Newham University Hospital, East London is part of Barts Health NHS Trust, the largest NHS trust in the country, serving 2.5 million people across East London.

The hospital provides maternity services to women in the London Borough of Newham and the Barking ward of the London Borough of Barking and Dagenham. The unit delivers around 6,500 babies every year, and numbers are increasing each year.

This was an unannounced inspection. Its purpose was to follow up on concerns about the maternity services identified at previous CQC inspections in November 2016. We did not conduct an in depth review of evidence against each of our five key questions and key lines of enquiry, hence we have reported our findings under two domains: safe and well-led.

Gynaecology services were not inspected on this visit.

Our key findings were as follows:

• Whilst there had been improvements and some progress against the previous requirement notice issued for governance and assurance in the maternity unit, there was still a need to improve and strengthen governance structure and reporting systems.
• Staffing issues continued to impact the delivery of care. Although there had been some staff recruitment, there continued to be shortages of midwifery staff at the time of our inspection. This included a shortfall in the number of experienced midwives. Whilst consultant cover had increased to 98 hours on the labour ward, out of hours cover was overstretched leading to delays in care.
• At the last inspection we had raised concerns about record keeping. The most recent cardiotocography (CTG) audit in February 2017 highlighted there were continuing problems with CTG record keeping, including incomplete documentation of risk factors, and failure to consistently comply with correct procedures for filing CTG documents. The trust had introduced measures to address the issues raised; however,it was unclear how CTG record keeping and oversight had improved as further auditing was yet to take place.

• At the previous inspection in November 2016, the security of babies in maternity services had been identified as a risk because of insufficient staff to monitor access to the unit. At this inspection the trust had implemented the electronic baby tagging system which had increased security. Further work was required to ensure all visitors to the maternity wards were monitored and signed in appropriately.

• Systems were not effective enough in monitoring the outcomes of audits and incident reports.

• Plans were in place to monitor and drive improvements throughout the maternity service, however progress was slow.
• Since the last inspection, some improvements had been made in assessing and monitoring the quality of the service with systems in place to improve engagement with staff.
• Most staff commented there had been improvement since the last inspection with the leadership much more visible and visiting the units on a regular basis.
• The trust had made progress in revising the governance team structure for women’s services, and progress on improving governance leadership with a new obstetric lead for clinical governance appointed in May 2017.
• There was an effective training programme for midwifery staff, although some midwives emphasised the lack of time they had to engage with this.
• Trainee doctors continued to be well supported and had opportunities to put their learning into practice.
• Processes were in place to assess and manage risk. These included the use of team briefings and the World Health Organisation (WHO) surgical safety checklist in obstetric theatre
• The service had a plan for continuous improvement in the management of infection prevention and control, and we saw good results from infection control audits. Women told us they were satisfied with the standard of cleanliness

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Take steps to ensure sufficient numbers of appropriately skilled staff are deployed to meet the needs of the service.
• Ensure that women receive timely treatment and pain relief, and that out of hours medical cover is effective in responding to and meeting the changing needs and circumstances of people using the service.
• Ensure all overdue serious incident reports are reviewed, actions are completed, learning is disseminated in a timely way, and processes are in place to effectively monitor progress.
• Ensure learning from incidents is used for the purposes of continually evaluating and improving services.
• Ensure that patient records, including cardiotocography (CTG) documentation, are comprehensively and consistently completed and that processes are in place to evaluate this

In addition the trust should:

• Ensure processes are properly utilised so that mothers and babies are kept continuously safe from unauthorised access to the units.
• Ensure delivery suite coordinators have supernumerary status with sufficient allocated time and resources to carry out their oversight and support role.
• Further consider funding for staffing a second obstetrics theatre to improve waiting times for caesarean.

• Take further action to ensure compliance with the trust’s target of 90% completion of mandatory training, including safeguarding training.

Professor Ted Baker

Chief Inspector of Hospitals

Newham University Hospital, in Plaistow, East London is part of Barts Health NHS Trust, the largest NHS trust in the country. The hospital offers a range of acute services to a population of approximately 300,000 people living in the London Borough of Newham. The hospital has approximately 344 inpatient beds, with over 1548 staff working there. The services the hospital provide include The Gateway Surgical Centre that offers elective surgery and diagnostic procedures in many different specialties, as well as housing the Trust's sports injuries clinic and fracture clinic.

