The Royal Free Hospital NewApproachFocused Report (Acutes ... › sites › default › files › new... · Thisreportdescribesourjudgementofthequalityofcareatthishospital.Itisbasedonacombinationofwhatwefound

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Royal Free London NHS Foundation Trust

TheThe RRoyoyalal FFrreeee HospitHospitalalQuality Report

Pond StreetLondonNW3 2QGTel:020 7794 0500Website:https://www.royalfree.nhs.uk/

Date of inspection visit: 18 July 2017Date of publication: 20/09/2017

1 The Royal Free Hospital Quality Report 20/09/2017

Letter from the Chief Inspector of Hospitals

We undertook an unannounced focused inspection in the critical care department of the Royal Free Hospital which isoperated by the Royal Free London NHS Foundation Trust.

The inspection was conducted because the Care Quality Commission (CQC) had received anonymous information thatthe implementation of a new patient record IT system (CCCIS) had meant patients had been harmed, and was creatingan ongoing a risk to patient safety.

During our inspection we found no evidence that patients had been harmed or were at a higher risk of harm as a resultof the implementation and use of the new IT system.

At the point of our inspection, we found staff had ceased to use the critical care clinical information system (CCCIS) inearly July 2017 in its full capacity as a result of the safety concerns being raised by individuals with the trust. Ourinspection therefore focused on how the project had been managed and implemented and the resulting service. Someelements of the CCCIS were still in use, including electronic prescribing and access to diagnostic imaging.

We have not rated any part of this inspection because of its specific focus which did not include all areas of our ratingsassessment model.

The summary of our key findings of our inspection were:

• No patients had been harmed as a result of implementing the new IT system. The mortality rate in the 12 monthsprior to our inspection was significantly better than the national average.

• Although incident tracking and documentation was consistent, there were variable approaches to resolving safetyconcerns. In addition not all staff felt the incident investigation system was effective.

• A key risk to the safety and sustainability of the service related to short staffing, including a 29% vacancy rate in thenursing team and a 26% vacancy rate amongst junior doctors.

• A dedicated project team had worked with clinical staff who had undertaken additional training to support the pilotscheme of a new CCCIS.

• There was evidence of a responsive approach to risk management during the CCCIS pilot although a significantnumber of clinical staff disagreed with this.

• Care and treatment was benchmarked against national standards through a programme of local audits andcontribution to national audits, including the intensive care national audit and research centre. There was evidencestaff improved care policies and protocols as a result of audit outcomes.

• We found evidence of significant and persistent disagreement and conflict between staff at different levels ofresponsibility. The senior leadership team had not demonstrably addressed this nor implemented timely strategiesto reduce pressure on affected staff.

Our key findings were:

• Although incident tracking and documentation was consistent, there were variable approaches to resolving safetyconcerns. In addition not all staff felt the incident investigation system was effective.

• A key risk to the safety and sustainability of the service related to short staffing, including a 29% vacancy rate in thenursing team and a 26% vacancy rate amongst junior doctors.

• A dedicated project team had worked with clinical staff who had undertaken additional training to support the pilotscheme of a new critical care clinical information system (CCCIS).

• There was evidence of a responsive approach to risk management during the CCCIS pilot although a significantnumber of clinical staff disagreed with this.

• During the early implementation phase, on-site support for clinicians had been provided on a 24-hour basis bynurses and pharmacists who were trained as ‘super users’.

Summary of findings


• Care and treatment was benchmarked against national standards through a programme of local audits andcontribution to national audits, including the intensive care national audit and research centre. There was evidencestaff improved care policies and protocols as a result of audit outcomes.

• The mortality rate in the 12 months prior to our inspection was significantly better than the national average.• We found evidence of significant and persistent disagreement and conflict between staff at different levels of

responsibility. The senior leadership team had not demonstrably addressed this nor implemented timely strategiesto reduce pressure on affected staff.

• Clinical governance and risk management strategies were well established and effective in service improvement butthere was limited evidence they were effective in driving good working relationships or project management.

• Senior divisional staff had instructed external NHS bodies to visit the unit and implement strategies to improveworking relationships and leadership.

There were also areas of practice where the trust should consider making improvements:

• The trust should work with all staff groups and their representatives to assess how staff can feel more involved inmajor changes within the trust.

• The trust should review how governance systems can be made more open and effective in relation to projectimplementation and conflict management.

Professor Edward BakerChief Inspector of Hospitals

Summary of findings


TheThe RRoyoyalal FFrreeee HospitHospitalalDetailed findings

Services we looked atCritical care


Contents

PageDetailed findings from this inspectionBackground to The Royal Free Hospital 5

Our inspection team 5

How we carried out this inspection 5

Background to The Royal Free Hospital

We carried out an unannounced focused inspection on18 July 2017 in the critical care department of the RoyalFree Hospital following anonymous concerns raised withus. The concerns related to the pilot phase of a criticalcare clinical information system (CCCIS) and relatedimpact on patient safety.

The critical care department has 34 beds within thesurgical and associated services division. The departmentwas recently moved from the urgent division and at thetime of our inspection a transitional leadership team was

in place. There had been recent significant changes to thegovernance structure at the hospital and therefore at thetime of our inspection most of the senior leaders werenew to their role.

We did not rate critical care services as part of thisinspection and instead collected evidence, includingthrough conversations with staff, to address the key partsof the safe, effective and well-led key lines of enquiry. Wedid not inspect any other hospital services as part of thisinspection.

Our inspection team

Head of Hospital Inspections: Nicola Wise, Care QualityCommission

The team included three CQC inspectors and twospecialist professional advisors. One specialist advisorwas an intensive care consultant and one specialistadvisor was an intensive care nurse.

How we carried out this inspection

Because of the specific concerns raised we focused ourinspection on answering three key questions; is theservice safe?, is the service effective?, and is the servicewell led?

To complete this inspection we:

• Reviewed information publically available about thecritical unit as well as data from our most recentcomprehensive inspection.

• Conducted an unannounced inspection on 18 July 2017.• Observed clinical care and reviewed patient records in

the critical care unit.

• Reviewed clinical governance and risk managementinformation in relation the launch and trial of the criticalcare clinical information system (CCCIS). This includedthe minutes of project board meetings, staff meetingsand divisional meetings.

• Spoke with 27 members of staff across all grades andlevels of responsibility. This included consultants, juniordoctors, senior and junior nurses, nurse educators,divisional and clinical directors, allied healthprofessionals, pharmacists and staff involved in theCCCIS development and launch.

Detailed findings


• After our inspection we asked the trust to submit astandard set of safety data so that we could establish itsperformance in mandatory areas alongside the focus ofour site visit.

Detailed findings


Safe Not sufficient evidence to rate –––

Effective Not sufficient evidence to rate –––

Well-led Not sufficient evidence to rate –––

Overall Not sufficient evidence to rate –––

Information about the serviceThe critical care department at the Royal Free Hospitalconsists of three ‘pods’ located on the same floor with 34beds. All of the beds can be flexed to provide level two highdependency care or level three intensive therapy care.

Between January 2017 and June 2017, 4,094 level threebed days were used out of a total available of 6,154, whichrepresented a level three occupancy rate of 66%. Duringthe same period, the unit used 2,272 levels two bed daysand 168 bed days. Between April 2016 and June 2017,critical care services cared for 2,151 patients. Overall,annual occupancy between June 2016 and June 2017 was103%.

