The inspection focused on the hospice and stroke unit at the Hospital of St John and St Elizabeth. We spoke with numerous staff, including nurses a consultant and doctors. We also spoke with six patients in the hospice and one patient in the stroke unit. Patients were positive about the care and treatment they had received.

We found patients received safe, effective care that was planned in a way that ensured their safety and welfare. Peoples' needs were assessed and reviewed by a multi-disciplinary team, however, the outcomes from these meetings were not always recorded on the patient notes. Initial assessments were conducted in the hospice and recorded in patient notes. Assessments in the stroke unit were not always recorded.

Information was provided in a format that met people's needs to ensure they understood and were able to make decisions.

There were arrangements in place to deal with medical emergencies. There were systems in place to monitor the quality of service provided.

Patients told us that staff asked for their permission before carrying out care activities. Staff obtained patients written consent before examinations or surgery was carried out. On St Johns' Hospice, staff did not always consult with patients or their relatives when a decision had been made by staff not to attempt resuscitation. The consultant told us that there were clinical reasons for not informing patients of the decision for staff not to attempt resuscitation but these were not documented in patients’ medical records.

Each patient had an individual care plan and an allocated nurse during each shift. Patients were aware who their allocated nurse was and stated they were treated "very well".

There were infection control policies and staff had completed training on infection control. The areas we visited were clean and well maintained. Patients told us that all areas were always "very clean" and they observed staff regularly carrying out cleaning duties.

The hospital carried out background checks on all employees that included, obtaining two references from previous employers, checking qualifications and that membership of professional organisations were up to date.

Patient records were kept secure, appropriately completed with the entries dated and signed by the relevant staff member. Staff files were easily accessible by managers if required and were kept in a mixture of paper and electronic formats.

Patients told us the hospital gave them adequate information about the wards prior to their admission and treated them with respect and dignity. Most, but not all patients told us that they were very satisfied with the quality of care received and spoke highly about the staff. Patients described staff as polite and courteous and stated that felt safe on the wards. Patients and carers told us that they had not seen their care plans and were not sure if the had one.

The Hospital of St John and St Elizabeth is one of the UK's largest independent charitable hospitals, with any profits used to fund the on-site hospice, St John's, which offers free care to more than 3000 patients and their families every year. The hospital was founded in 1856 with a Roman Catholic affiliation and is a registered charity. The hospital has 73 beds and facilities, which include; five operating theatres, diagnostic imaging, a three-bed level two-care unit, outpatient department, and a walk-in urgent care centre. The hospice is located within the main hospital.

The hospital provides surgery, medical care, and outpatient and diagnostic services for children, young people, and adults.

We inspected surgery and medicine, which included endoscopy, and end of life care. We also inspected the outpatients and diagnostics services using our comprehensive inspection methodology. We carried out the announced part of the inspection on 18, 19 October 2016, and unannounced visits to the hospital on 1 and 3 November 2016.

We did not inspect the GP service, which operates at this location, as this service is managed by another provider.

To get to the heart of patients’ experiences of care and treatment, we ask the same five key questions of all services: are they safe, effective, caring, responsive to people's needs, and 

well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we rate

We rated this hospital as good overall.

Medical care services were rated as good because:

• There was an open culture of incident reporting in which staff were encouraged to highlight any concerns and report accidents without fear of blame. All of the staff we spoke with said they received feedback from incident investigations, which we saw were shared with the whole team.
• St Andrew’s Ward (for medical care) had opened three months prior to our inspection and had established safe working practices, monitored through a clinical dashboard. During its initial three months, staff provided harm-free care in 98% to 100% of cases.
• Rates of mandatory training were good and all staff on St Andrew’s Ward were up to date with the required safety training.
• Staff followed hospital infection control and hand hygiene practices and the endoscopy unit outsourced scope decontamination to another provider. This took place within an established service level agreement and meant the hospital could continue to offer safe endoscopy procedures.
• Staff were establishing an audit programme for St Andrew’s Ward as well as a benchmarking exercise for the rehabilitation programme. Care for specific conditions was provided in accordance with the National Institute of Health and Care Excellence clinical guidance.
• Staff demonstrated adherence to the principles of the Mental Capacity Act (2005), and consent processes were embedded in all aspects of care.
• Staff were kind, caring, and compassionate in all of our observations. Patients told us staff were approachable and treated them well. Most patients said they felt involved in their care and understood their treatment plan.
• Patients were provided with facilities including ensuite bedrooms, TV access, and tablets with internet access. Relatives were able to stay overnight with their loved one if needed and had access to food and drink at all times.
• Staff provided individualised support and advice to endoscopy patients before and after their procedure. This helped reduce the risk a procedure would be cancelled due to poor bowel preparation and meant patients could access help whenever they needed it.
• The hospital complaints procedure was readily available in all clinical areas and staff demonstrated the ability to support patients in resolving complaints. Medical care services had received no formal complaints in the six months prior to our inspection.
• There were clear clinical governance arrangements, which enabled the senior team to identify and manage risks to the service. Good governance systems meant clinical staff worked within established hospital protocols and met regularly to assess the quality and management of the service.
• Staff were involved in the development of St Andrew’s Ward and the senior team engaged them with on-going consultation as the ward became more established.

However, we also found:

• Staff had not always documented daily safety checks on resuscitation equipment.