Newham is deprived, coming third out of 326 of local authorities, with 80% of the local population having a minority ethnic background. The population is predominantly young, with the majority of residents aged between 20 and 39.

As part of an inspection we carried out in 2014/15 of Barts Health NHS Trust, we inspected Newham University Hospital in January 2015 and rated the hospital overall as inadequate. Since 2015, significant changes were made to the leadership of the organisation at both an executive and site based level. We therefore recently returned to inspect Barts Health NHS Trust to follow up on our previous findings where we had found a number of concerns around patient safety and the quality of care. In July of this year we carried out an inspection of Whipps Cross Hospital and The Royal London Hospital, and returned to inspect Newham University Hospital on 1 November 2016.

We returned on this occasion to carry out a focused, unannounced inspection of five core services: Medicine (including older people’s care), Surgery, Maternity & Gynaecology, End of Life Care and Services for Children.

Our key findings were as follows:

Are services safe?

• Insufficient consultant cover in maternity resulted in less than 50% of women in labour with a consultant present on the labour ward. Staff told us this meant patients were waiting longer for pain relief and treatment.

• Maternity services lacked enough appropriately skilled midwives to meet the demand of a high proportion of complex cases. Despite this, staff did their best to ensure they provided the best care.

• Systems were in place to ensure that incidents were recorded, and staff were predominantly familiar with the process. However, incidents were not always investigated in a timely way. In maternity services there was a backlog of more than 150 incidents waiting to be reviewed. Whilst incidents related to end of life care were not easily identifiable.

• Learning from incidents was not consistently shared amongst staff. However, in medical care, we found root cause analyses were comprehensive and senior consultants had begun to develop a tracking system for factors that contributed to such incidents.

• There was insufficient consultant cover in end of life care services.

• At the previous inspection in May 2015, the security of babies in maternity services had been identified as a risk because of insufficient staff to monitor access to the unit. Although approval had been given, security measures had not been implemented and this remained a concern.

• There were low levels of training amongst certain groups of staff in Level 2 safeguarding adults and safeguarding children.

• Compliance levels with the World Health Organisation (WHO) surgical safety checklist were inconsistent, especially in The Gateway Centre.

• We found that infection control procedures were not followed for safe storage of deceased patients in the mortuary. We found that the mortuary area was dirty and there were no daily cleaning check lists available for completion by staff.

• Mortuary fridge temperatures were not routinely checked. There was no policy to determine correct transfer of deceased patients in the event of a fridge breakdown

• Sluice rooms on surgery wards were not always locked and chemicals were easily accessible.

• Hazardous waste was not always managed in line with national and international best practice safety guidance, including in storage and access control.

However:

• There were no surgical site infections for knee and hip replacements between October 2015 and June 2016.

• Medical care services reported no never events between October 2015 and September 2016.

• There were improvements in the number of maternity patients with management plans in their notes. Use of the modified early obstetric warning score (MEOWS) chart was at 97%.

• The hospital and community midwifery team worked proactively to support women to breastfeed and provided continuing support to women at home. The percentage of women breastfeeding remained high.

• There was good compliance with infection control training on surgical wards.

• On medical wards staff demonstrated consistent infection control practices in relation to hand washing, decontamination of the use of personal protective equipment and adherence to the bare below the elbow policy.

• Risks to children and young people were assessed, monitored and managed on a day-to-day basis; and risk assessments were child-centred, proportionate and reviewed regularly.

• There were business continuity and major incident plans in place. Senior staff were aware of the plans and were able to explain their roles in the event of an interruption to normal service.

Are services effective?

• Between March 2015 and February 2016, patients had a higher than expected risk of readmission than the national averages for both elective and non-elective medical admissions.

• In the 2015 National Lung Cancer Audit, 64% of patients were seen by a cancer nurse specialist. This was lower than the audit minimum standard of 80% and all measurements in the audit were below national targets. General hospital performance had deteriorated since 2014.

• Performance in the national lung cancer audit indicated the hospital had deteriorated in standards, including a 26% reduction in the number of patients who were seen by a cancer nurse specialist.

