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

• We inspected Urgent and Emergency services during this inspection to check if improvements had been made since our last inspection. The overall rating for the service was requires improvement. The rating for effective and caring improved to good. Safe, responsive and well led remained requires improvement
• We inspected Medical care (including older people’s care) and found the service had improved since we last inspected in 2017. We rated the service good overall. The rating for safe and responsive both improved from requires improvement to good.
• We inspected Surgery and rated the service requires improvement. The rating for effective improved to good; however the rating for the other domains remained requires improvement.
• We previously inspected Maternity services in 2015. On this occasion we rated the service overall requires improvement, although the rating for well led improved to good.

Patients we spoke with told us that they were generally pleased with the treatment they received but others told us of delays in being seen. One patient told us “everyone is nice and I have received very good care”.

Patients told us that “it is always busy but staff are very good”.

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.

Overall, people we spoke with told us that staff were helpful and worked hard. People told us that most of the staff were friendly and were responsive to their needs.

"Some staff are very good, some are not. I realise they have got an unthankful job but some of them could be more pleasant. Staff are obviously busy. You sometimes wait quite a while when you press the buzzer. Don’t know if they are busy elsewhere".

"I can’t say anything bad about it. I press the buzzer and they come quick. I think they do a great job".

"Mum has been here a day. No problems, staff are nice. They give good care. She is hearing voices and had a fall. All her needs seem to be taken care of".

Patients using the service had mixed views about the A&E department, some patients were generally pleased with the treatment they received but others told us of delays in being seen. One patient told us “everyone is nice”. Although patients were generally positive about their experience the evidence we reviewed demonstrated the A&E department continue to struggle with the volume of patients which sometimes impacts on the care received.

As part of this review additional visits were also carried out on 16th, 19th and 20th of September.

We spoke to mothers on the postnatal ward and asked them about the staffing levels and care they received. In general new mothers were happy with their experience although when speaking to a mother in the discharge lounge she was unhappy with the delay. One mother told us, “I have a history of fast labour but was assessed quickly when I arrived and was taken to the ward straight away, there were no delays. The midwives were all very attentive”. Another waiting in the discharge lounge told us, “I’ve been in the discharge lounge since 10am and told my partner to collect me, we’re still waiting four and a half hours later”.

When talking about staffing one mother told us, “staff had quite a lot of time for me actually”. She felt there were enough staff the previous night and a lot of staff came running to help when she experienced her complications. Another said, “I was not left alone during labour and had not been worried or anxious. Most of the staff attitudes were good, sometimes there are cultural differences and the staff are not aware how they come across, but I never feel it is deliberately towards me.”

Although mothers were happy with their care and we found improvements had been made since our previous visit we still found evidence of poor patient care and the skill mix of the midwives working the shifts was not satisfactory.

Based on these concerns an emergency action plan was agreed between the commissioners, the trust and NHS London. We subsequently made eight visits on a weekly basis from 12 October 2011 to 30 November 2011 to monitor progress with the action plan. We found that some improvements have been made but the trust continue to struggle to meet some of the targets. Whilst we are satisfied that the trust are making progress concerns remain and we will continue to follow these up.

We spoke to staff and patients during our visit at the hospital. Patients were generally happy with the care they received whilst in hospital but concerns were raised about Summary of our findings for the essential standards of quality and safety Page 3 of 28 how busy the service was by patients and staff. One patient told us, ‘‘Staff kept saying it’s very busy, very busy and staff were not helpful. There were less staff on labour, I asked if there were enough staff, they said, ‘no’’. Another patient told us, ‘The service was excellent; the staff did what they said they would do. We were not left alone, and staff reacted quickly to our needs’.

Staff were very concerned that the service was, ‘stretched’ and this was supported by other evidence we reviewed including incidents which had occurred in the maternity unit, staffing rotas as well as other documentation.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

Barking, Havering and Redbridge University Hospitals NHS Trust provides acute services across three local authorities: Barking & Dagenham, Havering and Redbridge, serving a population of around 750,000 and employing around 6,500 staff and volunteers.

Queens Hospital is the trust’s main acute hospital and opened as a private finance initiative (PFI) in 2006, bringing together the services previously run at Oldchurch and Harold Wood Hospitals. It is the main hospital for people living in Havering, Dagenham and Brentwood. The hospital has over 900 beds, including a hyper acute stroke unit (HASU). The Emergency Department (ED) treats over 150,000 walk-in and ambulance emergencies each year.

The trust was previously inspected in 2013, and due to concerns around the quality of patient care and the ability of the leadership team, the Trust Development Authority (TDA) recommended that the trust be placed in special measures.

We returned to inspect the trust in March 2015. A new executive team had been appointed, including a new Chair. Overall, we found that improvements had been made, however it was evident that more needed to be done to ensure that the trust could deliver safe, quality care across all core services.