We last inspected this department in August 2016 and ratedit as good overall. At this inspection, we did not rate theservice and instead focused on the safe, effective andwell-led domains. This was so we could review informationrelated to the planning, launch and monitoring of a newcritical care clinical information system (CCCIS) aboutwhich we received information regarding an immediate riskto patient safety. The CCCIS pilot was introduced in lateMarch 2017 and started with two bed spaces, which wasincreased to 11 bed spaces gradually. The number of bedswith CCCIS in use fluctuated between two and 11 for theduration of the pilot.

At our inspection, we found staff had ceased to use CCCISin early July 2017 in its full capacity as a result of the safetyconcerns of some individuals. Our inspection thereforefocused on how the project had been managed andimplemented and the resulting service. The electronicprescribing and medicines administration (EPMA) system,which formed part of the overall patient record system with

CCCIS, was still in use alongside a diagnostic imaging ITsystem. We included these functions in our inspection aswell as consideration of standardised data submitted to usby the trust afterwards.

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Summary of findingsOur key findings were:

• Although incident tracking and documentation wasconsistent, there were variable approaches toresolving safety concerns. In addition not all staff feltthe incident investigation system was effective.

• A key risk to the safety and sustainability of theservice related to short staffing, including a 29%vacancy rate in the nursing team and a 26% vacancyrate amongst junior doctors.

• A dedicated project team had worked with clinicalstaff who had undertaken additional training tosupport the pilot scheme of a new critical careclinical information system (CCCIS).

• There was evidence of a responsive approach to riskmanagement during the CCCIS pilot although asignificant number of clinical staff disagreed withthis.

• During the early implementation phase, on-sitesupport for clinicians had been provided on a24-hour basis by nurses and pharmacists who weretrained as ‘super users’. External floorwalkers werealso available 24/7 for 10 weeks post the go-live date.

• Care and treatment was benchmarked againstnational standards through a programme of localaudits and contribution to national audits, includingthe intensive care national audit and research centre.There was evidence staff improved care policies andprotocols as a result of audit outcomes.

• The mortality rate in the 12 months prior to ourinspection was significantly better than the nationalaverage.

• We found evidence of significant and persistentdisagreement and conflict between staff at differentlevels of responsibility. The senior leadership teamhad not demonstrably addressed this norimplemented timely strategies to reduce pressure onaffected staff.

• Clinical governance and risk management strategieswere well established and effective in serviceimprovement but there was limited evidence theywere effective in driving good working relationshipsor project management.

• The new site-based executive team had recognisedculture and leadership issues in the ICU departmentand had commissioned work with NHS Elect toimprove the situation.

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Are critical care services safe?

Not sufficient evidence to rate –––

Our main findings for safe were:

• Staff were confident in the use of the electronic incidentreporting system and there was evidence the seniorteam investigated reports.

• Not all staff we spoke with said they were confident thesenior team took incidents seriously and some staff saidthey did not receive feedback from reports.

• The unit demonstrated consistently good results ininfection control practice through hand hygiene andhospital-acquired infection audits.

• Controlled drugs were stored and administered inaccordance with national best practice guidance.

• An electronic prescription management system wasimplemented as part of the critical care clinicalinformation system (CCCIS) pilot. This includedimproved risk reduction for infusions but resulted inincreased medicine-related errors and challenges forstaff. The trust commented that this was an increase inthe reporting of medicine related errors as it was moretransparent to identify errors using an electronicprescribing and medicines administration compared toa paper drug chart.

• In the previous 12 months, 40% of reported incidentsrelated to medicines.

• An initial gap in staff training with the CCCIS hadresulted in the loss of 400 patient note entries. However,there was evidence CCCIS manufacturer staff wereresponsive to changing the system in response to stafffeedback.

• Average compliance with safeguarding training was 93%and 91% for all mandatory training, which did not meetthe trust target of 95%.

• During the CCCIS pilot staff demonstrated a lowthreshold for risk and reverted to paper-baseddocumentation if a patient deteriorated or if theircondition became more complex.

• The results of a CCCIS user survey indicated 71% ofnurses felt the system distracted them from providingactual clinical care to their patients and 24% said theyfelt the system was not safe, compared with 29% ofdoctors.

• There was a 29% vacancy rate for nurses, a 26% vacancyrate for junior doctors and two consultant vacancies.

• The service met the requirements of the Faculty ofIntensive Care Medicine in relation to nurse to patientand consultant to patient ratio.

Incidents

• Never events are serious incidents that are entirelypreventable as guidance, or safety recommendationsproviding strong systemic protective barriers, areavailable at a national level, and should have beenimplemented by all healthcare providers. Between April2016 and June 2017, critical care services reported onenever event. This related to the misplacement of anaso-gastric tube prior to the commencement offeeding. The senior team completed an investigationthat found differing policies between trust sites hadcontributed to this and as a result standardisedpractices were introduced.

• In accordance with the Serious Incident Framework2015, critical care services reported two seriousincidents between April 2016 and June 2017. Theincidents related to a medicines error and an allegationmade against the conduct of a member of staff. We sawa multidisciplinary team, including the clinical lead andpatient safety and risk manager, had completed a rootcause analysis in each instance. As a result, the criticalteam established more consistent working practicesand wider cross-team working, including with thepatient advice and liaison service and pharmacy team.

• Staff used an electronic system to submit incidentreports. During the pilot phase of the critical care clinicalinformation system (CCCIS), the trust implementationteam and project team worked with the senior criticalcare team to investigate incident reports submitted inrelation to the CCCIS. This included weekly meetingsbetween the project team and clinical lead.

• We found evidence the CCCIS project team hadmanaged risks associated with the system based onlearning from incident investigations. For example, theteam changed the colour of the screen used forprescribing to ensure staff recognised when they wereabout to issue a medicine instruction. In addition theteam revised the prescription guidance forimmuno-suppression medicine to make it moreappropriate to the critical care environment.

• Although staff were confident in the reporting ofincidents, some individuals told us they did not receive

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feedback. For example one member of staff said theyhad submitted incident reports in relation to the CCCISpilot. They said, “The senior team would mark theincident as ‘resolved’ but this felt like a tick-box exercise.I didn’t think it was resolved and didn’t get any feedbackfrom it.” However, we saw evidence that incidents werediscussed during daily CCCIS ‘checkpoint’ meetings andin daily safety briefings as part of shift handovers.

• Between March 2017 and July 2017 staff reported 280incidents. Of this 80% resulted in no harm, 19% resultedin low harm and 1% resulted in moderate harm. Onlyone of the incidents was directly attributed to the CCCISpilot. This involved a server failure which meant therewas a delay in electronic prescribing for a patient. Staffreverted to a paper-based system and the incident wasescalated to the project team. There was no harm to thepatient. One incident related to clinical staff fromanother medical service who refused to use the CCCIS tocomplete patient notes.

• Staff reported 25 incidents relating in some way to theCCCIS between March 2017 and June 2017. Incidentsrelated to missed medicine doses, incorrect medicineprotocols and medicines stopped in error. The clinicalgovernance lead identified the root cause of eachincident, which was most commonly unanticipatederrors in the system or the methods used by staff.Although these incidents provided a commentary onhow the CCCIS pilot was working, none of themoccurred as a result of specific system faults and none ofthem resulted in patient harm.

• A clinical informatics pharmacist had conducted acomparison of incident reports between January 2016to March 2016 and January 2017 to March 2017. Thiswas to identify any increase in incidents caused by theimplementation of CCCIS. This search found no increasein the submission of incident reports between theperiods. Despite this, four members of staff we spokewith said incidents had significantly increased duringthe pilot. We were not able to identify why the accountsdiffered.

