We spoke with 10 patients, 14 staff and four relatives across the four wards we visited at the hospital.

All the patients we spoke to told us they were treated with dignity and respect. However, some patients told us that doctors did not always pull the curtains when discussing care or examining them, but the nurses always did.

One patient said “The nurses are great. There are some people here that need help to eat and they get the help they need”. One relative said “The care has been really good and any minor complaints I have had, have been sorted out by the ward manager”.

Patients said the wards were kept clean and nurses always washed their hands.

We spoke with 70 people across the six wards we visited at the hospital.

All the people we spoke to told us they were treated with dignity and respect.

They said: "The staff are doing a wonderful job, they are polite and respectful". "I can't fault any of the staff; I have received a first class service." "This ward is brilliant, not like other wards I have been on."

People said the staff took time to discuss with them how things were going. One person said, "They always tell me what is happening like when the consultant is due to do his rounds ". Another person told us, “It is good that they discuss everything in the open. You don’t feel that they are hiding things from you”.

On all the wards most people said that they were satisfied with the food provided. One person said, “You couldn’t wish for a better service I reckon”. Another person said that they had wanted more gravy and that it was “no trouble at all”.

People said the wards were kept clean and nurses always washed their hands but they did comment that they did not see the doctors wash their hands.

People spoke positively about the staff. They said the staff were polite and nice but they were busy. A person on Cheerful Sparrows Male said, "They're very kind and polite to me. They take their time and treat me well."

All of the people spoken with did not have any complaints about the service but did say they would speak to a member of staff or a relative if they had any concerns. "I would definitely say something if things went wrong, but I have no complaints".

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.

People told us they were involved in their treatment and support. "I was given some leaflets when I first came here. I don’t think there is any room for improvement. I think my privacy and dignity has been maintained when I need privacy I've had it".

People felt safe using the service and that there were usually enough staff on duty. "The staff are so careful about looking after you they make sure you do not fall". “The staff are all so kind and friendly and the care they provide is second to none”. "It is a very open culture here we can ask each other anything or go to the management about any concerns".

They said that staff were well trained, polite, kind and caring. "Staff are very polite indeed I can not fault them". "Staff really understand what I need… they take great pains to explain things."

In some cases people said that they were given opportunities to say what they thought about the service. "I have not given my opinion about the service but feel at home and I know exactly what is going to happen. I could not have been better treated."

Most people were happy with their care and treatment. Some people said they were pleasantly surprised. They said that staff treated them with respect and were particularly complementary of the male staff who they said were extremely polite. People said that their treatment was clearly explained to them and they were involved in making decisions about what they wanted. People felt their dignity was respected. Some people felt that the curtains were insufficient to maintain their privacy when having conversations about their care and treatment.

Most people liked the food and said there was enough and there were choices on the menu. Some people who were on special diets did not feel that these were well catered for and did not think that the staff were always aware of the foods they could not tolerate. They said there were not always suitable alternatives. People liked the peaceful mealtimes.

We inspected services for children and young people at Queen Elizabeth the Queen Mother Hospital on 24 and 25 October 2018. The inspection visit on 24 October was unannounced and began at approximately 8.30pm.

This responsive inspection was undertaken because we had received concerning information from members of the public and staff about the Emergency department and children’s inpatient wards. We had also identified concerns about the care of children during our May 2018 inspection when we inspected the emergency department and operating theatres but did not review services for children and young people as a separate core service.

As part of this inspection, we reviewed the care and treatment of children and young people from birth to 18 years in the two acute hospital sites with children’s inpatient units. Some outpatient services for children are provided at the Kent and Canterbury Hospital site and from Buckland Hospital in Dover, but there are no inpatient services there. We did not inspect clinics or community services as the inspection was focused on the areas of concern.

We rated the children and young people’s services at Queen Elizabeth the Queen Mother Hospital as Inadequate overall. We fed back our immediate concerns to the chief executive officer, the director of nursing and quality, the medical director and the quality improvement programme lead.

The services for children and young people were not safe.

• Resources for children and young people with mental health problems were not sufficient to ensure they, other children and staff remained safe.
• The recognition and management of deteriorating patients was inconsistent and senior clinicians did not follow the trust protocols or national guidance on the management of sepsis.
• People were at risk of cross infection of communicable diseases because of poor facilities and poor practice.
• Staffing levels were insufficient to meet the needs of children and young people.
• There was insufficient attention paid to safe medicines management.
• Incidents were not identified, nor reported and there was very limited learning from incidents.

The services for children and young people were not effective.

• The trust could not identify shortfalls in care nor benchmark their performance against other trusts as there was limited participation in national audits.
• Local audit results were inaccurate and there were conflicting results from different audits. An example of this was a report of sepsis that gave falsely positive information and which could not have been accurate based on the early warning scores contained within the report.
• Pain was not always managed in a timely manner.
• Fasting times before surgery did not follow current best practice and put the needs of the service before the needs of the children.
• Staff had no training in de-escalation techniques or managing children with mental health problems.
• Staff reported that staff shortages were such that they could not attend planned training.
• The trust did not resource children’s services at Queen Elizabeth the Queen Mother Hospital in line with the current intercollegiate guidance.
• There were gaps in the seven-day service provision that meant children had to be treated in adult environments by adult staff.
• Out of Hours consultant cover did not meet the intercollegiate standards.