• Some staffing issues in maternity services impacted on women receiving timely pain relief.

• Results from the patient-led assessment of the clinical environment (PLACE) indicated significant deficiencies in the provision of appropriate nutrition for patients living with dementia. However, the dementia and delirium team had introduced improved monitoring of food and fluids for patients living with dementia as well as improvements to staff competencies, training and resources.

• Rainbow Ward was unable to deliver adequate pain management for patient controlled analgesia (PCA) and nurse controlled analgesia (NCA).

• Patient Reported Outcome Measures (PROMs) were worse than the England average for most measures.

• The trust contributed to the National Care of the Dying Audit (NCDA). The trust was below the England average on three out of the five clinical indicators and only achieved one out of the five organisational key performance indicators (KPI).

• An audit of the use of the Compassionate Care Plan (CCP) undertaken by the specialist palliative care team showed that only 8 (28.6%) out of 28 sets of patient notes had a documented CCP in their notes.

• The end of life CQUIN audit undertaken in August 2016 looked at 17 deceased patient notes. These showed that only 6 patients (35.3%) had their preferred place of care (PPOC) documented and only one patient was transferred to their PPOC.

• Not all the patient records we reviewed had pain assessments recorded, despite having diagnosed conditions which often cause pain and discomfort.

• Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) audits for the period January 2016 to October 2016 showed that 66.6% (201) forms were completed incorrectly.

• Levels of training in Mental Capacity Act and Deprivation of Liberty Safeguards were 74.4% which was below the Trust target of 90%

However:

• Medical services presented a comprehensive programme of 73 audits, pilot programmes and benchmarking exercises that took place in 2015/16, which staff used to establish compliance with national best practice guidance. Learning from audits was evident and staff demonstrated a commitment to on-going improvements.

• The hospital achieved a B grading in the Sentinel Stroke National Programme in March 2016, reflecting effective practice.

• Procedures and policies were up to date and reflected recent evidence for best practice and NICE guidelines in CYP services.

• Performance in the 2015 Heart Failure Audit was better than the national average for all four standards relating to inpatient care and in three of the seven standards relating to discharge. This included higher performance than the national average in multidisciplinary working, including in referrals to cardiology follow up and the heart failure liaison service.

• Outcomes for women and their babies in maternity services were within national guidelines.

• The maternity service was working towards level 3 of the UNICEF UK Baby Friendly Initiative to promote good care for new-born babies.

• There was a weekly hospital palliative care multidisciplinary meeting. Medical staff, nurses, social services and the chaplaincy attended this meeting.

• The hospital performed higher than the national average in the national British Thoracic Society Smoking Cessation Audit, with smoking status documented in 90% of records compared with 80% nationally.

• Multidisciplinary working and information sharing between wards and departments was effective.

• Surgical pathways were delivered in line with referenced national clinical guidance.

• There was effective pain management provision available in surgery.

• There were good continuing professional development opportunities for staff.

• All eligible nursing and medical staff had in-date revalidation at the time of our inspection.

Are services caring?

• We observed kind and compassionate care given to patients. Children, young people and parents were observed to be treated with dignity, respect and kindness during interactions with staff and relationships with staff were positive.

• However, in medical services, scores relating to privacy, dignity and wellbeing assessed in the patient-led assessment of the care environment audit (PLACE) indicated a sustained decline of 25% in scores between 2013 and 2016, with 2016 results ranging from 45% to 80% for individual wards.

• The majority of patients we spoke with were happy with the care and treatment they received. However, women using maternity services commented that at times there was a lack of respect, care and compassion and that midwives were often abrupt.

• Women using maternity services described good support around the choice of place of birth, including home birth and partners were welcome to stay.

• The trust had developed a Compassionate Care Plan to replace Liverpool Care Pathway for end of life care patients. However, we did not see evidence that this document was embedded across the trust.

• Palliative care patients were not prioritised for side rooms and there was a lack of facilities for dying patients and their relatives.

• The results from the bereavement survey undertaken between January and September 2016 showed that only 8% (1) of the respondents rated their overall experience as excellent, and only 15% (2) rated their experience as good.

• There was a poor response rate to the Friends and Family Test. Albeit, that recommendations rates were generally high.

Are services responsive?

