduled.


There was a clear disparity between how the trust was managing its overall medical workforce to

support emergency care across two geographical areas. Prior to the inspection, we asked the


trust to submit data relating to workforce vacancies (reported above). At the time of that

submission, there was a positive bias against vacancy rates for medical staff at King’s College

(King’s College Hospital) emergency department which was over-recruited. This compared

negatively with the medical workforce vacancy rate at Princess Royal University Hospital which

was under-recruited by 17.2%. At the time of the inspection, this vacancy factor had worsened to

a reported 22.3%.

Junior and senior medical staff alike reported challenges with ensuring medical shifts were

consistently filled with competent staff. Consultants had reported that until August 2018, they had

been working in a “Step-down” capacity to ensure junior doctor rota gaps were filled. There was

an apparent overly-bureaucratic approach to recruiting doctors with staff reporting significant time

lags between individuals leaving roles and recruitment commencing. Staff also told us the

process for seeking approval for vacant shifts to be filled by agency staff was complex, with the

Medical Director having to be approached for each shift to be approved. Staff linked this complex

and lengthy process to the financial special measure’s regime.

The department was established to have twelve whole time equivalent consultants. At the time of

the inspection, nine were in pos. Despite the vacancy gap, the department was providing 16

hours of consultant cover, seven days per week, in line with Royal College of Emergency

Medicine guidelines.

Turnover rates

From September 2017 to August 2018, the trust reported a turnover rate of 12.1% for medical






Sickness rates

From September 2017 to August 2018, the trust reported a sickness rate of 0.1% for medical







From September 2017 to August 2018, the trust reported that 3% of medical shifts in urgent and


emergency care were filled by bank staff and 44% of shifts were filled by locum staff. In addition,

53% of shifts were not filled by bank and locum staff to cover staff absence.




Staffing skill mix

In July 2018, the proportion of consultant staff reported to be working at the trust were higher

than the England average and the proportion of junior (foundation year 1-2) staff was also higher.

Staffing skill mix for the 114-whole time equivalent staff working in urgent and emergency

care at King's College Hospital NHS Foundation Trust.

This

Trust

England

average

Consultant 31% 29%



Junior* 31% 24%





Records

The department used both paper-based and electronic records to capture care interventions.

Paper records were stored in locked mobile notes trolleys which were located in visible areas

across the department.

We observed on multiple occasions when staff walked away from computer screens, leaving

confidential patient information on display. A screen in the ambulance triage bay was left

unattended for periods of up to five minutes, allowing passing visitors to view the screen.

Medicines

Medicines in the clinical decision unit were stored in accordance with local and national policies.

Staff reported they checked medicine refrigerator temperatures daily. However, a review of the

local temperature log demonstrated only temperatures for 30 January were recorded against the

month of January 2019. We asked to see previous records; however, staff were not able to locate

these at the time of the inspection.


Fridge temperatures in the resuscitation bay and Majors were checked and recorded daily. There

was evidence of action being taken where temperatures deviated from the normal range.

Controlled drugs stored in the clinical decision unit were checked twice a day. A review of the

controlled drug register confirmed these checks were carried out consistently with no gaps over a

two-month period. Controlled drugs stored in the major’s area were also checked daily. A review of

the controlled drug register confirmed these checks were carried out consistently.

Medicines in the major’s area were stored in a room which was accessed by way of a Digi lock.

Inside the room, several cupboards were locked; however, one large cupboard which contained a

significant supply of medicines was unlocked. This posed a risk as members of staff not

authorised to access medicines had access to these medicines.

In the resuscitation bay we noted during our first inspection, a full box of Dantrium 20mg

intravenous vials stored on top of the controlled drug cupboard. These medicines were still in situ

during our second unannounced inspection on 16 February 2019.

We previously reported that some medicines in the resuscitation area were stored in unlocked

cupboards and fridges to allow for easy access in the event of an emergency; this was recorded

on the departmental risk register. At this inspection, we noted a range of drugs continued to be

stored in an unlocked fridge. This included medicines such as lorazepam and diazepam. We also

noted the fridge contained a pack for the use in a process called rapid sequence induction and

intubation. Again, staff reported the fridge was kept unlocked to allow for the quick access of this

pack.

The local risk register contained mitigations which included the daily checking of the fridge stock to

ensure actual stock levels matched the anticipated stock levels. The pack containing the

medicines for rapid sequence induction contained a stock checklist. We reviewed the contents of

the pack against the checklist and found a range of discrepancies as detailed below. This meant

there was a risk that ampoules of medicines could be taken without the knowledge of staff. The

risk was further increased because we observed during the inspection, periods of time when

patients and visitors were left unattended next to the fridge containing the medicines. We were

therefore not assured by the risk mitigations suggested by the trust due to poor adherence to the

safeguards.

Medicine Name Anticipated Stock level Actual Stock Level

Suxamethonium Three Five

Rocuronium Three Two

Propofol Three Four

We reviewed a range of patient group directions which were located in the emergency department

triage cubicle. We noted no patient group direction (PGD) was in date; this included PGDs for

Paracetamol (expired August 2016); Ibuprofen (expired November 2016); Codeine Phosphate

(expired October 2015); Naproxen (Expired October 2015); Salbutamol (Expired November 2016);

and Tetracaine (expired May 2016). Patient group directions are written instructions for the supply

or administration of medicines to groups of patients who may not be individually identified before

presentation for treatment. We asked three nursing staff to direct us to the most recent patient

group directions, but they were unable to do so. We discussed this with the matron, however she

also was not aware of any more up-to-date PGDs. In the master PGD folder, there was a register

which should have included the names of all staff authorised to supply and administer medicines

subject to a PGD; this was blank.


In the children’s emergency department, we found further PGDs which had expired including those

for Paracetamol (expired August 2016) and Ibuprofen (expired November 2016) as examples.

Nursing staff were not able to direct us to more up-to-date versions. However, a consultant was

able to source the most recent version of patient group directions on the intranet. They could not

however, locate the master register which, according to the trust policy, was to be completed and

stored locally. The master register was a key document for evidencing which members of nursing

staff had been authorised to supply and administer medicines under a patient group direction.

Incidents

Staff could demonstrate how to report incidents through the trust intranet and could discuss what

type of incident they reported.

Never Events




never event.

From October 2017 to September 2018, the trust reported one incident classified as a never

event for urgent and emergency care. This was considered to be an incident which met the SI

criteria in January 2018.


The trust reported one never event which occurred in July 2018 and related to a patient

inadvertently being administered medical air instead of oxygen. We reviewed the root cause

analysis for this incident. The investigating panel included a specialist consultant, the head of

patient safety and a matron from the emergency department. There was some evidence of

elements of the duty of candour regulation being applied; the patient had been informed of the

incident and of the potential implications. However, the root cause analysis did not capture the

level of support the trust would provide to the patient, as is required by Regulation 20 of the Health

and Social Care Act (2008) (Regulated Activities) Regulations 2014.

A review of minutes for the acute and emergency medicine care group meeting suggested

compliance against the duty of candour regulation was reasonable, although one report suggested

that despite an initial conversation happening with a patient or relevant person, this had not been

recorded in the medical notes. Further, compliance against capturing when investigations had

been shared with relevant persons also showed varied performance.

The investigation considered contributory factors which included the high level of activity

experienced by the department and a lack of hospital beds impacting on the overall effectiveness

of the ED to operate within safe parameters; a shortage of one nurse for the shift in question; and

a lack of robust measures to prevent such an incident from occurring in the first place. There was

evidence that action had been taken because of the incident. This included briefing all staff on the

incident and the implications of not applying trust policies in terms of the possible impact to the

safety of patients. We spoke with three nurses who each reported they were aware of the incident

and the actions that had been taken as a result.

We had previously reported the department had experienced an increase in the number of falls

reported since November 2016. The trust had taken some action to ensure patients were


assessed and care plans introduced to mitigate against harm occurring. At this inspection,

departmental leaders again reported an increase in the number of patients sustaining injuries

because of falls whilst in the emergency department. Previous contributory factors had included

departmental over-crowding and staff not always completing falls risk assessments. A deep-dive

analysis was underway at the time of the inspection to explore further contributory factors.

We reviewed two root cause analysis reports linked to patients who had sustained a fall which

resulted in harm whilst they were in the emergency department and clinical decisions unit

respectively. The RCA in both cases recognised that a high impact assessment had been

completed which identified the patients were at risk of falls. However, there was no evidence of a

falls care plan being implemented despite, in one case, relatives of the family raising concerns

over the safety of their relative upon their departure from the department.

Contributory factors identified in relation to the patients fall included a shortage of nursing staff,

poor communication and a lack of a falls care plan. The placement of the patient in a non-visible

cubicle was also cited as a contributory factor. An action from the RCA was for nursing staff to

complete a falls audit to ascertain a baseline for compliance against the completion of falls risk

assessments. This is detailed below.

Criteria Compliance

Comments n (%)

Completion of Moving and Handling/falls

high impact risk assessment

42 84% Possible lack of understanding

of the question asked, re falls in

the preceding 12 months.

Completion of relevant actions against

findings in point 1.

31 62% Variety of actions missing, some

general comments documented.

Completion of a falls care plan within the

patient assessment

4 8% Very poor compliance against

target. For escalation to PDN

team and monitoring for

improvement.

(Source: Data request: DR243 WEB961798)

Subsequent falls audits suggested improvements had been made in the completion of high impact

assessments. However, the completion of subsequent falls care plans was inconsistent as

detailed below:

Month Percentage of completed High

Impact Assessments

Percentage of falls care plans

completed

June 2018 100% 90%

July 2018 92% 50%

September 2018 98% 60%

We noted the mitigations to ensuring patients at risk of falls were identified, assessed and

managed were not always robust. Although there was an audit programme in place which looked

to review care records for patients identified as falls risks, our own review of care records

suggested high risk patients were not always identified in a timely way. This included two patients

who had both presented with injuries having sustained falls at home. Falls risk assessments had

not been completed for either patient despite there being recorded modes of injury recorded in the


medical notes. This demonstrated that despite falls being a high-priority area for the service,

having been an known risk since November 2016, patients were still coming to harm, in part

because of a lack of robust response and action to mitigate against such risks.



(SIs) in urgent and emergency care which met the reporting criteria set by NHS England from


They were:

Incident type

King’s

college

Princess

Royal

Total

incident

s

Treatment delay meeting SI criteria 3 5 8

Sub-optimal care of the deteriorating patient meeting SI

criteria

4 4

Pending review (a category must be selected before incident

is closed)

1 2 3

Slips/trips/falls meeting SI criteria 2 2

Diagnostic incident including delay meeting SI criteria

(including failure to act on test results)

1 1 2

Abuse/alleged abuse of adult patient by staff 1 1

Unauthorised absence meeting SI criteria 1 1

Medication incident meeting SI criteria 1 1

VTE meeting SI criteria 1 1


Safety thermometer




their elimination.

Data collection takes place one day each month. A suggested date for data collection is given but

wards can change this. Data must be submitted within 10 days of the suggested data collection

date.


ulcers, no falls with harm and no new urinary tract infections in patients with a catheter from

October 2017 to October 2018 within urgent and emergency care. However, the methodology

used to calculate safety thermometer outputs was flawed and produced a level of false

assurance. A review of root cause analysis reports indicated that between May 2018 and October

2018, 41 falls had occurred across the emergency department with 10 resulting in minor harm;

one resulting in moderate harm and three resulting in major harm.

(Source: NHS Digital - Safety Thermometer)




The department undertook regular audits. These included national audits requested by the Royal

College of Emergency Medicine (RCEM); others were based on the National Institute for Health

and Care Excellence (NICE) guidance or considered other audits based on specific needs of the

department such as chest pain. There was a consultant lead for audits and each audit had a junior

doctor and nurse leading as a whole team approach. We saw results of some RCEM audits and

have referred to these in-patient outcomes.

There was an on-going review process for policies and guidelines used by staff in the emergency

department. Clinical governance meetings were used as a platform to discuss policies, procedures

and changes to clinical practice. Expiration dates for clinical policies were monitored and reported

monthly via the quality performance scorecard:

“6% (1 out of 17) of the care group’s guidelines on the Trust Clinical Guidance Database are within

their review date

81% of NICE guidance relevant to the care group has had an initial review”

We reviewed a range of printed policies and guidelines located throughout the department. This

included the treatment protocols for the acutely and seriously unwell child, produced by the South

Thames Retrieval Service. Several documents had been created in 2014; a review of the South

Thames Retrieval Service confirmed a host of their clinical guidelines had been updated in April

2018. This meant staff may have referred to paper-based guidelines which were no longer valid.


Patients in the clinical decision unit received regular hot meals and drinks. In the clinical decision

unit, staff were observed supporting patients who required assistance with eating and drinking.

We spoke with three patients in the major’s area who were awaiting care. Each patient reported

they had not been offered any refreshments, nor made away of the availability of drinking water.

One patient had been in the department for five hours when we spoke with them.


In the CQC Emergency Department Survey, the trust scored 6.3 for the question “Were you able

to get suitable food or drinks when you were in the emergency department?” This was about the

same as other trusts.


Pain relief

Patients told us they were offered pain relieving medicine on a regular basis. We reviewed 14

adult and paediatric records all of which recorded regular assessments of pain. A simple

numerical pain score was used and recorded. Staff were able to direct us to age appropriate pain

scoring systems which could be used for young children and those who could not verbally

communicate.

In the 2017/18 Royal College of Emergency Medicine (RCEM) Pain in children audit, Princess

Royal University Hospital performed better than the national average for undertaking a pain score


within 15 minutes. In addition, the hospital performed better than the national average against the

metric of ensuring patients in severe pain received appropriate analgesia within 60 minutes.

In the 2017/18 Royal College of Emergency Medicine Fractured Neck of Femur audit, Princess

Royal University Hospital performed better than the national average for the percentage of

patients who received a pain score within 15 minutes. The remainder of the data sample set was

too small to make any significant comparisons against national performance.


In the CQC Emergency Department Survey, the trust scored 5.8 for the question “How many

minutes after you requested pain relief medication did it take before you got it?” This was about

the same as other trusts.

The trust scored 7.7 for the question “Do you think the hospital staff did everything they could to

help control your pain?” This was about the same as other trusts.


Patient outcomes

RCEM Audit: Moderate and acute severe asthma 2016/17


asthma audit, Princess Royal hospital emergency department failed to meet any of the national

standards.





48.3%; UK: 19%.


results.


RCEM Audit: Consultant sign-off 2016/17

In the 2016/17 Consultant sign-off audit, Princess Royal University hospital emergency

department failed to meet any of the national standards.

The department was in the upper UK quartile for one standard:

• Standard 1 (developmental): Consultant reviewed: atraumatic chest pain in patients aged

30 years and over. This department: 27%; UK: 11%.

The department’s results for the remaining two standards were all within the middle 50% of

results.


The site did not report any data for Standard 2.


RCEM Audit: Severe sepsis and septic shock 2016/17

In the 2016/17 Severe sepsis and septic shock audit, Princess Royal hospital emergency

department failed to meet any of the national standards. The trust monitored outcomes of all

national audits they participated in; a trust-wide panel monitored audit outcomes and governance

processes required local clinical teams to produce actions plans to address any areas of concern.

The department was in the upper UK quartile for three standards:

• Standard 4: Serum lactate measured within one hour of arrival. This department: 78%; UK:

60%.

• Standard 6: Fluids – first intravenous crystalloid fluid bolus (up to 30 mL/Kg) given within

one hour of arrival. This department: 82.9%; UK: 43.2%.

• Standard 7: Antibiotics administered: Within one hour of arrival. This department: 74%; UK:

44.4%.


results.


Unplanned re-attendance rate within seven days

From October 2017 and September 2018, the trust’s unplanned re-attendance rate to A&E within

seven days was worse than the national standard of 5% and about the same as the England

average.


Unplanned re-attendance rate within seven days - King's College Hospital NHS Foundation

Trust


Unplanned Reattendance rate – Princess Royal University Hospital

(Source: Data request “PRUH Quality Indicator Scorecard January 2019)

Competent staff

We spoke with five registered nurses who each reported they had been assigned a mentor and

had received an annual appraisal. Each staff member told us they considered the appraisal

process to be a useful tool for identifying new development opportunities.

The hospital had previously employed six paramedics to complement the existing nursing and

medical workforce. At the time of the inspection, only one paramedic remained in post; they

reported they were leaving the trust to return to the ambulance service due to a lack of

progression and development within their role.

The department had been slow to introduce advanced clinical practitioners to complement the

existing nursing and medical workforce. However, a workforce review had been completed which

captured the importance of introducing such roles into the department. As a result, funding had


been secured for three existing members of staff to embark on an advanced clinical practitioner

course, commencing in 2019.

A practice development nurse was employed to support junior staff across the emergency

department. Junior nurses reported good mentoring support from more experienced nurses. Staff

reported a development programme was being designed at the time of the inspection and was due

to be launched in Spring 2019.

Junior trainee doctors generally reported being well supported by consultants. They told us a

consultant was always available to discuss clinical cases. There was some variation reported in

the quality of inductions afforded to junior doctors. One reported they received very little in the way

of a local induction before undertaking clinical work. Three other junior doctors told us they had

received a robust local and corporate induction. Each junior doctor we spoke with told us they had

a named clinical supervisor who were accessible.

Appraisal rates

From September 2017 to August 2018, 74% of staff within urgent and emergency care at the

trust received an appraisal compared to a trust target of 90%.


required

Appraisals

complete

Completion %







NHS infrastructure support 3 1 33%



(Source: Routine Provider Information Request (RPIR) - Appraisal tab)


The emergency department was supported by a team of physiotherapists and occupational

therapists. These allied health professionals were available five days a week between the hours of

8am and 4pm Monday to Friday. Their remit was to identify and support frail patients who required

support due to poor mobility or who were identified as being at risk of falls. The team was

supported by a frailty nurse practitioner. Their role was to liaise with community and rehabilitation

teams in order patients could be discharged more quickly from the acute care setting. This was

reported to reduce the length of time frail patients spent in the emergency department. The

initiative was also reported to reduce the number of reattendances; however, no data could be

provided to support this.

Seven-day services

The department provided care to adults and children 24 hours a day, 365 days a year.

Medical staff reported they were able to access diagnostic scanning for patients quickly and could

approach Radiographers directly if they needed urgent access to results. CT scanning and x-ray


facilities were located close to the ED and available 24 hours a day and mobile x-ray scanners

were available to be brought in to the resuscitation area.

Health promotion

Staff were observed signposting patients to relevant health promotion services during clinical

interviews. Additional information was provided to patients which directed individuals to smoking

cessation and weight loss support groups.

There were a wide range of patient information leaflets accessible in the main department.


We saw that staff obtained consent from patients and parents appropriately in relation to care and

treatment. Staff could explain how consent was sought and how they involved the patient. Staff

could explain their roles and responsibilities in relation to the deprivation of liberty safeguards

(DoLS) of patients.

Staff we spoke with could describe how they assessed mental capacity and their management of

the patient and escalation pathways if needed. Staff reported there were no exclusion criteria in

ED and the psychiatric liaison team could be involved in second opinions where there were

complex issues around mental capacity.

We spoke with five members of staff who could tell us the actions they would take if they had

concerns about an individual’s mental capacity. Staff working with children and young people

were knowledgeable about the concept of Gillick competence and Fraser guidelines. They were

aware of the legal guidelines which meant children under the age of 16 could give their own

consent if they demonstrated sufficient maturity and intelligence to do so, often referred to as

being Gillick competent. Staff were aware that should a child not be considered “Gillick

competent”, consent would be sought from the child’s parent or guardian. Staff could also

describe the scenarios in which an individual would be deemed to have parental responsibility.



32% of staff in urgent and emergency care compared to the trust target of 80%.


(Source: Routine Provider Information Request (RPIR) – Statutory and Mandatory Training tab)


Compassionate care

We spoke with nineteen patients and relatives during the inspection. In the majority of cases,

people were complimentary of the attitudes of staff. Patients reported they were kept informed of

their intended care but spoke of delays in accessing care in the first instance.

In the clinical decision unit, we observed nursing and occupational therapy staff speaking to

patients in a polite and friendly way.

In the major’s area, three patients we spoke with reported staff were helpful and friendly. However,

they reported staff were extremely busy and that it had taken significant time for each patient to


move through the emergency care pathway. Each patient was aware of their intended treatment

plan.

The way staff utilised clinical spaces across the emergency department resulted in the privacy and

dignity of patients being compromised. Patients were observed being cared for in corridors.

Further, due to the high occupancy rate of the hospital, patients with a confirmed decision to admit

were often moved to cubicles with another patient. Patients were placed one in front of the other

with a screen separating the patients. During the inspection, we consistently observed cubicles 6

and 7 being used to accommodate two patients respectively. We considered this breached the

privacy of patients.

We observed apathetic behaviours displayed towards patients who were placed in corridors until

an appropriate clinical space became available. On Wednesday 30 January, inspectors acted to

ensure an elderly relative and a frail patient were moved from a cold corridor to a warmer part of

the department. We observed a volunteer providing the elderly relative with a blanket and a warm

drink. However, multiple staff walked past the patient and relative who was visibly shaking from

the cold. At no time, did staff members stop to check on the welfare of the patient or the relative.

We further observed instances when relatives were left standing in the ambulance corridor whilst

their loved ones were treated in the resuscitation bay; staff did not act to move relatives who were

clearly distressed to more quiet areas, nor were seats located for elderly relatives.


The trust’s urgent and emergency care Friends and Family Test performance (% recommended)

was worse than the England average from October 2017 to September 2018. There was no data

submitted for April or May 2018.

In the most recent month, September 2018, the trust’s performance was 82% compared to

England average of 86.5%.

A&E Friends and Family Test performance - King's College Hospital NHS Foundation Trust



Emotional support

Relatives were encouraged to stay with their loved ones whilst care was provided in the

resuscitation bay in the majority of cases, specifically when patients were clinically stable. There

was an apprehension amongst staff of supporting relatives to remain with loved ones during active

resuscitation scenarios; relatives were observed being directed to wait outside the resuscitation

bay during such scenarios. Staff did not consider the wishes of relatives who may have wished to

remain with their loved one, as is supported by national and international evidence.

Reception staff were responsive to the needs of patients and relatives. We observed multiple

occasions when reception staff escorted visitors or patients to specific areas of the emergency

department.

Volunteers were observed spending time with patients and relatives.

Chaplaincy staff were available to support patients and relatives. Facilities and equipment were

available to enable families to take handprints of babies should bereaved parents so choose to

have these as memories.



The trust scored about the same as other trusts for each of the 24 Emergency Department

Survey questions relevant to the caring domain.


Q10. Were you told how long you would have to wait to be

examined?

3.8 About the

same as

other trusts

Q12. Did you have enough time to discuss your health or

medical problem with the doctor or nurse?

8.3 About the

same as

other trusts

Q13. While you were in the emergency department, did a doctor

or nurse explain your condition and treatment in a way you could

understand?

8.2 About the

same as

other trusts

Q14. Did the doctors and nurses listen to what you had to say?

9.1 About the

same as

other trusts

Q16. Did you have confidence and trust in the doctors and

nurses examing and treating you?

8.7 About the

same as

other trusts

Q17. Did doctors or nurses talk to each other about you as if you

weren't there?

8.7 About the

same as

other trusts

Q18. If your family or someone else close to you wanted to talk

to a doctor, did they have enough opportunity to do so?

7.5 About the

same as

other trusts

Q19. While you were in the emergency department, how much 8.8 About the



information about your condition or treatment was given to you? same as

other trusts

Q21. If you needed attention, were you able to get a member of

medical or nursing staff to help you?

7.8 About the

same as

other trusts

Q22. Sometimes in a hospital, a member of staff will say one

thing and another will say something quite different. Did this

happen to you in the emergency department?

8.6 About the

same as

other trusts

Q23. Were you involved as much as you wanted to be in

decisions about your care and treatment?

7.3 About the

same as

other trusts

Q44. Overall, did you feel you were treated with respect and

dignity while you were in the emergency department?

9.0 About the

same as

other trusts

Q15. If you had any anxieties or fears about your condition or

treatment, did a doctor or nurse discuss them with you?

7.3 About the

same as

other trusts

Q24. If you were feeling distressed while you were in the

emergency department, did a member of staff help to reassure

you?

6.3 About the

same as

other trusts

Q26. Did a member of staff explain why you needed these

test(s) in a way you could understand?

8.5 About the

same as

other trusts

Q27. Before you left the emergency department, did you get the

results of your tests?

8.1 About the

same as

other trusts

Q28. Did a member of staff explain the results of the tests in a

way you could understand?

9.0 About the

same as

other trusts

Q38. Did a member of staff explain the purpose of the

medications you were to take at home in a way you could

understand?

9.5 About the

same as

other trusts

Q39. Did a member of staff tell you about medication side effects

to watch out for?

5.1 About the

same as

other trusts

Q40. Did a member of staff tell you when you could resume your

usual activities, such as when to go back to work or drive a car?

4.9 About the

same as

other trusts

Q41. Did hospital staff take your family or home situation into

account when you were leaving the emergency department?

4.3 About the

same as

other trusts

Q42. Did a member of staff tell you about what danger signals

regarding your illness or treatment to watch for after you went

home?

5.3 About the

same as

other trusts

Q43. Did hospital staff tell you who to contact if you were worried

about your condition or treatment after you left the emergency

department?

7.4 About the

same as

other trusts



Q45. Overall... (please circle a number)

7.8 About the

same as

other trusts




The ED had a paediatric area which accepted babies, children and young people. There were

separate waiting areas for adult and child patients. The paediatric ED worked well with the

children’s ward to ensure children were in the most appropriate location.

The paediatric ED shared a play specialist with the children’s ward. Play specialists worked with

children to make sure the hospital environment was welcoming and fun and could provide

distraction techniques when a child required a procedure that may be painful or upsetting. We saw

a number of toys, stickers and DVDs designated for distraction available in the department.

There was no specific room designated for teenage patients in the children’s ED, however there

were suitable DVDs for that age group and card games and a laptop available for their use.

The ED had a clinical decision unit (CDU) where patients could stay for 24-48 hours. Patients

located here were under the care of the ED consultants.


We had previously reported a significant number of attendances to the department were elderly

patients. To meet the needs of this population, the ED had a frailty pathway in place designed for

patients who were well enough to be discharged but needed additional support to reduce their risk

of falls at home. The pathway provided ward-based occupational therapy and physiotherapy. We

observed therapy being provided by staff to patients in the CDU. Staff told us a community team

provided support in the home once the patient was discharged. Staff identified patients who were

suitable for the frailty pathway through nurse-led discussions, based on all available information

about the patient. Previously, the frailty pathway had been overseen by a geriatric consultant and

a frailty nurse specialist. However, at the time of this inspection, there was very little input provided

from the consultant geriatricians because they were diminished in numbers and had clinical

commitments predominantly at Orpington Hospital. The onus was on the frailty nurse specialist to

provide and support the service which operated Monday to Friday. Staff considered the frailty

pathway was not as effective as it could be due to the limited operating hours and small resource

committed to the service.


The trust scored about the same as other trusts for each of the three Emergency Department

Survey questions relevant to the responsive domain.

Question – Responsive Score RAG

Q7. Were you given enough privacy when discussing your

condition with the receptionist?

7.0 About the same

as other trusts

Q11. Overall, how long did your visit to the emergency

department last?

6.2 About the same

as other trusts


Q20. Were you given enough privacy when being

examined or treated?