The trust has continued its improvement plan, working closely with stakeholders and external organisations. On this occasion we returned to inspect the trust in September and October 2016, to review the progress of the improvements that had been implemented, to apply ratings, and also to make recommendation on the status of special measures. We carried out a focused, unannounced inspection at Queens Hospital of three core services that had previously been rated as inadequate in one or more domain – the Emergency Department (ED), Medical Care and Outpatients & Diagnostics (OPD). We also returned in October to carry out a more in-depth review of the trusts overall leadership and governance, where we also included an  announced inspection of Services for Children and Young People (CYP).

This inspection subsequently found that improvements had been made and ratings have been adjusted accordingly. Overall, we have found Queens Hospital as requires improvement.

Our key findings were as follows:

Are services safe?

• Compliance with infection prevention and control (IPC) practices across the services we inspected were found to be inconsistent. IPC standards were observed within services for children and young people (CYP) to be good, including appropriate hand-washing, use of hand gel and personal protective equipment. However, we observed poor compliance in the emergency department (ED) and diagnostics and imaging department, including a lack of consistent hand washing or using sanitising gel between patients. Compliance with standards for infection prevention and control and hygiene including cleaning schedules, decontamination, record keeping and audits required improvement across all services inspected.
• Safety thermometer data submitted nationally did not match the hospital’s divisional structure, making it hard to effectively benchmark performance against other trusts.
• Fire safety standards in CYP services, including areas around the NICU were not always maintained. This included variable understanding from staff on emergency procedures, fire doors repeatedly wedged open and a lack of clear signposting for the location of fire extinguishers.
• Medical staff were failing to meet trust targets for completion of mandatory training, across all topics.
• Compliance with resuscitation training in ED was poor and medical staff completion rates in basic life support training were below the trust target.
• Although nursing staffing levels had improved since the last inspection, some medical wards still had significant vacancy and turnover rates. On these wards, there was a reliance on bank and agency staff to fill vacant shifts. There was also reliance on locum doctors across the service.
• The ED had done a lot of educational work around sepsis and the early identification of a septic patient. Staff understood how to use early warning scores and described how to escalate concerns appropriately.
• Equipment and bedside safety checks were completed and there were procedures in place for staff to obtain technical support in the event of clinical equipment failure.
• Systems were in place to respond to deteriorating CYP patients using the paediatric early warning scores system and availability of a paediatric intensive care transfer service.
• There had been an improvement in the reporting of incidents and the sharing of lessons across the hospital.
• Staff were aware of their responsibilities with regards to duty of candour requirements, confirming there was an expectation of openness when care and treatment did not go according to plan.
• The dispensing and administration of medication on medical wards had improved, with prescription charts being used correctly and processes being correctly followed and audited.
• Nursing staff demonstrated an awareness of safeguarding procedures and how to recognise if someone was at risk or had been exposed to abuse. They knew how to escalate concerns and were up-to-date with appropriate levels of training.
• Patients on medical wards were assessed for a variety of risks on admission to the wards, using nationally recognised tools. Magnetic symbols were used on patient information boards to identify those patients at particularly high risk.
• The trust had changed their electronic records system and introduced the electronic patient record (EPR),
• There were appropriate protocols in place for safeguarding vulnerable adults and children, and staff were aware of the requirements of their roles and responsibilities in relation to safeguarding.
• Extensive safeguarding systems and processes were in place within CYP services to help identify children and young people at risk of avoidable harm. This included regular multidisciplinary meetings, supervision sessions delivered by the safeguarding team and monthly strategic dashboards that enabled staff to monitor referrals and patient outcomes.
• Staffing levels and skill mix were planned to ensure the delivery of outpatient, diagnostic and imaging services at all times.
• All medicines were found to be in date and stored securely in locked cupboards.

Are services effective?