• Although 140 additional bed days had been provided in September 2016 and October 2016 to meet winter pressure demand, the hospital could not fully staff these

• The trust suspended reporting on all 18-week referral to treatment target (RTT) waits from September 2014 and had not resumed reporting at the time of this inspection.

• There was variation within surgical specialisms about length of time taken to respond to complaints.

• Staff reported regular difficulties meeting demand in the maternity unit. This caused delays, including in planned induction of labour and in elective caesarean sections.

• The recovery facilities in theatre were not child friendly due to an absence of a recovery bay with appropriate décor.

• Emergency readmissions for non-elective patients under the age of one year and children between the age of one and 17 years were worse than the England average.

However:

• Between April 2015 and March 2016 the average length of stay for non-elective medical patients was 3 days, which was lower than the national average of four days.

• The hospital had implemented a patient flow coordinator role that worked proactively with a dedicated discharge consultant to prioritise medical discharges at weekends.

• The Greenway Centre provided daily walk-in appointments with a 60-minute target for each patient to be seen. Staff in the endoscopy unit were able to see patients who urgently needed a procedure but who had mixed up their appointment time.

• In response to the needs of the local population, a dedicated overseas team provided support and liaison for patients with complex needs around immigration, refugee or asylum status.

• An enhanced care bundle had been introduced to each inpatient ward area that provided staff with a care pathway and contacts to help those with complex social needs.

• Flow within the surgery system was well managed and theatre utilisation was around 84%.

• The average length of stay for elective and non-elective surgical patients was better than the England average.

• There was a substantial decrease in the percentage of surgical patients not treated within 28 days.

• There was an enhanced recovery programme and joint school for patients booked to have a hip or knee replacement.

• Between April and October 2016, 97% of end of life care patients had been seen by the specialist palliative care team within 24 hours of referral.

• Complaints were dealt with effectively, with learning identified, implemented and shared. Staff apologised to patients where a mistake had been made and offered a resolution to the problem.

• West Ham Ward was not a purpose built paediatric ward. However, The Rainbow Unit rebuilding project would provide modern inpatient and outpatient facilities for children and young people and was due to open in February 2017.

Are services well led?

• There were concerns about the categorising and length of time the trust took to complete incident reports and serious case reviews. Targets were not being met and there were concerns about the processes for managing incidents. There was a lack of evident assurance that learning was properly followed up and embedded.

• The risk register in maternity services did not reflect all the current risks. For example, it did not include the low levels of consultant cover in maternity services or the possible risks to patients.

• The hospital senior management team did not have sufficient oversight of the mortuary as it was managed centrally from Royal London Hospital by the Clinical Support Services which operated trust wide.

• The trust had an End of Life Care Strategy 2016 - 2019, which was based on the 5 priorities of care for the dying. This had been ratified by the trust on the 19th October 2016. However staff we spoke with were not aware that the strategy had been ratified by the trust and many nursing staff knew nothing about it.

• Many staff told us that culture and morale was much improved since the time of the last CQC inspection in Jan 2015. However, medical staff spoke variably of morale and working culture, including individuals who said they were concerned about the long-term impact of morale because of high levels of sickness and vacancies in nursing teams.

• A small proportion of staff said that there were pockets of bullying and harassment in existence.

• There was limited evidence of consistent and structured leadership on some wards, including on Tayberry ward and Silvertown ward. On Tayberry ward there was evidence staff did not always feel safe because of short-staffing and the volume of work.

• Medical staff did not always feel they were recognised for their skills, supported to develop or had access to appropriate management support.

• Staff engagement in the most recent NHS staff survey was lower than the national average.

• Although some services such as the endoscopy unit and Greenway Centre conducted their own patient engagement programmes, there was limited evidence information from engagement was used at a hospital-wide level.

However:

• There was a clearer governance structure with clearer lines of management accountability across services at Newham University Hospital, following Barts Health NHS Trust introduction of a new leadership operating model in September 2015. Many staff reported this as a positive and effective change.

• A quality improvement programme that included monthly monitoring of staff engagement, safety improvements, patient feedback and access and flow performance, had led to an increase in staff engaged through social media, over 1000 staff engaged through face-to-face meetings and a 6% increase in compliance with staff training between March 2016 and June 2016.