8.9 About the same

as other trusts


Access and flow

At previous inspections, we found that the hospital consistently failed to meet the target to see,

treat and discharge 95% patients within four hours. We had previously been told of a ‘whole

hospital approach’ to improving patient flow and increase bed capacity. At this inspection we

continued to observe poor flow across the emergency pathway. The department was congested

with multiple patients who had confirmed decisions to be admitted but no beds to move to.

Performance against the four-hour target remained poor with very little signs of improvement.

Median times to treatment remained above the national average as detailed below, again with little

sign of sustained improvements.

Staff reported a sense of “War zone” conditions with increased attendances, continued lack of

appropriate beds within the hospital, especially “Monitored” beds. These working conditions were

reported to be the accepted norm for staff in the department. There was no robust escalation

protocol. The site operations manager, who had been in post for approximately eight weeks

reported they had prepared a professional standards escalation policy however this remained in a

draft state at the time of the inspection. Delays in specialities responding to referrals was an

apparent common theme, which led to delays in decisions being made about patient care

pathways. Waits for diagnostic results was also reported as a significant reason for breaches.

Care group performance meeting minutes reported a lack of reporting radiologists was adding to

the delays experienced by the emergency department.

We previously reported there could be times when capacity was restricted on the children’s ward

leading to overcrowding in the children’s ED. It was reported by staff there had been occasions

when children had to have treatment in the corridor as the cubicles were full and the children’s

waiting room was too full to manage well. At this inspection, the challenge remained present with

the children’s ward only able to staff twelve beds. We noted multiple occasions when patients had

been transferred to King’s College Hospital for inpatient care and treatment because of a lack of

children’s beds. There continued to be no formalised strategy to resolve this despite there being

sufficient space on the children’s ward, and an obvious demand for such beds being generated by

the local population. A business case was reported to be in the draft stages with an update

scheduled for April 2019.

The trust acknowledged the on-going challenges faced regarding the delivery against

constitutional standards. At the time of the inspection, the hospital was under significant

operational pressure. The trust provided the following narrative to describe the operational status

of the hospital and of the measures they were taken to manage demand and capacity:

“The site experienced significant challenges from the beginning of the week commencing 28th

January 2019 with a minus 75 (-75) bed position declared at the 09:00 flow meeting. This position

showed limited improvement throughout the day which was reflected in the site being unable to

avoid three of our patients breaching the 12-hour standard within ED. Despite remedial action taken,

and given the seriousness of the site position, internal incident was then declared at the PRUH on

28th January at 17:31 that evening.

Throughout the week the hospital experienced consistently high number of patients within

Emergency Department (ED) requiring admission, such that 23 patients were awaiting a bed in the


department at 08:30 on the 30th January 29 on the 31st January and 22 on the 1st February. Acuity

of patients was high, with beds required for various specialities, namely Hyper-Acute Stroke Unit

(HASU), cardiac and ITU beds; this was compounded by limited discharge profile across the site,

with a resultant negative bed prediction on a daily basis. Throughout this period there was escalation

to the surge hub and community partners for support 3 times a day with additional sector-wide calls

being held – out nearest acute trust was also under significant pressure, which limited mutual aid,

this also delayed several stroke repatriations leaving the site earlier in the week.

Dedicated multidisciplinary discharge teams (MDT) were in place, including at the weekend, with

additional senior doctor support for medicine in recognition of the high number of medical outlying

patients, which rose to 42 at its highest peak, across the site. The discharge lounge was fully staffed

and operational (7-days a week) and an initiative to support medical interface within the discharge

lounge to avoid delay for patients leaving the wards was trialled. The organisation continued to drive

our “golden discharge” initiative to promote multispecialty discharge planning within our daily board

rounds with view for patients being discharged to leave the hospital before 10am each day.

Every effort was made to manage patient flow within the hospital and as part of the trusts internal

incident action plan the following additional measures were put in place;

i. All senior leadership teams within the Care Group (Clinical Director, General Manager and

Head of Nursing) to attend site meetings and cascade to respective teams for line by line

review of all in-patients with management plans and escalation of delays for expediting;

ii. Site meetings to be attended by all support services including radiology, therapy,

pharmacy, infection control and transport to facilitate comprehensive and timely patient

management planning;

iii. Transfer of Care team attendance at all site meetings and full ward review for suitable

patients who may be cared for in a community-based setting. During this period 68 patients

were identified as suitable for community-based rehab / management and subsequently

discharged from hospital;

iv. All escalation areas opened across both PRUH and Orpington sites resulting in further 34

beds being available;

v. Review of all elective activity with cancellation for any non-urgent cases to support

emergency flow;

vi. Boarding initiated, in line with trust policy, at 09:00 site meetings and progress / impact

reviewed throughout the day via ED safety huddles and site meetings.

One of the further challenges encountered during this period was the number of infection control

precautions in place across the organisation which impacted on our response to the high volume of

side room requests, ability to undertake the number of deep cleans requested in a timely manner

and practicality of admitting patients within restricted wards. During the week of the 28th January the

hospital had five wards across the site on restriction / precaution as advised by our infection control

team and resultant 10 lost beds which we were unable to admit patients into. These remained closed

throughout the week. Daily infection control meetings were in place, chaired by the Director of

Nursing, to address rapid, systematic management of outbreaks following an agreed outbreak plan

to help reduce the impact within the hospital.

Ambulance attendances, and subsequent acuity, remained high. Between the period of the

inspection 31st January – 1st February the department consistently experienced surges in

attendances with up to 9 ambulance attendances within one-hour periods between the hours of

13:00, 16:00 and 21:00 daily. Whilst the safety of our patients is paramount there is a balance of

risk when managing capacity within the emergency department and being able to offload

ambulances that are queueing which is overseen by the EPIC and ambulance triage nurse. Where


possible the department will corridor nurse, but this is dependent on staffing levels at the time and

the balance of risks in the ED, for example the numbers of patients in the resuscitation area.

Following implementation of these plans, despite ED remaining challenged, due to improvements

over the preceding 24 hours in the discharge profile and flow and the length of time the site had

been on internal incident, the Director of Operations at the Princess Royal University Hospital made

the decision for the internal incident to be stood down at 12:34 on Thursday 31st January. At this

time the site had returned to a business as usual position. It was recognised that resuscitation beds

in ED remained over capacity at 7 and in response to this, an ITU consultant, who is also a corporate

medical director, visited the department with a plan to step down 2 patients from critical care into

the recovery area to create 2 additional HDU spaces and transfer 2 patients from the resuscitation

area in ED to Critical Care.

The PRUH is currently working with partners across the healthcare economy and has on-site support

from Hunter Healthcare Consultancy and ECIST, in order to improve internal ED processes,

emergency flow and discharge processes across the PRUH and South Sites. As part of this joint

working, improvement plans have been agreed which will aid senior leaders within the department

to drive teams/individuals operationally and allow focus on the strategic changes needed to

strengthen the functioning of the ED. The plan also compliments existing work streams in place as

part of the organisation’s transformation strategy and continued collaboration with ECIST.

Whilst we acknowledge the impact of poor site flow on the ED, this is not the sole driver of the poor

performance and congestion in the department. It is evident that the estate is not fit for purpose and

that this inhibits the effective use of capacity. A Business Case for the ED expansion is a top priority

for the Kings Executive Team for 2019/20. Likewise, there are equally important improvements

required in the management of non-admitted pathways in the ED and ambulatory pathways (recently

funded business case) alongside those required for the flow of patients from ED to acute beds and

thence to specialty inpatient beds aligned to further work on the discharge processes and social

care pathways. These pathway and process improvements are part of the transformation work with

Hunters and ECIST.”

Median time from arrival to treatment (all patients)

The Royal College of Emergency Medicine recommends that the time patients should wait from

time of arrival to receiving treatment should be no more than one hour. The trust did not meet the

standard for 11 months over the 12-month period from October 2017 to September 2018.

In the most recent month the trust’s median time to treatment was 76 minutes compared to the

England average of 61 minutes.

Median time from arrival to treatment from October 2017 to September 2018 at King's

College Hospital NHS Foundation Trust




(Source: Data request PRUH Quality Indicator Scorecard January 2019)

Percentage of patients admitted, transferred or discharged within four hours (all

emergency department types)

The Department of Health’s standard for emergency departments is that 95% of patients should

be admitted, transferred or discharged within four hours of arrival in the emergency department.

From November 2017 to October 2018 the trust failed to meet the standard and performed worse


In the most recent month, October 2018, the trust admitted, transferred or discharged 78% of

patients within four hours of arrival in the emergency department compared to the England

average of 89%.

Four-hour target performance - King's College Hospital NHS Foundation Trust




admitted

From November 2017 to October 2018 the trust’s monthly percentage of patients waiting more

than four hours from the decision to admit until being admitted was similar to the England

average.

From November 2017 to May 2018 performance against this metric was higher than the national

average however since May it has been similar to the England average.


admitted - King's College Hospital NHS Foundation Trust

(Source: NHS England - A&E SitReps).

Number of patients waiting more than 12 hours from the decision to admit until being

admitted


Over the 12 months from November 2017 to October 2018, 186 patients waited more than 12

hours from the decision to admit until being admitted. The highest numbers of patients waiting

over 12 hours were in August 2018 (29), March 2018 (26) and April 2018 (24).

Month Number of patients waiting

more than 12 hours to

admission

November 2017 8

December 2017 0

January 2018 9

February 2018 10

March 2018 26

April 2018 24

May 2018 16

June 2018 21

July 2018 13

August 2018 29

September 2018 20

October 2018 10


Percentage of patients that left the trust’s urgent and emergency care services before

being seen for treatment

From October 2017 to November 2017 the trust performance was worse than the England

average; however, since then there has been no data reported nationally for this metric.

Percentage of patient that left the trust’s urgent and emergency care services without

being seen - King's College Hospital NHS Foundation Trust


Median total time in A&E per patient (all patients)


From November 2017 to October 2018 the trust’s monthly median total time in A&E for all

patients was higher than the England average.

In the most recent month, September 2018, the trust’s monthly median total time in A&E for all

patients was 202 minutes compared to the England average of 154 minutes.

Median total time in A&E per patient - King's College Hospital NHS Foundation Trust





(Source: Data request – PRUH Quality Indicator Scorecard January 2019)



From October 2017 to September 2018 there were 147 complaints about urgent and emergency

care services. The trust took an average of 29 working days to investigate and close complaints.

This is not in line with their complaints policy, which states complaints should be closed within 25

working days.

The breakdown of the subjects of complaints are shown in the table below:

Subjects No. of complaints



Communications 15


Waiting Times 10

Other 7








Commissioners); 1






However, at the time of the inspection, the department was reporting compliance in responding to

complaints within the agreed timescales. Complaints and responses were monitored at clinical

governance meetings. We reviewed three complaint responses as part of the inspection process.

There was evidence that senior leaders had been involved in completing investigations with

responses approved and signed by the trust medical director. Actions from complaints were

identified and there was evidence these actions had been instigated.

At the time of the inspection, 30 complaints had been reported between 1 April 2018 and 31

January 2019. Two of these had led to serious investigations being undertaken. Of the 30

complaints, three were open at the time of our inspection. We reviewed the end to end process

for one of the complaints, which related to a patient who had needs associated with dementia.

The concern was clearly identified, which related to lack of discharge papers and notification to

the patients next of kin. An acknowledgement letter was sent, and consent was obtained to look

into the matter. A divisional response was generated by the matron, and the final letter, which

included an apology was signed by the medical director.





Leadership

At our previous inspection, we reported changes to the leadership and reporting arrangements for

the emergency department and wider hospital. Previously, there was no substantive general

manager in post and the deputy head of nursing post was vacant. At this inspection the leadership

team for the emergency department was relatively new with continued interim appointments to

critical roles. An interim clinical lead had been appointed in October 2018; and a new general

manager appointed in September 2018. A new head of nursing had been appointed earlier in

2018.

We again heard of “Change fatigue” being a significant factor across the department, in part

because of the churn of leadership of the emergency department.

There required a level of micro-management from the executive team to help the emergency

department leadership better understand their roles, responsibilities and remits. This work was

captured in an emergency department action plan. The roles of the nurse and consultant in charge

was further being developed to ensure those individuals assuming those roles were aware of their

responsibilities.

Although theoretically a triumvirate of leaders had been established, in practice, the department

was clinically led with little input from operational and nursing staff. There was a lack of joined up

working; this was perhaps most obvious through our observation of the daily team meeting. During

the inspection, we noted that at times of significant surge, there was little in the way of effective

clinical leadership. The interim clinical lead remained in the office and was not directing the

department from the “Front line”. The matron and head of nursing were observed “Fire-fighting”,


trying to generate capacity across the department. There was no robust or strategic approach at a

local level to address the challenges of the department.

Not all senior nursing leaders demonstrated they had the skills and competency to fulfil their duties

effectively. The head of nursing remained elusive during the inspection despite requests for

interview from inspectors. One senior nurse was not able to direct us to the nursing workforce and

establishment figures for the department, advising us this was the remit of the head of nursing.

When questioned about patient group directions, one senior nurse showed no awareness of the

issue and again directed us to another, more junior member of the nursing team. There was a lack

of awareness of the needs of patients. When we challenged nursing staff on not releasing

ambulances to allow them to manage out-of-hospital cases, the response was “We don’t want to

release the ambulances because we know they will return with more patients”. Not only did this

demonstrate a lack of awareness of the impact of poor leadership, but also demonstrated very

little insight into the wider needs of the local population, or of the inherent risks of such cavalier

attitudes. There was a lack of traction on making improvements in the completion of falls care

plans. This was despite there being numerous incidents in which patients had sustained harm, and

despite falls to harm being a significant risk for the department since before November 2016.

One senior nurse in the department demonstrated such disregard for adult patients. On two

occasions, the senior nurse made flippant and misjudged comments to CQC inspectors about

patients including the phrase “…Smelly, stinky adults”. The nurse was also observed arguing with

medical colleagues in the presence of patients and visitors about the most appropriate pathway for

a patient, which we felt to be wholly unacceptable and inappropriate. We considered the behaviour

of the individual to be bordering on bullying as it was apparent the junior doctor whom they were

challenging was uncomfortable with the situation. The nurse demonstrated no insight in to their

behaviour or of the impact they had on other people around them.

Vision and strategy

We previously reported a lack of vision or strategy for the emergency pathway. This remained the

case at this inspection. Whilst some progress had been made on generating business cases for

the expansion of the department, an emergency department action plan was used as the

mechanism for change.

Culture

There was vehement animosity directed towards the executive team from staff across the

emergency department. There was a general consensus amongst front line staff that

organisational leadership was poor, inconsistent, and a view the executive did not understand the

challenges of the department. In comparison, organisational leaders considered the challenges of

poor performance to be associated with the behaviours and attitudes of staff in the department

and across the wider hospital. It was apparent through our interviews with staff that a “Done too”

culture existed amongst staff in the emergency department. Learned helplessness and a lack of

accountability both contributed to a lack of change across the emergency department. There was

a sense amongst the departmental leadership team that the performance challenges across the

department existed solely because of “Flow and environmental issues”. Whilst these were both

contributing factors, local leaders were not owning the internal challenges. For example, the

management of the sub-acute pathway was sporadic and poorly thought through. Staffing of the

sub-acute pathway was reactive despite a commitment from the senior executive team to fund the

necessary vacancies to ensure the sub-acute pathway operated smoothly and consistently. There

was no robust local ownership of the non-admitted pathway breaches which occurred on a

frequent basis. Data presented in the “Access and Flow” section of this report reflects the lack of


impact any improvement initiatives have had in the department. Most noticeably, performance

against the non-admitted pathway remains stagnant whilst performance against the number of

patients in the “Majors” admitted pathway” are seeing increasingly longer waits.

Morale was low across the medical and nursing workforce. There was a disconnect in

relationships between doctors and nurses which appeared to go unresolved.

There was a sense of reactive firefighting across the emergency care pathway as compared to

there being a joined-up approach. Escalation protocols were weak and had little impact on

assisting the emergency department to decompress. Delays in specialities reviewing their patients

were observed; there was a lack of escalation to more senior clinical decision makers. For

example, on our second unannounced inspection, at 10am, two patients who had been referred to

speciality during the early hours had still not been reviewed. The output and learning from daily

safety meetings was to “Escalate earlier” however, in practice, this was not occurring.

Governance

The emergency department fell under the management, performance and quality auspices of the

acute and emergency medicine care group which was led by a clinical director. Trust governance

structures determined the design of local level governance arrangements. Local care group

meetings were divided in to three sections; care group clinical governance; care group operational

governance and a wider care group meeting. Outputs from the operational and clinical governance

meetings were fed to the umbrella divisional operational governance meetings for the Princess

Royal University Hospital and south sites. The emergency department held monthly governance

meetings which had standing agenda items. These included a review of red, amber and yellow

incident reports; a high-level review of all incidents by way of reported category; complaints;

clinical audit; mortality reviews; infection control and “Other patient safety issues”. Outputs from

the local ED governance meeting were then fed in to the wider care group meetings which also

had similar standing agenda items.

Minutes of the ED governance meeting were high level and often lacked any significant detail.

Whilst risks were discussed, there appeared little insight in to why developments or progress had

not been made. Performance and quality trajectory graphs showed consistent “yo-yo”

performance, with improvements made one month and then deteriorating performance the

following. This was most noticeable against infection control audit performance, falls resulting in

moderate or major harm, and overall departmental performance against constitutional access

targets. Whilst staff reported actions and work plans to resolve areas of challenge and risk,

sustained non-compliance and poor performance was suggestive of a lack of insight in to the real

challenges of the department and wider hospital operational workings. Repeated poor

performance had appeared to go unchallenged, with a level of acceptance apparent due to a lack

of grip and robust action to resolve what were, long standing issues.

Whilst generalised data was provided at the ED governance meeting in relation to the number and

types of incidents reported, there was no reported output. Violence, aggression and security

concerns were a repeated high reporting category. There was no reference as to whether any

work was being undertaken to tackle this area of concern. The topic of violence and aggression

did not fall under any of the risks reported against the department risk register.

We observed the notice board in the clinical decision unit contained audit data dating back to

November 2014. Whilst staffing levels were displayed, as well as the name of the nurse

responsible for the clinical decision unit being updated, information including the number of falls,

the rate of meticillin resistant Staphylococcus aureus (MRSA) cases was blank.



As we have previously reported, performance management and the management of risk was poor.

Whilst staff demonstrated an awareness of the challenges they incurred, there was little in the way

of effective action to resolve longstanding poor performance. Information was provided monthly to

departmental leads. Similar topics were discussed monthly, however actions were either not

identified or, where they had been, were ill thought through as they had not delivered the

necessary improvements.

Daily safety huddles had been introduced as a means of improving the operational effectiveness

of the emergency department. The daily safety and operational meeting considered the

performance of the department including compliance against the national four-hour target. In

addition, patients nearing a 12-hour breach were discussed on an individual basis as compared to

looking for resolution to decompress the emergency department more sustainably. The meeting

itself was attended by the site operations manager, clinical lead and nursing representatives. A

representative from the Urgent Care Centre also attended but we noted they arrived late so they

were not involved in earlier discussions. The meeting was interrupted by phones ringing

throughout which distracted key decision makers. There was no consideration of the experience of

patients with focus predominantly placed on those patients nearing the twelve-hour decision to

admit breach target. Information from the meeting was used to support the wider hospital bed

meeting. Staff reported that whilst the safety meetings occurred frequently during the week,

facilitation of the meetings at weekends had been sporadic. This resulted in the director of

operations having to mandate the meetings occurred.

The trust had appointed another third-party consultancy to support with the turnaround of the

emergency department. Staff working across the ED reported significant “Change Fatigue” and a

sense of being “Done too”. ED staff told us they felt they had the solutions to resolve the

performance and quality challenges however they reported a sense of restrictive practice being

bestowed upon them from the executive team. Staff told us they felt as though the executive team

“Knew better” and that anecdotally, the emergency team and culture of the department “Was the

problem”. This led to the sense of vehement animosity we previously referred to in this report. Our

assessment was that of a significant breakdown in relationships between departmental staff and

that of the wider trust leadership team. Multiple attempts had been made to resolve longstanding

performance issues across the emergency pathway, however these had consistently failed to

deliver. It appears that at no point human factors, cultures and behaviours had been considered as

being contributory factors to the on-going challenges. Dismissive attitudes, a lack of insight, and

poor understanding of risk and operational management all contribute to the persistent failings of

the urgent care service at Princess Royal University Hospital.


The local leadership team was able to monitor performance of accident and emergency

performance against the four-hour target in real time. Information was shared during bed

management meetings which occurred throughout the day.

The emergency department reported to the wider Division B governance meeting. Key quality

indicators such as the emergency access target, workforce expenditure, incidents, risks and

complaints were all reviewed and scrutinised before being discussed at executive level.

Engagement


We opted not to inspect this key line of enquiry at this inspection due to the pressing challenges

associated with the quality and safety of patient experiences. Please refer to our previous reports

for a summary of this key line of enquiry.


The department used audits to continuously drive improvement within the department. We saw

that clear actions were identified, and re-audits planned following implementation of the actions for

continuous improvement in patient care and governance processes.

Surgery


Princess Royal University Hospital (PRUH) provided care and treatment for patients undergoing

general and specialist surgery. This includes; urology, trauma and orthopaedics, elderly care,

gynaecology, colorectal, bariatrics, ophthalmology and endoscopy services.

The service consists of surgical wards, theatres, the day surgery unit and an endoscopy unit.

There were 30033 surgical admissions between January and December 2018. Of these, 4782

were elective admissions, 14259 were day cases and 10992 were emergency admissions.

In addition, 7461 patients were admitted for endoscopy procedures between January and

December 2018.

There are 110 inpatient beds across five surgical wards including surgical ward 3, ward 4, ward 5,

ward 6 and ward 7.

Surgical ward 3 has a total of 20 beds in four bays and four side rooms. The ward is mainly used

as a short stay unit. Staff admit patients from the emergency department; however, they also

admit few elective patients.

Surgical ward 4 has a total of 14 beds in three bays and two side rooms. Staff informed us the

ward was originally used to admit elective patients, but they now had long stay patients.

Surgical ward 5 has a total of 28 beds in six bays and four side rooms. This is an acute surgical

ward. Staff admit bariatric patients and patients stepped down from the intensive care unit.

Surgical ward 6 has a total of 20 beds in four bays and four side rooms. This was originally a

urology ward but at the time of our inspection, the ward admitted most of the medical outliers

within surgical wards.

Surgical ward 7 has a total of 28 beds including 4 side rooms. Specialities admitted on the ward

include fractured neck of femur, trauma and orthopaedics. This included frail and elderly patients

and a Geriatrician was based on the ward five days a week.

The service has six operating theatres within the main hospital unit. One of the theatres was

closed by management during our inspection.

The recovery area consists of 12 beds. The intensive care unit (ITU) used two of the beds within

the recovery area due to insufficient beds on the ITU.

The endoscopy unit consist of a nine-bedded admission and recovery area, and two procedure

rooms.


The Alan Cumming Day Surgery Unit is a standalone unit consisting of a large reception area, 30

trolley beds, six theatres, a six-bedded recovery area, an ophthalmology waiting area, a discharge

room and two pre-assessment rooms.

We visited five surgical wards and theatres, the endoscopy unit and the day surgery unit during

our inspection from 30 January 2019 to 1 February 2019. We spoke with 28 members of staff

including consultants, junior doctors, nurses, allied health professionals and ancillary staff. We

spoke with 12 patients and three relatives. We also spoke with four parents who accompanied

their children to the day surgery unit at the time of our inspection. We reviewed 11 patient records

and prescription charts.


Mandatory training

The service provided mandatory training in key skills to all staff, however, there had been

no improvement in completion rates for medical staff since our last inspection. Medical staff

were performing below the trust target of 80% for completion of mandatory training, with an

average completion rate of 53%.

The trust provided us with up to date mandatory training records for surgical staff at the Princess

Royal University Hospital (PRUH) following our inspection.

A breakdown of compliance with mandatory training courses as of February 2019 for qualified

nursing staff in surgery is shown below:

Module No. of

staff

No. of staff

compliant

% of staff

compliant

Target

Met

Antimicrobial Prescribing and Stewardship

[once]

316 274 86.7%

Yes

Appraisal 284 276 97.2% Yes

Aseptic Non-Touch Technique Level 1 [Once] 205 201 98.0% Yes

Aseptic Non-Touch Technique Level 2 [Once] 259 193 74.5% No

Blood Transfusion [2 Years] 313 286 91.4% Yes


Governance) [ 1 Year]

316 271 85.8%

Yes

Dementia [Once] 316 265 83.9% Yes

End of Life [Once] 313 284 90.7% Yes

Equality & Diversity [Once] 316 313 99.0% Yes

Fire [2 Years] 316 309 97.8% Yes

Health & Safety [Once] 316 315 99.7% Yes

Infection Control (Clinical) [2 Years] 316 307 97.2% Yes

Manual Handling (Clinical) [2 Years] 316 266 84.2% Yes

Mental Capacity and Consent [Once] 316 240 76.0% Yes

Patient Falls [3 Years] 314 257 81.8% Yes

Preventing Radicalisation Level 3 316 278 88.0% Yes

Resuscitation 316 263 83.2% Yes

Safeguarding Adults Level 2 [3 Years] 316 302 95.6% Yes

Safeguarding Children Level 2 [3 Years] 316 282 89.2% Yes

Safer King's 4 0 0.0% No

Security, Manual Handling, Fraud [Once] 17 17 100.0% Yes

Venous Thromboembolism [Once] 301 294 97.7% Yes


The 80% target was met for 19 of the 22 mandatory training modules for which nursing staff were

eligible.

A breakdown of compliance for mandatory training courses as of February 2019 for medical staff

in surgery is shown below:

Module No. of

staff

No. of staff

compliant

% of staff

compliant

Target

met

Antimicrobial Prescribing and Stewardship

[once]

164 89 54.3%

No



Blood Transfusion [2 Years] 157 85 54.1% No


Governance) [ 1 Year]

164 81 49.4%

No

Dementia [Once] 164 62 37.8% No

End of Life [Once] 158 64 40.5% No

Equality & Diversity [Once] 164 119 72.6% No

Fire [2 Years] 164 107 65.2% No

Health & Safety [Once] 164 112 68.3% No

Infection Control (Clinical) [2 Years] 164 98 59.8% No

Manual Handling (Clinical) [2 Years] 10 7 70.0% No

Manual Handling (Non-Clinical) [Once] 164 114 69.5% No

Mental Capacity and Consent [Once] 110 44 40.0% No

Patient Falls [3 Years] 39 6 15.4% No

Preventing Radicalisation Level 3 164 87 53.0% No

Resuscitation 164 76 46.3% No

Safeguarding Adults Level 2 [3 Years] 164 104 63.4% No

Safeguarding Children Level 2 [3 Years] 164 116 70.7% No


Security, Manual Handling, Fraud [Once] 45 18 40.0% No

Venous Thromboembolism [Once] 163 116 71.2% No

The 80% target was not met for any of the 22 mandatory training modules for which medical staff

were eligible.

The service had implemented an electronic system to manage all training and development of

staff. Training was delivered through electronic learning systems as well as face-to-face. Some of

the medical staff we spoke to confirmed they could access training on electronic systems. They

were unable to explain why completions rates for medical staff was low. There was a lack of

oversight from senior management for the monitoring of medical staff mandatory training. We

found mandatory training for medical staff was not a risk on the surgery risk register.