• The senior team had conducted a ‘risk round-up’exercise to review incidents and complaints betweenAugust 2016 and February 2017 as a strategy to identifythemes for learning and improvement. We saw this ledto improved and more frequent guidance for staff. Forexample, confidentiality guidance was improvedfollowing an avoidable data breach and more specifictraining for securing central lines was issued.

• Consultants led monthly multidisciplinary morbidityand mortality (M&M) meetings to review patient deathsand identify areas for improvement in clinical care,process or policy. We looked at M&M records from March2017 to May 2017 and found staff maintainedconsistently detailed records of mortality and identifiedcontributing factors such as staff expertise,healthcare-related infections and delays in care ortransfer. During this period there were no unexpecteddeaths.

Cleanliness, infection control and hygiene

• As at July 2017, 96% of staff had up to date infectioncontrol level one training and 80% had up to date leveltwo training. The trust’s minimum target was 95%.

• The critical care team and trust infection control teamused a scorecard to track cumulative cases ofmethicillin-resistant Staphylococcus aureus (MRSA),Clostridium difficle (C.Diff) and methicillin-sensitiveStaphylococcus aureus (MSSA). Between June 2016 andJune 2017 there were no cases of hospital-acquiredMSSA, MRSA or C.Diff reported in critical care.

• An infection control nurse conducted a ‘reducing risks’spot check in critical care every two months. Thisinvolved an observation of staff providing care toidentify areas of good practice that would normallypresent the growth or spread of C.Diff or MRSA. Thelatest results related to March 2017, May 2017 and June2017, in which critical care achieved 100% compliance.

• A senior nurse conducted a hand hygiene spot checkobservation of staff in up to 10 bed spaces each month.Results from March 2017 to June 2017 demonstrated anoverall compliance rate of 98%. This was an averagefigure and reflected 100% compliance in three monthsand 91% compliance in one month. Non-compliancewas found when a consultant, registrar and nurse didnot follow World Health Organisation hand hygieneguidance before or after a patient contact and did notuse hand gel or hand wash appropriately. The auditingnurse brought this to the attention of the staff involvedand reminded them of critical care policy.

Environment and equipment

• We found six cardboard boxes containing pulp productsstored on the floor of the dirty utility room in the eastcritical care unit. This represented poor infection controlpractice related to the risk of contamination withspillages.

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• The CCCIS system integrated IT equipment so thatphysician and nursing documentation and informationfrom medical devices was displayed directly intomonitors. However, staff consistently describedproblems with access and slow workflows when usingthis system.

• An assigned technician was responsible for maintainingmedical equipment as part of a rolling preventativemaintenance programme. In July 2017, 76% of plannedmaintenance was up to date.

• We looked at all of the resuscitation trollies in criticalcare and found staff had signed daily safety checklistson every day in the three weeks prior to our inspection.Trollies were fully stocked and all equipment andconsumables items were ready for use.

Medicines

• Controlled drugs were stored and administered inaccordance with national best practice guidance. Thisincluded electronic prescribing and checks on dosageand type of medicine by two nurses.

• The CCCIS had included an electronic patient drugchart, similar to a medicine administration record (MAR).However, staff told us this did not automaticallyhighlight any outstanding medicines needed if they didnot manually open and check the page. In addition,doctors told us prescribing from the related electronicprescribing and medicines administration system(EPMA) system caused delays to care due to thecomplexity of the system. For example, there was nofunction to rapidly identify commonly-prescribedmedicines and instead doctors had to search and selectfrom thousands of drug combinations. In addition thesystem did not retain completed prescriptions asimmediately available for longer than five days. Thismeant it was not immediately clear to staff whenprescriptions had been issued. After our inspection thetrust advised us they had improved EPMA access withthe introduction of a search system and mechanismprescribers could use to quickly find commonmedicines. We were not able to confirm why prescribingclinicians were unaware of this during our inspection.

• The trust commented that the EPMA system had amedication administration 'wizard' which guided thenurse through medicines administration andhighlighted overdue medicines at the top of thelist. They stated that the drug chart highlighted clearly

any overdue medicines or urgent (or STAT) medicines,and the nursing home page (or landing page) guided thenurse towards what was due in the next two, four and 12hours aiding their organisation for medicines.

• Staff had reported two medicine administration errorsand three medicine errors relating toimmunosuppression as a result of incorrect use of theEPMA. We spoke with the senior critical care team aboutthis who told us the complexity of the prescribingsystem, including a combined system for identifying thetype of medicine, dose and route, had led to mistakes.However, staff in the clinical education team told us theelectronic prescribing function had been implementedto address an increase in medicine errors that occurredprior to the pilot scheme. In addition a consultant toldus medicine errors during this period had doubled butthe pharmacy team told us there had been no increasein errors as a result of the system. For example onepharmacist said, “There was an increase in incidentreports but this was reflective of the high level of tensionamongst some members of the critical care team. Somestaff started submitting large numbers of incidentreports that were queries not incidents. We providedsupport to these staff but the reports weren’t treated asincidents because that’s not what they were.” Thepatient safety team and clinical governance lead hadconducted a comparison of prescribing errors beforeand after the introduction of EPMA. This showed anincrease from eight errors overall in 2016 to 25 errorsbetween January 2017 and June 2017.

• The EPMA included the management of infusions, whichenabled the electronic system to send informationdirectly to infusion devices. This meant patientsreceived infusions as part of a ‘closed loop’ system thatprotected them from inaccurate doses.

• A team of critical care pharmacists provided dedicatedcover and each member of this team had completedextended EPMA training as ‘super users’ to enable themto support staff during the pilot. In addition, apharmacist joined at least one consultant-led wardround each day and conducted their own twice-weeklyward round. The team increased this to a daily wardround during the pilot phase of CCCIS as a safetyverification strategy to ensure medicine administrationwas accurate and safe.

• Between March 2017 and July 2017, 40% of reportedincidents related to medicines. Of these, 46% involved

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controlled drugs and 37% related to medicineadministration. Staff highlighted 22 medicine incidents,which represented 19% of the total, as requiringdiscussion with the EPMA and CCCIS project team. Ineach case we saw evidence of learning or systemdevelopment. For example, following an incident inwhich a prescribed dose of medicine was missed, theproject team changed EPMA to ensure dose times weremore accessible on the system.

• The concerns staff raised with us regarding medicineprescribing in the CCCIS were reflected in the results of astaff survey that indicated 62% of doctors and 40% ofnurses frequently experienced difficulty in medicineadministration.

• Staff raised concerns with us that the electronicprescribing and medicines administration system(EPMA) that was part of the CCCIS did not includerestricted access. This meant any member of staff withan IT smart card could access it, including staff withoutprescribing privileges. We spoke with a member of thetrust implementation team about this who told us thiswas a feature of the software and the trust did not havethe ability to override it. However, there had been noreported instances of inappropriate prescribing as aresult of this. In addition the pharmacy team hadrestricted access to antibiotics used forimmune-suppression to clinical specialists in that area.

Records

• Staff described significant problems in saving patientnotes on the CCCIS due to confusion over the operatingsystem and the complexity of how notes needed to besequenced. For example if they entered notes in anorder that was not compliant with the software, notescould be lost. A senior clinician told us 400 patient noteentries had been lost in this manner. At the time of ourinspection staff had ceased to use most of the CCCISsystem and were using paper-based records forobservations and care records. CCCIS was still in use forreviewing blood results and diagnostics.

• Allied health professionals had not always hadappropriate access to the CCCIS. For example, onephysiotherapist had received no formal training on theuse of the system and the trust had failed to provide anindividual log-in card. This meant they relied on a

temporary card and one-to-one support fromfloor-walkers to access the system. They told us thiscaused delays to patient care because it took more timeto complete observation records.