Improvements were needed in the care and compassion shown to children and families.

• Receptionists in the main accident and emergency department were sometimes offhand with parents of children. We observed that staff did not make eye contact nor smile at parents who were very anxious and needed reassurance.
• One receptionist told a mother of a visibly unwell child that she was lying about not being triaged.
• Senior staff used unfavourable stereotypes when describing parents, particularly those from specific areas.

The services for children and young people were not responsive.

• The flow of children and young people through the accident and emergency department was confused and not understood by staff.
• Senior staff and operational staff argued in front of the inspection team about which was the correct pathway for children to move through the department.
• Children were required to wait in the adult waiting area. This included at night when it was crowded and when some adults were likely to be drunk or volatile.
• The service for children with mental health problems was insufficient and failed to protect the children, other children or staff. Whilst this service was commissioned by the Clinical Commissioning Group from a third party, the inadequacy should have been addressed by the trust.
• There was limited provision for and a lack of understanding of the needs of children and young people with learning disabilities or autism.
• There were frequent breaches of the four-hour emergency department target.
• Urgent referrals were not always seen within the expected referral to treatment times.
• The journey to theatres had not been adapted to be child friendly.
• A lack of overnight accommodation for mothers of babies on the Special Care Baby Unit meant that establishing breastfeeding was more difficult, increased the risk of maternal mental ill health and was likely to impact negatively on mother and baby bonding.
• There was very limited consideration of the needs of young people aged 16 years to 18 years.

The services for children and young people were not well led.

• There was not a clear, well understood vision and strategy for the service.
• Governance and risk management processes were ineffective and provided false assurance to the board.
• Leadership was confused with a lack of oversight of all the children using trust services.
• Staff reports of the culture within the service were variable with some reporting bullying, oppression and not being listened to.
• The NHS Staff Survey results for 2017 showed that overall the trust was in the worst 20% of trusts nationally for staff engagement. The results had worsened for many key findings since 2016.

We saw several areas of good practice including:

• Parents reported very positively about the care and support the staff on the Special Care Baby Unit offered them.
• Child bereavement boxes had been purchased by the hospital charity for use in the emergency department when a child had died.
• The routine use of heel warming made heel prick blood testing less painful and more effective.
• Staff who were exceptionally busy dealing with a high demand and very sick children remained kind and gentle towards the children.
• Staff had a clear understanding of their safeguarding role and responsibilities and there was an effective system to provide prompt child protection medicals when needed.

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

Importantly, the trust must:

• Provide suitable accommodation for children and young people with mental health problems.
• Review their booking and triage processes to ensure all staff are clear about the pathway children take through the emergency department and to minimise the time before they are assessed by a qualified children’s nurse.
• Ensure that equipment checks required by trust policies are carried-out.
• Ensure the safe management of medicines.
• Ensure that clinicians are aware and follow trust policy and national guidance on the safe management of deteriorating children, testicular torsion and sepsis identification and management.
• Ensure that children wait in the children’s waiting area at all times. They must not be exposed to volatile behaviour, inappropriate television programmes and unpleasant sights and sounds in the adult waiting area.
• Review the care of children aged 16 years to 18 years and ensure that their needs are fully considered.
• Ensure submission of data to national audit programmes to allow benchmarking against other children’s services and to drive improvements.
• Ensure that they adhere to a local audit plan and use the results to drive service improvements.
• Carry out a learning needs analysis for nursing staff working with children and young people to assist in identifying what training is necessary and where there are gaps in staff skills and knowledge.
• Ensure that staff are provided with the necessary training and support to ensure they can carry out their work competently.
• Ensure compliance with the Health and Social Care Act 2008: code of practice on the prevention and control of infections. To include ensuring there are appropriate isolation facilities in the children’s emergency department for children with communicable diseases.
• Review their policy and usual practice on pre-operative fasting for children to ensure it is aligned to national guidance.
• Ensure that up to date policies and protocols are available to staff.
• Ensure that the needs of children and young people presenting in mental health crisis are considered and met.
• Ensure the views of children and young people are taken into consideration to aid service provision and make sure the care and treatment meets their needs and reflects their preferences.
• Ensure that there are no breaches of the four-hour admission to treatment target for children attending the emergency department.
• Develop a clear vision for children’s services that is recognised and shared by all staff caring for children and young people.
• Ensure that data and information provided to the board is an accurate reflection of the services being provided to avoid the risk of false assurance.
• Undertake an assurance review of their children’s service to identify gaps in their assurance and governance processes.
• Ensure that there is clear, accountable leadership of services for all children from birth to 18 years (and beyond 18 years for looked after children and children in need).

Additionally, the trust should;

• Provide staff with training in the care of children and young people with autism and learning disabilities.
• Ensure that the pathway for providing care when a child dies is known and understood by all staff likely to be affected.
• Provide all staff including senior leaders with training in equality and diversity.
• Consider providing customer service training for reception staff in the emergency department.

Professor Edward Baker

Chief Inspector of Hospitals