(Source: DR115 PRUH surgery mandatory training)

Safeguarding


agencies to do so.


Staff were aware of their responsibilities in relation to safeguarding vulnerable adults and children

and could locate and describe the trust safeguarding policy. Staff escalated safeguarding incidents

to the safeguarding team.

The trust had a safeguarding adults’ policy as well as a safeguarding children policy. The trust’s

policy for female genital mutilation (FGM) set out staff’s responsibility for identifying and reporting

known or suspected cases of FGM. These policies were available on the trust intranet, which was

accessible for all staff.

Staff had received safeguarding adult and children training and demonstrated a good

understanding and knowledge of the types of abuse patients may experience.

A breakdown of compliance for safeguarding training courses for nursing staff at the PRUH is

shown below:

Module No. of

staff

No. of

staff

compliant

% of staff

compliant

Target

met

Safeguarding Adults Level 2 [3 Years] 316 302 95.6% Yes

Safeguarding Children Level 2 [3 Years] 316 282 89.2% Yes

The 85% target was met for each of the safeguarding training modules for which qualified nursing

staff were eligible.

A breakdown of compliance for safeguarding training courses for medical staff at the PRUH is

shown below:

Module No. of staff No. of staff

compliant

% of staff

compliant

Target

met

Safeguarding Adults Level 2 [3 Years] 164 104 63.4% No



The 85% target was not met for any of the safeguarding training modules for which medical staff

were eligible.


The service generally controlled infection risks well. Staff kept equipment and the premises

clean. However, decontamination of endoscopes was carried out in a room used for both

clean and dirty equipment.

All areas of the units visited were visibly clean and tidy including the day surgery unit, surgical

wards, theatres and the endoscopy unit.

The service had established policies for infection prevention and control (IPC), which were

followed by staff. These were based on the Department of Health’s code of practice on the

prevention and control of infections, and included guidance on hand hygiene, use of personal

protective equipment (PPE), and management of the spillage of body fluids.

There was easy access to PPE. Aprons and gloves were available in all areas we inspected, and

we observed staff using PPE as required. There was good access to antibacterial hand gels as

well as handwashing and drying facilities. Services displayed signage prompting people to wash


their hands and gave guidance on good hand washing practice. We observed bed space curtains

were labelled with the date they were last changed.

Staff were ‘bare below the elbow’ and adhered to infection control precautions throughout our

inspection, such as hand washing and using hand sanitisers when entering and exiting the unit

and bed spaces.

Waste management, including those for contaminated and hazardous waste was in line with

national standards. A colour coded system was used for cleaning equipment on all units visited to

prevent cross contamination between different areas. There were housekeeping staff for cleaning

wards and cleaning staff understood cleaning frequency and standards. Green ‘I am clean’

stickers were used to identify which equipment staff had cleaned and were ready to be reused.

Where patients had a known or suspected infection, they were nursed in single side rooms on

surgical wards. Isolation signs indicated which patients required barrier nursing and gave guidance

about what types of precautions were needed.

Needle sharp bins were available on all units visited. All bins we inspected were correctly labelled

and none were filled above the maximum fill line.

Decontamination of endoscopes was carried out in a decontamination room used for both clean

and dirty equipment. There was no demarcation between clean and dirty areas. This was not in

line with national guidance. The British Society of Gastroenterology Guidance for Decontamination

of Equipment for Gastrointestinal Endoscopy specifies there must be separate areas for the

receipt of endoscopes following patient use (dirty area) and for the storage and drying of

endoscopes following automated reprocessing (clean area). The guidance recommended that

separate teams of staff work in these areas and not cross between them to avoid the risk of cross

contamination. This was not the case during our inspection.

However, clean and dirty scopes were labelled, placed in colour coded bags and separated to

avoid contamination.

Hand hygiene audit results for the PRUH and south sites showed planned surgical services

achieved 91% compliance between July 2018 and January 2019. Theatres and anaesthetics

achieved 94% during the same period.

The service displayed information within surgical wards. Information displayed within surgical ward

6 showed the last clostridium difficile (C.diff) was reported in August 2017 and the last Methicillin-

resistant Staphylococcus Aureus (MRSA) was reported in April 2017.

Information displayed within surgical ward 7 showed there had been no incident of MRSA or C.diff

in the last three months. Information displayed within surgical ward 3 showed there had been no

MRSA or C.diff in the last 3 months.


The service had suitable premises and equipment in theatres and surgical wards, however,

the endoscopy unit was not fit for purpose.

There were six operating theatres at the PRUH, one of which was closed at the time of our

inspection. There was secure access to theatres. Each theatre had an anaesthetic room, a

dedicated sluice room and a preparation room. There was safe flow from clean to dirty areas. We

observed separate scrub facilities and clean preparation areas for setting up instruments.

Ward areas were generally accessible to patients and staff. There was enough space to move

beds along corridors between theatres and other diagnostic areas. There were adequate toilet and

bathroom facilities on each ward. This included en-suite bathroom facilities in side rooms.


The day surgery unit had six operating theatres and five anaesthetic rooms. The unit had four bay

area’s consisting of 30 beds. Each bay area was separated by a curtain and linked to other bay

areas. This meant children went through adult bay areas to enter or exit the paediatric bay area.

The main recovery unit had 12 beds. Two of the recovery beds were used by the critical care unit

(CCU) due to insufficient CCU beds. The unit was insufficient to accommodate the number of

procedures undertaken by the service. Staff informed us patients were sometimes recovered in

theatres. We found patients were often kept overnight in the recovery area due to lack of bed

spaces on surgical wards. On the first day of our inspection, staff informed us four patients had

stayed in the recovery area overnight.

Theatre supplies were stored in secure electronic storage system accessed with staff finger prints.

The system recorded what staff were removing and which theatre it was going to.

At our last inspection staff reported surgical instruments laparotomy sets used in theatres were

more than 17 years old. During this inspection, we found the situation regarding equipment

remained the same. The equipment had been maintained in the correct manner and was fit for

purpose. However, staff told us the sets often had damaged or broken items. Staff were forced to

make up sets by opening small sets or buying from small item budget.

We reviewed equipment checks from September 2018 to January 2019 on surgical ward 6,

surgical ward 3, the main recovery unit and day surgery unit. We found staff maintained a

documented programme of daily checks in most areas.

We observed resuscitation equipment was readily available on the units. We found the

resuscitation trolley and difficult airway trolley was regularly checked in most units we inspected.

However, we found some blank spaces in the adult resuscitation trolley checklist for surgical ward

6. These included 21, 22, 23 and 28 October 2018, 29 December 2018, and 20 and 26 January

2019. There were no gaps in daily checklist for the other units visited.

Equipment inspected had maintenance stickers showing they had been serviced in the last year.

We checked a random sample of supplies on trolleys within the units and saw they were all in their

original packs and in date.

The endoscopy unit consisted of nine bedded admission and recovery area, and two procedure

rooms. Staff informed us the unit was small when compared with the number of referrals and

procedures undertaken. Senior staff informed us they would require at least four procedure rooms

to cope with the demand on the service.

At the time of the last inspection endoscopy decontamination was on the hospital’s risk register

and Joint Advisory Group (JAG) accreditation had not been achieved. JAG accreditation had still

not been achieved during our recent inspection. JAG accreditation demonstrates that the

endoscopy service has met nationally-recognised endoscopy standards.

During our inspection, decontamination of endoscopes was carried out within the theatres

department due to space constraints in the endoscopy unit. In addition, the unit outsourced some

referrals due to its limited capacity. Staff informed us although the decontamination machines

were relatively new they often developed faults thereby slowing down decontamination processes.

Staff informed us there were plans to build a decontamination unit in the basement.


Staff completed and updated risk assessments for each patient. They kept clear records and

asked for support when necessary.


The surgical service used the national early warning system (NEWS) for monitoring the condition

of patients and identifying if their condition deteriorated. Staff had completed observations and

recorded NEWS scores in all inpatient records reviewed.

Our review of patient records demonstrated staff had completed risk assessments with respect to

falls, nutritional needs and venous thromboembolisms (VTE). Compliance with VTE checks were

monitored and results for the PRUH and south sites showed planned surgical services achieved

89% compliance between July 2018 and January 2019. Theatres and anaesthetics achieved 99%

during the same period.

We noted that risks were managed positively through the appropriate use of interventions. For

example, this included ensuring high risk patients who needed surgery were not admitted as a day

case. Pre-operative assessments included a review of patients’ previous and current health

problems and needs. Assessments had been carried out in line with guidance on pre-operative

assessment for both day case and inpatients.

Nursing staff reported the critical care outreach team (iMobile) were responsive when their advice

or interventions were required.

Staff followed a sepsis pathway for the management of patients whose condition met the criteria.

Theatre staff used the ‘five steps to safer surgery’ World Health Organisation (WHO) checklist; this

is a nationally recognised system of checks before, during and after surgery, designed to prevent

avoidable harm and mistakes during surgical procedures.

We observed the WHO checklist was completed appropriately during a surgical procedure in the

main hospital theatre. However, in another instance within the day surgery unit, we noted the final

sign out had been completed before the end of the surgical procedure. We observed three other

surgical procedures briefly and noted staff completed the checklist appropriately.

The service conducted WHO checklist audits to make sure staff followed the appropriate

procedure. WHO checklist audit results showed staff compliance rate was 92.5% between

January 2018 and December 2018.

Nurse staffing

The service had enough nursing staff with the right mix of qualifications and skills, to keep

patients safe and provide the right care and treatment.


rate has increased over the 12 months and was now above 90%. Total WTE had increased by

over 1,000.


Staffing group

Planned

staff –

WTE

Actual

staff –

WTE

Fill

rate

Planned

staff –

WTE

Actual

staff –

WTE

Fill

Rate

Qualified nursing & health visiting

staff (Qualified nurses) 129.5 101.7 78.5% 1305.3 1186.5 90.9%



• Princess Royal University hospital – 289.9 WTE in post (90% fill rate)



A site breakdown can be seen below;

• Princess Royal University surgery department: 15.5%

From September 2017 to August 2018, the trust reported a turnover rate of 14% in surgery. This

was higher than the trust target of 10%.



From September 2017 to August 2018, the trust reported a sickness rate of 3.1% in surgery

which was higher than the trust target of 3%.




agency usage rate of 15.7% in surgery. This left 11.4% of available hours unfilled.




Nurse staffing had improved since our last inspection and senior staff informed us they had

recruited staff to vacant positions and they were now fully established.

The service displayed staffing information within surgical wards and in theatres and we noted

planned staffing was in line with actual staffing numbers on all units visited.

Senior staff informed us staffing establishment on the endoscopy unit was for five days a week.

The unit opened for seven days a week and bank staff were used to fill gaps in the shift.

Medical staffing


rate had increased over the 12 months and was now above 90% although the total number of

WTE has decreased.


Staffing group

Planned

staff –

WTE

Actual

staff –

WTE

Fill

rate

Planned

staff –

WTE

Actual

staff –

WTE

Fill

Rate


Medical & Dental staff - Hospital 898.8 793.6 88.3% 732.9 660.6 90.1%

A breakdown by site can be seen below:

• Princess Royal University hospital – 173.4 WTE in post (83.9% fill rate)





From September 2017 to August 2018, the trust reported a turnover rate of 5.5% in surgery. This

was lower than the trust target of 10%.



From September 2017 to August 2018, the trust reported a sickness rate of 1.3% in surgery.


From September 2017 to August 2018, the trust reported a bank usage rate of 16% and locum

usage rate of 54% in surgery. This left 30% of available hours unfilled.




In July 2018, the proportion of consultant staff reported to be working at the trust was similar to

the England average and the proportion of junior (foundation year 1-2) staff was lower.

Staffing skill mix for the whole-time equivalent staff working at King's College Hospital


This

Trust

England

average

Consultant 50% 48%


Registrar Group~ 34% 27%

Junior* 8% 13%






Data received from the trust showed there were about 17 junior doctor vacancies across different

specialities. Some of the junior doctors we spoke to informed us there were gaps in rotas which

lead to junior doctors being overworked. They said they were sometimes unable to attend training

due to pressure on the wards.

Records



Electronic patient records (EPR) had recently been implemented and were used to record patient

information on surgical wards. The electronic system was password protected and we noted staff

logged out once they had finished using the system.

Staff used paper records for documenting patient information in the day surgery unit. Patient

records were kept in trolleys in the day surgery unit. Staff in the day surgery unit informed us

although most staff had completed training to use the electronic record system there were

insufficient computers on the unit to implement the use of system.

We looked at a random sample of 11 patient records across all surgical wards and the day surgery

unit and noted records were clear, legible and the name and grade of staff reviewing the patient

was clearly documented. We found that assessments for VTE, pressure areas, nutrition and pain

had been completed using national risk assessment tools. The records included evidence of the

daily ward round review and completed care plans.

Patient discharge summary were completed with details of the referral, diagnosis, investigations

and medication.

Medicines

There were systems to ensure the safe supply and administration of medicines. Some audit

results were below trust standards.

Medicines (including controlled drugs) were stored securely in locked cabinets and fridges.

Controlled drugs (CD) were managed appropriately. Regular audits were completed regarding the


accuracy of controlled drug (CD) documentation. The nurse in charge held the keys to CD

cupboards.

Staff monitored fridge temperatures on most units visited. However, we found no documentary

evidence to show that staff monitored fridge temperatures in the theatre department.

There were two drug trolleys kept within the clinical room on surgical ward 7. The drug trolleys

were not fixed to the wall in line with national guidelines. We noted two drug trolleys were kept

near the nurses’ station due to space constraints within the clinical room.

Tamper evident seals, were in use to ensure emergency medicines were readily available when

needed and fit for use. Regular checks of emergency medicines and equipment was carried out by

staff.

Staff had access to medicines disposal facilities including sharps bins and this was managed

appropriately.

We checked prescription charts and saw that information on patient details and allergy statuses

were complete. Prescription charts were signed after each dose was administered and there were

no unexplained gaps in the administration of medicines. Antibiotics were reviewed in line with the

trust policy.

All surgical wards had pharmacist support who were involved in monitoring and maintaining

medicines stock.

The pharmacy team carried out trust wide medication audits to determine adherence to local and

national guidelines. Audit results were rated green (98% and above), amber (88% to 97%) and red

(87% and below).

Audit results for the third quarter of 2018/19 showed the surgery, theatres, anaesthesia and

endoscopy division on PRUH and South Sites scored 85% (rated red) for adherence to national

safety alerts. A breakdown of the audit results showed theatres and recovery room 2 within the

day surgical unit (DSU) received most of the red ratings. Most theatres in the DSU received a red

rating for four out of eight indicators. This included compliance with safety alerts in relation to

calcium gluconate, flumazenil, glucagon and 0.5ml insulin syringes.

Theatres within the main hospital were mostly rated green in eleven of 12 indicators. However,

three of the six theatres, the recovery unit and the theatre store scored a red rating for compliance

with national safety alerts in relation to 0.5ml insulin syringes.

The eight surgical wards were mostly rated green in the 12 indicators. Areas of non-compliance

included 0.5ml insulin syringes (two wards), calcium gluconate (one ward), purple enteral syringes

(one ward) and midazolam 10mg/2ml ampoules (two wards).

During the same period, the controlled audit report showed the division scored 90% (rated amber).

The medicines safety and security audit for the same period showed the division scored 79%

(rated red). Wards and clinical areas were audited for a number of indicators including whether

storage areas were secure, monitoring of room and fridge temperatures, and whether medicines

were in date.

Incidents

The service managed patient safety incidents well.

Staff at all levels could tell us how to report an incident and told us they received feedback both

on individual incidents they reported and on incidents that affected their unit. Learning from


incidents were shared during handovers, team meetings and on notice boards within clinical

areas.




never event.

From October 2017 to September 2018, the trust reported four incidents classified as a never

event for surgery. There had not been any never event in relation to surgical services at the

PRUH.


(SIs) in surgery which met the reporting criteria set by NHS England from October 2017 to

September 2018.

These were:


incidents

Pressure ulcer meeting SI criteria 15




Medication incident meeting SI criteria 2

Sub-optimal care of the deteriorating patient meeting SI criteria 2


Staff reported 1392 incidents in relation to surgical services at the PRUH between January 2018

and December 2018. One incident reported related to death, 12 where major injury had occurred,

36 for moderate harm, 267 for minor harm, 782 where no harm occurred and 297 were identified

as ‘prevented or avoided harm’.

Twenty-three of the incidents were rated red and 74 were rated amber and required root-cause

analysis (RCA) investigation. We reviewed three investigation reports and found appropriate

investigations had taken place. We found the trust had identified the root causes, analysed the

contributing factors to the incident and identified actions to reduce the risk of similar incidents

occurring in the future.

The duty of candour requires providers of health and social care services to notify patients (or

other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to

that person. Staff we spoke with were aware of their responsibility to apologise and be open and

honest and share the information with the patient and their carer’s. Staff understood their

responsibility under the duty of candour regulations and we saw examples of the correct process

being followed from our review of investigation reports.

The service held monthly mortality and morbidity meetings. These were informed by a deceased

patient summary and learning points were recorded and shared with staff.

Safety thermometer


The service used safety monitoring results well.

Staff collected safety information and shared it with staff, patients, and visitors. Managers used

this to improve the service.

The Safety Thermometer is used to record the number of patient harms and to provide immediate

information and analysis for frontline teams to monitor their performance in delivering harm free

care. Measurement at the frontline is intended to focus attention on patient harms and their

elimination.

Data collection takes place one day each month – a suggested date for data collection is given

but wards can change this. Data must be submitted within 10 days of suggested data collection

date.

Following our inspection, information from the services’ performance data showed there had been

no incident of hospital acquired pressure ulcer between January 2018 and December 2018.

During the same period there had been nine incidents of falls with harm.

(Sources: DR118 PRUH Planned surgery scorecard)





Staff had access to guidelines on the trust’s intranet system. We reviewed a sample of this and

saw they were up to date and in line with best practice. This included the National Institute for

Health and Care Excellence (NICE) recommendations.

During our last inspection, the endoscopy unit was not accredited by the Joint Advisory Group

(JAG) for Endoscopy. The unit was still not accredited by the time of our inspection.

Nursing and medical staff assessed the needs of patients on admission and throughout their stay.

Treatment and care was planned and delivered in line with evidence based guidance, standards

and best practice.

Staff conducted monthly audits to ensure staff complied with best practice standards. These

included infection control audits, VTE risk assessment, WHO checklist audits and pain

management audits amongst others. Audit results were reflected within the integrated

performance scorecard for surgery, theatres, anaesthesia and endoscopy. These were regularly

reviewed by senior staff to improve the service.




Staff used a malnutrition universal screening tool (MUST) to identify patients who were at risk of

malnutrition. There were five steps for this risk assessment and involved weighing the patient

regularly to monitor any weight changes and allocate a score based on risk.

Our review of patient records showed staff completed nutrition and hydration assessments for

inpatients. Staff confirmed they had access to dietitians and could refer patients to them when

necessary.


There were protected meal times on surgical wards during which visiting was restricted. Staff

assisted patients during meal times were required.

We reviewed the menu offered to patients. This was developed to meet individual nutritional needs

based on the British Dietetic Association standards.

Pain relief

Staff assessed and monitored patients regularly to see if they were in pain.

Our review of patient records showed patients on the unit had been assessed for pain

management. Staff used a pain scoring tool alongside observing for the signs and symptoms of

pain. Pre-operative assessments included in patient records included information for about any

existing pain management and medication.

Patients we spoke with told us they received pain relief when they required it and that it was

reviewed regularly.

Staff had access to a pain specialist team who they could refer patients too.

Patient outcomes


improve them.

From July 2017 to June 2018, all patients at Princess Royal University Hospital had a lower

expected risk of readmission for elective admissions when compared to the England average.


• General surgery patients at Princess Royal University Hospital had a lower expected risk of


• Urology patients at Princess Royal University Hospital had a similar expected risk of


• Ear, nose and throat (ENT) patients at Princess Royal University Hospital had a lower

expected risk of readmission for elective admissions when compared to the England

average.

Elective Admissions - Princess Royal University Hospital




All patients at Princess Royal University Hospital had a lower expected risk of readmission for

non-elective admissions when compared to the England average.



• General surgery patients at Princess Royal University Hospital had a lower expected risk of


• Trauma and orthopaedics patients at Princess Royal University Hospital had a higher

expected risk of readmission for non-elective admissions when compared to the England

average.

• Urology patients at Princess Royal University Hospital had a lower expected risk of


Non-Elective Admissions - Princess Royal University Hospital





National Hip Fracture Database

In the 2017 National Hip Fracture Database for PRUH, the risk-adjusted 30-day mortality rate

was 5.2% which was within the expected range. The 2016 figure was 7.1%.

The proportion of patients having surgery on the day of or day after admission was 87.5%, which

met the national standard of 85%. This was within the top 25% of trusts. The 2016 figure was

83.7%.

The perioperative medical assessment rate was 99.2%, which failed to meet the national

standard of 100%. This was within the top 25% of trusts, and was an improvement on the 2016

figure, which was 95.3%.

The proportion of patients not developing pressure ulcers was 98.4%, which failed to meet the

national standard of 100%. This was within the middle 50% of trusts. The 2016 figure was

99.1%.

The length of stay was 15.2 days, which falls within the top 25% of trusts. The 2016 figure was

15.9 days.

(Source: National Hip Fracture Database 2017)

Bowel Cancer Audit

In the 2017 Bowel Cancer Audit for PRUH, 41.3% of patients undergoing a major resection had a

post-operative length of stay greater than five days. This was better than the national aggregate.


The 2016 figure was 50%.

The risk-adjusted 90-day post-operative mortality rate was 1.4% which was within the expected

range. The 2016 figure was 2%.

The risk-adjusted 2-year post-operative mortality rate was 22.3% which was within the expected


The risk-adjusted 30-day unplanned readmission rate was 13.2% which was within the expected


The risk-adjusted 18-month temporary stoma rate in rectal cancer patients undergoing major

resection was 48% which was within the expected range. The 2016 figure was 48.2%.

(Source: National Bowel Cancer Audit)

National Vascular Registry

In the 2017 National Vascular Registry (NVR) audit, the trust achieved a risk-adjusted post-

operative in-hospital mortality rate of 0% for Abdominal Aortic Aneurysms. The 2016 figure was

0%.

Within Carotid Endarterectomy, the median time from symptom to surgery was 10 days, which

was better than the audit aspirational standard of 14 days.

The 30-day risk-adjusted mortality and stroke rate was 2.8%, which was within the expected

range.

(Source: National Vascular Registry)

Oesophago-Gastric Cancer National Audit

In the 2016 National Oesophago-Gastric Cancer Audit (NOGCA), the age and sex adjusted

proportion of patients diagnosed after an emergency admission was 20.5%. Patients diagnosed

after an emergency admission are significantly less likely to be managed with curative intent. The

audit recommends that overall rates over 15% could warrant investigation. The 2015 figure was

23%. The 90-day post-operative mortality rate was not reported by the trust.

The proportion of patients treated with curative intent in the Strategic Clinical Network was

42.2%. This was similar to the national aggregate. This metric is defined at strategic clinical

network level; the network can represent several cancer units and specialist centres); the result

can therefore be used a marker for the effectiveness of care at network level; better co-operation

between hospitals within a network would be expected to produce better results

(Source: National Oesophago-Gastric Cancer Audit 2016)

National Emergency Laparotomy Audit

The National Emergency Laparotomy audit awards three ratings for each indicator. Green ratings


indicate performance of over 80%, amber ratings indicate performance between 50% and 80%

and red ratings indicate performance under 50%.

In the 2016 National Emergency Laparotomy Audit (NELA), the Princess Royal University

hospital achieved an amber rating for the crude proportion of cases with pre-operative

documentation of risk of death. This was based on 121 cases.

The site achieved an amber rating for the crude proportion of cases with access to theatres within

clinically appropriate time frames. This was based on 87 cases.

The site achieved a green rating for the crude proportion of high-risk cases with a consultant

surgeon and anaesthetist present in the theatre. This was based on 67 cases.

The site achieved a green rating for the crude proportion of highest-risk cases admitted to critical

care post-operatively. This was based on 43 cases.

The risk-adjusted 30-day mortality for the site was within the expected range based on 121

cases.

(Source: National Emergency Laparotomy Audit)

Patient Reported Outcome Measures

In the Patient Reported Outcomes Measures (PROMS) survey, patients are asked whether they

feel better or worse after receiving the following operations:

• Groin hernias

• Varicose veins

• Hip replacements

• Knee replacements

Proportions of patients who reported an improvement after each procedure can be seen on the

right of the graph, whereas proportions of patients reporting that they feel worse can be viewed

on the left. This was not broken down by location.


In 2016/17 performance on groin hernias was about the same as the England average. On the

EQ VAS indicator, the trust had less patients report they felt worse but also less patients report

they felt improved too.

For varicose veins, performance was worse than the England average.

For hip replacements, performance was about the same as the England average.

For knee replacements was about the same as the England average.


Competent staff


work performance.

All staff went through an induction period and orientation. New starters were allocated a mentor

for a specified period to help them settle into their role. New nurses completed competencies

which had to be signed off by their mentor. Staff within all units visited had opportunities to attend

relevant study days and formal teaching sessions when available. Staff informed us they had

been provided with relevant training required to carry out their role. Paediatric trained nurses

cared for children who attended the day surgery unit for surgical procedures.

Medical staff received an orientation and induction programme following their employment. Junior

doctors we spoke with reported the hospital provided good teaching and regular learning

opportunities. They also felt they had good support from consultants who also provided clinical

supervision. However, some junior doctors said they were sometimes unable to attend training

due to pressure on the wards.

From September 2017 to August 2018, 86% of staff within urgent and surgery care at the trust




required

Appraisals

complete

Completion

%














Information provided by the trust following our inspection showed 99% of staff at the PRUH had

received an appraisal as of February 2019. However, this did not include completion rates for

medical staff.


Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare

professionals supported each other to provide good care.

Staff reported good working relationships with other teams. Patient records showed input from

allied health professionals including physiotherapist, dietitians, occupational therapists,

pharmacists, nursing and medical teams were working well together and provided good standard

of care to patients. We observed allied health professionals attended ward rounds with doctors

and nurses.

Staff on the ward were aware of how to refer patients to the therapy team. Staff could easily locate

contact details for the therapists and had knowledge of what patients should be referred to them.

The service held multidisciplinary team meetings attended by staff from different specialities. In

addition, each ward held daily handover meetings and board rounds where they discussed

relevant information with a focus on patient care.

There were daily board rounds on surgical wards attended by consultants, nurses as well as

therapy staff.

The trust had a transfer of care team consisting of discharge coordinators, social workers and

therapists. Each ward had a discharge coordinator attached to it. Discharge coordinators attended

huddles, board rounds and liaised with social services, patients and families to facilitate patient

discharge.

Seven-day services

There was suitable provision of services at all times to ensure care and treatment delivery

and supporting achievement of the best outcomes for patients.

Medical and nursing staff provided cover on the ward 24 hours a day, seven days a week.

Consultant cover was available seven days a week, including on call outside normal working

hours.


There was dedicated National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

theatre access 24 hours a day, seven days a week.

The day surgery unit opened from 7.30am to 8.30pm.

The endoscopy unit open seven days a week from 8am to 6pm.

The iMobile team (the critical care outreach team) was available seven days a week, 24 hours a

day to assess and provide support for deteriorating patients on wards.

Physiotherapists and occupational therapist were available five days a week. Speech and

language therapy and dietetics were available on all weekdays to patients across all specialities,

as required.