We found surgery required improvements with regard to safety because;

• The World Health Organisation (WHO) surgical safety checklist in use was not always completed according to national and local guidance.
• The recording of controlled drugs was not always to the required standard in the anaesthetic room and recovery area of the operating theatre department. 

• Medicines were not always kept separately by product and were removed from the original packaging, and the guidance information.

However;

• There were sufficient numbers of suitably trained staff available to meet patients’ needs. Staffing levels and skill mix were planned, implemented, and reviewed. Any staff shortages were responded to promptly to meet patients’ needs. Effective handovers between shift changes ensured staff provided safe and appropriate care.
• Staff understood and fulfilled their responsibilities to raise concerns and report safety incidents and near misses. They understood their responsibilities in ensuring the duty of candour was applied. Mandatory safety training was provided to staff.
• Patient records were stored securely, were legible, and were mainly completed in accordance with best practice.
• All patients underwent a risk assessment to determine their individual risk of developing blood clots, pressure ulcers and falls. A National Early Warning Score (NEWS) tool was used to identify deteriorating patients, and was acted upon.
• Plans were in place and were tested to respond to emergencies.

We found overall the outpatients and diagnostic imaging department were good because:

• There were sufficient numbers of suitably skilled and experienced staff. They were supported to access safety training and other development opportunities in order to provide safe and response treatment and care.
• Prescribed medicines were managed safely. In outpatients, radiology medicines were stored in locked cupboards in the department. Lockable medicines fridges were subject to daily temperature checks, which were recorded.
• There was evidence treatment in outpatient’s services was delivered in line with national guidance and best practice. Staff with specialist skills and knowledge supported their colleagues to provide advice or direct support in planning or implementing care to ensure patients received the treatment and care they needed. Teams made appropriate referrals on to specialised services to ensure patients’ needs were met.
• We observed care provided by nursing, medical, and other clinical staff. Throughout the outpatient and diagnostic imaging departments, all staff were helpful and professional, putting patients and their relatives at ease.
• Staff told us the local leadership within outpatients was good. All managers were approachable, supportive and staff were proud of their service. Staff felt involved and were keen to improve systems and processes to ensure patients received the best care. Staff at all levels said managers were easily visible and accessible.
• All the consultants we spoke with commented on the proactive and responsive style of leadership. Issues and concerns were promptly followed up and resolved and clinicians were involved and consulted about changes. Feedback was sought and responded to when considering changes or developments to services.
• Consultants spoke positively about the care and safety within the outpatient, radiology and diagnostics and urgent care departments.

However;

• Personal and confidential information was not always securely stored. For example, patient’s personally identifiable information was kept in a communication book, which could be read by unauthorised people. We saw the lockable cupboard in outpatients was already full with box files leaving no room to put away additional paperwork
• Risk registers did not reflect all areas of concern. For example, managers were aware hand hygiene audits the hospital undertook had not included the outpatients department. They were aware some staff were not following the bare below the elbow policy. Therefore, risks to patients were not being managed.
• The audit programme was not sufficiently detailed to identify which audits would apply to the OPD.

We found good practice in relation to end of life care overall because;

• Staff were empowered to report incidents in a working culture, which valued their input and experience. Senior staff demonstrated thorough investigations and a root cause analysis of each incident and shared learning with all staff.

• Staff had acted upon an infection control audit that found 12 areas of urgent attention in July 2016 and August 2016. As a result an action plan was implemented and the hospice team made significant progress towards its completion. 

• There had been a steady decrease in the number of preventable falls as a result of staff work to ensure harm-free care was provided.

• Medical care was consultant-led and there was provision for medical cover at an appropriate level of seniority 24-hours, seven days a week.
• The nursing team worked flexibly to meet the needs of patients, including increased cover when a patient needed a higher level of care.
• Hospice care was provided in line with London Cancer Alliance Palliative Adult Network guidance, according to the gold standards framework. This was benchmarked against national guidance from the National Institute of Health and Care Excellence.
• A rolling programme of audit contributed to quality monitoring and staff used the outcomes to improve care and treatment, including in the provision of effective and safe pharmacy services. Staff had used the results of audits to improve discharge planning and documentation and this was monitored on an ongoing basis.
• Multidisciplinary working was embedded in the service and patients were cared for by a range of professionals who co-ordinated care through a structured system of meetings and assessments.

•  

  Hospice services performed consistently well in the Friends and Family Test and the most recent results, from July 2016 to September 2016, indicated 100% of respondents would recommend the service.

• The Hospice@Home service provided an individualised service to meet people’s needs. In addition, staff tried to ensure people were able to die in their preferred location where possible. This was audited and there was a consistent approach to improve the resources available to staff to ensure this was achieved.
• Staff told us they felt well supported and had access to managers whenever they wanted. They also said they felt engaged with the running of the service and were able to contribute on a regular basis.
• The hospital encouraged staff and patient participation in research trials where these were deemed to be safe.
• Previous audits indicated good compliance with requirements of do not attempt cardiopulmonary resuscitation (DNACPR) documentation.

However, we also found:

• An audit identified the use of the malnutrition universal scoring tool as an area for improvement, which senior staff were planning to re-audit in November 2016. Although patients indicated some improvements in food in the hospital, a survey demonstrated they felt the choice available had been reduced.

Ted Baker

Deputy Chief Inspector of Hospitals