• We found a number of clinical guidelines on the trust intranet were out of date. There was also issues with access to trust policies and guidelines for agency staff who had no computer access.
• The ED performed worse than the national average in a number of Royal College of Emergency Medicine (RCEM) audits, including sepsis and septic shock, asthma in children, and paracetamol overdose.
• Feedback from locum doctors was that training was limited and they felt training for them was not a priority.
• Staff understanding of consent, capacity and Deprivation of Liberty Safeguards (DoLS) was varied.
• Imaging Local Rules for the hospital had not been updated since 2012.
• The standardised relative risk of readmission for all elective procedures was higher than expected in comparison to the England average.
• Multidisciplinary team working was effective across disciplines. Most staff said they were supported effectively, and they felt valued and respected.
• The pathways for patients with cancer were not always correctly managed. There was poor communication with tertiary centres, which caused delays with patients requiring tertiary treatment/diagnosis at other specialist hospitals.
• The hospital performed worse than the previous year in both the Myocardial Ischaemia National Audit Project (MINAP) 2013/14 and the National Heart Failure Audit (2013/14). In the Lung Cancer Audit 2015, the trust was below expected standards for three key indicators relating to process, imaging and nursing measures.
• The majority of patients in ED were assessed for pain and offered appropriate pain relief.
• We observed good multidisciplinary (MDT) working between the emergency department (ED) and a number of other services, including psychiatric liaison and the nutritional team.
• Nursing and medical staff completed a variety of local audits to monitor compliance and drive improvement. Staff told us that these led to meaningful change across the medical service.
• In the National Diabetes Inpatient Audit (NaDIA) 2015, the hospital scored better than the England average for thirteen indicators out of twenty-one indicators.
• The majority of staff received annual appraisals on their performance. Staff were satisfied with the quality of the appraisal process. The trust was supporting nurses with the revalidation process.
• Patients attending the services we visited received care and treatment that was evidence based and in line with best practice.
• The outpatients department and diagnostic and imaging services had introduced clinics Monday to Sunday to clear patient waiting list backlogs.
• CYP services consistently met nine of the ten recommendations in the Royal College of Paediatrics and Child Health Facing the Future 2015 standards, which meant patients received timely and expert care from qualified staff.
• Although there were gaps in the provision of some therapies, including occupational therapy, the hospital had made sustained progress in the increased provision of some services. For example, a paediatric epilepsy nurse had been recruited, a diabetes specialist team was in place and a dedicated paediatric dietician and pharmacist were in post.

Are services caring?

• Patients and relatives across the services told us staff were predominantly kind, respectful and helpful. However, in ED we observed some negative interactions between staff and patients.
• Staff overall provided psychological and emotional support to patients and relatives and could signpost them to other support services if required.
• Bereavement services, were readily available to patients and their relatives. This included a multi-faith chaplaincy service and support from nurses.
• The safeguarding children’s assurance group evaluated the feelings of children and young people with a learning disability and their parents and used the results to improve the service.
• In the Friends and Family Test (FFT) the ED scored between 71% and 88% of patients recommending the department to others. This was below the England average.
• Privacy curtains were not being drawn in the main diagnostic and imaging department, and the emergency room in ophthalmology had bays that did not promote patients privacy and dignity.
• The trust performed slightly below the national average in the National Cancer Experience Survey 2015.

Are services responsive?

• The main waiting area and paediatric waiting area in ED were very busy during our second unannounced inspection, and some patients were unable to sit down.
• There was no lead for dementia within the service at the time of our inspection.
• The percentage of patients being seen and treated in ED within the recommended four hour timeframe and number of patients who left the department without being seen was worse than the national average.
• The ED was not meeting its 15 minutes triage indicator for a high proportion of patients. The average time to triage was 28 minutes.
• The trust’s performance for the 62 day cancer waiting time was consistently below the 85% England average from 1 March 2015 to 31 May 2016.
• 14% of appointments were cancelled by the hospital. This was higher than the England average of 7.2%.
• Patient information leaflets were not standardly available in languages other than English.
• The Patient Advice and Liaison Service (PALS) did not always respond to complaints in a timely manner.
• Paediatric phlebotomy services were in place to enable blood to be taken from children by staff trained to recognise needle phobia and to use distraction techniques. However, children and young people who needed a blood test were sometimes seen in adult outpatient phlebotomy.
• The ED worked closely with local GPs to ensure they were meeting the needs of the local population.
• There were a number of specialist teams available such as a frail and older people team, psychiatric support, domestic violence team, and alcohol liaison services.
• There had been an 88% reduction in the overall backlog of patients waiting over 52 weeks since May 2016. This reflected an increased effort from the trust to reduce referral to treatment (RTT) times for patients using their services.
• The hospital was using a range of private providers to assist in clearing the backlog of appointments where there were most demand services.
• The outpatients department and diagnostic and imaging services had introduced clinics Monday to Sunday to clear patient waiting list backlogs.
• People living with dementia received tailored care and treatment. Care of the elderly wards had been designed to be dementia friendly. A specialist dementia team and dementia link nurses were available for support and advice.
• Support for people with learning disabilities was available. There was a lead nurse available for support and advice. There was a monthly safeguarding and learning disability operations group.
• Catering menus offered many options to cater for those with different nutritional requirements.
• Play specialists were available in CYP services and they provided children with a range of activities. There were three well-equipped play areas available, including a covered outdoor play area.
• A sensory room and mobile sensory equipment was available to help support children and young people with sensory needs, learning disabilities or needs relating to autism.
• A dedicated paediatric learning disabilities nurse had developed a hospital passport for children and visual communication aids. This helped staff to communicate with patients and to understand their likes, dislikes and worries.
• Transition services were in place for children moving into adult services. This included support to gradually build their independence and one-to-one support as they were moved onto an adult pathway.