Pharmacy services were available from 8.45am to 7pm, Monday to Friday. The unit opened from

10am to 5pm on Saturday and public holidays, and from 11am to 5pm on Sunday. Staff could

contact an on-call pharmacist out of hours.

Staff had access to imaging services seven days a week and out of hours.

(Source DR134 – Pharmacy Service)

Health promotion

Staff provided patients with relevant information to assist them prepare for their surgery. This

included instructions regarding fasting, medication and wellness.

There were health promotion activities within the trust related to smoking cessation, alcohol

reduction and obesity reduction.

Staff assisted with patient rehabilitation by helping them to get out of bed and attain

independence following their surgery. Staff also referred patients to physiotherapy for

rehabilitation as required. Ward staff confirmed there was a physiotherapist attached to each

ward to facilitate patient rehabilitation.



decisions about their care. They followed the trust policy and procedures when a patient could

not give consent.

Staff had access to mental health/deprivation of liberty safeguards guidelines on the trust

intranet. Staff could talk about the deprivation of liberty safeguards (DoLS) and how this would

impact a patient on the unit. Staff were aware of their responsibilities under the mental capacity

act.

The clinicians we spoke with were all aware of the concept of shared decision-making with

patients. The sample of patient records we reviewed demonstrated consent for treatment and

surgery was completed. Patients told us staff explained treatment and care and sought their

consent before proceeding.

Our review of patient records showed consent forms were completed correctly with all

appropriate sections completed.

Staff reported easy access to the mental health liaison team.


Staff completed Mental Capacity Act (MCA) and DoLS training. Information provided following our

inspection showed 40% of medical staff and 76% of nursing staff had completed the training.


Compassionate care



Feedback from patients and their relatives was mostly positive. We spoke with 12 patients and

three relatives. They were positive about the care provided and described it as “fantastic”, “good

“and “brilliant”. One patient said they had “no fault with the care”.

We spoke with four parents who attended the day surgical unit with their children. They described

the care as “amazing” and “perfect” and said staff had been “brilliant”. They said the staff were

accommodating and engaging.

All observations of care we made were positive, with staff showing kind and compassionate care.

Staff were skilled in communicating with patients and relatives; we observed this on every ward

we visited. Staff were courteous, professional and engaging. We saw staff maintaining patient

privacy and dignity by drawing the curtains around patient areas before completing care tasks.

The service encouraged patients and their families to complete feedback forms to monitor patient

satisfaction with their care.

The Friends and Family Test response rate for surgery at King's College Hospital NHS

Foundation Trust was 15%, which was worse than the England average of 21% from October


However, a breakdown of the friends and family test result by ward showed surgical wards at

Princess Royal University Hospital (PRUH) had a similar or better response rate when compared

with the England average.

Friends and family test response rate at King's College Hospital NHS Foundation Trust, by

ward.


4. The total responses exclude all responses in months where there were less than five responses at a particular ward

(shown as gaps in the data above), as well as wards where there were less than 100 responses in total over the 12

month period.

5. Sorted by total response.

6. The formatting above is conditional formatting which colours cells on a grading from highest to lowest, to aid in

seeing quickly where scores are high or low. Colours do not imply the passing or failing of any national standard.

The PRUH day surgery unit had 21% response rate and 93% of patients confirmed they would

recommend the unit. Surgical ward 3 had 25% response rate and 98% of patients confirmed they

would recommend the unit. Surgical ward 4 had 47% response rate and 97% of patient confirmed

they would recommend the unit. Surgical ward 5 had 21% response rate and 96% of patients

confirmed they would recommend the unit. Surgical ward 6 had 18% response rate and 96% of

patients confirmed they would recommend the unit.


Emotional support


Staff provided emotional support to patients and patients had access to the trust’s counselling

service, and the multi-faith chaplain service. We saw information leaflets about the chaplaincy

service on all wards visited.

Patients and relatives informed us they could speak to staff about their concerns. Families and

carers were encouraged to visit and where possible to support their relative.

Staff understood the impact that a person’s care, treatment or condition had on their wellbeing and

on those close to them.



We saw that staff communication with patients was good, with full explanations provided by staff to

patients and their relatives.

All patients we spoke with confirmed staff introduced themselves, explained procedures and

obtained their consent before conducting them. They confirmed they were informed about their

care and were regularly updated by staff.



The trust did not always provide services in a way that met the needs of local people.

There were clear guidelines for admission to the day surgery and surgical wards. Patients were

admitted to the unit via referral from GPs and via the emergency department. There was access

to pre-assessment clinics, which facilitated preparation and planning for surgery based on patient

need and any identified risks.


Patients were accommodated in single rooms or in single sex bays. Data from the trust showed

there were no mixed sex accommodation breaches in the 12-month period to our inspection.

However, we noted patients sometimes stayed in the recovery area overnight due to lack of beds

on the wards. During our inspection, four patients had stayed in the recovery unit overnight. The

recovery area did not provide single sex accommodation and had no toilet facilities.

Bed management meetings took place daily to identify potential capacity issues in the hospital.

Staff informed us surgical wards were originally designed to admit specific specialities. However,

by the time of our inspection, there were mixed specialities on surgical wards due to bed

pressures. For example, surgical ward 6 was originally a urology ward. However, by the time of

our inspection, the ward admitted most of the medical outliers within surgical services.

Each ward had a discharge coordinator attached to it. Discharge coordinators attended huddles,

board rounds and liaised with social services, patients and families to facilitate patient discharge.

Each ward had a patient flow board, which provided details of each patient’s consultant, date of

admission, expected discharge date, acuity and risk identification magnets (e.g. falls, Venous

thromboembolism (VTE) and dementia).

There was a quiet room within surgical wards for breaking bad news to families. Visiting hours on

surgical wards was from 2pm to 8pm.

At the time of our inspection, staff were drafting a business plan for the expansion of the

endoscopy unit. The endoscopy unit consisted of two procedure rooms and nine beds for

admission, recovery and discharge. Data received from the trust showed over 7400 patients were

admitted for endoscopy procedures in the last year. Staff informed us the endoscopy unit was too

small to meet the demands for the service. Senior staff informed us they would require at least

four procedure rooms to meet the demand of the service. The service outsourced some of its

referrals to Denmark Hill and independent health care providers.



Patients were provided with information leaflets when they attended pre-operative assessments

outlining key information and what to expect. We observed several information leaflets on a variety

of topics were available in all clinical areas and wards visited. This included information about

various surgical procedures, the chaplaincy service and the Patient Advice and Liaison Service

(PALS).

Staff confirmed that they could access interpreting services for patients through a help line and

face-to-face.

Patients confirmed they were offered beverages and food. Food menus offered a range of options

including vegetarian, easy to chew, high energy, gluten free, best renal choice and healthy diet.

The menu also featured some Asian food options and kosher diet was available on request.

Staff assessed patients’ learning disability (LD) needs and referred them to the LD team for

additional support where necessary.

Staff used standardise indicator markers to identify patients with complex needs. For example,

patients living with dementia were identified with a forget me not flower on the patient flow board in

surgical ward 7. Surgical ward 7 admitted mainly frailty and elderly patients. There were dementia

champions on surgical wards.


Surgical wards provided single sex accommodation and access to separate toilet and bathing

facilities.

Access and flow

People could not always access the service when they needed it. Waiting times from referral

to treatment and arrangements to admit, treat and discharge patients were not always in line with

good practice.

From August 2017 to July 2018 the average length of stay for all elective patients at Princess

Royal University Hospital was 3.1 days, which was lower than the England average of 3.9 days.


• General surgery elective patients at Princess Royal University Hospital was 3.1 days, which

was lower than the England average of 4.0 days.

• Urology elective patients at Princess Royal University Hospital was 1.9 days, which was

lower than the England average of 2.5 days.

• Colorectal surgery elective patients at Princess Royal University Hospital was 5.6 days,

which was lower than the England average of 7.0 days.

Elective Average Length of Stay - Princess Royal University Hospital


The average length of stay for all non-elective patients at Princess Royal University Hospital was

5.6 days, which was higher than the England average of 4.9 days.


• General surgery non-elective patients at Princess Royal University Hospital was 4.8 days,


• Trauma and orthopaedics non-elective patients at Princess Royal University Hospital was

8.0 days, which was lower than the England average of 8.7 days.

• Urology non-elective patients at Princess Royal University Hospital was 3.7 days, which

was higher than the England average of 2.8 days.

Non-Elective Average Length of Stay - Princess Royal University Hospital



Referral to treatment (percentage within 18 weeks) - admitted performance

From October 2017 to September 2018 the trust’s referral to treatment time (RTT) for admitted

pathways for surgery was worse than the England average.

In the most recent month, September 2018, the trust scored 52.2% compared to the England

average of 66.6%.


One specialty was above the England average for RTT rates (percentage within 18 weeks) for




Eight specialties were below the England average for RTT rates (percentage within 18 weeks) for






Urology 54.4% 76.7%




ENT 26.8% 63.5%


Data provided for surgical services at Princess Royal University Hospital (PRUH) showed the

service scored 75% between January 2018 and December 2018.

A breakdown of referral to treatment times by speciality for the PRUH is provided below:

Speciality

UNDER

18WKS

OVER

18WKS Total

Sum of

Performance

Accident & Emergency 7 7 100.00%

Breast Surgery 3451 167 3618 95.38%

Cardiothoracic Surgery 70 3 73 95.89%

Colorectal Surgery 6401 958 7359 86.98%

ENT 16623 5997 22620 73.49%

General Surgery 19615 11766 31381 62.51%

Gynaecological Oncology 9 9 100.00%

Gynaecology 12787 4293 17080 74.87%

Hepatobiliary & Pancreatic

Surgery 9 9 18 50.00%

Maxillo-Facial Surgery 32 15 47 68.09%

Neurosurgery 18 17 35 51.43%

Ophthalmology 21377 2936 24313 87.92%

Oral Surgery 6 2 8 75.00%

Orthodontics 1 1 100.00%

Pain Management 2265 194 2459 92.11%

Plastic Surgery 13 18 31 41.94%

Trauma & Orthopaedics 21371 8106 29477 72.50%

Upper Gastrointestinal

Surgery 2873 363 3236 88.78%

Urology 5007 2133 7140 70.13%

Vascular Surgery 1632 240 1872 87.18%

Grand Total 113567 37217 150784 75.32%

(Source: DR136 RTT performance PRUH surgery)

A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was

due to arrive, after they have arrived in hospital or on the day of their operation. If a patient has

not been treated within 28 days of a last-minute cancellation, then this is recorded as a breach of

the standard and the patient should be offered treatment at the time and hospital of their choice

Over the two years, the percentage of operations cancelled at the trust and patients not treated

within 28 days have been worse than the England average.

Percentage of patients whose operation was cancelled and were not treated within 28 days

- King's College Hospital NHS Foundation Trust


Cancelled Operations as a percentage of elective admissions - King's College Hospital


Over the two years, the percentage of cancelled operations at the trust has been similar to the

England average. Cancelled operations as a percentage of elective admissions only includes

short notice cancellations.


A breakdown of cancelled operations at the PRUH is provided below:

Data received from the trust showed between January 2018 and December 2018, the percentage

of patients at the PRUH whose operation was cancelled and were not treated within 28 days

Number of last minute cancelled operations and 28 day breaches for PRUH - Jan-Dec 18

Period

Number of last

minute cancellations

in the qmonth

Total ElectivesBreaches of the

standard

% Last Minute

Cancelled Ops% 28 Day Breaches

Jan-18 36 1294 7 2.8% 19.4%

Feb-18 39 1069 2 3.6% 5.1%

Mar-18 33 993 3 3.3% 9.1%

Apr-18 44 998 0 4.4% 0%

May-18 34 1110 5 3.1% 14.7%

Jun-18 49 978 3 5.0% 6.1%

Jul-18 17 1028 2 1.7% 11.8%

Aug-18 26 957 0 2.7% 0%

Sep-18 34 966 1 3.5% 2.9%

Oct-18 43 1121 3 3.8% 7.0%

Nov-18 42 1141 0 3.7% 0%

Dec-18 21 844 3 2.5% 14.3%

Total 418 12499 29 3.3% 6.9%


(6.9%) was similar to the England average. A breakdown of the figures showed five months

(January, March, May, July and December 2018) when the percentage of 28-day breaches were

significantly high.

The percentage of last-minute cancellations (3.3%) was higher than the England average. Staff

informed us surgeries were sometimes cancelled due to lack of beds or the need to prioritise

emergency surgery.

Information provided by the trust indicated 50% of cancellations were as a result of patients who

“did not attend” their appointments (DNAs). The trust state they are looking to implement a two-

way SMS service to remind patients to attend their appointment.

The service integrated performance scorecard figures from December 2017 to December 2018.

showed bed occupancy was 87.6% (amber). The trust target was 85.7%.

During the same period, theatre utilisation for the main theatres was 79%, slightly less than the

target of 80%. Theatre utilisation for the day surgery unit theatres was 74.7%.

During our inspection, we noted there were a number of medical outliers on surgical wards. Data

from the trust showed between July 2018 and December 2018, the number of non-surgical

patients on surgical wards had been 4923.

Staff informed us the endoscopy unit was not meeting its performance targets for endoscopy

procedures. A breakdown of waiting times for endoscopy procedures on the PRUH site is provided

below:

(Sources: PRUH bed occupancy surgical specialities; DR133 – integrated performance scorecard

surgery, theatres, anaesthetics and endoscopy; DR257 - Endoscopy)

Since the inspection the trust informed us there was a considerable backlog of patients waiting for

urgent and routine endoscopies. We have reviewed the Trust's action plan and will continue to

monitor its progress in reducing this backlog.


PRUH Site Diagnostic Waiting Time Performance for Endoscopic procedures

DM01 Performance Reporting Month

Row Labels 201801 201802 201803 201804 201805 201806 201807 201808 201809 201810 201811 201812

Colonoscopy 14.66% 16.17% 27.91% 35.71% 28.96% 28.26% 44.86% 50.00% 47.23% 52.77% 54.77% 60.41%

Routine 18.62% 15.91% 34.07% 47.64% 40.28% 35.93% 53.48% 62.99% 57.81% 59.24% 63.69% 68.37%

Two Week Wait 3.57% 13.86% 13.98% 11.48% 10.59% 6.72% 13.33% 6.59% 5.00% 9.80% 8.90% 11.90%

Urgent 13.73% 20.27% 21.88% 34.72% 21.30% 31.18% 50.00% 69.23% 56.57% 58.33% 65.02% 68.85%

Cystoscopy 15.12% 6.78% 6.82% 15.00% 8.11% 23.19% 37.84% 4.44% 10.17% 11.76% 6.90% 9.52%

Routine 17.24% 7.89% 6.25% 20.00% 11.54% 27.91% 46.00% 6.45% 13.51% 11.11% 9.09% 12.50%

Two Week Wait 5.56% 7.69% 16.67% 7.14% 0.00% 13.04% 20.00% 0.00% 4.76% 16.67% 0.00% 0.00%

Urgent 20.00% 0.00% 0.00% 0.00% 33.33% 25.00% 0.00% 0.00% 0.00% 0.00%

Flexi sigmoidoscopy 16.50% 26.60% 23.81% 37.84% 33.61% 44.96% 60.80% 54.20% 46.15% 58.82% 67.54% 72.19%

Routine 15.58% 27.42% 25.71% 37.33% 35.06% 48.00% 64.38% 62.67% 50.00% 62.99% 69.17% 75.57%

Two Week Wait 20.00% 21.43% 20.00% 44.44% 33.33% 47.06% 71.43% 12.50% 15.38% 23.08% 40.00% 80.00%

Urgent 18.75% 27.78% 20.00% 33.33% 29.63% 37.84% 50.00% 55.00% 46.51% 57.45% 68.75% 62.75%

Gastroscopy 12.87% 17.74% 25.54% 39.40% 44.53% 39.52% 46.01% 44.07% 40.56% 47.60% 48.67% 53.23%

Routine 16.89% 20.10% 29.44% 45.82% 53.23% 47.81% 55.56% 50.40% 49.10% 55.59% 56.65% 57.75%

Two Week Wait 1.89% 9.62% 8.33% 11.43% 14.47% 8.99% 12.28% 6.45% 4.76% 11.49% 8.43% 8.00%

Urgent 7.14% 16.90% 30.77% 43.75% 46.38% 48.00% 43.21% 53.95% 46.94% 54.13% 55.12% 59.09%

Grand Total 14.25% 17.19% 25.55% 36.60% 35.15% 33.79% 46.54% 46.85% 43.35% 50.91% 53.42% 58.82%




Staff told us they would refer patients and their relatives to the Patient Advice and Liaison Service

(PALS) if the complaint could not be managed at ward level.

We saw leaflets in all clinical areas visited providing visitors with information about how to make a

complaint. This included information about the PALS.

From October 2017 to September 2018 there were 222 complaints about surgical care. The trust

took an average of 30 days to investigate and close complaints. This was not in line with their


A breakdown of subject can be seen below:






Communications 25





Other 4



Waiting Times 4


Restraint 1



Commissioners); 1


Of the complaints, 139 (63%) were regarding King’s College, 70 (32%) regarding Princess Royal

and the remaining were about Orpington and Beckenham Beacon.


Further information received from the trust showed from 1 April 2018 to 31 January 2019, there

were 67 complaints about surgical services at Princess Royal University Hospital. Information

provided showed initial acknowledgement letters and investigations were completed in line with

the trust guidelines.




Leadership

Managers had the right skills and abilities to run a service providing sustainable care.

A clinical director, general manager and head of nursing for surgery, theatres, anaesthesia and

endoscopy led surgical services on Princess Royal University Hospital (PRUH). The team was

supported by clinical leads for specialities. Nursing staff were led by two matrons for surgical

wards and a matron each for the day surgery unit, endoscopy unit and theatres. Band 7 ward

managers supported matrons on the ward.

Staff on all units visited were generally positive about the leadership team and felt the local

leadership team were visible and approachable. They felt well supported by the local leadership.

Lines of accountability and responsibility on the units were clear and staff understood their roles

and how to escalate problems.

Doctors felt supported by the wider team as well as medical colleagues and told us they received

good support from consultants.

Vision and strategy

The trust had a vision for what it wanted to achieve; however, plans had not been

implemented due to financial constraint.

Staff were aware of the trust’s overarching vision to provide the best quality care. Senior staff

informed us they had achieved one of their goals for surgical services, which was to improve nurse

staffing and reduce the vacancy rate. Senior staff said they wanted to improve staff retention and

the services’ performance quality indicators.

Senior staff informed us the endoscopy unit remained one of their main priorities for 2019/2020.

Staff were aware about plans to create a decontamination unit for endoscopes in the hospital

basement. There was a business case in place for the unit; however, we were informed this had

not yet been implemented due to financial constraints. At the time of our inspection, the service

was preparing a business case for the expansion of the endoscopy unit.

Culture

Managers promoted a positive culture that supported and valued staff, creating a sense of

common purpose based on shared values.

Staff were positive about the culture within surgical services. Staff felt they had opportunities to

develop in their role and felt they worked in a friendly environment. We noted a number of staff

had risen through the ranks to senior positions. Staff felt part of the team and said they were well

supported by their line manager.

Staff said they had good working relationships with other team members within the service. Staff

said the service was open and transparent and they could raise any concerns with senior staff.

However, staff felt there was a disparity in the way resources were allocated between trust sites.

Staff felt the PRUH site was allocated less resources when compared to the main trust site at

King’s College Hospital (KCH). For example, medical staff felt consultant positions were filled at

KCH, whilst there were vacant positions on the PRUH site.

In addition, staff pointed out the trust did not have standardised pathways for patient care across

sites. For example, patients who attend the emergency department with back pain at KCH had


access to MRI scans in the department, whereas, patients attending the PRUH site were admitted

to the orthopaedic unit.

Governance

The trust used a systematic approach to continually improve the quality of its services.

Surgical services at the PRUH sat under the PRUH and south sites division for acute and

emergency care, post-acute medicine, surgery and theatres, and women and children. The

divisional leadership consisted of a medical director, director of operations and director of nursing.

There were governance leads for different specialities under surgery, theatres, anaesthesia and

endoscopy. This includes the service’s general manager, clinical director, head of nursing, patient

outcomes lead, patient safety and governance lead consultant and a patient safety manager.

The service held bi-monthly clinical governance meetings and a monthly care group risk and

governance meetings.

We reviewed minutes of last six clinical governance meetings. They showed staff discussed

issues from previous risk and governance meetings including incidents and trends, audits, risks on

the risk register and advance directives. Staff also discussed safety nets and alert, root-cause

analysis reports and the GREATIX report. The GREATIX report was used as a means to gather

positive feedback about staff and recognise outstanding staff contributions. Staff were encouraged

to report positive feedback about other staff using the GREATIX report.




The service conducted monthly audits to monitor performance against established standards. A

monthly performance scorecard was shared with surgical specialities and this provided an

overview of performance against clinical indicators.

There were 26 surgical risks on the risk register and these reflected our findings during the

inspection. Seven risks were identified as major risks and 19 were identified as minor or moderate.

There were controls in place to mitigate the risks and the risks were regularly reviewed by senior

staff. However, low compliance with mandatory training for medical staff was not identified as a

risk on the risk register.

We noted endoscopy decontamination was no longer on the risk register. This was on the risk

register during our last inspection in 2017. By the time of our current inspection, decontamination

of endoscopes took place within the theatre unit. However, staff expressed concern about the

suitability of the endoscopy unit and insufficient facilities to carry out the number of procedures

referred to the unit. The risk of harm due to equipment was identified as a major risk for the

endoscopy unit. This was in reference to a specific high definition scope and scope guides.

Controls in place included ensuring procedures for high risk patients were carried out by

experience clinicians and referring patients to the KCH site which had high definition equipment.

Although the suitability of the endoscopy unit was not specifically identified as a risk on the risk

register, staff recorded action taken regarding a business case for the expansion of the unit within

the risk regarding equipment.

We reviewed an endoscopy ‘work in progress’ report from August 2018. This highlighted various

issues regarding the endoscopy unit and action plans regarding those issues. Issues highlighted


on the report included JAG accreditation, refurbishment of the decontamination unit and staff

training amongst others.

Following our inspection, the trust informed us there was a major programme for endoscopy

decontamination at the PRUH. The programme was monitored monthly at a decontamination

meeting chaired by the chief nurse and attended by clinical leads.

Another major risk identified on the risk register included anaesthetic (intensive care unit) cover

out of hours. This highlights risk of delay in reviewing patients who were acutely unwell due to the

number of services covered by anaesthetic registrars out of hours. Controls in place included

increase in iMobile nursing capacity, added tier of junior intensive care unit (ICU) doctors to cover

ICU, use of locum anaesthetic staff or ICU consultants. In addition, the service was actively

recruiting to fill anaesthetic registrar positions.




Staff informed us they could access information they needed to provide safe and effective care.

Patient records were held secure electronic systems in inpatient surgical wards.

The intranet was available to all staff and contained links to guidelines, policies and procedures.

All staff we spoke with knew how to access the intranet and the information contained therein.

All staff had access to their work email and senior staff informed us they provided organisational

information and updates to staff on regular basis. Relevant information was displayed on notice

boards in clinical areas and in staff rooms.

We saw relevant information displayed on notice boards within staff rooms. These included key

policy information, incidents and trends and training dates for mandatory training amongst others.

Engagement

The trust engaged well with patients, staff, the public to plan and manage appropriate services.

The head of nursing attended weekly meetings with ward sisters and with sisters in the theatres.

Staff had access to information about the service and the trust through newsletters and the

intranet. We observed staff notice board highlighted clinical information, incidents and trends,

areas of learning, as well as opportunities for training.

The service engaged patients through feedback forms. Feedback from patients were used to

improve the service. The information board on each ward visited displayed information about

improvements made following patient feedbacks. For example, feedback was provided to medical

teams to complete discharge letters prior to all discharges following complaint about discharge

letters.


The trust was committed to improving services by learning, promoting training, and

innovation.

Surgical ward 6 was awarded the ward of the month in February 2018 for performing beyond their

normal duties to ensure excellence in care and patient experience. In July 2018 the ward was also

presented with Kings recommendation for outstanding services to the trust in recognition of their

commitment and dedication.


Learning from incidents was well embedded in surgical services and we observed information

about incidents, current trends and learnings were displayed on staff notice boards.

Surgical wards were in various stages of accreditation for the Kings way accreditation for wards.

This aimed to implement standards for all members of staff across the trust. Wards were

accredited based on a number of indicators including infection control, medicines management,

equipment checks, effective patient feedback mechanisms, communication between clinical teams

and care amongst others. Up to 65% score indicated the ward was at an early stage or making

improvement, 66% to 84%, indicated the ward was working towards accreditation, 85% and over

meant the ward achieved full accreditation. Wards that maintained over 85% score for two years

were rated as ‘Exemplar’.

End of life care


End of life care encompasses all care given to patients who are approaching the end of their life

and following death. It may be given on any ward or within any service in a trust. It includes

aspects of essential nursing care, specialist palliative care, and bereavement support and

mortuary services.

The trust had 2,370 deaths from August 2017 to July 2018.


The trust submitted data following inspection which showed there were 1,175 deaths at the

Princess Royal University Hospital from January 2018 to December 2018. The specialist

palliative care team saw 1,329 patients between April 2017 and March 2018.

The trust has advisory palliative care teams on both acute sites. Both are consultant-led, with

nurse specialists, social work and administrative support. Referrals and end of life care (EOLC)

notifications are made via the trust electronic patient record (EPR). Seven-day visiting Kings

College is provided by specialty registrars and by Clinical Nurse Specialists at Princess Royal

University Hospital (PRUH).

Consultants provide a 24-hour telephone advice service across site. DH and PRUH have

bereavement offices, chaplaincy and mortuary services. There are link nurse forums on both

sites and an established programme of medical, nursing and Allied Health Professionals

education.

(Source: Routine Provider Information Request (RPIR) – Context acute tab)


Mandatory training

The service provided mandatory training in key skills to all staff and made sure everyone

completed it.





Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met











Governance) [ 1 Year] 14 13 93% Yes






In end of life care the 80% target was met for 13 of the 15 mandatory training modules for which



medical staff in end of life care is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met















In end of life care the 80% target was met for nine of the 13 mandatory training modules for

which medical staff were eligible.



The practice development told us mandatory e-learning was registered on the trust mandatory

training platform. They received updates on nursing staff compliance and if required, remind them

when and which training was due.

We spoke with portering staff who told us that in addition to training provided by their employer

(different from the trust), they received training from mortuary staff. This included moving and

handling of bodies. We saw that mortuary staff were up to date with mandatory training.

Safeguarding


agencies to do so. Staff had training on how to recognise and report abuse, and they knew

how to apply it.


A breakdown of compliance for safeguarding training courses as of October 2018 at trust level

for qualified nursing staff in end of life care is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met


(Source: Routine Provider Information Request (RPIR) – Training tab

All members of staff we spoke with understood their responsibilities for safeguarding patients and

reporting any potential safeguarding concerns. There were clear processes in place and staff

could describe the necessary steps they would take to raise concerns. They knew how to find

additional information on the trust’s intranet and how to report concerns if they felt a person was at

risk of abuse. Staff were also able to demonstrate an understanding of the types of concerns

which may alert them to a possible safeguarding concern.

Nursing staff were aware of the signs of abuse and they told us they would report any concerns to

the person in charge of the shift or the ward manager. All members of mortuary and bereavement

staff had completed safeguarding adults and safeguarding children level two training.