• Where a patient was transferred from an inpatient wardto critical care, the patient at risk and resuscitation team(PARRT) provided a verbal handover and completedpaper-based patient notes. However, PARRT nurses toldus if they had needed to use the CCCIS, critical carenurses or the matron had provided support.

• A lead member of staff in informatics demonstrated howthe CCCIS project team was responsive to staff feedbackin relation to records. For example within 24 hours of thelaunch doctors had asked to have the ward roundpaperwork redesigned. The CCCIS manufacturer teamredesigned this overnight and project staff describedthem as “very responsive”.

Safeguarding

• As at July 2017, 95% of critical care staff had up to datesafeguarding adults level one training and 94% had upto date level two training. Staff were also required toundertake child safeguarding training and 94% of staffhad up to date level one training and 89% had up todate level two training. The trust’s minimum target was95%.

Mandatory training

• At the time of our inspection, 91% of critical care staffwere up to date with mandatory training. This was lowerthan the trust target of 95%. However, this was anoverall average and reflected full compliance in six ofthe 22 training topics.

Assessing and responding to patient risk

• Staff used a patient acuity tool they had designedin-house to assess patients’ clinical needs as well as theskill mix of staff needed. This was a new flowchart-basedsystem that enabled staff to respond quickly to thechanging needs of patients.

• During the pilot phase of the CCCIS system, critical carestaff worked to a low threshold for patient risk. Thismeant if a patient deteriorated staff could remove themfrom the CCCIS and revert to a paper-based system forrecords and observations. This meant patient safety wasnot compromised because a back-up system was in

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place. However, clinical staff told us the complexity ofthe CCCIS meant it had been difficult to identify patientswhose conditions deteriorated as quickly as they wouldusually.

• There was a demonstrable gap in planning for risks topatients in the software manufacturer’s design team.This was because there was no evidence theyincorporated the feedback of clinical staff in relation tosafety systems and features.

• Some staff told us the CCCIS did not allow them tomaintain safe levels of oversight of each patient’sclinical background and developing medical needs. Thiswas because of the number of stages or actions theyneeded to complete to find notes and observations. Forexample, one patient complained of abdominal painsfollowing liver surgery. A senior nurse told us the CCCISwas so complicated that the patient’s medical teamwasted over two days trying to identify the problemwhen they felt it could have been found much morequickly using the previous paper-based system.

• The PARRT team had been trained to navigate the CCCISsystem so they could assess patients who weredeteriorating and ensure they could access dischargesummaries for patients being transferred to a ward.

• The CCCIS software manufacturer compiled a list ofsafety concerns raised by staff, which the senior projectteam identified as most commonly relating to the lengthof time it took to navigate the system. From speakingwith staff and looking at the minutes of risk meetings itwas clear there were significant differences in clinicalsafety judgement between members of staff. This meantthere was not a consistent approach to identifyingpatient risk and deciding when to remove CCCIS.

• Clinical staff described safety concerns with regards tothe use of CCCIS to monitor patient risk. For example,one member of staff identified a patient who was placedat additional risk following a failed transplant becausenone of the clinical staff involved in their care could findthe information they needed in CCCIS.

• The results of a CCCIS user survey indicated 71% ofnurses felt the system distracted them from providingactual clinical care to their patients and 24% said theyfelt the system was not safe, compared with 29% ofdoctors.

• Resuscitation was part of the trust’s mandatory trainingprogramme for all staff. As at July 2017, 95% of criticalcare staff had up to date basic training and 91% hadadvanced training. This partially met the trust’sminimum target of 95%.

• In August 2016, the PARRT completed an audit ofobservation charts and nursing notes in 13 wards toidentify if ward staff provided appropriate care forpatients who were deteriorating. The audit found staffhad appropriately escalated and commencedobservations for patients who had triggered thenational early warning scores (NEWS) system, which thehospital used to identify early deterioration and plan forcritical care if needed. Overall the PARRT team foundward staff had completed 92% of expectedobservations.

• A June 2016 handover audit found inconsistencies andstandards between shifts during nurse handovers, whichmeant safety checks could be missed. As a result, thecritical care team formalised handovers with theintroduction of a new guidance tool and the PARRTteam provided additional training on the use of theSBAR tool. SBAR is an acronym for Situation,Background, Assessment, Recommendation; atechnique that can be used to facilitate prompt andappropriate communication.

Nursing staffing

• A team of 138 whole time equivalent (WTE) nurses,supported by 13WTE healthcare assistants (HCAs)provided care in the critical care unit. This represented ashortage of 56WTE nurses and 3WTE HCAs against theestablished number needed to fully provide the service.

• Staff reported a significant increase in the time taken tocomplete patient handovers during the implementationperiod of the CCCIS. For example, nurses told usindividual patient handovers increased from around 15minutes to over 40 minutes. This was reflected in clinicalgovernance meeting minutes.

• Nurses were allocated in their teams to a critical carepod for two months at a time. This meant staff gainedskills in each area of critical care and experienceworking with different senior nurses.

• The unit regularly used bank and agency nurses to makeup shortfalls in the permanent team. We found thatnurses were appropriately qualified and experiencedand the senior nurse in charge verified this prior to eachshift.

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Medical staffing

• Consultant to patient ratio met the national standardsset by the Faculty of Intensive Care Medicine (FICM). Thisincluded on-site consultant cover from 7.30am to9.30pm seven days a week with three consultantsMonday to Friday and two consultants at weekends. Aconsultant reviewed each patient within 12 hours ofadmission and the consultant to patient ratio did notexceed the FICM standard of 1:15.

• Five junior doctors provided care during the day andfour junior doctors provided this overnight. One doctoracted as a ‘float’ for the rest of the hospital to reviewpatients who needed a ward review after discharge fromcritical care.

• There was a 26% vacancy rate for junior doctorsbetween May 2017 and July 2017 due to resignations.

• The senior team had submitted a business case for therecruitment of more doctors, including additionalconsultants to provide improved weekend cover.

• The senior medical team had completed a businesscase to increase recruitment of junior doctors andmiddle grade doctors.

• Consultants led twice daily ward rounds in line withFICM guidance. However, senior clinical staff told us thatduring the CCCIS pilot, morning ward rounds had beensignificantly extended, sometimes by three hours. Theytold us this delayed patient care and extended theadmissions process unnecessarily. This was reflected inthe minutes of clinical governance meetings we lookedat.

• A North East and North Central Adult Critical CareNetwork peer review in November 2016 noted thatconsultant on-call cover overnight was insufficient andthe unit did not always meet the GPICS guidance ratio ofjunior doctors to patients as 1:8.

Are critical care services effective?


Our main findings for effective were:

• A November 2016 peer review by the North East andNorth Central London Adult Critical Care Networkidentified overall good standards of care, with mostconcerns relating to staffing levels.

• Staff demonstrated they were responsive to changingand updating policies and procedures based on thelatest best practice guidance.

• Care and treatment was benchmarked through a gapanalysis and action plan system that assessed carepractice against national standards, including thatissued by the National Institute of Health and CareExcellence. However, there was limited evidence actionplans were used effectively.

• The patient risk and safety manager completed regularaudits and assessments to improve safe care againstnational confidential enquiry into patient outcomes anddeath (NCEPOD) guidance.

• The unit participated in the Intensive Care NationalAudit and Research Centre (ICNARC) data collectionprogramme used to assess and benchmark quality care.

• The mortality rate in the 12 months prior to ourinspection was better than the national average.