• Individual specialist teams were empowered to establish new policies and improve existing policies as a result of patient engagement

• Although some difficulties remained in gaining the support of midwifery staff affected by changes the trust had imposed, morale among many midwives had improved since the last inspection.

We saw several areas of outstanding practice including:

• Safeguarding practices in the Greenway Centre were highly specialised and staff proactively developed these to meet the increasingly complex needs of the local population. This included multidisciplinary specialist input and monthly tracking of patients with specific needs, including through the provision of advocates who spoke Romanian or Portuguese.

• Staff took innovative steps to improve engagement with patients living with diabetes. For example, to improve the care of young people with diabetes, staff introduced remote video chat appointments. This reduced the number of wasted appointments and patients gave very positive feedback about the flexibility this afford them.

• Staff introduced innovative measures to improve access and flow, particularly at a weekend. This included the implementation of consultant-led discharge ward rounds and a new patient flow coordinator post. In addition staff had negotiated 24-hour, seven-day-a-week access to a social worker that meant complex discharges could be planned outside of the previous Monday to Friday model.

• An overseas team provided dedicated support to patients cared for on an inpatient basis who had complex needs relating to immigration, asylum or refugee status.

• There was a clear, sustained focus on offering opportunities to student nurses and medical trainees. Feedback from site visits by sponsoring universities were consistently good with continuous levels of compliance against quality markers for developmental education.

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

Importantly, the trust must:

Services for children

• The trust must ensure incidents are investigated in a timely way and in accordance with published guidance. 12 (2)(b)

Maternity

• The trust must ensure steps are taken to provide additional consultant posts to mitigate the risks and meet the care and treatment needs for women and babies at NUH. 18 (1)

• The trust must ensure that measures to ensure the security of babies in maternity services are implemented. 15 (1)(b)

• The trust must ensure the backlog of incidents awaiting review are addressed; and serious incidents are correctly identified. 17 (2)(a)(b)(f)

• The trust must ensure learning from incidents, complaints and peer reviews is used for the purposes of continually evaluating and improving services.17 (2)(e)(f)

• The trust must ensure staff are clear about their roles and responsibilities under legislation around capacity and deprivation of liberty. 11(3) & 13(5)

End of Life Care

• The trust must ensure that reporting processes are able to identify, review and learn from information that relates to the end of life care it provides such as through complaints, incidents and satisfaction surveys. 17(1)(2)(a)(b)

• The trust must ensure that the Compassionate Care Plan it has developed is embedded across the hospital. 9(3)

• The trust must ensure that it meets the national guidance [‘Commissioning Guidance for Specialist Palliative Care: Helping to deliver commissioning objectives’ (Dec 2012.)] which recommends a minimum requirement of 1 whole time equivalent consultant in palliative medicine per 250 hospital beds (NUH has 344 beds). 18(1)

• The trust must ensure that systems and processes are in place to enable proper management and oversight of the mortuary to be assured. 17(1)

• The trust must ensure that standards of cleanliness and hygiene are maintained in the mortuary. 15(1)(2)

• The trust must ensure that the premises and equipment within the mortuary are properly maintained and fit for purpose. 15(1)(c)(e)

• The trust must ensure there are systems in place to determine appropriate transfer of deceased patients in the event of a fridge breakdown. 17(1)

• The trust must ensure that pain for patients at the end of life, is properly assessed and treated.9(3)(a)(b)

• The trust must ensure that Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms are completed correctly. 9(1)(a)(b), 11(1)

• The trust must ensure that due consideration is given to the privacy and dignity of patients at the end of life in relation to facilities available for them and their relatives. 10(1)(2)(a)

• The trust must ensure that systems are in place to effectively monitor the effectiveness of services provided to the dying patient in relation to its fast track process and patients’ preferred place of care. 17(1)(2)(a)

In addition the trust should:

Medical care

• The trust should ensure learning from infection prevention and control audits is communicated to all staff.

• The trust should ensure interpreting services are readily and proactively provided to reduce the safeguarding risk associated with relying on relatives and friends to interpret clinical care.

• The trust should ensure the nutritional and hydration needs of patients are met. This includes patients with complex needs including dementia, co-morbidities and where they are cared for as a medical outlier.