The service controlled infection risks well. They used control measures to prevent the

spread of infection. Safety systems, processes and practices were implemented and

communicated to staff.

The portering department and mortuary staff followed standard operating procedures. These were

aligned with Health and Safety guidance about safe handling of the deceased.

There were systems to support staff in preventing and protecting people from a healthcare-

associated infection. Deceased patients confirmed to be an infection control risk were stored in a

safe manner.


Porters we spoke with could describe the process for transferring a deceased patient who may

have been infectious. The porters used personal protective equipment that was readily available

on the ward when they transferred the patient to the trolley. At the point they left the ward they

were required to remove the personal protective equipment and dispose of it. Personal protective

equipment was not used outside of the clinical area to prevent the potential spread of infection.

Post mortems were carried out daily at the Princess Royal University hospital. The post mortem

room had three tables equipped with extraction and wash down facilities. Each table had its own

colour coded storage containers for use during the procedure. Staff told us that all leakages were

wiped up immediately and trays with bodies on were cleaned once the body was removed.

Staff in the mortuary had access to a changing room, hand washing facilities and protective

clothing. This included specialist clothing when handling bodies with highly infectious diseases.

Personal protective equipment (PPE) such as gloves and aprons, was available throughout the

mortuary area and we observed staff using it appropriately.

All areas of the mortuary were visibly clean, and we saw there were regular audits to check

compliance with the infection prevention and control processes. The mortuary staff were

responsible for the regular scheduled cleaning. Suitable equipment and cleaning products were

available as well as coloured waste bags in line with Control of Substances Hazardous to Health

requirements.

Medical and nursing staff followed trust policies on infection, prevention and control. For example,

they were bare below the elbows in line with trust policy, used antibacterial hand gel when they

moved between patients, washed their hands, wore personal protective equipment and disposed

of waste correctly. This ensured that patients receiving end of life care were cared for as safely as

possible. Wards we visited where end of life care patients were cared for were visibly clean. There

were sufficient hand washing facilities available for staff to wash their hands as well as hand

sanitisers placed at entry and exit points.


The service had suitable premises and equipment and looked after them well.

Patients receiving end of life care were cared for throughout the hospital. Nursing staff told us

there was a sufficient supply of syringe drivers and pressure relieving equipment and this

equipment was provided promptly when requested. The maintenance of equipment supported staff

to keep people safe. Staff had access to syringe drivers to provide end of life patients with

anticipatory medicines.

The trust used syringe drivers that met national safety standards. One brand of syringe driver was

used across all wards. This reduced the likelihood of confusion or error by staff, particularly bank

or agency staff. The trust had a planned maintenance schedule to ensure syringe drivers were

serviced. This was managed by the medical equipment library. Syringe drivers were stored and

delivered or collected from the equipment library. Nursing staff explained the process to report a

faulty syringe driver and told us they got a prompt response from the equipment library.

Access to the mortuary was for authorised people only and visitors were usually notified to

mortuary staff in advance. There were 67 spaces to hold bodies in the mortuary, each of which


could accommodate bodies up to 25 stone in weight. Larger bodies were stored off site with a

specialist provider.

In preparation for winter pressures and an anticipated increased demand for storage space, the

service commissioned a hard-shell storage facility with fridges which could accommodate 48

additional bodies. This was positioned directly to the back of the mortuary at the end of a

concealed entry point. We saw that all fridges were double locked and there was closed circuit

television on them at all times which could be observed on a screen in the mortuary.

Fridge temperatures in the mortuary were recorded daily and records we viewed had no gaps in

recording. An alarm sounded if the fridge temperatures dropped below the required temperature.

Faults on the fridges were alerted through the hospital switchboard to the mortuary and

maintenance teams, who were available 24 hours a day to respond to any problems.

The viewing room where family members spent time with their relative’s body was well maintained

by mortuary staff. We were told it was recently refurbished by ‘Friends of the PRUH’.


Staff did not always complete and update risk assessments for each patient.

The trust introduced a treatment escalation plan (TEP) in November 2018. This was a plan to

ensure that every patient had their ceiling of care considered and documented formally, in line with

the national initiative. Treatment options were identified which staff discussed with the patients and

or their relatives as well as any decisions on whether resuscitation would be attempted.

Members of the leadership team told us recognition of the dying patient remained a challenge to

address. The expectation was that doctors would feel more confident to act according to the TEP,

but at the time of inspection, it was too early to assess the impact.

We reviewed 12 sets of electronic patient records and similar to the previous inspection, found

little evidence of individualised care planning or regular monitoring for comfort. Seven records did

not include a malnutrition universal screening tool (MUST) risk assessment score. There was no

action plan for the five which had a MUST risk assessment. We discussed this with the specialist

palliative care team who acknowledged that this was an area that required development with ward

staff.

There was a triage system in operation for half a day Monday to Friday. A clinical nurse specialist

or consultant reviewed every patient flagged as end of life on the electronic patient record. They

entered their findings on the record, including any further actions or no further actions required.

Members of the SPCT told us this system gave them a good overview of current patients at the

end of life and assisted ward staff to be proactive in their care.

Not all patients at the end of life were referred to the palliative care team but nursing staff told us

that when referrals were made the team always responded quickly. Ward staff were very positive

about the responsiveness of the palliative care team. Patients referred to the specialist palliative

care team were discussed at the weekly palliative care multidisciplinary meeting.

The electronic records system enabled the SPCT to have immediate access to the records of

patients who had been identified by ward staff as nearing their end of life. Staff were able to

contact the SPCT for advice if they required support with that judgement. The SPCT told us their

aim was to see every dying patient daily and ward staff confirmed this was most often the case

and stated that they felt well supported by the SPCT.

Nurse staffing


The service had enough nursing staff with the right qualifications, skills, training and


treatment.

The trust reported staffing numbers for specialist palliative care teams at Kings College Hospital

(KCH) and Princess Royal University hospital (PRUH) sites for August 2018.

Staffing group

Planned

staff Actual staff Fill Rate

Qualified nursing & health visiting staff (Qualified

nurses) 16 13.9 87%



staff in the specialist palliative care team at the PRUH. This was higher than the trust target of 8%

and the trust average for nursing staff of 10.2%.


There was a turnover rate of 8.8% from September 2017 to August 2018, which was lower than

the trust target of 10%.


The reported sickness rate from September 2017 to August 2018, was 4.6% which was higher

than the trust target of 3% and the average for nursing staff of 3.3%.


There was no bank or agency staff usage reported during this period.


The trust submitted data for January 2019 following this inspection which showed there were no

vacancies in SPCT nursing staff. The wholetime equivalent (WTE) was 6.6. and the fill rate was

6.6. This was an increase since the time of the last CQC inspection in 2015.

Medical staffing

The service did not have enough staff with the right qualifications, skills, training and


treatment.

The trust reported staffing numbers for specialist palliative care teams at Kings College Hospital

(KCH) and Princess Royal University hospital (PRUH) sites for August 2018.


Staffing group

Planned

staff

Actual

staff Fill rate

Planned

staff

Actual

staff

Fill

Rate


Medical & Dental staff -

Hospital 35.7 20.5 57% 10.8 3.9 36%

There has been a large decrease in both the planned and actual number of WTE at the trust.



care. This was higher than the trust target of 8% and the trust average vacancy rate for medical

staff of 10.2%.


• King’s College – 43.8%

• Princess Royal University – 70.1%


From September 2017 to August 2018, the trust reported a turnover rate of 16% in end of life

care. This was higher than the trust target of 10% and the trust average for medical staff of

12.4%.


• King’s College – 22.2%

• Princess Royal University – 0%


From September 2017 to August 2018, the trust reported a sickness rate of 0% in end of life

care.

(Source: Routine Provider Information Request (RPIR) - Sickness tab)

There was no bank or agency staff usage reported during this period.

(Source: Routine Provider Information Request (RPIR) - Medical agency locum)

Following inspection, the trust submitted data for January 2019 which showed wholetime

equivalent (WTE) for medical staffing to be 6.9 with a fill rate of 3.7. This meant there was a

vacancy rate of 3.2 (46.4%).

On- site medical staff had increased since the time of the last inspection in 2015. Two whole time

equivalent palliative care consultants were appointed to the PRUH team in June 2017 and were

on-site 9:00am to 5:00 pm Monday to Friday and telephone on-call outside these hours.

Records

Records did not always clearly demonstrate the needs of the dying patient.


The hospital used a centralised electronic records management system. This allowed all nursing

and medical staff to access patient records from any computer in the hospital. Patient records

were secure as each member of staff required a log in username and password to access the

record.

Members of the SPCT team acknowledged that further improvements needed to be made to the

electronic patient record so that the needs of the dying patient could be more integrated and easily

identified.

The SPCT used a separate palliative care electronic data base which was accessible only to

members of the SPCT. This included patient details, assessment and input by members of the

team. We viewed two patient records on this database and saw there was a comprehensive

record of SPCT current involvement.

Medicines


medicines.

Medicines were prescribed, stored and administered to people in line with current legislation and

national guidance such as the National Institute for Health and Care Excellence (NICE). The trust

used electronic prescribing and management of medicines, which reduced the possibility of

medicines errors.

Patients receiving end of life care were prescribed anticipatory medicines to manage symptoms

that may be present at the end of life. Anticipatory medicine is prescribed to be given when it is

needed, rather than on a regular basis. Medicines were prescribed in advance to ensure

symptoms such as pain, agitation and nausea could be managed.

Medicines were administered by a syringe driver where the oral route became inappropriate and

symptoms were continuous. Nurses were trained to set up syringe drivers and did not rely on the

SPCT to do this.

Non-Medical Prescribing is the prescribing of medicines, dressings and appliances by health

professionals who are not doctors. Three of the specialist palliative care nurses could prescribe

medicines. However, it was the accepted view of members of the SPCT that prescribing should be

the responsibility of general medical teams. Ward nursing staff told us in most cases, doctors were

proactive in prescribing medicines for patients on end of live care. One junior doctor told us they

had a good understanding of medicines related to the dying patient and they accessed these on

the electronic patient medicines record.

Incidents



whole team and the wider service.




never event.

From October 2017 to September 2018, the trust reported no incidents classified as never events

within end of life care.



In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents

(SIs) in end of life care which met the reporting criteria set by NHS England from October 2017 to

September 2018.


There were 36 incidents related to palliative care and end of life care between January 2018 and

December 2018. Of these 25 related to medicines; eight were where the DNA status was not

recorded, and three related to poor end of life care documentation. Learning and actions included

a rolling programme of training for ward staff on syringe drivers and training for all staff on

communication with the dying patient. We saw record of training carried out by ‘super users’

trained to train nursing staff. The SPCT facilitated a communication skills simulation training

session for nursing and medical staff. This had been well attended and feedback was very

positive.

Staff we spoke with were aware of the process for reporting incidents and could describe

occasions when they had raised incidents. There were processes to be followed for investigating

incidents. Staff informed us that feedback was shared at a local level by managers and through

trust-wide communication when appropriate.

All incidents were discussed at the specialist palliative care clinical governance meeting held every

eight weeks. Managers investigated incidents and shared lessons learned with the whole team

and the wider service. Feedback and learning from incidents were shared at SPCT consultant

meetings held every two months and at SPCT nurse team meetings held each month. General

nursing staff told us incidents were shared in their daily safety huddles and in e-mails. They told us

the ones most frequently related to end of life care were around medicines and pain management

in particular.

We reviewed two recent incidents logged by mortuary staff on the electronic incident reporting

system, one of which was where a deceased patient did not have sufficient identification. We were

told that a member of staff from the ward was asked to come to the mortuary and identify the

patient. Ward staff were e-mailed a reminder about the correct identification process when

transferring a body. The other incident related to injuries to deceased patients due to positioning

errors on the concealment trolley. Refresher training for portering staff was initiated and no further

such incident had occurred.

Bereavement office staff logged an incident which related to the late completion of the Medical

Certificate of Cause of Death (MCCD), which affected four deceased patients over the course of

one weekend. We discussed this with bereavement staff and saw the clinical director had been e-

mailed with concerns and there had been an improvement since then.



The service did not always provide care and treatment based on national guidance and

evidence of its effectiveness.

Similar to our findings at the last CQC inspection in May 2015, there was no care plan and review

system for care of the dying patient readily accessible to nursing or clinical staff on the wards. As a

result, not all aspects of NICE guidance NG31 ‘Care of dying adults in the last days of life’ were

followed. We saw there was a paper copy of ‘Priorities for Care of the Dying Person’ (as set out by


the Leadership Alliance for the Care of Dying People) available. One part set out the priorities of

care (identify; communicate; assess; respect; establish – ICARE) and the other set out the daily

care plan review of the patient’s end of life care plan.

Ward nurses told us it was ‘frustrating’ not to have an end of life care plan as it was possible to

overlook certain aspects of good care.

The practice development nurse told us that in the absence of any electronic end of life care plan,

they spent a significant amount of time on wards, reminding nursing staff ‘to think ICARE’. They

acknowledged that whilst nurses could use the standard ‘nursing core care plans and evaluation

booklet’, this was not relevant to the patient’s care needs at the end of their life. We were told that

discussions were underway to add the end of life care plan to the patient electronic record.

Members of the specialist palliative care team (SPCT) acknowledged there was no comprehensive

way for nursing staff to record the dying patient’s end of life care plan. They also told us that

certain aspects of patient care were difficult to audit; for example, regular assessment of symptom

control and four hourly review and delivery of care by nursing staff. We saw that at a recently held

study day, suggestions were invited for how improve the electronic patient record documentation

for patients nearing the end of life.

The end of life care annual report to the trust board in February 2019 identified several areas

where there was limited documentation to support aspects of care. These were identified as

decisions around nutrition and hydration; assessment of capacity and documentation of preferred

place of care or death.

We reviewed minutes from the specialist palliative care development meeting where lack of end of

life care plan was discussed briefly. August 2018 minutes recorded that in the meantime, nursing

staff were using the standard nursing care plan. It was also noted there was uncertainty about

whether an end of life care plan could be included in electronic patient records to be introduced in

November 2018. Minutes from the October 2018 meeting referred to the end of life care plan with

the suggestion of exploring how a neighbouring hospital managed their end of life care plan within

electronic records. The December 2018 minutes acknowledged there was still no progress on an

end of life care plan. It was agreed that a plan would be presented to this meeting in February

2019 and following that, to the trust end of life strategy group for further discussion.

There was a cross-site audit of prescribing practice to review the prescribing practice and

documentation of patients started on a strong opioid as compared to the recommendations of the

NICE CG 140 guidelines. NICE clinical guideline CG 140 Palliative Care: Strong Opioids for Pain

Relief, published in May 2012 and updated in August 2016, focuses on the use of strong opioids in

the management of patients with advanced disease.

The overall aim was to understand the prescribing practice of strong opioids at Kings College

Hospital Trust, to identify areas of good practice and areas for improvement. Recommendations

from the audit included specialist advice to be sought when prescribing opioids in hepatic and or

renal failure. The need to consider and prescribe laxatives for patients commencing or already on

opioids should be highlighted and should be documented if not required. Morphine as the first line

opioid to be prescribed in patients without contraindication should be highlighted and any

contraindication should be documented.

A group of doctors undertook a quality, innovation, productivity and prevention (QIPP) project on

end of life decisions. This was to explore the move from paper to electronic records and the way in

which resuscitation status was documented. The aim was to raise awareness of the standard; get

admitting doctor to consider resuscitation status and increase the number of valid decisions

‘recorded.


The project gathered evidence from 262 patient notes between March and May 2018 across 11

wards. Stickers were produced with ‘Have you documented Resus Status? Please record this

patient’s resuscitation status on EPR.’ All blank clerking documents were replaced with stickered

versions over a period of two weeks and the expectation was the resuscitation status was

recorded on the electronic patient record (EPR) within 24 hours.

Outcome of the QIPP showed there was a resuscitation decision on 48.5% of clerking booklets

before the intervention and on 54.4% afterwards. There was a significant improvement in

recording of resuscitation decision on the EPR from 45.3% to 72.1%.


The Malnutrition Universal Screening Tool (MUST) is used to assessed patients at risk of

malnutrition. Decisions around nutrition and hydration should form part of the end of life care plan.

During inspection we reviewed 12 sets of electronic patient records, seven of which did not include

a MUST assessment. Of the five records which had an assessment, four did not have an action

plan to guide staff on how they should manage the fluid and nutritional needs of the dying patient.

The end of life care annual report to the trust board in February 2019 identified several areas

where there was limited documentation to support aspects of care. These included nutrition and

hydration. Most members of the SPCT we spoke with highlighted this as an ongoing problem.

They said they continued to remind ward staff to complete a MUST as part of the care of the dying

patient.

Nursing staff told us they encouraged patients to eat and drink for as long as they could in their

last days of life. They acknowledged this was not formalised and they did not record the frequency

with which fluids were offered to patients at the end of their lives.

Pain relief

Staff did not always assess and monitor patients regularly to see if they were in pain.

There were no specialist pain assessment tools in use for those people who had difficulties in

communicating. Staff told us they ensured patients did not experience lengthy periods of pain.

Where the patient was non-verbal, they observed behaviours or responded to family member’s

request for pain relief. However, since there was no end of life care plan, it was not always

possible to ensure a patient’s pain levels were regularly assessed and monitored in accordance

with the ‘priorities of care of the dying patient.

During this inspection, we observed patients who were at the end of their life were prescribed

medicines to manage any change in their pain or symptoms and to avoid any unnecessary delay

in administration if a patient’s needs changed. These medicines are known as anticipatory

medications for symptoms that may not be encountered very frequently and known to occur at end

of life or were predicted to occur. This included associated medication for pain, agitation, nausea,

respiratory secretions and breathlessness.

A referral to the SPCT was automatically generated once anticipatory medicines were prescribed.

A team member visited the patient as soon as possible and usually within hours, to ensure that the

automatically prescribed dose was at the correct level. We noticed two occasions where the

patients were identified as dying, and in their last few days and hours of life but were not

prescribed anticipatory medicines. We queried this with separate nurses who told us the patients

were “not quite at that stage yet.” However, the purpose of anticipatory medicines is that they

should be ready to be administered as soon as the patient begins to experience pain, rather than

waiting for a prescription to be written up.


Patient outcomes


improve them.

The trust participated in the end of life care audit: Dying in hospital 2016 and performed better

than the England average for each of the five clinical indicators.

The trust answered yes to five of the eight organisational indicators. The ones which they

answered no to were:

• Between 1 April 2014 and 31 March 2015, did formal in-house training include/cover

specifically communication skills training for care in the last hours or days of life for allied

health professional staff?

• Was there face-to-face access to specialist palliative care for at least 9am to 5pm, Monday

to Sunday?

• Does your trust have one or more end of life care facilitators as of 1 May 2015?


There was an audit of 23 patient records between June and August 2018. The focus was to

assess how the priorities of care (identify; communicate; assess; respect; establish – ICARE) were

applied. The audit showed there was good recognition of the dying patient in 91% of the records;

sensitive communication in 92% and awareness of care after death in 96%.

However, the audit also identified there was 0% assessment of organ donation, advance decision

to refuse treatment and Lasting Power of Attorney. Seven per cent of records recorded the wishes

of those identified as important to the patient and 33% identified the patient’s hydration and

nutrition needs. The patient’s physical, psychological, spiritual and social needs were considered

in 40% of records. The auditor found that 56% of patients looked comfortable at time of the spot

check.

We were told by a practice development nurse improved recording was part of the end of life

teaching programme.

The trust submitted data to the 2018 National Audit of Care at the End of Life (NACEL), the

outcome of which is due to be published in May 2019. This national audit focuses on the quality

and outcomes of care experienced by those in their last admission in acute, community and

mental health hospitals throughout England and Wales.

Competent staff




From April 2018 to September 2018, 96% of staff within end of life care at the trust received an

appraisal compared to a trust target of 90%.

Staff group

Individuals

required (YTD)

Appraisals

complete

(YTD)

Completion

rate









The trust submitted data following inspection which showed that all clinical nurse specialists had

current appraisals.

We were told that new nursing and medical staff were provided with palliative and end of life care

training during their mandatory trust induction. Members of the specialist palliative care team

(SPCT) delivered palliative care and end of life care training in junior doctor foundation trainee

education as well as in general medical teaching and to nursing staff. We saw there was an end of

life care training plan, which included communication training; end of life care and medicines at the

end of life. The SPCT at the Princess Royal hospital contributed to 77 hours of training to a total of

785 staff across the trust between October and December 2018.

The SPCT facilitated a communication skills simulation training session for nursing and medical

staff with actors. We were told this was well attended and feedback was very positive.

The SPCT held a study day shortly before this inspection. Topics covered included presentations

on bereavement and loss, withdrawal of treatment, symptom control and lessons learned from a

recently published report. There were 50 attendees at this study day which included nursing staff

and student nurses, healthcare assistants and allied healthcare professionals. We saw the

feedback on the relevance of the day to practice was very positive. The expectation was that a

study day would be held twice yearly, and it was hoped it would also attract medical staff

attendance.

The specialist palliative care team (SPCT) had a number of clinical nurse specialists (CNS) in post

that completed extra training and had relevant clinical experience. For example, three were non-

medical prescribers. All CNSs were registered mentors and syringe driver ‘super users’ which

meant they trained nurses on how to set one up. There were monthly team action learning and

case reflection meetings held.




The Princess Royal University Hospital (PRUH) palliative care consultants attend monthly

consultant/senior team meetings at Kings College Hospital (KCH). Members of the specialist

palliative care team (SPCT) told us they worked closely with colleagues from other specialties to

achieve the best possible outcome for patients. However, they commented that meetings of

interest and relevance to the PRUH team were mainly held at KCH. Since there was a significant

amount of travel involved, it was not always possible to attend.

Doctors told us there were weekly multidisciplinary meetings (MDM) on the ward. These were with

all professionals involved in the patient’s care and included clinicians, medical staff, allied health

professionals and a member of the Chaplaincy team. Part of the focus of these MDMs was to

discuss the patient’s presentation, their current medical and social support and to consider


whether the patient may be in their last weeks or days of life. A doctor told us they were supported

in this by the specialist palliative care team (SPCT) who were always available to offer training,

support and guidance. We saw records of these meetings where the patients were listed in order

of priority for allocation to a member of the SPCT.

A member of the SPCT spent time each day in the accident and emergency department to review

any patients appropriate for the service. Ward staff we spoke with were aware of how to contact

the hospital SPCT and were positive about the input and care delivered by the team. They told us

how the SPCT helped to improve the pathway for end of life patients between the emergency

department and the ward.

Referrals to the SPCT came from various professionals, including nursing, medical and allied

health professionals. Whilst there was access to allied health professionals including

physiotherapists, occupational therapists and speech and language therapists, they were not part

of the specialist palliative care hospital team.

Seven-day services

There was an improved palliative care clinical nurse specialist seven-day service introduced in

April 2018. There was cover between 9am and 5pm Monday to Sunday, including bank holidays.

The clinical nurse specialists offered a visiting service to the wards and reviewed palliative patients

with complex needs or symptoms already on the caseload. Nursing staff told us this additional

weekend cover was essential but there were times when they felt stretched to fulfil the hours. They

emphasised that good teamwork was essential to the provision of this service.

However, consultant cover remained at a similar level. They provided a service between 9am and

5pm Monday to Friday and telephone on-call outside of these hours.

Chaplaincy services were multi-faith and provided an on-site service between 9am and 5pm

Monday to Sunday and out of hours telephone on-call at all other times.

Health promotion

The SPCT told us they provided support to a wide range of patients in receipt of palliative care and

not just those in the last days of life. These included patients who had comorbidities that affected

their health and wellbeing who may need specific guidance on health promotion.

The team monitored the wellbeing of any patients in receipt of palliative care and took appropriate

action to promote health and wellbeing, for example by reviewing medication, sign posting to care

support networks amongst other actions.





The trust submitted data following inspection which confirmed that all clinical nurse specialists in

the Specialist Palliative Care team (SPCT) completed Mental Capacity Act (MCA) training.

Staff understood the relevant consent and decision-making requirements of legislation and

guidance, including the Mental Capacity Act 2005. Mental Capacity Act 2005 guidance was

available on the trust’s intranet along with other associated documents such as the trust’s consent

policy, dementia policy and safeguarding adults at risk policy.


Ward staff demonstrated a good understanding of the MCA; they could show us where relevant

documentation related to Mental Capacity Act was on the intranet. When patients could not give

consent, staff made decisions in their best interest, taking into account patients’ wishes, culture

and traditions.

The trust carried out an audit of decisions and documentation of 1541 completed DNACPR forms

between 1 January and 9 May 2018. Some of the findings included 8% of forms not completed by

or co-signed by a consultant; 24% did not evidence discussion with relatives or family. The audit

also identified limited evidence of ward nurses being involved in DNACPR decisions or being

informed of decisions. It was highlighted that this was a significant risk where ward nurses were

unaware of patients’ CPR status and resulted in attempts made to resuscitate a patient who was

not for resuscitation.

The trust introduced a treatment escalation plan (TEP) in November 2018. This was a plan to

ensure that every patient has their ceiling of care considered and documented formally, in line with

the national initiative. It included any decisions on whether resuscitation would be attempted.

We reviewed five patient records where the TEP electronically recorded ‘do not attempt cardio

pulmonary resuscitation’ status. We reviewed the accompanying (DNACPR) forms, the majority of

which were appropriately completed. All five had capacity recorded, although in one where it was

recorded the patient lacked capacity, staff could not locate the mental capacity assessment. There

was no documented record of discussion with family on three forms; this was similar to findings at

the last CQC inspection in 2015.

Compassionate care

Staff cared for patients with compassion. Feedback from patients confirmed that staff

treated them well and with kindness.

Patients were respected and valued as individuals and were treated with kindness and

compassion. We observed several examples of staff interacting with patients and those close to

them with kindness and dignity. Staff told us how important it was that their role extended to

supporting the families of the dying and enabling them to spend as much time together as

possible.

Patients and their family members told us staff treated their relative with dignity and respect, they

explained what was happening and were always caring. One patient told us, “I can’t fault any of

the staff; they are all so kind and positive.” Another said, “All the staff have such a nice way about

them”. A relative told us “Everyone seems to be able to find time to talk to [relative] and knows

their name which makes them feel like a whole person rather than a patient in a bed.” A patient

and their relatives praised the ward nurses and the palliative care team who visited daily. They told

us how their fears and concerns were answered factually but sensitively.

Nursing and mortuary staff told us transfer of bodies from the hospital ward to the mortuary

hospital by porters was done in a discreet and respectful manner. They were made aware in

advance of any religious or cultural wishes to consider and were sensitive to the feelings of other

patients on the wards.

A member of the portering staff told us they were mindful of the language they used to discuss

transfer of a body in case any member of the public overheard. They also described how they

continued to maintain the dignity of all patients by ensuring the bodies were treated with respect

and the journey to the mortuary was as dignified as possible. This showed that all staff concerned



in removing a patient from the clinical setting were sensitive to those who may have suffered a

loss or were receiving care at the time.

A member of the chaplaincy service told us a baby memorial service took place each month in

remembrance and commemoration of babies who died. They arranged this in conjunction with the

bereavement office and all bereaved parents were invited to attend.

We spoke with staff about their support needs when a patient died. We were told that in most

instances, they accepted this as part of their role. However, there were times when a patient’s

death affected them. At such times, they got support from colleagues, the specialist palliative care

team and members of the chaplaincy.

Emotional support

Staff provided emotional support to patients and their relatives to minimise their distress.