• The unit did not meet the Intensive Care Society andFaculty of Intensive Care Medicine standard that aminimum of 60% of nurses hold a post-registrationqualification in intensive care medicine.

• Critical care performed variably in the 2016 generalmedical council (GMC) junior doctor satisfaction surveyand performed poorly in the nurse staff survey inrelation to manager support for appraisals.

• A multidisciplinary team of allied health professionalsprovided specialist care.

Evidence-based care and treatment

• Critical care was part of the North East and NorthCentral London Adult Critical Care Network. Thenetwork conducted a peer review of the unit inNovember 2016 to review quality improvement andshare best practice. The network reported on overallgood standards of evidence-based care and notedconcerns about staffing levels for consultants, juniordoctors, nurses and pharmacists. For example, bednumbers had increased from 24 to 34 but the number ofpharmacists had decreased from 2.9 whole timeequivalents (WTE) to 1.9WTE.

• Critical care staff had established a local audit plan of 10clinical audits for 2017 to monitor and assess the use ofhigh impact interventions such as for taking bloodcultures, prescribing antibiotics and managing urinarycatheters. Individual staff also had audit responsibilitiesin specialist areas such as nutrition, need safety andtracheostomies.

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• A June 2016 renal protection protocol compliance auditfound staff did not always adhere to the protocol. As aresult educational leads provided additional training tojunior doctors and clinical practice educators workedwith nurses to ensure they complied with bedsideprotocol.

• Trust care and treatment guidelines were integrated intothe use of the clinical information system (CCCIS). Forexample, a dietician told us they maintained careplanning in line with trust guidance regardless ofwhether a patient had been cared for using the CCCIS ornot.

• A lead nurse in clinical informatics had supported thecritical care team in the implementation of the CCCISpilot to identify strategies to produce audit data thatcould be used to identify good practice andbenchmarking. For example, some staff raised concernsthat medicine errors had increased as a result of thesystem. To address this the clinical informatics nurseattempted to audit incident reports in relation to thisbut inconsistencies in the pilot scheme meant this couldnot be achieved. This meant there was a lack of auditdata to establish the benefits and outcomes of thesystem. However, as the pilot ran for a limited period oftime with a maximum of 11 beds in use it was notpossible to undertake meaningful audit.

• Staff demonstrated they were responsive to changingand updating policies and procedures based on thelatest best practice guidance. For example, staffremoved a specific brand of mouthwash from theventilator-associated pneumonia care bundle afterinformation it did not benefit the patient. In addition,staff updated the sepsis guidelines with regards to thefluids used for first line resuscitation following newresearch outcomes.

• Critical care participated in the trust’s overarching gapanalysis and action plan (GAAP), which assessedcompliance with clinical guidance (CG) from theNational Institute for Health and Care Excellence (NICE).For example out of the 25 guidelines issued in CG83rehabilitation after critical illness in adults, critical carewas fully compliant with 19, partially compliant with fiveand non-compliant with one. Areas of partial ornon-compliance related to the lack of printedinformation for patients on their condition andtreatment and lack of provision for follow-up followingdischarge. There was limited evidence staff planned toaddress areas without full compliance with an action

plan. For example, they had identified the need forfurther discussions with the senior team but there wasno timescale, formal process or implementation lead forthis.

• GAAP found critical care to be fully compliant with 27 of35 recommendations in NICE CG135 in relation to organdonation for transplantation.

• Clinical and quality teams, including the patient safetyand risk manager (PSRM), assessed care deliveredagainst national confidential enquiry into patientoutcomes and death (NCEPOD) guidelines. In 2016, theteam found the unit to be partially compliant withNCEPOD0612 in relation to the time taken to intervenein a cardiac arrest. In addition, six recommendationswere made to improve compliance with NCEPOD1105sepsis management. This included through the use ofstandardised preformas, improved communication withpatients and the inclusion of sepsis on deathcertificates.

• In February 2017, the PSRM made tworecommendations to ensure critical care staff were fullycompliant with NCEPOD2014 in relation totracheostomy care. This included the use of WorldHealth Organisation checklists when staff insertedtracheostomies.

Pain relief

• Staff prescribed patient-controlled analgesia (PCA)where appropriate. Although this was included in theEMPA, staff told us the system did not show how muchof the medicine the patient had required. As a result apharmacist met with the pain team, who identified newPCA equipment that would work more consistently withthe electronic prescribing and medicines administration(EPMA) and CCCIS systems.

Nutrition and hydration

• The CCCIS system enabled dieticians to documentfeeding plans and malnutrition assessments, includingthe prescription of total parenteral nutrition.

Patient outcomes

• The unit participated in the Intensive Care NationalAudit and Research Centre (ICNARC) data collectionprogramme used to assess and benchmark quality care.

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Between January 2016 and December 2016, thestandardised mortality ratio was 0.96, which was betterthan the national average and meant fewer patientsdied than were expected.

• Between March 2016 and April 2017 1% of patients whowere discharged from critical care were readmittedwithin 48 hours. This was similar to the national averageof 1.1%.

• Between April 2016 and June 2017 the mortality ratewas 13%, which was significantly better than thenational average of 22%. During the same period, 837patients experienced a delayed discharge. Thisrepresented 50% of admissions.

• As a result of audit feedback, staff introduced RichmondAgitation and Sedation Scale (RASS) to the nursingobservations to ensure patients were not over sedated.

Competent staff

• As at July 2017, 45% of nurses held a post-registrationqualification in critical care. This was worse than theIntensive Care Society and Faculty of Intensive CareMedicine minimum standard of 60%. However, the trustinformed us that they had an ICU bank that had 52 ICUBand 6 nurses all of whom had the ICU post registrationcourse. Additionally, all band 5s were sent on theintensive care course within the first 6 months of starting(pending availability), and then on the next available ICUcourse.

• The CCCIS project team and trust implementation teamprovided training for staff nurses and doctors in the useof the new system. We asked 20 members of staff aboutthis. One member of staff said the training was notadequate because it had not been specific enough tocritical care. For example, they said the training ondischarge processes was generic and did not supportthe complex liaison often needed for discharges. Thetraining consisted of four hours face-to-face trainingfollowed by three hours of online learning, which staffwere required to complete themselves. Staff told us thegap of up to 12 weeks between training and the systemroll-out meant they had lost many of the new skills.

• A team of bank nurses initially took the CCCIS trainingand a senior nurse ensured at least two were rosteredonto every shift during implementation. A senior nursetold us the project team increased this immediatelywhen they realised there were not enough trained staffbut that this was restricted due to short staffing.

• A team of ‘super users’ had provided one-to-onesupport and guidance for clinical staff on the use of theCCCIS system. Critical care nurses and staff from thesoftware manufacturer made up the super user teamand pharmacists provided additional support as theywere trained in the electronic prescribing function of thesoftware.

• Staff told us the trust implementation team hadprovided ‘cluster’ training days after the CCCIS projectwas one year into development. This included trainingall senior band seven nurses as super users. In addition,a team of external non-clinical floorwalkers were trainedto assist clinical staff in the use of the system. Membersof this team were available 24-hours, seven days a weekduring the first ten weeks of the pilot scheme.

• The critical care pharmacy team had provided bedsidelearning sessions for clinical staff in the use of the EPMAas well as delivering an online prescription trainingcourse and practical prescription sessions in the twoweeks prior to implementation.

• The patient at risk and resuscitation team (PARRT)provided on-site resuscitation training to clinical staffand each nurse consultant or clinical nurse consultantwas a faculty member for team based simulationtraining.