• The trust should ensure premises and equipment are clean and secure in relation to the control of substances hazardous to health.

• The trust should ensure staffing levels are actively monitored and reflected accurately in daily safer staffing meetings. This means the senior nurse in charge on each ward should agree with the staffing level reflected by the site manager in the safety briefing.

• The trust should ensure staff are supported to work safely and effectively through the provision of consistent and structured support.

• The trust should ensure nurses have access to training and professional development in line with their career plans and/or professional development plan.

• The trust should ensure staff who wish to undertake additional qualifications relevant to their role are supported to do so.

Surgery

• The trust should ensure there is clear differentiation between adult and paediatric resuscitation equipment on the resuscitation trolley.

• The trust should ensure there is good compliance with all steps of the World Health Organization surgical safety checklist.

• The trust should ensure that referral to treatment time is evidenced.

• The trust should ensure that all staff have level 2 safeguarding training and safeguarding children.

• The trust should ensure all staff have training in Mental Capacity Act and Deprivation of Liberty Safeguards.

• The trust should ensure that there is better feedback about incidents to surgery staff and that there is shared awareness of the top three departmental risks.

• The trust should ensure sluice room doors on surgical wards are kept locked and all chemicals are locked away in a cupboard.

• The trust should endeavour to recruit to anaesthetic staff grade vacancies.

• The trust should improve upon data collection of appraisal rates.

• The trust should improve upon Patient Reported Outcome Measures (PROMs) measures.

Services for children

• The trust should ensure infection prevention and control on Rainbow Ward always complies with the trust’s policies for infection prevention and control.

• The trust should ensure expressed breast milk is stored separately from other products.

• The trust should address maintenance issues in a timely way, ensuring thorough investigation and repairs.

• The trust should ensure CYP services should have a robust plan and system of clinical audit in place to monitor adherence to evidence based practice.

• The trust should ensure staff on the NNU make themselves aware of the UNICEF Baby Friendly accreditation programme, a global accreditation programme to support breast feeding.

• The trust should ensure Rainbow Ward delivers adequate post-operative pain management of children.

• The trust should ensure there are facilities for parents to prepare or purchase food.

• The trust should ensure there is a range of information leaflets for children and their parents or carers across both Rainbow Ward and the NNU.

• The trust should improve recovery facilities in theatres to ensure areas for children are child friendly with appropriate décor.

• The trust should improve on emergency readmissions for non-elective patients under the age of one year and children between the age of one and 17 years.

• The trust should develop a long-term local strategy for CYP services.

• The trust should ensure the agendas for governance meetings always reflect the governance meetings terms of reference.

• The trust should ensure identified risks are always included on the trust’s risk register in a timely way, and record actions the service is taking to mitigate risks clearly on the risk register.

Maternity

• The trust should ensure further recruitment to providing sufficient number of appropriately skilled midwives to meet the needs of the service.

• The trust should consider funding for staffing a second obstetrics theatre to improve waiting times for caesarean

• The trust should ensure better working relationships across the maternity service; fostering better communication and morale.

• The trust should ensure that midwifery staff are supported to attend the role specific training programme.

End of Life Care:

• The trust should ensure that medical and nursing files are easy to navigate and in order.

• The trust should give consideration to all services that link in to the overall vision of end of life care, such as chaplaincy and therapies, in its draft business case to increase staffing.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We visited the stroke ward and an elderly ward.

At our last inspection we found patients privacy and dignity was not always respected. At this inspection most patients we spoke to told us they felt their privacy and dignity was respected. Patients said, “staff introduce themselves when entering the room and, they say please and thank you” and “staff are friendly and polite and always close the curtains when providing care.”

We found people’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Most patients we spoke with felt they were well looked after and had everything they needed. One patient said “everyone’s caring here.”

Staff we spoke to told us they had undergone safeguarding training in 2012 or 2013. Staff were able to describe the different types of abuse, actions they would take and who they would involve and inform.

At our last inspection we found patients were not always supported to eat and drink. At this inspection we observed patients at lunchtime and found they were assisted or supported to eat their meals in a timely manner. Most patients we spoke to told us the food was very good. One person said “they get to choose what they want and there are always things they like on the menu.”