Are services well led?

• The trust had developed a clinical vision and strategy and communicated this to staff of all levels across the hospital.
• There was a system of governance and risk management meetings at both departmental and divisional levels across core services, however this had not yet developed effectively in some areas at the time of inspection. An external organisation had worked with the trust on ensuring their governance structures were more robust.
• Managers and clinical leads were visible and approachable.
• There was evidence staff could confidently provide feedback to the senior team and that changes were considered and implemented where possible.
• Staff were encouraged to engage in research and pilot schemes to drive a culture of change to improve practice and the delivery of patient care
• However, there was no clear vision and strategy for the ED service as we were told plans for the department were constantly changing. Some staff did not know about the departments plans to close King George Hospital accident and emergency department at night.
• Although senior divisional staff had a good understanding of the risks to their respective services as recorded on the risk register; staff responsible for the immediate delivery of clinical care were not always aware of the recorded risks for their service.

We saw several areas of outstanding practice including:

• The hospital provided tailored care to those patients living with dementia. The environment in which they were cared for was well considered and the staff were trained to deliver compassionate and thoughtful care to these individuals. Measures had been implemented to make their stay in hospital easier and reduce any emotional distress.

• The trust had awarded the neonatal and community teams for their work in providing babies with oxygen home therapy, which significantly improved the quality of life for families.
• A dedicated paediatric learning disability nurse had introduced support resources for patients, including a children’s hospital passport and visual communication tools. This helped staff to build a relationship with patients who found it challenging to make themselves understood. This had been positively evaluated and received a high standard of feedback from parents and patients.
• Child to adult transition services were comprehensive and conducted with the full involvement of the patient and their parents. This included individualised stages of empowering the person to gradually increase their independence, the opportunity to spend time with paediatric and adult nurses together and facilities for parents to spend the night in adult wards when the young person first transitioned.

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

Importantly, the trust must:

• Take action to improve levels of resuscitation training.

• Ensure there is oversight of the training done by locum doctors, particularly around advanced life support training

• Take action to improve the response to patients with suspected sepsis

• Take action to improve poor levels of hand hygiene compliance

• Ensure fire safety is maintained by ensuring fire doors are not forced to remain open.

• Ensure staff have a full understanding of local fire safety procedures, including the use of fire doors and location of emergency equipment

• Ensure hazardous waste, including sharps bins, is stored according to related national guidance and EU directives. This includes the consistent use of locked storage facilities.

In addition the trust should:

• Endeavour to recruit full time medical staff in an effort to reduce reliance on agency staff.

• Ensure there is sufficient number of nurses and doctors with adult and paediatric life support training in line with RCEM guidance on duty.

• Increase paediatric nursing capacity.

• Ensure policies are up to date and reflect current evidence based guidance and improve access to guidelines and protocols for agency staff.

• Take action to improve the completion of early warning scores

• Improve appraisal rates for nursing and medical staff.

• Regularise play specialist provision in the paediatric ED.

• Consider how to improve ambulance turn around to meet the national standard of 15 minutes

• Ensure staff and public are kept informed about future plans for the ED.

• Restructure the submission of safety thermometer data to match the current divisional structure.

• Continue to monitor hand hygiene across non-compliant wards and follow action plans detailed on the current corporate and divisional risk registers.

• Monitor both nursing and medical staffing levels. Follow actions detailed on corporate and divisional risk registers relating to this.

• Monitor and improve mandatory training compliance rates for medical staff. Improve completion rates for basic life support for nursing and medical staff.

• Continue to work to improve endoscopy availability and service, as detailed on the corporate risk register.

• Make patient information leaflets readily available to those whose first language is not English.

• Ensure consent to care and treatment is always documented clearly.

• Ensure each inpatient has an adequate and documented nutrition and hydration assessment.

• Ensure there are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.

• Ensure there are appropriate processes and monitoring arrangements in place to improve the 31 and 62 day cancer waiting time indicator in line with national standards.

• Ensure the 18 week waiting time indicator is met in the outpatients department.

• Ensure the 52 week waiting time indicator is consistently met in the outpatients department.

• Ensure percentage of patients with an urgent cancer GP referral are seen by a specialist within two weeks consistently meets the England average.

• Ensure the number of patients that ‘did not attend’ (DNA) appointments are consistent with the England average.

• Ensure the number of hospital cancelled outpatient appointments reduce and are consistent with the England average.

• There is improved access for beds to clinical areas in diagnostic imaging.

Professor Sir Mike Richards

Chief Inspector of Hospitals