• The CCCIS project board had implemented a trainingstrategy for the system ahead of its implementation thatidentified the study commitment required and whichstaff groups were to be prioritised. We noted that alliedhealth professionals were included in the strategyalthough senior clinical staff told us they were notincluded in the training.

• As this was a focused inspection we did not look indetail at staff appraisals. However, results from the 2016staff survey indicated that 81% of staff said their trainingand development needs were discussed in their lastappraisal although only 39% said they received supportfrom their manager to achieve this. In addition, 16% ofrespondents said they left the appraisal feeling that theirwork was valued. This was significantly worse than thetrust average of 30%.

• Critical care performed variably in the 2016 generalmedical council (GMC) junior doctor satisfaction survey.For example the overall satisfaction rate of respondentswas 72%, which represented a slight improvement of1% from the previous survey results in 2013. Satisfaction

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with induction, work load and handovers haddeteriorated during this period and satisfaction withlocal teaching and educational supervision hadimproved.

• An education programme was in place to give staffaccess to specialist learning opportunities. In 2016 and2017 this included a guest speaker for brainstem testing,devastating brain injury and out of hospital cardiacarrest as well as sessions on delirium and acquiredkidney injury. We saw this programme combined anaudit approach and led to improved clinical practice.For example, a July 2016 audit checked clinical practiceand documentations against the 2013 Clinical PracticeGuidelines for the Management of Pain, Agitation andDelirium in Adult Patients in the Intensive Care Unit andNICE CG 103 in relation to the management of delirium.The audit found significant shortcomings in how staffcared for patients with delirium. For example, staff haddocumented RASS scores more than four times every 12hours for only 30% of patients. In addition, despite 42%of assessable patients triggering the confusionassessment method for intensive care units (CAM-ICU),staff had not assessed any patients for delirium using avalidated tool. As a result more specialised training wasintroduced for doctors to set RASS targets at wardrounds and nurses undertook more thorough trainingon the assessment and management of delirium. Inaddition, acute delirium management guidelines wereestablished and a local policy on assessment andmanagement of delirium was developed.

• Although all new nurses undertook a supernumeraryperiod during which they were mentored, we sawnegative feedback from this process in nurse meetingminutes. Senior nurses who acted as mentorscommented that they had no guidance on what toinclude for new nurses during supervision and alsonoted that short staffing meant they were often too busyto provide new nurses with a meaningful experience.Although senior staff at the meeting acknowledged thisas a concern, there was no immediate resolution. Afterour inspection the trust told us mentors were givenstructured guidance and support in the form ofcompetency booklets and from the clinical educationteam. We were not able to identify why staff we spokewith were unaware of these.

Multidisciplinary working

• The multidisciplinary team had not been included intraining for using the new CCCIS and the systemincluded only basic documents for staff to write notesand observations rather than the templates they hadpreviously used. This meant writing notes was moretime-consuming and allied health professionals told usthey often lost notes they had written because thesystem only saved them if they were entered in aspecific sequence.

• A nurse consultant led the PARRT, which was staffed byclinical nurse specialists who provided a 24-hour, sevenday service. This team provided rehabilitation andtracheostomy weaning for patients who had beendischarged from critical care.

• A multidisciplinary team of allied health professionalsprovided specialist care. This included sixphysiotherapists, an occupational therapist, twodieticians and two speech and language therapists.

• Weekly multidisciplinary team meetings took place toreview patients who had been admitted to critical carefor over 14 days. As a result of this approachrehabilitation was implemented earlier and the overalllength of stay and readmission rate had decreased.

• We looked at the rota for floor walkers and super usersfor the CCCIS pilot for March 2017 and April 2017. Fivenurse super users and an EPMA pharmacist wereavailable 24-hours, seven days a week during thisperiod.

Are critical care services well-led?


Our main findings for well led were:

• We found significant, on-going disparities and conflictsbetween staff at different levels of responsibility andseniority.

• Staff gave varying feedback on the working culture andatmosphere, including some who described bullyingand in appropriate behaviour from colleagues.

• Clinical governance and risk management strategieswere well established and effective in serviceimprovement but there was limited evidence they wereeffective in driving good working relationships or projectmanagement.

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• The senior leadership team had not resolved theon-going concerns of staff during the implementationphase of the clinical information system (CCCIS). A staffsurvey to gather experience of using the CCCIS indicated60% of the nurses and doctors who responded felt thesystem was unsafe.

• The senior leadership team had failed to act onsignificant conflict in the department.

• Although there was evidence of regular staffengagement, survey results were poor and typicallyworse than the rest of the trust. There was very limitedevidence of coherence and drive in the senior team toresolve this.

• There was evidence the CCCIS project teamimplemented strategies to reduce risk and address theconcerns of clinical staff.

• There was a lack of consistent evidence thatdepartmental managers had the capacity to monitor theworkload and level of responsibility of their staff.

• The working culture of critical care meant that staff didnot always feel involved in decision-making thataffected them.

• The most recent staff survey took place in September2016 with a response rate of 45%. The departmentperformed worse than the rest of the trust in 57% of thequestions asked.

• The new site-based executive team had recognisedculture and leadership issues in the ICU department andhad commissioned work with NHS Elect to improve thesituation.

Leadership of service

• A divisional director had overall responsibility for thesurgery and associated services division and a clinicaldirector maintained oversight of anaesthetics, theatresand critical care. A divisional director of operations,supported by a senior operations and clinical managerprovided operational leadership. A divisional director ofnursing supported by two matrons led nursing care.Thiswas a new leadership team implemented in early July2017.

• A project manager and clinical lead had led theimplementation phase of the CCCIS with support from aresponsible officer and dedicated project team.

• Staff told us the use of the CCCIS had reduced theamount of time they could spend with patients becauseof the additional time needed to navigate the system.There were no contingency plans from the leadership in

place for this. For example one nurse said, “Basicobservations were taking 20 minutes to document.That’s 20 minutes we’d normally spend talking topatients and their relatives. Facing away from them andpaying attention to two computer screens instead madeit difficult for them to interrupt us or speak to us.”

• It was not clear that the leadership structure in criticalcare had supported staff during a time of transition andadditional pressure in the unit. For example one seniormember of staff said, “The support for the CCCIS wassuper, especially the prescribing system. I was verysurprised none of the doctors engaged with us as superusers. This was open to everyone so it was reallydisappointing no-one in the senior team looked into thisand encouraged doctors to become more involved.”

• Staff told us they felt there were gaps in leadershipduring the pre-implementation phase of the CCCIS pilot.This was because they undertook training up to fivemonths before the system was launched, which meantthey needed refresher training and had not been givenany practical practice in using the system.

• There had been recent significant changes in theleadership structure of critical care, including within theleadership team for the pilot scheme implementation ofthe CCCIS. This included a new divisional director andclinical lead. In addition, the trust had reconfigureddirectorates and critical care had moved from theurgent care division to the surgical and associatedservices division.

• To better understand the additional pressure onworking relationships described by the majority of staffwe spoke with, we asked 14 people about input andsupport from the leadership team. One senior clinicalmember of staff said, “From my point of view there hasbeen zero input from anyone above matron level. Ihaven’t had any input from or seen any clinical directorsor the head of nursing in the unit for the whole timewe’ve had problems.” One member of staff said, “I feelthat we were listened to. I submitted incident reportsand spoke to the matron about my concerns and I gotgood feedback and support.” One member of staff said,“We as a team have been placed in the middle ofdisagreements between senior staff. The clinical directorwas clear they had better ideas than CCCIS and didn’twant it to work while others were pushing us to workwith it. We lost momentum because of these competingdemands and the balance between professionals wasnot well established. The leadership team did not try

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and bridge the gap between doctors and nurses.” Oneclinical member of staff said, “The leadership function inthis hospital is very much focused on performance andnot on staff wellbeing. I have never worked somewherethat is so uncaring and lacks even the most basic ofleadership. The [CCCIS project] failed because there wasno joined-up working between budget holders andclinical staff. Now the trust is looking for scapegoats andpeople to blame so I think the already very highturnover rate will get even worse.”