The specialist palliative care team (SPCT) included a palliative care social worker who provided

emotional support for patients and their families. This service was in place for the 12 months prior

to inspection and over 300 patients and relatives had availed of the service. Patients were seen on

a one to one basis or with family members if they chose; relatives were offered post-death

support. The social worker told us they used resources including memory boxes and books to help

people work with their grief. They also assisted family members with the administrative tasks

associated with the death of a person.

Members of the chaplaincy team were available 24 hours, seven days a week. There were

approximately 30 chaplaincy volunteers of different faiths and beliefs at the Princess Royal

University Hospital, who provided patients with various forms of support. This included bedside

visiting and communion as well as being generally available to patients or relatives who just

wanted to talk. One chaplain told us ward nurses alerted them to patients who did not have many

or any visitors so that they could be visited.

Some staff we spoke with told us they had training in how to break bad news. They reported that

they had to be prepared for a range of emotions, adjust their approach depending on the reaction

of the person and deal with them as sympathetically as possible.



Patients and their relatives spoke positively about their level of involvement and understanding of

the decisions that needed to be made in relation to care. One patient told us, “Staff couldn’t be

more inclusive with me – they tell me everything and respect the times when I am not able to join

in.”

Some nursing and medical staff told us they attended a communication skills simulation training

session facilitated by the specialist palliative care team (SPCT) with actors. They told us this

experience was invaluable to them to ensure sensitive and clear communication with the dying

patient and their family members.

The SPCT provided patients with support and information about their options for care and had

conversations with patients about their preferred place of care. They also supported ward staff by

providing guidance for the care of patients during the time they were receiving end of life care.

All wards had set visiting times; however, allowances were made for visitors of patients in receipt

of end of life care. Their visitors were allowed open visiting which gave them the flexibility to visit


whenever they wanted and stay if they liked. Staff told us they recognised the impact of a person

dying had on the wellbeing of patients’ relatives and did their best to support them during this time.

The bereavement officer provided a compassionate and responsive service to bereaved families

and provided further advice as required. They understood how certain religions required that their

dead were buried as soon as possible after death. In such circumstances, they tried to ensure all

the relevant paperwork was completed as soon as possible to issue the death certificate and

release the body within the appropriate time.

The bereavement officer kept relatives updated of any delays with releasing the body; for

example, where a post mortem was required. They also facilitated viewing of the body and met the

deceased’s relatives at reception to accompany them to the mortuary viewing room.



The service planned and provided services in a way that met the needs of local people.

The hospital had no designated palliative care ward or beds; palliative care patients or those at the

end of life were nursed across all wards. Side rooms were allocated wherever possible; nurses

told us not all patients wanted to be in a side room at the end of their life, preferring instead to be

in a ward with others. Patients with an infection risk were prioritised for the side rooms to prevent

cross infection with other patients.

Referrals to the SPCT could be made any time during a patient’s treatment. This allowed early

involvement of the team and time to facilitate the most appropriate care and treatment. The

enhanced supportive care services promoted better access, and earlier integration of supportive

care for cancer patients. The palliative care team encouraged referrals from nursing, medical and

allied health professional staff from across the hospital. The specialist palliative care team (SPCT)

worked closely with the local hospice to discuss joint patients and plan their care, support and

treatment.

Advance care planning is a process that enables individuals to make plans about their future

health care. Advance care plans provide direction to healthcare professionals when a person may

not be able to either make or communicate their own healthcare choices.

The trust had a ‘Pro-active Elderly Advance Care ‘(PEACE) plan for residential care home

patients. They were initiated for patients with advanced, progressive, incurable conditions who

were expected to die within 12 months or if they were at risk of dying from a sudden acute crisis in

their condition. The PEACE plan was not in place for patients who lived in their own homes.

We spoke to staff about advance care planning who told us most patients did not have one. They

told us it was not always possible to explore a patient’s end of life wishes and formulate them into

an ACP; there were times when the patient was not ready to consider this.

There were no visiting time restrictions for family and friends visiting a patient in the last days or

hours of life. This allowed family and friends unlimited time with the patient. The SPCT arranged

parking vouchers to enable family members to park for free for the duration of the time they spent

with their dying relative. The bereavement officer told us did all they could to assist the bereaved

with the administrative aspects of their relative’s death. This included making an appointment with

the registrar to register the death.




The specialist palliative care team (SPCT) saw all patient referrals, although they did not

necessarily provide support at that time. Members of the team told us this was important because

they saw it as a way to educate staff on the ward; to give them confidence in their own skills to

care for the patient at the end of life.

Members of the SPCT told us there was active treatment of the dying patient on occasion and they

provided training to doctors to give them confidence to recognise when to cease active treatment.

They supported medical and nursing staff on how to recognise the dying patient and encouraged

them to manage the patient’s medical and nursing needs.

Ward staff told us the SPCT was supportive and attended the ward daily. This was to formally

review referrals or to offer advice, guidance and assurance to nursing and medical staff. They

always responded quickly when asked to review a patient and were most likely to be called when

a patient presented with challenging pain management needs. Ward staff told us the addition of a

palliative care social worker (January 2018) to the SPCT made a positive difference to patients at

the end of life and their relatives. The social worker offered group and individual sessions which

allowed them to explore the practical and emotional aspects of death and dying.

Doctors told us there were weekly multidisciplinary meetings (MDM) on the ward. These were with

all professionals involved in the patient’s care and included clinicians, medical staff and allied

health professionals and a member of the chaplaincy usually attended. Part of the focus of these

MDMs was to discuss the patient’s presentation, their current medical and social support and to

consider whether the patient may be in their last weeks or days of life. A doctor told us they were

supported in this by the specialist palliative care team (SPCT) who were always available to offer

training, support and guidance. We saw records of these meetings where there was decision

making and planning about future patient care.

There was an audit of preferred place of care (PPC) and preferred place of death (PPD) done in

2016. The aim was to assess the documentation of preferred place of death within the palliative

care database. Results showed that of the 26 records reviewed, 15 (58%) had the end of life care

tab completed and therefore their PPC and PPD could be recorded. This meant the preferences

for the remaining 11 could not be recorded. The conclusion was that there was under recording

within the palliative care database of patient preferences. The recommendation was to re-audit of

PPC and PPD; however, this had not happened as there were plans at that time to revise the

patient record system, which was delayed.

The practice development nurse told us about the current drive to recruit end of life care link

nurses on each ward. These were members of staff who were given additional training to advise

and offer support to staff on each ward to aid the delivery of care to end of life care patients. We

were told that most wards had one link nurse. There was no data available at the time of

inspection to clarify the target number of link nurses and the number currently in post.

When possible, side rooms were provided for patients who were on the end of life pathway.

Relatives were encouraged to stay on the wards and were provided with folding beds and reclining

chairs. However, there was just on folding bed per floor. We spoke to two families on separate

floors, both of whom said the folding bed was already in use and they were sleeping on a reclining

chair. One relative who had stayed the previous six nights in their relative’s room said a folding

bed would be most welcomed. We spoke with a member of the SPCT about this who said they

would ask staff on other hospital floors to supply a bed if possible.

The Chapel was a multi-faith space and was open 24 hours a day, seven days a week for people

of any faith or none. Prayer mats for people with a Muslim faith was available. We saw copies of

the Holy Bible and Koran and multi-faith books. There was an ablution area next to the chapel for


people to wash themselves before prayer. Whilst there were no facilities for relatives to wash the

body of the dead according to their specific religious and cultural practice, mortuary staff told us

this had not been raised as an issue.

The chaplaincy team included or had access to representatives from many faiths. Referrals were

made in a number of ways that included by phone from members of staff, relatives, friends, faith

representative, or the patient themselves. Once referred, patients were visited as soon as possible

and visited each day if that was the patient’s wish. Members of the chaplaincy accessed the

patient electronic record (EPR) to see patients already referred to the SPCT in which case they

were prioritised for a visit.

Between January and December 2018, the chaplaincy team undertook an average of 40 visits to

ward-based patients each week. These included patients indicated as palliative care and end of

life care on the electronic patient record. In addition, they received approximately 15 direct

referrals from ward staff each month and they responded to 334 out of hours callouts.

There was no current facility built into the EPR for ward staff to refer patients to the Chaplaincy. In

the absence of an end of life care plan where a patient’s spiritual needs should be considered in

accordance with the ‘priorities of care of the dying patient’; it was not always clear whether all

patients were offered the opportunity to meet with a member of the chaplaincy.

The hospital bereavement service took account of different faiths and cultures. Arrangements

were in place to ensure documentation needed to help with the registration of death was handled

swiftly. This meant arrangements for burial could take place quickly for people who required

funerals for cultural and religious reasons.

Access and flow


The trust submitted data that showed there were 1,329 inpatient referrals to and seen by the

specialist palliative care team (SPCT) between from August 2017 to July 2018. Of these, 996

(74.9%) were new referrals, 250 (18.8%) were second referrals, and 67 (5.0%) were third

referrals.

Of the 996 new referrals, 361 (36.2%) were for patients with a main diagnosis of cancer and 600

(60.2%) were for patients with non-cancer diagnoses. There was an increase in non-cancer

patients on the previous two years (56% in 2015-16 and 33% in 2014-15).

Submitted data showed there was reliable information on time from referral to assessment

available for 1,316 of the 1,329 referrals to the SPCT. Ninety-one per cent (1,160) of referrals

were seen within one day of referral and 97.8% within three days. There was a very small

(unspecified) number of referrals seen after two days from referral. We were told this was

attributed to requests for later assessment from other specialties or family and bereavement

referrals. Discharge information included 12% of patients referred were discharged from the

SPCT, 23% were discharged home, 5% were discharged to a hospice and 7% were discharged to

a care home. Fifty-one per cent of referrals ended in the patient’s death.

Where a patient had a rapidly deteriorating condition and may be entering a terminal phase, an

application could be made on their behalf (with their or their carers’ consent) for the NHS to fund

their care (Fast Track Pathway for NHS Continuing Health Care funding). The purpose of this

pathway was to expedite care provision in the setting of the patient’s choice. Consideration should

be given to a patient’s preferred place of care or death as part of the priorities for care of the dying

patient.


Complex discharges at the Princess Royal University Hospital were led by the transfer of care

bureau, in conjunction with discharge coordinators, ward teams and the specialist palliative care

team. For residents of one local authority, there was an in-reach nurse based on-site from the

hospice who worked closely with the SPCT and discharge coordinators to move patients from that

local authority once they were medically stabilised.

A cross trust audit of fast track palliative care patients was carried out between December 2017

and April 2018. Twenty-four patient discharges were reviewed, and results showed that 22 (92%)

of submissions were made and approved within three days, with 19 of these (79%) made and

approved within one day. The audit showed that the average time to discharge to home was 2.5

days and 8.6 days to a nursing home.

Nursing staff told us the SPCT responded quickly when asked to facilitate a rapid discharge, for

example, to return to their own home within 24 hours with their care package, medicines and

equipment timed for their arrival home.




From October 2017 to September 2018 there were no complaints about end of life care.

(Source: Routine Provider Information Request (RPIR) - Complaints tab)

The end of life care annual report was presented to the trust board in February 2019. This

reflected the work of the specialist palliative care teams at the Princess Royal University hospital

and Kings College Hospital between January and December 2018. The report identified 32

complaints with an end of life care theme at the Princess Royal University Hospital. The report

did not separate out themes for the individual hospitals but recorded the most common themes

as clinical/medical care; communication; nursing care; failure to treat with respect, empathy,

dignity, staff behaviour and professionalism.

We reviewed complaints between 1 April 2018 and 31 January 2019 and saw there were three

where the primary issue related to end of life care. We reviewed one of these and noted there

was a clear and detailed process from its acknowledgement through to the final letter of apology.

We saw the opportunity to meet with representatives from the care group had been offered as

part of the complaint process.

Staff told us complaints about the service did not happen often, but if they did, they were made

aware of the nature of the complaint and any actions taken by the trust to ensure the issues that

led to the complaint did not happen again.

Members of the bereavement service told us they occasionally received verbal complaints from

relatives. This related to the late completion of the Medical Certificate of Cause of Death (MCCD)

which doctors must sign before the body can be released and was reflected in the Bereaved

Carers Survey 2017-2018. Relatives were not able to make any arrangements until they received

the MCCD. We saw an e-mail sent by bereavement office staff to the clinical director highlighting

the additional distress this delay caused for relatives. We were told there was a significant

improvement since then and the MCCD was completed more quickly.



Leadership

Managers at all levels in the service had the right skills and abilities to run a service

providing high-quality sustainable care.

End of Life Care sits within the post-acute medicine division. The leadership team included a

clinical director (with responsibility for Princess Royal University Hospital and King’s College

Hospital), service manager and matron.

There was effective and professional leadership which encouraged and supported the delivery of

person-centred care and we saw this throughout each part of the service. This included the

specialist palliative care team (SPCT), mortuary service, chaplaincy and the bereavement service.

Staff we spoke with across the wards were aware of the SPCT. They told us they had a working

relationship with them.

The trust chief nurse chaired the end of life care strategy group and represented end of life care at

board level. End of life care was also represented at board level by a non-executive director.

Vision and strategy

The service had a vision for what it wanted to achieve and workable plans to turn it into

action

The vision of the specialist palliative care team (SPCT) was to deliver excellent end of life care for

people across the trust. They told us they did this through early identification of those that were

dying, individualised care planning, delivery of compassionate care and proactive support to dying

patients and those close to them

Members of the SPCT said their vision was to continue to build on the current provision of service

for those patients in their last year of life. They wanted care for end of life care patients to start

from the front of the hospital in the emergency department and continue right through all other

hospital departments. Members of the SPCT said their vision was to continue to build on the

current good provision of service for those patients in their last year of life. They told us their goal

was to achieve the best quality of life for patients and their families.

The trust had an end of life care strategy (2017-2020) which was discussed, and its progress

monitored in the end of life care operational and steering group meetings. Implementation was

overseen by the clinical director, executive lead and non-executive director.

The strategy included nine key priorities, for example; improving the identification of people that

were dying; enhance the use of the Five Priorities for Care of the Dying Person to support ward

teams to care for the dying patient; upskill ward teams to enable them to develop and implement

individualised end of life care plans and upskill ward teams to enable them to deliver skilled,

compassionate, high quality care. The accompanying work plan indicated completion dates and

person with responsibility for the action.

Staff we spoke with within the SPCT understood their role in delivering the end of life care strategy

and reviewed progress against key milestones set out in the strategy document.

Culture

Managers promoted a positive culture that supported and valued staff, creating a sense of

common purpose based on shared values.


Staff told us they enjoyed and took great pride in caring for end of life patients. They said that end

of life care was more integrated within the trust than at the time of the last CQC inspection, and it

felt more like a shared responsibility with nurse and doctors across the hospital.

There was a recognition of the importance of ensuring patients received a good end of life care

experience across all staff groups throughout the hospital. Staff we spoke with showed a

commitment to delivering good quality end of life care and there was positive feedback from

nursing and care staff across the wards about the level of support they received from the SPCT.

Members of the SPCT, mortuary and bereavement team demonstrated a strong team ethic and a

structured working relationship.

Staff we spoke with were aware of the duty of candour. The duty of candour requires that every

healthcare professional must be open and honest with patients when something that goes wrong

with their treatment or care causes, or has the potential to cause, harm or distress. There had

been no incidents reported that required them to exercise the duty of candour.

A volunteer chaplain was recognised by the trust with a dignity lifetime achievement award in 2018

for their outstanding services in support of patients and families.

Governance

The service used a systematic approach to continually improve the quality of its services.

End of life care had a clear governance framework. This ensured responsibilities for end of life

care went right up to trust board level. There was a range of meetings at which end of life care

was discussed. These included the end of life care strategy group and the palliative care clinical

governance group. The group met every eight weeks and risks and adverse incidents were

discussed. This meeting was held jointly with Kings College Hospital (KCH). The report from this

meeting went to the post-acute medicine governance meeting and from there to the trust level

quality and governance meeting.

The clinical lead presented the end of life care annual report to the trust board in February 2019.

This reflected the work of the specialist palliative care teams at the Princess Royal University

hospital and Kings College Hospital between January and December 2018. The report updated

progress on work across the trust to improve end of life care; particularly in relation to embedding

the ‘Five Priorities for Care of the dying’ into practice to standardise and improve quality of care for

patients and those close to them.

The resultant work plan included monitoring training; funding for communication skills training;

developing end of life care volunteers; learning from national audit 2018 (to be published May

2019); assess impact of seven-day working and safe prescribing at end of life (in response to

lessons learned from a recently published report). The plan identified other areas of development

including the appointment of a clinical director for end of life care to improve leadership. Advance

care planning was an area for improvement as well as streamlining rapid discharges from hospital

and improving care after death for relatives and family members.

All patients referred to the SPCT were discussed at the weekly multidisciplinary meeting. Clinical

issues and concerns were raised at these meetings. There were separate weekly team meetings

at which operational issues and service improvement issues were discussed and monthly cross-

site consultant meetings.



The service had effective systems for identifying risks, planning to eliminate or reduce

them, and coping with both the expected and unexpected.

There was a cross site palliative care risk register which was up to date and reflected the risks

staff had told us about throughout our inspection. The investigation of incidents and complaints

was led locally and discussed in the palliative care clinical governance group held jointly with

Kings College Hospital.

There were three risks, one of which related to inadequate office space for palliative care team to

function effectively. We saw the risk action summary included a space audit with outcome and

plan awaited. Another risk recently added was insufficient staff training in the prescribing and

administration of opioids leading to prescribing and administration errors; action included targeted

training offered to high risk areas.

The most recently added risk (December 2019) included lack of appropriate care due to lack of

palliative care provision. This related to a lack of palliative care provision in and out of hours to the

frailty unit at the Princess Royal University hospital (PRUH). Historically a local hospice visited the

frailty unit each week, but this was no longer the case and the PRUH palliative care team was

unable to resource this. A meeting was planned with the hospice to discuss a way forward with

this.


The service collected, analysed, managed and used information well to support all its


Leaders had access to a range of performance measures about quality, operations and finances,

and used it to improve the service. The information systems facilitated the management of data in

line with data security standards.

The specialist palliative care team had access to up to date patient information on the electronic

patient record. They also had had ready access to the electronic system ‘coordinate my care’

(CMC), an NHS clinical service designed to deliver integrated and coordinated medical care built

around each patient’s personal wishes. Information held on CMC often included patients end of life

wishes. Members of the SPCT could add relevant details as they were decided.

Engagement

The service engaged well with patients and staff to plan and manage appropriate services.

Members of staff in the bereavement service told us they had recently initiated a way to gather

information from relatives on their experience and that of the deceased. This was gathered on a

handheld electronic device and bereaved relatives were offered the opportunity to record their

experiences and those of the deceased during their time in hospital when they came to the

bereavement office to collect the Medical Certificate of Cause of Death. The handheld device was

out of service at the time of this inspection so there was a temporary suspension of this

information gathering exercise.


The service was committed to improving services by learning from when things went well

and when they went wrong, promoting training and research.

There was a pilot project run by the specialist palliative care team (SPCT) which offered shortened

one-day training on communication in end of life. The training offered participants an opportunity to

develop skills in having end of life care conversations with patients and relatives.


The SPCT developed ‘Kwiki’ information pages on the trust intranet to support trust staff with

easily accessible information on palliative care, end of life care, DNACPR, rapid discharge and

syringe pump use.

Outpatients


King’s College Hospital NHS Foundation Trust have 1.3 million outpatient attendances a year

across four main sites and other community centres. Each of the trust three divisions are

responsible for their own outpatient service delivery and quality. The Princess Royal University

Hospital and south sites have a single central booking team, while the King’s College Hospital

site has separate booking function/teams for a variety of services across the divisions. The trust

has an Outpatients Efficiency Programme underway which is led by a director of delivery and

outpatients and two clinical leads. The focus of the programme is to set in place standardised

good best practice and systems for outpatients across the trust and to improve the patient’s and

staff experience.

(Source: Acute Routine Provider Information Request – context tab)

During our inspection we visited outpatient services at the Princess Royal University Hospital

(PRUH), Queen Mary’s Hospital at Sidcup (QMS) and Beckenham Beacon. We visited clinics in

the following specialities: colorectal surgery, renal medicine, general surgery, trauma and

orthopaedics, ophthalmology, dermatology, urology, haematology and the phlebotomy service.

We spoke to 35 members of staff including nurses, healthcare assistants, doctors of all grades,

administrators, technicians and managers. We spoke to 10 patients and their relatives. We

observed care in outpatient clinics and looked at nine sets of patient records.

Total number of first and follow up appointments compared to England

The trust had 1,484,801 first and follow up outpatient appointments from August 2017 to July

2018. The graph below represents how this compares to other trusts.


(Source: Hospital Episode Statistics - HES Outpatients)

Number of appointments by site

The following table shows the number of outpatient appointments by site, a total for the trust and

the total for England, from August 2017 to July 2018.

Site Name Number of spells

King's College Hospital 991,833

Princess Royal University Hospital 396,211

Kings College Dental Hospital 152,800

Queen Mary's Sidcup 143,086

Beckenham Beacon 92,779

This Trust 1,884,927

England 107,320,812


Type of appointments

The chart below shows the percentage breakdown of the type of outpatient appointments from

August 2017 to July 2018. The percentage of these appointments by type can be found in the

chart below:

Number of appointments at King's College Hospital NHS Foundation Trust from August 2017 to

July 2018 by site and type of appointment.




Mandatory training

The service provided mandatory training in key skills to all staff and made sure everyone

completed it.

Staff had access to mandatory training and most staff we spoke to were up to date with their

mandatory training. All staff were able to access online training courses and could review their

own training record through a training portal on the trust intranet; staff showed us how they

accessed this.

While some staff we spoke with told us they struggled to find time to complete training when they

didn’t have sufficient staff cover, most staff told us that managers were aware of this and were

planning to set aside time in rotas so staff could complete training.

However, apart from fire safety training, all face to face training was held at the King’s College

Hospital (KCH). Managers we spoke with told us that this had a significant impact on scheduling

staff in the department, as most staff lived locally and travelling to KCH for a half-day of training

would often mean they needed to be released for the whole day.



Trust level



Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met

















In outpatients the 80% target was met for 12 of the 14 mandatory training modules for which




Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met







Fire [2 Years] 44 27 61% No







In outpatients the 80% target was met for two of the 12 mandatory training modules for which

medical staff were eligible. It should be noted that this was for medical staff across outpatient

services and the majority of these staff were from the KCH site.

Princess Royal University Hospital

A breakdown of compliance for mandatory training courses as of October 2018 at location level

for qualified nursing staff in outpatients is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met
















In outpatients the 80% target was met for 11 of the 13 mandatory training modules for which

qualified nursing staff were eligible. This meant that most nursing staff had received training

essential to providing safe patient care.

There were no medical staff for Princess Royal University Hospital. Medical staff were managed

within clinical service lines and were therefore not allocated to outpatients specifically.

Queen Mary’s Hospital


for qualified nursing staff in outpatients is shown below:

Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met







Slips, Trips and Falls [3 Years] 18 15 83% Yes







In outpatients the 80% target was met for nine of the 12 mandatory training modules for which


essential to providing safe patient care.


for medical staff in outpatients is shown below:


Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met










In outpatients the 80% target was met for six of the eight mandatory training modules for which


Most medical staff were managed within clinical service lines and were therefore not allocated to

outpatients specifically.


Safeguarding


agencies to do so.

The trust had safeguarding policies and procedures in place across the trust, providing information

on who to contact within the trust, staff responsibilities and a framework detailing safeguarding

principles. The trust intranet had electronic safeguarding notification forms as well as access to

additional information associated with safeguarding.

Staff had received training on relevant safeguarding modules and knew how access to guidelines

and further advice where needed. We saw information on the safeguarding process displayed

within staff areas at Queen Mary’s at Sidcup and Beckenham Beacon, although there were no

details for the safeguarding lead should staff need to contact them.

Staff we spoke with could describe how to recognise potential safeguarding concerns and the

steps they would take if they identified this in a patient. Staff told us they were aware of the risk of

female genital mutilation (FGM) but had received no specific training on this.



Trust level



Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met





In outpatients the 85% target was met for two of the three safeguarding training modules for

which qualified nursing staff were eligible.



Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met




In outpatients the 85% target was not met for any of the safeguarding training modules for which

medical staff were eligible. It should be noted that this was for medical staff across outpatient

services and the majority of these staff were from the KCH site.




Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met




In outpatients the 85% target was met for two of the three safeguarding training modules for

which qualified nursing staff were eligible. This meant that most nursing staff had received

training essential to protecting patients from abuse and neglect. Although the target was not

quite met for the Safeguarding Children Level 2 module, children were primarily seen within the

children’s outpatient service located next to the main outpatient department at the PRUH.

There were no medical staff for Princess Royal University Hospital. Medical staff were managed

within clinical service lines and were therefore not allocated to outpatients specifically.

Queen Mary’s Hospital



Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met




In outpatients the 85% target was met for both of the safeguarding training modules for which


essential to protecting patients from abuse and neglect.



Module

Staff

eligible

Staff

trained

YTD

Compliance

Target

Met



In outpatients the 85% target was met for both of the safeguarding training modules for which




The service mostly controlled infection risk well. Staff kept equipment and the premises visibly

clean.

At all sites we visited, staff used I am clean stickers to indicate when equipment had been cleaned

and was ready for use. Curtains were changed and dated, and sharps bins were managed

appropriately. Personal Protective Equipment (PPE) was available in clinical areas and we saw

staff using PPE appropriately. Hand sanitiser was available throughout the departments, and we

saw posters displaying the five moments of hand hygiene near handwashing facilities. Hand

hygiene compliance for outpatient services was consistently above the trust target of 90%,

achieving 98.8% in January 2019.

However, cleaning logs were inconsistently completed. At Beckenham Beacon we saw daily

cleaning logs completed and up to date. At the PRUH, while most cleaning logs were completed

regularly, we saw one log in the treatment room which had not been completed since November

2018. In the West Kent Eye Centre, we saw limited evidence of cleaning rotas and at Queen

Mary’s at Sidcup no room cleaning records were available. This meant that while the room looked

visibly clean, there was no assurance that it had been adequately cleaned to prevent the risk of

infection. The trust supplied cleaning audits for the PRUH and Beckenham Beacon. Audits for

Beckenham Beacon were consistently above 95% between November 2018 and January 2019

across all areas. Cleaning completion rates for the PRUH was also generally above 95%, although

information from the trust did not include the main outpatient department and was for December

2018 only.

At the time of the inspection, the PRUH was managing an increase in norovirus in the local

community. We saw that the site had several large signs displayed at entrances and near

reception desks. Patient information letters were also given out to inform patients of the risks and

provide advice to minimise any potential spread. This meant staff took appropriate action to

mitigate infection, prevention and control risks.


The service did not always have suitable premises and equipment.


At the PRUH, the main outpatient department was clean, bright and ordered and staff kept clinical

and waiting areas tidy and clear of obstruction. Equipment checks were up to date and the resus

trolley was stocked, tagged and had daily and weekly checks complete. This meant that staff could

be assured that they would have all necessary equipment available to them in the event of a

patient emergency.

At our last inspection, we highlighted concerns regarding the suitability of the plaster room. While

this area was clean and ordered, the space remained cramped and had potential trip hazards

which posed a risk to patients with limited mobility. The main door to the plaster room was a fire

door which should be kept shut but which was propped open during the clinic opening hours. The

plaster area was split into two rooms; the first had a partition separating the waiting area from the

treatment area with space for one treatment chair, and the second main room had space for two

treatment couches.