We found staffing levels on the two wards were inadequate to meet people needs. On the day of our inspection most of the patients and staff we spoke to said that both wards were regularly short staffed. Most relatives we spoke to told us they felt there were not enough staff on duty. We saw evidence to show that shifts were not always covered. The arrangements for arranging temporary nursing cover for shifts did not always work effectively.

We found staff were not always appropriately supported. We found staff did not always have appraisals and many had not had one in the past twelve months. Although there were regular clinical meetings, there was no evidence that team meetings occurred. Staff did not always have individual meetings with their managers to discuss their work, career and general issues.

At our last inspection we found the patients' personal records were not always accurate and fit for purpose. At this inspection we found that whilst there was still some gaps in recording, improvements had been made. Most patients’ records we checked contained completed weight charts, nutritional screening tables and pressure sore information.

Patients told us what it was like to be in hospital and 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 are treated with dignity and respect and whether their nutritional needs are met.

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 to us.

The inspection team was led by two Care Quality Commission (CQC) inspectors joined by a practising professional and an Expert by Experience who has personal experience of using and caring for someone who uses this type of service.

We spoke to seven patients and three visiting relatives on the medical ward. On the stroke ward we spoke to seven patients and four relatives. One person said, “I am kept informed of changes of my medication.” Another said, “The different tests results are discussed with me.” While another said, “I am updated with how my treatment is progressing”.

People's diverse needs were catered for. A patient of African origin, said “staff understand my needs culturally, as they attend to my skin care and use appropriate creams for my hair.”

Patients made positive comments about the care on the stroke ward and a medical the ward we visited. The views expressed included,” Nurses and doctors are fabulous”, “They cannot do enough for you”, “very good care”, and “An excellent place to come if you need care and treatment.” One person said, “I am kept informed of changes of my medication.” Another said, “the different tests results are discussed with me.” While another said, “I am updated with how my treatment is progressing”.

Patient’s said that their dignity and privacy was respected most of the time but some of the people we spoke to said the curtains did not always close and that people could still see through some of the screens provided.

Following our last inspection in September 2018, we rated Newham hospital maternity as inadequate overall.

We had serious concerns that systems to assess, monitor, and mitigate risks to patients receiving care and treatment were not operating effectively. We also had concerns that governance systems and processes were not operating effectively. We served the trust with a Section 29A Warning Notice, served under Section 29A of the Health and Social Care Act 2008, on 18 October 2018. The notice required the trust to make significant improvements by 16 November 2018 and to send us details of how they were making improvements.

The trust responded on 16 November 2018 with an explanation of action taken to respond to the immediate safety issues and an improvement plan to address the specific concerns included within the warning notice.

We conducted this follow-up inspection on 14 and 15 January 2019. The inspection was unannounced. The inspection focused mainly on the issues identified in the warning notice where significant improvement was required in improving leadership, strengthening governance and oversight, engaging staff and addressing safety concerns specified in the warning notice as detailed below.

Governance and systems to assess, monitor and improve the quality of services:

• Improving data quality and data governance processes

• Improving complaints and SI processes

• Improving learning from complaints and incidents

• Improving standards of documentation

• Ensuring maternity support workers are trained in carrying out observations

• Improving governance of change

• Improving security of patient information

• Improving understanding of governance by junior staff

Providing safe care and treatment:

• Ensuring clinical equipment was clean and fully checked.

• Ensuring high standards of hand hygiene

• Ensuring immediate labelling of specimens

• Strengthening the process for providing assurance of equipment checks

• Ensuring proper segregation of waste

• Ensuring medicines were stored in locked fridges and replacing fridges in poor condition.

• Ensuring ward managers supported and supervised maternity care assistants and support workers

The trust had achieved progress in addressing our concerns; however, there was still work to do to deliver and sustain progress. We judged that the requirements of the warning notice had been met as far as possible within the short timescale.

We rated Safe and Well led as requires improvement and requiring ongoing effort to achieve sustainable change.

We saw outstanding practice in the leadership and drive shown by the acting head of midwifery.

The trust should:

• Continue to monitor all areas of the improvement plan, even when some stages are apparently complete, to ensure all new processes are fully embedded.

Professor Ted Baker

Chief Inspector of Hospitals