• There was not consistent evidence that departmentalmanagers had the capacity to monitor the workload andlevel of responsibility of their staff. For example, oneindividual who had been involved in theimplementation of the CCCIS project said they wereexpected to working increasing hours for no extra payon top of their clinical work until they escalated this tothe senior team.

• Some staff told us the lack of coordination from theleadership team meant that some staff individuallyrefused to participate in the CCCIS pilot and madeunilateral decisions without consultation, whichaffected working relationships and patient care. Thiswas because they felt care decisions were not wellcoordinated and there was a lack of safety oversightfrom senior responsible staff.

• We found a lack of leadership support specifically forbank nurses. For example, a temporary workforce officewas responsible for this staff group but nurses we spokewith did not know how to contact them or how to obtainsupport. For example one nurse said, “I’ve never met theperson who is responsible for us. We just have to lookafter ourselves. Usually this is okay but it means we’renot taken seriously when something goes wrong. I fileda complaint two years ago in a bullying incident and itstill isn’t resolved. It certainly isn’t a priority [for thetrust].” The trust subsequently commented that the ICUbank was managed by ICU matrons though the band 7structure. Staff booked shifts through this system. Allstaff were supported from band 7 and matrons. Bankstaff were allocated to teams of nurses led by a band 7.Bank staff attended cluster education days along withsubstantive staff and were also offered training andeducation to ensure they are compliant with mandatorytraining. Any complaints should be reported through tomatron who would escalate to the trust wide bank teamto investigate.

• The new divisional director acknowledged the concernsabout team coherence and leadership and outlined aplan to improve this, including support from anotherNHS agency to look at structure, culture and leadershipas well as another project to improve workforcedynamics.

Vision and strategy for this service

• Critical care had a 10 year strategic vision to address thehospital’s expansion plans and meet the clinical needsfor post-operative patients. The vision outlined anambition to stabilise staffing levels, achieve an ITsolution and open 11 high dependency beds specificallyfor post-operative care.

• The clinical information system (CCCIS) project teamhad collected feedback from staff involved in the pilotscheme as a strategy to improve the system for otherareas of the hospital and ensure it was improved if thesenior team relaunched it in critical care. Staff told usthey expected this to happen as part of a critical careimprovement programme and a redesigned strategy forthe service that was in the process of development.

Governance, risk management and qualitymeasurement

• A divisional board met monthly to review quality, clinicalgovernance and departmental risk registers. We lookedat the latest available minutes from the urgent caredivisional board meeting and found it was well attendedby appropriate staff and focused on risk managementand quality of care provided. This took place prior to thechange in divisional membership.

• The CCCIS project team and the clinical risk lead hadcompleted a risk assessment for the roll-out of theCCCIS, including from discussions and training with staff.At the point the project was suspended there were 31items on the assessment log, of which 19 were open andunresolved. Resolved risks were clearly documented insome cases. For example, doctor documentationtraining had been redesigned and redelivered followingchanges to CCCIS. However, other risks had beenmarked as resolved but without well-defined outcomes.For example, a key risk was noted as the resistance ofsome critical care staff to the pilot scheme. Although thestatus of this risk was marked as closed, there was noevidence a strategy to engage with detached staff hadbeen completed.

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• We spoke with staff who had provided care to patientswhilst using the CCCIS system in its pilot phase. Onenurse told us they had reported a number of errors orissues with the system to the project team but hadreceived no reply or resolution. For example, it was notclear where nurses should record nasogastric aspirate,which led to an inconsistent approach to recording andinaccurate output totals being calculated. In addition,patient global assessment of pain could not be correctlyrecorded.

• Twice-weekly implementation meetings took placebetween critical care staff, the trust project team and asenior trust board team. Weekly board meetings alsotook place but some staff told us the senior responsibleofficer was not approachable and did not act onfeedback. In addition one senior member of staff saidthey felt meeting minutes were not accurate and did notrepresent the process or outcomes of meetings. Duringthe pilot scheme senior sisters met with the matron,floor walkers and super user team every day to identifyemerging problems with the system so they could beresolved or escalated without delay. The CCCIS projectmanager prepared a daily report for the softwaremanufacturer support team so that on-going issuescould be addressed. We looked at three daily reportsand found them to be detailed and to include specificconcerns and requests for solutions for the CCCIS.

• The team of super users compiled a record of concernsand risks associated with the CCCIS raised by staff eachday and presented these to the senior leadership team.

• Although the governance system in place meant risks topatients were consistently managed, it did notdemonstrably contribute to cohesive team working. Forexample, senior staff told us they had not beenconsulted in the removal of the CCCIS and instead someclinical staff had decided to stop using it withoutconsulting the wider team. In addition six members ofstaff told us they had not been supported by somemembers of the senior leadership team and that thelack of governance in relation to staffing had resulted indifficult working conditions some people were blamedfor the pilot scheme’s failure. One member of staff said,“We got an email two weeks ago to say they wereswitching the system off. I was surprised because wewere getting good feedback from staff right up to thatpoint and the working teams were looking at this everyday. We’ve had no formal debrief, no meeting from the[senior team] so I don’t know what’s happening.”

• Three working groups had been established during theCCCIS pilot to provide trouble-shooting support to staffand to drive development and improvements. As part ofthis approach, the clinical governance lead had issuednurses and doctors with a survey to find out if they feltthe CCCIS was a safe system. The results indicated that60% of both staff groups felt the system was not safe.

• The CCCIS project team used a risk register to monitorand assess risks relating to the implementation of thesoftware. We found when CCCIS was removed fromcritical care, the project team transferred remaining risksto the departmental register. This team had managedrisks appropriately during the implementation of thesystem. For example they identified one risk relating tothe continuity of patient documentation when theymoved between services, such as from critical care todiagnostic imaging and back again. The risk occurredbecause of the different patient records systems used bythe different departments. This risk was mitigated by thecritical care nurse to patient ratio of 1:1 and by thereviews completed by a nurse and junior doctor beforeand after each transfer for diagnostics.

• From our conversations it was clear that clinical staff feltaffected by the financial pressures of the trust. Staff toldus they felt pressured to implement the CCCIS due tofinancial pressure from the senior team and nurses toldus they felt no additional CCCIS training had beenprovided due to financial issues.

• We looked at the minutes of the EPMA working groupmeeting, which was used by the project team to identifyand resolve issues with the system. This includedspecific feedback from staff on why certain aspects weredifficult to follow but did not include a time frame forresolution.

• We looked at a sample of project board meetingminutes relating to the implementation of the CCCISbetween February 2017 and June 2017. We saw themeetings were consistently well attended and that theconcerns raised with us were repeatedly discussed inthe meetings. In addition there was evidence of seniormultidisciplinary working to resolve concerns raised byclinical staff that the CCCIS was clinically unsafe. Thisincluded reviewing training, on-site technical support,support from the system manufacturer and monitoringof incident reports. There was evidence the project teamimplemented strategies to reduce risk and address the

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concerns of clinical staff. For example, the project teamestablished a training programme for expert staff ineach of the three component areas of CCCIS to providemore targeted technical and developmental support.