During the inspection, we found that the second main plaster room did not have any call bells.

Government standards on the design of outpatient services, including plaster rooms, advised that

staff-to-staff call systems needed to be in place for all areas where staff consult, examine and treat

patients. The first room had one cord in the corner by a storage unit and one wall-mounted alarm

in the main waiting area, although staff thought this had been disconnected several years ago

when the treatment and waiting areas had been swapped. This meant that any staff treating a

patient who might deteriorate in the main room would need to leave the patient to call for or seek

support from staff in the main outpatient department. The plaster room treated both adult and

paediatric patients. We reviewed the outpatient risk register and the call bell risk was not present.

This was poor practice and meant that the trust had failed to recognise the risk this posed to

patient safety.

The West Kent Eye Centre at the PRUH was generally tidy and organised. Although some old

equipment was stored at the end of some corridors, this was generally out of the way of patients

and the main waiting areas. Equipment that was in use had in-date Portable Appliance Testing

(PAT), although we noted that old equipment that was out of date remained stored in the

department corridors. The two laser treatment rooms had code locks and signs to indicate when

they were in use, to ensure that there was no unauthorised access. Most sharps bins were dated

and suitably managed. The resus trolley was stocked, tagged and had up to date checks.

However, the trolley was located in the main waiting area near the entrance to the department and

was some distance from the intravitreal injection and fluorescein treatment rooms where patients

would be most likely to have a reaction to treatment. This meant that staff might not have been

able to access emergency equipment as quickly as they needed to.

At Queen Mary’s at Sidcup, the ophthalmology service was temporarily located on the third floor

while refurbishment was being completed on the second floor. Staff told us that the refurbishment

was currently on track to be completed in the summer of 2019 and was a year overdue. The

department layout was confusing and included multiple waiting areas and side rooms. While most

waiting areas were clearly visible to staff either from reception or staff areas, one waiting room

was located off the main corridor beyond a laser treatment room and out of line of sight of staff.

There was no call bell or system in the waiting room which meant that if anyone waiting in this

area collapsed or needed help they would not be immediately visible to staff.

Staff we spoke with told us that equipment availability was an issue and that sometimes clinics

had to stop due to lack of available equipment. Staff told us that the process for some equipment

maintenance, such as getting replacement light bulbs for slit lamps, was lengthy and required

approval from King’s College Hospital.


At Beckenham Beacon, the department was tidy and free of clutter. All equipment we checked had

been PAT tested and was in date. The resus trolley was tagged and had daily checks complete

with all the contents expiry dates documented. Sharps bins were all dated and appropriately

managed.


Staff completed and updated care plans for each patient. They kept clear records and

asked for support when necessary.

We reviewed nine sets of patient records and found that care plans were documented, dated and

signed. At the PRUH, all records we reviewed had completed WHO safety checklists where

relevant for the procedure. However, we did not see this or a shortened version in use at Queen

Mary’s at Sidcup during our observation of the intravitreal injection procedures.

At the PRUH, staff had access to call buttons in each of the clinical rooms and could describe how

they would respond if a patient became unwell in their department. However, the plaster room did

not have call bells or cords in the main treatment room and staff we spoke with told us they would

need to leave the patient to call for or seek support from staff in the main outpatient department if

a patient became unwell. This meant there was a risk that staff might not be able to provide

emergency assistance to patient in a timely manner.

At Beckenham Beacon and Queen Mary’s at Sidcup, the services had an urgent care centre on

site but for any patients who required more urgent care staff told us they would call for an

ambulance to take the patient to an A&E.

Most patient referrals were electronically managed, and staff logged and tracked this through the

patient information management system. Urgent referrals were picked up by the outpatient

appointment booking team (OPAC) and this was overseen by the outpatient service manager. This

meant that there was an appropriate system to ensure patients with urgent clinical needs were

seen in a timely manner.

Nurse staffing

Not all services had enough nursing staff, with the right mix of qualification and skills, to

keep patients safe and provide the right care and treatment.

Managers at all sites and departments we visited told us they had nursing vacancies, some of

which were substantive and some maternity or absence cover. Managers across all services told

us that nursing establishments were generally quite small, which left limited room for flexing staff

to cover unexpected absences. Staffing establishments were based on patient activity and

contracted budgets. Managers described the recruitment process as slow and time consuming

and this was impacting their ability to fill posts or find cover.

Managers in the ophthalmology service at both West Kent and Queen Mary’s told us the staffing

establishment was insufficient to meet the volume of patients or maintain adequate safety,

particularly in the Rapid Assessment Unit (RAU), and that they had over-established both services

to maintain patient safety and flow. Managers told us that the lack of nursing staff at West Kent

had contributed to increased waits for pre-assessment and led to theatre cancellations. At Queen

Mary’s staff told us that the RAU frequently struggled to cover shifts, particularly on the weekend

and, that the service used regular bank staff to cover absences. Managers told us that the service

was working with commissioners to increase the baseline establishment for the units.


At Queen Mary’s, the service had only one qualified nurse injector with one in training. At the time

of the inspection, the nurse injector was absent which meant that medical staff were having to

cover this work, and this was impacting on patient flow and waiting times in the department.

At Beckenham Beacon, the dermatology service had recently lost the senior sister who had also

been a surgical nurse. The service had plans to increase the surgical skills amongst the nursing

staff to increase the number of nurse-led clinics. This would improve the skill set amongst the

nurses and meant that patients would be waiting less time for certain surgical procedures.

All departments had established morning huddles where staff were briefed on activity and staff

allocation for the day.


and August 2018. Although the fill rate has decreased, there are over 75 more WTE in post.


Staffing group

Planned

staff –

WTE

Actual

staff –

WTE

Fill

rate

Planned

staff –

WTE

Actual

staff –

WTE

Fill

Rate


(Qualified nurses) 1.5 3 202.7% 82.3 78.4 95.3%


• Princess Royal University Hospital – 18.9 WTE in post (117.1% fill rate)

• Queen Mary’s Hospital – 19 WTE in post (108.6% fill rate)


Vacancy rates


This was higher than the trust target of 8%


• Princess Royal University Hospital: -9%

• Queen Mary’s Hospital: 11.5%

The negative figure indicates that there were more WTE in post than planned. However, during

our inspection managers told us that they had a number of vacancies which meant they struggled

to have enough staff to suitably cover the department, particularly if additional clinics were

requested.


Turnover rates





• Princess Royal University Hospital: 22%

• Queen Mary’s Hospital: 13%

Higher nursing turnover rates posed a risk to services being suitably staffed as managers told us

the recruitment process could be slow.


Sickness rates

From September 2017 to August 2018, the trust reported a sickness rate of 3.6% in outpatients.



• Princess Royal University Hospital: 1.9%

• Queen Mary’s Hospital: 1.9%




agency usage rate of 16.2% in outpatients. This left 20.5% of available hours unfilled.




Medical staffing

The services had enough medical staff with the right qualifications, skills, training and


treatment.

Most medical staff we spoke with told us that medical rotas were covered. In the main outpatient

department at the PRUH, we spoke with medical staff from several different service lines. Staff

told us that they received sufficient support from senior clinicians and that there had been a

general reduction in agency spend over the past year. This was good practice and meant that the

service had made improvements in ensuring there were sufficient permanent medical staff to care

for patients safely. Within the colorectal service, staff told us they had an effective system in place

to ensure adequate cover for clinics during staff leave, and there was now a 100% fill rate

amongst registrar and consultant staff.

At the West Kent Eye Centre, managers told us the service had previously been one of the highest

spenders on locum usage in the trust. During the past year, the service had a successful

recruitment drive and had markedly reduced the locum spend. This was good practice.


We received mixed feedback about supervision of medical staff from senior doctors. Junior

medical staff we spoke with who worked across West Kent and Queen Mary’s told us they were

never left unsupervised in the RAU and there was always access to senior clinical support.

However, other medical staff we spoke with at Queen Mary’s told us that the RAU was “almost

never” fully staffed and they struggled to meet patient demand, seeing up to 60 patients a day

when at full staffing the maximum allowed was 40. This meant there was a risk that there were

insufficient medical staff to care for patients safely.

At Beckenham Beacon, the dermatology service was fully staffed across the consultant staff

group. The clinical director told us there had been a large turnover in medical staff in the last three

years and that this had impacted on service wait times. The service had worked on job planning

across the consultant group and this had improved clinic capacity and response times in the

department.


and August 2018. Fill rate has increased nearly 10% however the total number of WTE has

decreased by 40.


Staffing group

Planned

staff –

WTE

Actual

staff –

WTE

Fill

rate

Planned

staff –

WTE

Actual

staff –

WTE

Fill

Rate

Medical & Dental staff - Hospital 107.6 83.3 78% 49.7 43.7 87.9%



• Queen Mary’s Hospital – 1 WTE in post (100% fill rate)


Vacancy rates


This is lower than the trust target of 10%.



• Queen Mary’s Hospital – 0%


Turnover rates






• Queen Mary’s Hospital – 0%

(Source: Routine Provider Information Request (RPIR) - Turnover tab)

Sickness rates

From September 2017 to August 2018, the trust reported a sickness rate of 0% in outpatients.



From September 2017 to August 2018, the trust reported a bank usage rate of 4.3% and locum

usage rate of 89.9% in outpatients. This left 5.8% of available hours unfilled.



(Source: Routine Provider Information Request (RPIR) – Medical agency locum)

Records



We reviewed nine sets of patient notes and found them to be clear with completed clinical

summaries, nursing and medical documentation, WHO checklists and GP letters. All records were

completed, signed and dated. Staff we spoke with told us that they rarely had issues with

accessing patient notes or patient information and that the proportion of patient notes which were

unavailable had reduced a lot over the last few years. This meant that staff had access to relevant

information when seeing patients.

At the PRUH, the outpatients service was still predominantly running on paper records. An

electronic patient records (EPR) system was in the process of being rolled out across the services

which meant that depending on the specialty, some clinics used only paper records and others

used a combination of EPR and paper notes.

At the last inspection in 2017, we found that patient records were not stored securely and left

unattended in areas accessible to patients. Since the last inspection, the service had introduced

lockable notes trolleys and we saw these being used and secured when not in use. However, we

saw the patient notes were left unattended and visible in consulting rooms. While staff shut doors,

these were unlocked and not secured. This meant there was still a risk that patient records could

be accessed by unauthorised persons.

Some staff we spoke with also raised concerns around the manual handling of patient notes. Staff

told us that the boxes of notes could be quite heavy, and they struggled handling the notes on a

regular basis.


At the ophthalmology services at the West Kent Eye Centre and Queen Mary’s Hospital, staff used

a combination of paper and electronic records systems. Medical staff we spoke with told us this

could be frustrating as they currently had to input information into both records. However, this was

a temporary arrangement while the service moved fully over to EPR.

Services at Beckenham Beacon currently used paper-based notes, although some clinical

information was held on EPR and the move over to this system was due to happen later in 2019.

While most notes were stored securely, in the urology clinic some patient notes were stored in a

room which had dual entry points, one of which was unlocked and accessible to patients.

Medicines


medicines.

Medication records we reviewed were appropriately completed, signed and dated. None of the

services stored controlled drugs in the department, and all medications we checked were in date

and appropriately stored. Room and fridge temperature checks were completed and in range,

which meant that medicines were being stored at the correct temperatures. Staff we spoke with

knew how to escalate any issues with room or fridge temperatures.

Staff at the PRUH had access to pharmacy staff on site between 8.45am and 7pm, Monday to

Friday, from 10am to 5pm on Saturdays and between 11am and 5pm on Sundays. Outside of

these hours, a pharmacist was available by telephone.

At the last inspection, the service did not suitably store or manage FP10 prescription pads in the

outpatient department at the PRUH, which meant they were at risk of theft or misuse. During our

inspection, we found that the service no longer used FP10 prescription pads but had prescription

pads specific to the outpatient department which could only be filled directly at the hospital

pharmacy. These were stored in a locked cabinet in the clean utility area, so they were

inaccessible to patients and we did not observe any prescription pads left unattended during our

inspection. This was an improvement on our last inspection and meant that the service had fully

addressed the risk posed.

We reviewed the trust medicines management policy. While the policy included details on the use

of prescription pads for outpatients, it did not include details on staff responsibilities or how the

trust should monitor the storage and use of prescription pads. This had been an area for

improvement identified at the previous inspection. This meant that the service still lacked clear

guidelines on staff responsibilities and oversight of the use of prescription pads.

Incidents

The service did not always manage patient safety incidents well.

Staff recognised incidents and reported them appropriately. All staff we spoke to knew how to

report incidents and had access to the online reporting system used by the trust. Managers

investigated incidents, but feedback was inconsistent, and lessons were not always shared with

the whole team.

In the outpatient department at the PRUH, some nursing staff told us that they received incident

feedback as part of the morning huddle. Medical staff we spoke with received incident feedback

through their clinical specialty and gave examples of recent incidents where it had led to changes

in practice. For example, within the colorectal service the service was writing guidelines for

pancreatic cyst management following an incident.


At the West Kent Eye Centre, managers we spoke with described difficulties in having sufficient

time to investigate incidents. In the operational performance report for outpatient services across

PRUH and the south sites, we saw that there had been an increase in the number of incidents

under investigation and a sharp increase in the incidents not reviewed from 111 incidents in

November 2018, to 346 incidents in January 2019. This meant that staff did not thoroughly

investigate all incidents, and therefore important learning was not shared.

However, managers at the West Kent Eye Centre could give clear examples where incidents had

led to improved processes. For example, staff had not been checking the calibration of tonometers

which led to patient incidents. Since the incidents, the service had started regular calibration

checks and managers audited the checks.

At Queen Mary’s Hospital, feedback from incidents was inconsistent. Managers were able to give

examples of incidents where learning had been shared cross-site, however some clinical staff we

spoke with told us that they did not always receive feedback or learning from incidents.

At Beckenham Beacon, staff held regular meetings where incidents and learning was discussed

and staff we spoke with were able to give examples of incidents which had led to changes in

practice. This was good practice.

When things went wrong, staff apologised and gave patients honest information and suitable

support. Duty of candour is a regulatory duty that relates to openness and transparency and

requires providers of health and social care services to notify patients (or other relevant persons)

of relevant safety incidents. However, some staff we spoke with in the outpatient department at the

PRUH did not know about the duty of candour requirements or regulation but could access

information through the trust intranet. We also saw evidence in minutes from the care group

clinical governance meetings that duty of candour was discussed when incidents were reviewed

and the service audited compliance with duty of candour requirements. At Beckenham Beacon we

saw contact and advice for staff on duty of candour displayed and staff knew how to access further

information if needed.

Never Events




never event.

From October 2017 to September 2018, the trust reported no incidents classified as a never

event for outpatients.



In accordance with the Serious Incident Framework 2015, the trust reported eight serious

incidents (SIs) in outpatients which met the reporting criteria set by NHS England from October


These were:


incidents



Confidential information leak/information governance breach

meeting SI criteria 1

HCAI/Infection control incident meeting SI criteria 1



Of the eight incidents reported, four occurred at the PRUH and three of the four were regarding

delays to treatment. The trust monitored and reviewed serious incidents as part of the care group

clinical governance meetings and we saw evidence of incidents and action plans being discussed

as part of these meetings.


Safety thermometer

Services collected and monitored safety information. While this was not submitted to the NHS

Safety Thermometer, the service monitored information through operational performance reports.

We saw that the service regularly reported on falls and infection control and that the outpatient

services across PRUH and the south sites were consistently above the 90% target for hand

hygiene compliance and that falls resulting in moderate or major harm had reduced from January

2018.

Within departments, we saw patient information on falls prevention and how to reduce the risks to

patients.




effectiveness.

Staff had access to a range of guidelines through the trust intranet and staff in outpatient services

knew how to access these. We reviewed several guidelines and found they followed National

Institute for Health and Care Excellence (NICE) best practice where relevant.

The trust reviewed clinical guidelines within service specialties and clinical governance meetings.

For example, staff in ophthalmology outpatient services had reviewed optic neuritis guidelines, and

implemented a new evidence-based approach as a result of the discussion.

We also saw evidence of staff following NICE guidelines on new glaucoma referral assessments

and patients referred with age-related macular degeneration and services adapting processes to

comply with guidelines.

The ophthalmology service had audited the management of giant cell arteritis (GCA) within the

rapid access unit at Queen Mary’s Hospital to ensure that trust guidelines met the standards. As a

result of this audit, the service had improved the stock of oral prednisolone to improve the

responsiveness of the treatment.




All outpatient departments we visited had water available to patients in waiting areas. At the

PRUH, the main outpatient department had installed vending machines in the waiting area, so

patients were able to buy food without having to leave the department waiting area.

Pain relief

Staff assessed and monitored patients to see if they were in pain. Staff used recognised pain

assessment tools and supported those unable to communicate using suitable tools and gave

additional pain relief to ease pain.

Information provided by the trust showed that between March 2018 and February 2019, 100% of

staff audited knew how to assess pain in patients, including non-English speaking patients, and

that pain was appropriately assessed and documented.

We observed staff asking patients about their pain and comfort levels during treatment and

patients we spoke with raised no concerns about their pain management during appointments.

Patient outcomes


improve them.

While there were no national clinical audits specifically for outpatient services, within service lines

staff contributed to relevant audits and collected information on patient outcomes. For example,

within the renal clinic the service submitted haemodialysis patient demographics and outcomes

into renal registry.

Staff conducted internal audits on patient outcomes and used this to improve services. For

example, within the ophthalmology service at Queen Mary’s Hospital staff had audited selective

laser trabeculoplasty (SLT) outcomes for patients with glaucoma. The audit had met the treatment

target reduction of intraocular pressure, which slows the progression of glaucoma, for 82% of

patients.

Follow-up to new rate


• the follow-up to new rate for Queen Mary's Sidcup was similar to the England average.

• the follow-up to new rate for Beckenham Beacon was similar to the England average.

• the follow-up to new rate for Princess Royal University Hospital was higher than the England

average.

• the follow-up to new rate for King's College Hospital was higher than the England average.

• the follow-up to new rate for Kings College Dental Hospital was similar to the England average.

Follow-up to new rate, King's College Hospital NHS Foundation Trust.



The follow-up to new rate measures how many follow-up appointments a patient has for each new

appointment. A higher number of follow-up appointments can indicate treatment taking longer and

therefore not being as effective. The follow-up to new rate for the PRUH was higher than the

England average and similar to the rate at King’s College Hospital (KCH). This meant that patients

being seen at these sites were more likely to have more follow-up appointments and be receiving

treatment for longer, which could mean that patients were not receiving as effective treatment.

Competent staff

The service made sure staff were competent for their roles. Managers appraised staff’s work

performance and held supervision meetings with them to provide support and monitor the

effectiveness of the service.

New staff received a corporate induction at the KCH site, and then local inductions were organised

by departments.

Most staff we spoke with had received an appraisal and had training needs discussed and

identified through this process. Staff were generally supported to access development

opportunities outside of mandatory training. Administrative staff we spoke with in the outpatients

department at the PRUH told us they had been supported by their manager to access conflict

resolution training.

Staff within the urology service at Beckenham Beacon told us they had been able to access

enhanced clinical skills training to support their professional development. Managers within the

dermatology service told us of their plans to develop nursing roles in order to increase nurse-led

clinics.

However, while staff generally described managers as supportive for accessing additional training,

some staff described a lack of progression opportunities at the trust due to the service structures.

For example, in the plaster room staff told us the trust had removed the team manager position

from the team structure which left no room for progression for the current orthopaedic

practitioners.

Medical staff were able to access clinical supervision. Junior medical staff we spoke with told us

they were supported by senior staff to develop skills, and there was a focus on learning. However,


some medical staff at Queen Mary’s Hospital told us that they struggled to attend teaching

sessions due to the clinics overrunning and not leaving enough time to travel to KCH where the

teaching was located. This meant not all staff had access to development opportunities to improve

their skills and competencies.

Appraisal rates

From September 2017 to August 2018, 80% of staff within the outpatients department at the trust


Trust wide


required

Appraisals

complete

Completion

%









Allied Health Professionals 65 58 89%





Qualified Allied Health Professionals 3 2 67%




required

Appraisals

complete

Completion

%






Appraisal rates for staff at the PRUH were above the trust target of 90% across all staff groups.

This was better than the trust comparison and meant that most staff in outpatient services were

receiving appraisals and had the opportunity to discuss development.






Staff held regular multidisciplinary team (MDT) meetings within outpatient specialties. However,

cross-specialty MDT meetings remained limited, which meant there continued to be limited

opportunity for specialisms to exchange ideas and share learning. This was a concern that had

been identified during our previous inspection. However, where MDT meetings were in place,

these worked effectively to support coordinated patient care.

Within the colorectal service, staff held weekly MDT meetings usually via tele-link so all relevant

sites could contribute. Meetings included medical, nursing, radiology, pathology and clinical nurse

staff and discussed patient treatment plans. The dermatology and ophthalmology services

participated in a weekly MDT tele-link meeting with maxillofacial to review referrals and discuss

patient treatment plans. This was effective practice.

Services engaged with community services to ensure continuity of care for patients and improve

outcomes. For example, the colorectal service had links with clinical nurse specialists in the

community who supported patients regarding such things as wound care and drain management

advice.

Seven-day services

Outpatient clinics generally operated from 8.30am-5.30pm Monday to Friday, with some variations

for clinics at Beckenham Beacon and Queen Mary’s Hospital. None of the services offered any

evening clinics or regular weekend clinics, with the exception of the Rapid Access Unit in

ophthalmology, which operated every day between 8am and 6pm.

Some specialties, such as ophthalmology and orthopaedics, had run additional weekend clinics to

address patient backlogs but these had begun to reduce as the backlogs had decreased.

Health promotion

The service supported patients to live healthier lives.

At the PRUH, we saw a range of health information available to patients in the waiting area. This

included information to help patients manage their own health, and additional support groups

patients could access outside of the hospital.

Staff worked with community services to support patients in the community. For example, the

colorectal service worked with stoma nurses to support patients around weight loss and diet

advice.

At Queen Mary’s Hospital, we saw patient boards with information on common conditions. At

Beckenham Beacon, leaflets were available on a range of subjects and local support groups which

patients could access. Services also had information for patients on the different clinics which staff

could print when needed.



decisions about their care. They followed the trust policy and procedures when a patient could

not give consent.

Staff we spoke to understood the need to obtain consent and we observed staff checking patient

details and seeking consent prior to treatment. In the notes we reviewed, we saw consent forms


were completed for patient appointments, although we found patients were not given their copy of

the consent form as these remained in the records we reviewed. This was not best practice.

Staff had access to guidance and advice on consent and capacity through the trust intranet. The

intranet included a range of guidance on consent.

Services audited consent and whether staff documented this. Information provided by the trust

showed that between March 2018 and February 2019, 100% of records audited had a completed

and documented consent record.



55% of staff in outpatient department compared to the trust target of 80%. All were registered at

King’s College Hospital. At the PRUH, medical staff were managed within clinical service lines

and were therefore not allocated to outpatients specifically.




Compassionate care



During our inspection, staff were polite and friendly towards patients. At the PRUH and

Beckenham Beacon, we observed patients being greeted when arriving in the department and

staff taking the time to interact with patients. During the consultations we observed, staff were

respectful and considerate and patients we spoke with at all sites described feeling happy with the

staff and service they received.

The ‘heat map’ dashboard for patient experience found that between July and December 2018,

87% of patients across outpatient services in PRUH and south sites would recommend the

service. The highest proportion of negative comments related to waiting times and this was

echoed in the feedback we received from patients while on inspection. However, we did not see

any displays within the department indicating patient feedback and responses to these from the

trust.

Privacy and dignity of patients was not always maintained in the outpatient services. At the PRUH,

the plaster room waiting area was separated only by a partition wall that did not reach the ceiling

and temporary screen from one of the treatment spaces. This meant that people in the waiting

area could overhear patients having treatment. This had been raised as a concern in the previous

inspection and staff told us that while they had a radio on to try and mask any sounds, nothing had

structurally changed in the room since the last inspection. This was poor practice and did not

protect patients’ privacy and dignity whilst receiving treatment.

In the West Kent Eye Centre, patients we spoke with told us that they could overhear reception

staff talking at the desk. At Queen Mary’s Hospital in Sidcup, several clinic rooms had clear

windows which meant that patients were visible to anyone passing outside. This meant patient

dignity and privacy was not always maintained.

Emotional support



Staff we spoke with were mindful of the emotional wellbeing of patients and took steps to support

patients and families where necessary. Patients we spoke with described most staff as supportive,

particularly when the treatment was difficult.

At Queen Mary’s Hospital, we observed staff building a good rapport with patients and putting

them at ease before intravitreal injections. However, patients at West Kent Eye Centre told us that

the long wait times for appointments sometimes increased their anxiety before procedures.

Patients at the PRUH had access to the multi-faith chaplaincy and could use the hospital

chapel/prayer room that was open 24 hours a day.



Patients who attended services on a regular basis spoke positively of staff, describing them as

taking the time to reassure patients and talk them through the procedure.

Patients told us that staff kept them informed of what was happening with their care, including wait

times. The service used text messaging to remind patients of their appointments and there was a

message function where a voicemail could be left instead if a patient did not have a mobile phone

listed.

At Beckenham Beacon and the PRUH, we saw information regarding advocacy services for

patients, as well as how to request a chaperone if they required. Information was also available for

support networks, such as local dementia wellbeing and support groups, drug and alcohol groups

and home library services.



The trust did not always plan and provide services in a way that met the needs of local

people.

The outpatient clinics at all sites we visited had sufficient seating for patients to wait with the

exception of the plaster room at the PRUH and ophthalmology clinic at QMS. The waiting area for

the plaster room was seven chairs in a small room separated with a partition wall. Patients were

advised by a sign that they would be seen in the order of arrival and could not pre-book

appointments. The ophthalmology clinic at QMS did not have sufficient seating, the area was small

and could be difficult for people with limited sight to navigate. Some chairs were in an area out of

sight of the reception and clinicians. The environment was not listed on the departments risk

register but the clinics were due to move to a refurbished area.

The main seating area at the PRUH was large, bright and clearly signposted inside and outside of

the building. Inside were signs indicating where consultant’s patients should sit and a reserved

area for wheelchair users. The paediatric clinic was separate but next to the adult clinic and staff

told us that adult patients with children were given the option of waiting in the paediatric area.

Beckenham Beacon had two separate waiting areas. At the back of the clinic was a smaller area

where patients with children could wait, there was a sign at the reception desk inviting patients to

ask. However, this area was not designated children only and did not include any toys or books.

The ophthalmology clinics at QMS and West Kent Eye Centre had signs on a yellow background

making it easier for patients with limited vision to read. Signs for all clinics we visited were clear

and clinics were easy to find.


Each clinic we visited had different ways of communicating waiting times for patients. At the PRUH

waiting times were displayed for each consultant on a screen behind reception and a screen on

the reception desk. At Beckenham Beacon, waiting times were not displayed and administrative

staff we spoke with were unaware of the wait times.

The phlebotomy service at Beckenham Beacon had a small white board near reception explaining

it was a walk-in service and waiting times could be up to an hour. The service used a ticket

machine; however, the machine was not working properly and unable to display the number being

called. During our visit, the tickets ran out and were replaced. This caused confusion for some

patients as numbers were out of sync and people were concerned their number had been missed.

