King's College Hospital NHS Foundation Trust is a large provider of acute and specialist services that serves a population of over 1,000,000 in south east London and Kent. The trust operates from three acute sites; King's College Hospital Denmark Hill, Princess Royal University Hospital Bromley and Orpington Hospital.

The trust has over 1300 beds including 1050 acute, 125 maternity and 144 critical care beds. The trust receives over 250,000 emergency attendances, 115,000 inpatient spells and 960,000 outpatient attendances. All core services are provided from King's College Hospital Denmark Hill and Princess Royal University Hospital while inpatient, outpatient and surgical services are provided from Orpington Hospital.

We inspected the King’s College hospital Denmark Hill site and the Princess Royal University hospital on the 13 October 2016. The inspection was a focused inspection, carried out to review the progress made by the trust following our comprehensive inspection in April 2015. We had asked the trust to make improvements in a number of areas and issues requirement notices explaining how the regulations were not being met.

We did not visit the Orpington Hospital site but we spoke with staff and reviewed information provided to us by the trust.

Following this inspection we did not change the rating of the trust. Although there had been many improvements, there were areas still requiring further attention, as indicated below.

Princess Royal University Hospital

• Continue to work with key stakeholders to improve patient flow throughout the hospital to reduce waiting times in the ED, cancellation of operations and delayed discharges.

• Review and improve patient record documentation to ensure it is fully completed, and in line with national guidance. This includes the recoding of do not attempt cardio-pulmonary resuscitation (DNACPR) orders.

King’s College Hospital – Denmark Hill

• Improve safeguarding training completion rates.

• Ensure the documentation of the use of mechanical restraints mittens in CCU is recorded in patient care records.

Professor Sir Mike Richards

Chief Inspector of Hospitals

People told us what it was like to be a patient in King's College Hospital. They

described how they were treated by staff and their involvement in making choices

about their care. They also told us about the quality and choice of food and drink

available. This was because this inspection was part of a themed inspection

programme to assess whether older people in hospitals were treated with dignity

and respect and whether their nutritional needs were met.

The inspection team was led by a Care Quality Commission (CQC) inspector

joined by two compliance inspectors, a practising professional and an Expert by Experience. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We spoke with more than 40 patients as well a number of people who were visiting on the day. Patients felt that the hospital promoted the dignity of older people, and respected their choices. Patients had their treatment explained and were provided with a rough guide of the proposed length of their stay at the hospital.

A typical comment was, “staff are very knowledgeable about the care I am receiving, the consultants, nurses and junior doctors, discuss with me the treatment I am receiving and the possible outcomes”.

Patients spoke of their confidence in the service and felt safe when under the care of the hospital. They acknowledged that the hospital made appropriate provision for patients, with staffing levels that enabled a good patient experience. Staff interaction and engagement with patients promoted their wellbeing.

A patient told us, "it is my local hospital since I was a young child, I feel lucky, I would not change this for anywhere else, it is special and there are lovely doctors and nurses here".

Another person talked of the benefits of living near the hospital, they said, “the hospital is top class; I am of the opinion that I could not have been treated any better anywhere else; staff are professional and cheerful at the same time, which makes my disability easier to bear”.

A relative who visited daily told us they felt reassured by what they observed. They observed that staff were approachable and mindful of the needs of elderly people; they saw that patients received good support from staff especially at mealtimes, and had adequate nourishment and drinks.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We made an unannounced visit to King's College Hospital on 9th February 2012.

We spoke with people on the following wards, wards in the Health and Ageing Unit, (Marjorie Warren, Donne and Byron ), The Emergency department (ED), Oliver Ward, Christine Brown, Lonsdale, Annie Zunz, Katherine Monk, Mary Ray, Matthew Whiting, Davidson, Philip Isaacs Day Treatment Ward, Princess Elizabeth, Rays of Sunshine.

People receiving care and treatment at King's College Hospital told us that they were well looked after and that staff were generally sensitive and kind.

Elderly people said that nursing staff were gentle when carrying out personal care tasks. We saw that staff talked to patients in a kindly and respectful manner.

We heard from staff of the commitment within the hospital to providing good quality care for people with dementia. To further this there is a team who provide advice and training throughout the hospital. This helps to ensure that the needs of people with dementia are recognised and understood.

One of the wards has been redesigned to provide an environment which addresses the specialist needs of people with dementia. The ward is designed to provide a calming environment with features to help with people’s orientation and trigger memory.

Visitors told us that they liked the environment and feel that their relatives benefit from it.