• In advance of the implementation of the CCCIS, theproject team established workflow teams for doctors,nurses, pharmacists and key administrative staff incritical care. This was established in May 2016 andincluded 15 nurses and 11 doctors or senior nurses, ofwhich four were critical care consultants. However, wedid not see evidence this system took place in practiceand there was inconsistent evidence of consultantinput. For example, two consultants declined to attendall seven of the workflow meetings, one consultantdeclined to attend three meetings and only oneconsultant attended all workflow meetings. This meantthere was limited input into workflow developmentfrom this staff group. We were told the reason forinconsistent consultant input and engagement at thedevelopment stage was due to staffing issues and highvacancy rates. Staff felt that that the trust should nothave tried to implement the new system at this time butdid so due to financial pressures.

• The project team used a hazard summary tool in eachphase of CCCIS implementation to monitor risks topatients and staff and identify mitigation strategies.These included improving training and developingdepartment policy frameworks to ensure care could beprovided safely during the pilot phase. For example therisk of creating a discharge summary for the wrongpatient was mitigated by training for staff and a systemimplemented to ensure that only information consentedby the patient was sent to their GP as part of thedischarge process.

• At the time of our inspection there were eight items onthe critical care risk register. The senior team hadclassified two risks as extreme, five risks as high and onerisk as moderate. The extreme risks related to a 26%vacancy rate amongst junior doctors and a lack ofpatient flow and capacity.

Culture within the service

• Six members of staff told us they felt they had beenpressured into implementing the CCCIS for patientsbefore they felt ready to do so. One member of staffsaid, “[The trust] made it very clear to us we were tolaunch on time at all costs due to their financialobligation. This was contradictory to how safely we

normally work, where patient safety always comes first.Instead the divisional director of nursing at the time wasreally pushing us to move forward and we increased thesystem from four beds to 11 beds before we were ready.”Another member of staff said, “There has been lots ofblaming around why the system didn’t work. Seniormanagers have bullied some individuals for not makingit work and the chief executive has e-mailed [criticalcare doctors] to assign blame, which is completelyinappropriate.” One member of staff said, “Doctors hadenormous problems adapting to the new system. Withthe exception of some junior doctors, most of the teamcould not manage their workflows on the system. Thiswas astonishing. A number of this team refused to usethe CCCIS and bullied those of us who were there tohelp. Two consultants made derogatory and hurtfulcomments about us when we tried to help. The systemwas not inherently unsafe but their attitude made itunsafe.” Another member of staff said, “Some of themore junior staff who were floor walkers for the CCCISpilot struggled with the attitude of some other clinicalstaff. We were told we were ‘only’ nurses and so couldn’thelp doctors with the system. I felt there was anenormous lack of leadership during this period. The[senior team] would listen to us but not do anything. It’sa very uncomfortable position to be in when somedoctors used the system without any problems but theothers victimised us when they couldn’t manage it.”

• Nursing staff and allied health professionals we spokewith about the implementation of the CCCIS saidalthough support was provided, it put pressure on therelationship between different teams. One member ofstaff said, “Some of the [critical care team] decided theyjust didn’t like the system and so refused to use it. Thatmade for a difficult and tense working environment andmade the situation much worse.”

• The working culture of critical care meant that staff didnot always feel involved in decision-making thataffected them. For example, nurses told us the removalof the CCCIS was abrupt and they did not know why thishad happened. Nurses we spoke with at all levels saidthey had received no information about the reasons forthis and did not know what would happen next. Onenurse said, “The consultants have been told what’shappening but no-one else has. That’s demoralisingafter we spent so much time getting used to it.” Wefound consultants had reduced the number of CCCISbeds to zero and had made the decision unilaterally to

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cease using the system. There was no evidence ofengagement with the divisional team, matron or projectteam regarding this. After our inspection the trustprovided evidence of e-mails sent to all critical carenurses regarding the suspension of the CCCIS. We werenot able to confirm why the nurses we spoke with wereunaware of this.

• Staff involved with the CCCIS project team told us theteam had been under-resourced and that, “Stress levelswere very high.” They told us this was because of staffturnover and a lack of interest in existing staff joining theteam.

Staff engagement

• There were inconsistencies in how the senior unit teamand trust implementation team had engaged criticalcare staff in the implementation of the CCCIS and usingfeedback to direct this. For example, senior band sevennurses told us they had not been involved in the projectand the nurses who had been responsible for this hadnot asked for input or suggestions from them. Thismeant some members of the nursing team felt thesystem had not been developed with their needs inmind. In addition only one critical care consultant hadbeen involved in the design and adaptation of thesystem. Consultants told us this was due to shortstaffing and vacancies in the team. We spoke with thechief information officer about this. They saidconsultants from two other NHS trusts had offered tospend time with their critical care counterparts tosupport them in using the system as their home trusthad successfully implemented this. In addition nurses inthe project team and the nursing lead for informaticshad met with a range of critical care staff to discuss theirneeds and how the software could be adapted.

• Two critical care research nurses had completed useracceptance testing of the CCCIS and attended planningmeetings with the software manufacturer. This enabledthem to provide direct support and training to criticalstaff in advance of implementation. Although this teamwere not available throughout the pilot programme,alternative staff did ensure support and guidance wascontinual.

• The CCCIS project team demonstrated how theyresponded to staff concerns in the use of the system by

implementing improvements. For example, the teamadded symbols to the diagnostic and imaging testsordering page to make it easier for clinical staff toidentify what they needed to order.

• The most recent staff survey took place in September2016 with a response rate of 45%. The departmentperformed worse than the rest of the trust in 57% of thequestions asked. For example, 19% of respondents saidthere were enough staff to do their job properlycompared with 31% in the rest of the trust. Thedivisional board had reviewed staff survey results inApril 2017 and conducted a benchmarking exercise toidentify how results compared to other NHS trustsnationally.

• The senior trust team had acted on some of thenegative results from the staff survey that indicated lowlevels of engagement and job satisfaction amongstnurses and junior to mid-grade doctors. This includedobtaining support from an external organisation to workwith critical care teams to improve relations.

• The CCCIS project team conducted user surveys withnurses and doctors to gauge levels of confidence as wellas qualitative feedback on the use of the system. Thesurveys generated large quantities of qualitativefeedback in which respondents described concernsabout clinical safety and risk. Although there werenumerous forums in which the project team and clinicalgovernance teams discussed risks and hazards, therewas limited evidence the concerns from the surveyswere used to inform on-going implementation orimprove patient safety. This was reflected in the declineof survey responses from up to 30 per day in May 2017 tozero per day in June 2017.

• Staff met within their professional group peers at leastmonthly. We saw from looking at the minutes ofmeetings that feedback from individuals was discussedand areas for improvement identified. For example,consultants were aware of poor feedback from juniordoctors in the GMC survey and identified a weekly timeslot where more regular teaching would be possible.

• The trust board had not included front-line nursesresponsible for CCCIS training and implementation inproject meetings. A nurse told us this meant they feltdisconnected from the project team and not readilyable to contribute to improvements with the feedbackthey gained from working on the unit.

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Areas for improvement

Action the hospital SHOULD take to improve

• The trust should work with all staff groups and theirrepresentatives to assess how staff can feel moreinvolved in major changes within the trust.

• The trust should review how governance systems canbe made more open and effective.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


Documents

The Royal Free Hospital NewApproachFocused Report (Acutes ... › sites › default › files › new... · Thisreportdescribesourjudgementofthequalityofcareatthishospital.Itisbasedonacombinationofwhatwefound