Staff did not inform patients of the change and we saw patients’ queue to ask the receptionist

whether they had been missed. Patients we spoke with at the phlebotomy service told us that

waiting times could fluctuate depending on the time of day. The walk-in phlebotomy service had

been relocated to Beckenham Beacon from the PRUH and patients we talked with were given the

option of booking an appointment at the PRUH or attending the walk-in service; they were happy

to attend the walk-in service as it was more convenient for them.

The phlebotomy service at the PRUH was limited to pre-booked appointments and patients from

in-hospital referrals. The sign for this clinic was small and reception staff told us it needed to be

bigger as it was not immediately obvious for patients and meant that patients waited unnecessarily

at the main outpatient desk.

The ophthalmology clinic at QMS was in a temporary location and several clinic rooms had clear

windows meaning patients were visible to anyone passing outside. The clinic was waiting to move

to a refurbished area and staff told us they had consulted a representative from the RNIB who

gave advice ensuring the area would be appropriate and signs in a format suitable for patients with

visual impairment. The clinic had been based it its temporary location for over a year and was due

to move by July 2019. Staff we spoke with were aware of factors that could impact patient

attendance, such as poor weather and evenings being darker during winter and would be flexible

to patients requests where possible.

Surgical Appliances, which involves supplying and fitting orthopaedic footwear and supports, ran

clinics across two sites giving patients the option to attend the clinic most convenient for them.

Staff told us that the clinics would anticipate emergency referrals from patients attending

emergency department being sent and worked flexibly to accommodate these.

Outpatient services at the PRUH, were designed and adapted to suit demand in the local

population. Staff told us that the dialysis programme was being expanded to address an

increasing demand from local patients. There was limited parking at all sites we visited. The PRUH

had a car park which appeared full most of the time. Staff told us that after 8am spaces in the car

park were limited and that local residents had concerns over patients parking in local streets.

Beckenham Beacon had very small car park and this was used by patients of a number of

services including those outside of the trust.

Did not attend rate


• the ‘did not attend’ rate for Beckenham Beacon was similar to the England average.

• the ‘did not attend’ rate for Kings College Dental Hospital was higher than the England average.

• the ‘did not attend’ rate for King's College Hospital was higher than the England average.

• the ‘did not attend’ rate for Princess Royal University Hospital was similar to the England

average.


• the ‘did not attend’ rate for Queen Mary's Sidcup was higher than the England average.

The chart below shows the ‘did not attend’ rate over time.

Proportion of patients who did not attend appointment, King's College Hospital NHS

Foundation Trust.


Staff in the ophthalmology service told us that one of the highest rate of DNAs were follow up

appointments booked 12 months in advance. To try and improve this, the clinic was intending to

change how it booked follow up appointments, booking closer to the time to increase the likelihood

of the patient attending. Staff told us they were analysing which patient groups were more likely to

DNA and what could be done to address it. Staff in the urology service at Beckenham Beacon told

us that they called patients who had DNA’d after the clinic as patients with a catheter could

become a clinical risk if they were not seen. If they were unable to contact the patient, they would

inform the patient’s GP. Text reminders were sent to all patients before appointments unless they

had opted out of the service. We saw receptionists checking with patients, when they checked in,

that the patients’ mobile number was up to date.


The service did not always take into account of patients’ individual needs.

Not all staff we talked to were aware of a flagging system being used to indicate patients that

might have additional needs. At the PRUH, reception staff told us there was a flagging system on

the clinic list to indicate a patient with extra needs and if possible, these patients would be

prioritised. However, staff in other clinics were unaware of any flagging system either on electronic

or paper notes and told us they would only find out if a patient had additional needs when they

arrived at the clinic. This meant that these patients might wait longer if they required additional

support to be arranged.

Staff told us they could access telephone interpreting services 24 hours a day, seven days a

week. Face to face interpreting (including British Sign Language) and written translations were

also available upon request.


Patient transport service was available to help patients attend clinics however at the PRUH staff

told us patients were often late for appointments and could wait several hours to be taken home.

At Beckenham Beacon, one patient who had used this service, told us that they were informed

they could not bring their carer with them in the arranged transport and that a member of clinic

staff would be available for assistance. When the patient arrived, they were told there was no staff

member available to assist them and meant the patient was unable to get any refreshments from

the café.

The staff we spoke with demonstrated a good understanding of the importance of keeping adult

and paediatric clinics and waiting areas separate where possible. The PRUH had separate adult

and children’s outpatient areas and adult patients attending with children had the option of waiting

in the children’s outpatient area. At Beckenham Beacon, staff told us that the paediatric clinic was

run on a Monday morning in the clinic rooms nearest the second waiting area, so adults and

paediatric patients could be seated separately. A sign at reception indicated to adult patients with

children that there was a separate area to sit. However, this was not a dedicated child friendly

area.

Staff we spoke with in the urology clinic at Beckenham Beacon understood the importance of

maintaining patient’s privacy and dignity. They showed us the patients changing rooms and

screens used across the waiting area to maintain patient’s privacy when they were wearing

hospital gowns. Where possible patients would be booked into single sex clinics. If a clinic was

mixed, patients would be grouped at the beginning or end of the list so there was no mixed sex

changing areas. Staff showed us a booklet they had created so patients were given as much

information as possible about their treatment.

At the clinics we visited posters were visible offering patients the opportunity to access a

chaperone and the chaperone policy was displayed on the TV screen in the waiting room at the

PRUH. Disability toilets were clearly signposted and there were leaflet stands with information

about local services such as the Bromley Heart Support Group and support groups for dementia

and wellbeing.

The plaster room at the PRUH had not changed since our last inspection and staff told us there

were no plans to. The entrance to the clinic was not clear and staff had to prop open a fire door, so

patients could see where the clinic was. The small waiting area was a room with a partitioned wall

which did not reach the celling. A screen was used to separate the waiting area from clinical area

and meant patients waiting could hear what was being said during the appointment. Staff told us

they used a radio and would talk quietly with patients to maintain patient’s privacy. Patients had to

walk through this partitioned area to reach the second clinical area. Staff told us they had

requested a curtain to separate where patients were being seen and create a corridor to the

second room. This had been requested in October 2018 and at the time of our visit it had not been

fitted.

Since our last inspection, storage shelves for equipment had been fitted and staff were waiting for

a second storage unit. Filing cabinets were still being used for storage. Staff showed us different

casting tape in colours for patients to choose and easy cut tape that was used for more vulnerable

patients. A receptionist had been added to the clinic within the last few weeks; staff told us this

was to ensure that appointment outcomes were recorded, and patient activity accurately recorded.

The clinic staff had added children friendly stickers on the walls but there was no other provision

for children. There was no dedicated paediatric clinic with several orthopaedic clinics being held at

the same time. While this meant that there could be a mix of adults and children being treated in


the plaster room, potentially leading to a safeguarding risk, the service had a member of staff at

the reception desk during clinics and orthopaedic technicians were also present.

Access and flow


referral to treatment were not always in line with good practice.

New appointments for outpatient clinics were centrally booked by the Outpatient Appointment

Centre (OPAC) team and follow up appointments booked by each service. Patients could call the

central team to rearrange the initial appointment with each service managing patients thereafter.

The OPAC team also took calls from patients opting to cancel appointments via the text reminder

service. Appointments cancelled out of hours would generate a call list that the OPAC team

managed. This meant that the service had systems to ensure that patient cancellations were

managed appropriately, and patients did not get lost in the system if they cancelled their first

appointment.

Outpatient rooms and nurses were managed by the outpatient team and while clinical services

could request additional clinic times, this was not always possible and dependent on the capacity

of the outpatient team. This meant that patients could be waiting longer for appointments when

services struggled to arrange additional clinics based on patient demand.

Outpatient managers told us they had worked with services to design clinic and booking processes

to help manage appointment flow. For example, cancer services would block certain days to allow

for results from CT scans to come through ensuring patients did not attend appointments

unnecessarily and time was efficiently managed.

Waiting times were displayed in the department but had to be manually updated by staff meaning

the times were not always correct. Staff told us that patients from ED could be booked in overnight

leading to patients arriving at clinics that staff are unaware of. Staff would have to chase up the

patient notes which held up clinics.

Staff told us that orthopaedic clinics would often overrun, and we saw clinic lists that were double

and triple booked, bunching new patients at the same time. Staff told us this contributed to delays

in the plaster room. Staff also gave examples of recent issues where patients were booked to see

a consultant at 4.45pm when the x-ray department and the plaster room closed at 5pm. Staff in the

plaster room told us they would stay to see patients after 5pm but there was a risk that if a patient

was not suitable for casting there was no clinician to refer back to and a patient might have to

attend ED. This was raised by staff as a concern and the booking system changed. The service

was due to introduce a virtual fracture clinic in March 2019 and staff told us this would help

manage demand, improve triage and reduce patient waiting times.

Service managers had weekly meetings where referral to treatment time (RTT) performance was

reviewed. Managers showed us the live dashboard used to track patients, which was clear and

could be filtered at site and speciality level. This meant that managers were able to access real-

time performance information and clearly see patient flow in the service.

The trust had employed an external company to increase capacity across several clinics and

services had run additional weekend clinics to reduce the backlog of patients waiting to be seen.

At the time of the inspection, these clinics had now largely stopped as the more significant waiting

times had reduced.


Managers we spoke with were aware that the longest wait time within their service and regularly

monitored the patient tracking list (PTL) to track the patients open to the service and were aware

that the longest wait time in their service

At the time of the inspection, the process for triaging referrals to the ophthalmology service at

QMS was complicated and time consuming. electronic referrals were printed at the PRUH, logged

and sent to QMS via courier where they would be triaged and sent back to PRUH to be booked by

the OPAC team. The service was due to move completely to electronic triaging the week after our

visit to improve this process. This would reduce the risk of losing patient notes or referral in transit

and speed up the triaging process for new referrals.

Staff in the ophthalmology service at QMS told us that new appointments booked by the OPAC

team were sometimes not appropriate as they did not have the specialist understanding for this

patient group. Part of the work being undertaken by the Get it Right Frist Time (GIRFT) team was

to introduce a localised booking team and a partial booking system which would embargo

appointments for more than 4-6 weeks in advance. This was to try and minimise last minute

cancellations.

Staff across ophthalmology services at both QMS and West Kent Eye Centre told us that there

were a number of factors which resulted in clinic delays. The service was currently using both

electronic and paper notes, which meant that staff needed to input information into both systems.

Lack of equipment and staff had impacted flow in the departments, particularly with visual field

testing. Staffing levels in pre-assessment clinics at the PRUH had led to a number of cancellations

for surgery. The matron told us they had increased nurse staffing above establishment as a result

and this had reduced cancellations, but the nurse establishment had remained unchanged. Staff

on both sites told us there was not enough capacity for the number of patients being seen and that

staff stayed in clinic passed the last appointment time.

The dermatology clinic at Beckenham Beacon had recently been working through a backlog of

cancer two week wait referrals, which had built when the service transferred from Orpington

Hospital, and had seen waiting times improve. Additional clinics were outsourced to increase

capacity however these stopped in December 2018. Managers were aware of current wait times

potential demand and capacity issues. The service had remodelled their clinic structure to

increase the appointment slot capacity from 23 to 80 slots which meant that more urgent patients

could be seen in a timely way.

There were no standard processes to check for lost to follow up patients or managing ‘displaced’

patients at the trust. Managers we spoke with in the dermatology service told us they had changed

their process following an issue after a consultant left and their patients had to have follow up

appointments rebooked. The service had started to use outpatient waiting lists on the appointment

booking system (PiMS) to manage these patients. However, this incident had highlighted the lack

of standard process within the trust to manage these patients and dermatology managers were

due to share this learning at a clinical governance meeting with other services.

Referral to treatment (percentage within 18 weeks) – non-admitted pathways

From October 2017 to September 2018 the trust’s referral to treatment time (RTT) for non-

admitted pathways has been worse than the England overall performance. The latest figures for




Referral to treatment rates (percentage within 18 weeks) for non-admitted pathways,

King's College Hospital NHS Foundation Trust.


Referral to treatment (percentage within 18 weeks) non-admitted performance – by

specialty

Seven specialties were above the England average for non-admitted pathways RTT (percentage

within 18 weeks).









Twelve specialties were below the England average for non-admitted pathways RTT (percentage

within 18 weeks).



Other 86.6% 90.9%



ENT 82.6% 86.4%


Urology 75.8% 86.9%








Referral to treatment (percentage within 18 weeks) – incomplete pathways

From October 2017 to September 2018 the trust’s referral to treatment time (RTT) for incomplete

pathways has been worse than the England overall performance. The latest figures for



Referral to treatment rates (percentage within 18 weeks) for incomplete pathways, King's



The trust had a number of patients who had been waiting over the 52-week maximum on the RTT

pathway and was behind trajectory for recovery programme to reduce this patient group,

although managers told us the majority of these patients were waiting for appointments at the

King’s College Hospital site.

Referral to treatment (percentage within 18 weeks) incomplete pathways – by specialty

Three specialties were above the England average for incomplete pathways RTT (percentage

within 18 weeks).






16 specialties were below the England average for incomplete pathways RTT (percentage within

18 weeks).






Other 85.0% 89.9%






ENT 77.0% 86.5%

Urology 75.3% 86.4%






Cancer waiting times – Percentage of people seen by a specialist within 2 weeks of an

urgent GP referral (All cancers)

The trust is performing worse than the 93% operational standard for people being seen within two

weeks of an urgent GP referral. The performance over time is shown in the graph below.

Percentage of people seen by a specialist within 2 weeks of an urgent GP referral (All

cancers), King's College Hospital NHS Foundation Trust



Cancer waiting times – Percentage of people waiting less than 31 days from diagnosis to

first definitive treatment (All cancers)

Percentage of people waiting less than 31 days from diagnosis to first definitive treatment

(All cancers), King's College Hospital NHS Foundation Trust

The trust is performing better than the 96% operational standard for patients waiting less than 31

days before receiving their first treatment following a diagnosis (decision to treat). The

performance over time is shown in the graph below.


Cancer waiting times – Percentage of people waiting less than 62 days from urgent GP

referral to first definitive treatment

The trust is performing worse than the 85% operational standard for patients receiving their first

treatment within 62 days of an urgent GP referral. The performance over time is shown in the

graph below.

Percentage of people waiting less than 62 days from urgent GP referral to first definitive

treatment, King's College Hospital NHS Foundation Trust





lessons from the results, however these were not always shared with all staff.

The trust has a clear policy on complaints and outlines that a patient should receive an

acknowledgement within three working days and a response, where possible, within 25 working

days however this was due to be reviewed in November 2017. All service we visited had posters

and leaflets providing information for patients on the patient liaison service (PALS) and how to

make a complaint. Staff understood how to escalate complaints and could signpost patients to

PALS, however not all staff had access to regular staff meetings and were not aware of learning

from incidents or complaints.

At PRUH most of complaints were about limited parking and waiting times to be seen, particularly

in orthopaedics.

The ophthalmology service at WK, complaints centred around appointment cancellation and

rebooking. Staff told us this was due to capacity issues as urgent appointments could push back

routine ones. When a compliant was raised staff told us they would try and deal with the complaint

as quickly as possible and phone patients when applicable but were unable to provide any

examples.

Staff in the ophthalmology service at QMS were able to give examples of where complaints had

led to changes in the service. For example, the department had structured their phone cover and

allow administrative staff to complete other work, introducing a rota. However, this led to a rise in

the number of complaints as patients were less able to get through. As a result, the service

stropped using the rota the number of complaints fell.

Staff in the urology clinic at Beckenham Beacon were able to provide examples of learning from

complaints and incidents, leading to changes in practice. Staff were clear changes were made to

benefit the patients, improve the service and they welcomed feedback. They held a huddle each

morning where information would be shared, and we saw minutes from the monthly staff meeting

where incidents and shared learning was discussed.


From October 2017 to September 2018 there were 277 complaints about outpatients. The trust

took an average of 27 days to investigate and close complaints. This is not in line with their



A breakdown of subject can be seen below;



Communications 51





Waiting Times 12




Commissioners); 5




End of Life Care 1

Other 1



Commissioning Services 1

A breakdown of complaints by site is below:

Site No. of complaints

King’s College Hospital 165

Princess Royal University Hospital 56

Queen Mary's, Sidcup 38

Orpington Hospital 8

N.B there were a further 10 complaints split across the smaller sites.


We reviewed the complaints electronic system during the inspection. We noted there were 81

complaints between 1 April 2018 and 31 January 2019 for PRUH outpatients. The way the data

was recorded meant some of the complaints related to day surgery, maternity and cancer

services. Therefore, data included all patients who were not in-patients. We reviewed an example

of a complaint and the end to end process for response. There was a clear procedure, with

acknowledgement, investigation and outcome, which included a written apology.






Leadership

Most managers at the PRUH and south sites had the right skills and abilities to run a

service providing high-quality sustainable care.

Leaders we spoke with understood the challenges to the quality and sustainability of their services

and were engaged in projects to drive improvements. Leaders were aware of where the issues in

the department were and could identify actions needed to address them. However, most

managers and staff we spoke with described feeling frustrated at the slow movement of any

improvement work. Staff across several departments gave examples of business cases being

submitted and taking significant periods of time for action.

Not all leaders were visible and approachable for staff. Most staff we spoke with described local

leaders as present and approachable, however staff across all sites we visited told us that there

was limited visibility of senior trust management including the executive team. This was an area

for improvement which had been identified during the last inspection and continued to be the case.

Some departments which had been involved in the Get It Right First Time (GIRFT) work described

greater visibility of the executive team, however most frontline staff struggled to name anyone from

the executive team.

Most staff we spoke with described managers as supportive and having made positive changes to

their area of work. While some staff had received mixed levels of support from their immediate line

manager, they told us they had been able to raise concerns and discuss them with more senior

managers where needed and had been able to resolve concerns.

Some managers we spoke with struggled to keep on top of managerial duties due to staffing

constraints and having to pick up additional clinical work. While they described feeling supported

by their managers, the clinical workload had not reduced. This was particularly a challenge for

staff who covered more than one site. This meant that managers could not always provide strong

leadership to their teams.

Vision and strategy

The outpatients service had a vision for what it wanted to achieve and workable plans to

turn it into action.

There was an overall vision, mission and strategy for the trust built on four interconnected BEST

strategies Best Quality Care; Excellent Teaching and Research; Skilled “Can Do” Teams and Top

Productivity. These were supported by a series of principles, the Trust’s ‘Firm Foundations’:

rigorous governance; sound finances; strong partnerships; compelling communications; robust IT

and information and fit for purpose infrastructure.

The outpatient department had a defined vision around improving efficiency and digitalisation. All

staff we spoke with were aware of the transition to electronic patient records, and this was in the

process of being rolled out across services at all sites.

Each service line had plans for development and improvement. The trust had carried out a

‘Getting it Right First Time’ (GIRFT) programme in some areas of outpatients at the trust (such as

ophthalmology and orthopaedics), which was a national productivity programme, in partnership

with NHS Improvement. Within the ophthalmology service at the PRUH and at Queen Mary’s at

Sidcup, managers described longer-term plans to increase community services. The orthopaedic


service had approval for introducing a virtual fracture clinic in March 2019, this was designed to

improve flow in the service and move to a multidisciplinary approach. Service managers were

aware of how plans fitted into the overall trust strategy.

Staff we spoke with were aware of strands of their department strategy and how these related to

their area of work, although some staff told us improvement plans could often be delayed. Most

staff we spoke with understood that the trust was in financial special measures, which could

impact the timeliness of projects, and slow down the approval process for business plans.

Culture

Most managers promoted a positive culture that supported and valued staff and which

centred on the needs of people who use the services.

Most staff told us they felt supported by their managers and all staff we spoke with took a patient-

centred approach to their work and demonstrated a focus on patient care.

While staff felt positive and proud to work in their service and there was a strong local identity at all

the sites we visited, we saw very limited connection to the trust identity and most staff we spoke

with had little to no contact with the King’s College Hospital (KCH) site. Staff told us that they often

felt like the poor relation and felt the trust focus was on the services at KCH, and that the PRUH

and was seen as “a thorn in their side”. Staff we spoke with felt the service could be overlooked

and this was having a negative impact on staff morale. However, some managers described the

separate identities more positively, and felt that a sense of competition between the two sites had

driven improvements locally.

Managers described areas of good peer support amongst the PRUH and south sites, and where

possible they tried to flex staff across sites when needed. There was variable crossover with

services at KCH, amongst managers or frontline staff, and this was very much dependent on

individual services, and staff members who had more links or attended more meetings at KCH.

Staff told us they felt comfortable raising concerns with their managers and were aware of the

Freedom to Speak Up Guardian. However, staff from several areas told us that while they could

raise concerns with managers, they felt this would often not get resolved or concerns were not

listened to higher up.

Governance

The service did not always have a systematic or consistent approach to improving the

quality of its services. In some outpatient clinic areas, management and governance

structures helped to create an environment in which excellence in clinical care would

flourish. However, this was inconsistent and not all outpatient clinic areas were able to

safeguard high standards of care.

The governance structure for outpatient services at the PRUH and the south sites was not always

clear and consistent. Governance was devolved to care groups comprised of clinical specialities,

and each care group operated independently. While outpatients nursing and management were

part of the post-acute medicine care group, several clinical specialties which had outpatient

services came within a different care group. In addition, some of the services and staff

management structures crossed over with services at KCH. For example, the ophthalmology

service at Queen Mary’s at Sidcup was included as one of the south sites with the PRUH and

shared a matron with the West Kent Eye Centre based at the PRUH, but it reported to KCH for all

service governance matters. This meant that lines of accountability and management were not

always clear and there was a risk that issues or opportunities for learning and improvement were

not shared.


Within care groups, services had regular governance and risk meetings which fed into the care

group, the divisional risk and governance group and finally the divisional management board.

Services at Beckenham Beacon and Queen Mary’s at Sidcup held local governance meetings.

Managers at Beckenham Beacon told us they had previously struggled to attend meetings held at

the PRUH and that the structure had now shifted with meetings being held at Beckenham Beacon

which meant that more staff were able to attend. We reviewed a number of minutes from the care

group clinical governance meetings. These were detailed and covered incidents, complaints,

safety concerns and risks, patient feedback and any performance issues.

Not all services and teams had regular team meetings, which meant that there were not always

clear systems for staff to receive the information and updates. While some of these teams had

experienced a number of management changes and some had higher staff turnover, the lack of

established routes to raise concerns, discuss learning and service changes meant there was a risk

that staff did not always receive the necessary information needed to perform their roles, and were

reliant on informal routes to raise concerns.


The outpatients service had systems in place to manage current and future performance,

and for identifying and managing risks.

All service lines received regular performance information from the central Business Intelligence

Unit (BIU) at KCH, and managers could access real-time information through the central trust

reporting system.

Care group performance reports were reviewed monthly and information we viewed was

consistent and clear across the reports produced. Performance reports included a summary of

individual metric definitions which meant that staff using the reports had clear guidance on how the

information was put together.

Most managers we spoke to had a good understanding of the performance of their service, and

described performance dashboards as helpful for service planning and development. The

Outpatients Service Manager at the PRUH received daily performance information for patients on

the RTT and cancer two week wait pathways and oversaw booking for these patient groups. While

there was a weekly cancer meeting and a fortnightly RTT meeting, performance was

predominantly monitored and managed within service lines. However, some managers had limited

knowledge of how their service or department was performing and told us they struggled to

regularly monitor information due to having to cover clinical work in the department.

All specialities that provided outpatient clinics had a risk register. We reviewed the risk register

that was provided by the trust and saw that risks identified by service managers we spoke with

were present on the register. Risks had controls in place, records of ongoing actions and an

identified responsible member of staff. However, some risks had not been reviewed for several

months and there was no due date for the next review on the register. This meant that leaders

could not always be assured that the status of risks were regularly scrutinised or acted upon.


The trust collected, analysed, managed and used information well to support its activities,

using secure electronic systems with security safeguards.

Managers could access service information through a central reporting unit and could make

requests for specific information from the Business Intelligence Unit (BIU) at KCH. Managers we


spoke with felt confident in the accuracy of information produced by the BIU, and used information

to improve service planning.

For patients on the RTT pathway, the trust had a centralised RTT validation team based at KCH,

which checked patients who were approaching or who had breached the 18-week deadline.

Service managers also reviewed the patients through the Patient Tracking List (PTL) and

investigated and potential breaches to ensure that the information was correct.

PTL information was validated within service lines, who managed their own PTL, rather than

through the Outpatients Service Manager at the PRUH. However, the Outpatients Service

Managers had oversight of the cached-up clinics report which checked that all appointments in the

service had an outcome. This was processed by the administrative staff within the outpatient

department, who liaised with the relevant medical secretaries to check any unknown outcomes.

This ensured that patients received the appropriate follow-up after their appointment.

Some services had developed additional reports with information checks to ensure that patients

were monitored within clinical systems.

At Beckenham Beacon, the dermatology service had developed processes to manage follow-up

patients who may be lost to follow-up. These are patients who were due a follow-up appointment

which had not been booked and were not visible, or actively monitored by the service. The trust

did not have a standard process or protocol to capture these patients, as all follow-up

appointments were managed through individual services, but the dermatology service described

the processes they had implemented to ensure their patients were suitably monitored. This was

due to be discussed at the divisional governance meeting.

In the fracture clinic and plaster room, staff had highlighted several patients who had been not

been coded correctly following their appointment. Outpatient managers had allocated additional

administrative resources to address this and ensure that patient appointment information was

correctly entered.

Engagement

The trust did not always engage well with patients, staff, the public and local organisations

to plan and manage appropriate services.

In all the sites we visited, we saw posters asking patients for feedback on the service, and most

sites had feedback cards available to patients in the waiting area. At the main outpatient

department at the PRUH, the service also had an electronic patient feedback screen in the waiting

area, however, this was not working, and staff told us it had not worked since it had been installed

before our last inspection in 2017. This meant the trust may have missed opportunities to engage

with patients about the outpatient service.

Service managers we spoke with acknowledged that gathering patient feedback could be a

challenge in the outpatient department, and the service was working with the Business Intelligence

Unit (BIU) to adapt some of the patient questions to improve the specificity of feedback. The

PRUH had also run some patient drop-in sessions to involve patients in service development,

however, there were no regular patient groups or forums that the service engaged with.

Services engaged well with staff locally in design and improvement, however, there was limited

engagement with staff in any trust initiatives or plans. While staff we spoke with felt that they could

offer suggestions for improvement locally, we saw limited active engagement of staff towards any

trust planning or development and staff described feeling disengaged with trust-level initiatives.


Services collaborated with local and partner organisations effectively to support delivery.

Managers from a range of clinics we visited gave examples of working with local organisations to

develop patient pathways and services for the local population. Services were engaged with local

networks for dermatology and ophthalmology, to support the design and provision of services.


The trust had established systems and processes for improving services by learning from

when things went well and when they went wrong, promoting training, research and

innovation.

The trust had a quality improvement (QI) programme which was open to all staff and through

which staff could develop QI skills while completing projects specific to their area of work. One

staff member we spoke with told us about their project on electronically reviewing referrals to

improve the efficiency of the triaging process.

Staff we spoke with who had completed the trust’s QI ‘yellow belt’ training were positive about the

skills training. However, staff also commented that the project work could be time consuming, with

no additional time off allocated to complete the work, and this could be an obstacle to some staff

pursuing the training.

Documents

King's College Hospital NHS Foundation Trusts_College... · 2019. 6. 12. · They were confident 90% of files pertaining to fit and proper persons were up to date, although they were