Parents of child patients in the Emergency Department and on children’s’ wards told us that they were happy with the service. They found that staff were kind and caring, and that they were involved in decision making. One of the parents spoken to described the excellent service experienced in the Emergency Department for an injury sustained by their child.

Another parent said, “When I arrived at ED I was concerned about my child’s condition, we were seen promptly by the doctor, I am pleased that she was treated here in my local hospital, it is such an excellent service to have in our community”.

All of the parents spoken to on the wards were pleased with the way their children were cared for.

One parent said, ‘’The child’s voice is the most important thing they consider in the hospital and they are central to everything that happens’’.

Senior medical and nursing staff described the challenges faced when working at the busy emergency department as rewarding.

The following remarks were received from staff, “We provide an emergency service for people requiring urgent care, good teamwork is most important when responding and treating the people that come through our doors",

" the enthusiasm and inspiration of staff is fuelled by the desire to deliver the quality of care and treatment people need to treat their condition and make them well again.”

Feedback overall was very positive from people that use the service. We heard of the confidence people have in the services provided at the hospital. People using the stroke unit were pleased with the prompt response of the staff, and the subsequent treatment and care they received. Older people felt they were well cared for on the wards, and that staff listened and responded appropriately to their needs. The maternity service experiences for people were considered good, with suitable numbers of experienced staff personnel available. Mothers found that ante natal services were well coordinated, and that in-patient care and support were consistent and reliable.

People found that communication with staff was generally was good with procedures explained. People find that discharge arrangements are well organised but occasionally difficulties are experienced in keeping other care providers informed of last minute changes. Staff are trained and knowledgeable on policies and procedures that protect vulnerable people. They were enthusiastic and positive about their role and the support that they receive to work well. Staff receive both mandatory and specialist training. Support and guidance is available from senior staff within the ward and from a range of specialists.

Our rating of services stayed the same. We rated it them as requires improvement because:

• Not all staff had completed the required safety related mandatory training, which was as we found on our previous inspection.
• The environment in which patients received treatment and care was not always suitable or risk assessed. Privacy was not always achieved in some areas, and equipment had not been checked in a consistent manner.
• Medicines optimisation was not always achieved, and standards related to infection prevention and control were inconsistent.
• Patient risk assessments were not always completed and updated.
• Expected patient outcomes were not always met in some specialties.
• Access to some services were not meeting some of the expected targets in outpatients and once referred for admission. Waiting times from referral to treatment, arrangements to admit, treat and discharge patients was not always in line with good practice.
• Communication and engagement with staff by leaders was not always as strong as it could be, and some staff reported low morale.

However:

• There were enough staff with the right skills and experiences and staff had access to professional development, were competent for their roles, and had opportunities for a review of their performance.
• Care and treatment was delivered by a multidisciplinary team, in line with evidence based national guidance such as National Institute for Health and Care Excellence (NICE) and professional colleges.
• The staff recognised the importance of reporting and learning from incidents. Investigations led to the sharing of information learned and improvements.
• Patients were treated with respect and dignity, were involved in decisions about their care and were provided with information and choices.
• The co-ordination and delivery of services took account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances.
• Most clinical areas were led by staff who had the right experience, skills and knowledge. They understood the trusts values and strategic aims and fostered a culture where staff could do their best.

Our rating of services stayed the same. We rated it them as requires improvement because:

• Not all staff had completed the required safety related mandatory training, which was as we found on our previous inspection.

• The environment in which patients received treatment and care was not always suitable or risk assessed. Privacy was not always achieved in some areas, and equipment had not been checked in a consistent manner.

• Medicines optimisation was not always achieved, and standards related to infection prevention and control were inconsistent.

• Patient risk assessments were not always completed and updated.

• Expected patient outcomes were not always met in some specialties.

• Access to some services were not meeting some of the expected targets in outpatients and once referred for admission. Waiting times from referral to treatment, arrangements to admit, treat and discharge patients was not always in line with good practice.

• Communication and engagement with staff by leaders was not always as strong as it could be, and some staff reported low morale.

However:

• There were enough staff with the right skills and experiences and staff had access to professional development, were competent for their roles, and had opportunities for a review of their performance.

• Care and treatment was delivered by a multidisciplinary team, in line with evidence based national guidance such as National Institute for Health and Care Excellence (NICE) and professional colleges.

• The staff recognised the importance of reporting and learning from incidents. Investigations led to the sharing of information learned and improvements.

• Patients were treated with respect and dignity, were involved in decisions about their care and were provided with information and choices.

• The co-ordination and delivery of services took account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances.

• Most clinical areas were led by staff who had the right experience, skills and knowledge. They understood the trusts values and strategic aims and fostered a culture where staff could do their best.