We undertook an unannounced focused inspection in the critical care department of the Royal Free Hospital which is operated by the Royal Free London NHS Foundation Trust.

The inspection was conducted because the Care Quality Commission (CQC) had received anonymous information that the implementation of a new patient record IT system (CCCIS) had meant patients had been harmed, and was creating an ongoing a risk to patient safety.

During our inspection we found no evidence that patients had been harmed or were at a higher risk of harm as a result of the implementation and use of the new IT system.

At the point of our inspection, we found staff had ceased to use the critical care clinical information system (CCCIS) in early July 2017 in its full capacity as a result of the safety concerns being raised by individuals with the trust. Our inspection therefore focused on how the project had been managed and implemented and the resulting service. Some elements of the CCCIS were still in use, including electronic prescribing and access to diagnostic imaging.

We have not rated any part of this inspection because of its specific focus which did not include all areas of our ratings assessment model.

The summary of our key findings of our inspection were:

• No patients had been harmed as a result of implementing the new IT system. The mortality rate in the 12 months prior to our inspection was significantly better than the national average.
• Although incident tracking and documentation was consistent, there were variable approaches to resolving safety concerns. In addition not all staff felt the incident investigation system was effective.
• A key risk to the safety and sustainability of the service related to short staffing, including a 29% vacancy rate in the nursing team and a 26% vacancy rate amongst junior doctors.
• A dedicated project team had worked with clinical staff who had undertaken additional training to support the pilot scheme of a new CCCIS.
• There was evidence of a responsive approach to risk management during the CCCIS pilot although a significant number of clinical staff disagreed with this.
• Care and treatment was benchmarked against national standards through a programme of local audits and contribution to national audits, including the intensive care national audit and research centre. There was evidence staff improved care policies and protocols as a result of audit outcomes.
• We found evidence of significant and persistent disagreement and conflict between staff at different levels of responsibility. The senior leadership team had not demonstrably addressed this nor implemented timely strategies to reduce pressure on affected staff.

Our key findings were:

• Although incident tracking and documentation was consistent, there were variable approaches to resolving safety concerns. In addition not all staff felt the incident investigation system was effective.
• A key risk to the safety and sustainability of the service related to short staffing, including a 29% vacancy rate in the nursing team and a 26% vacancy rate amongst junior doctors.
• A dedicated project team had worked with clinical staff who had undertaken additional training to support the pilot scheme of a new critical care clinical information system (CCCIS).
• There was evidence of a responsive approach to risk management during the CCCIS pilot although a significant number of clinical staff disagreed with this.
• During the early implementation phase, on-site support for clinicians had been provided on a 24-hour basis by nurses and pharmacists who were trained as ‘super users’.
• Care and treatment was benchmarked against national standards through a programme of local audits and contribution to national audits, including the intensive care national audit and research centre. There was evidence staff improved care policies and protocols as a result of audit outcomes.
• The mortality rate in the 12 months prior to our inspection was significantly better than the national average.
• We found evidence of significant and persistent disagreement and conflict between staff at different levels of responsibility. The senior leadership team had not demonstrably addressed this nor implemented timely strategies to reduce pressure on affected staff.
• Clinical governance and risk management strategies were well established and effective in service improvement but there was limited evidence they were effective in driving good working relationships or project management.
• Senior divisional staff had instructed external NHS bodies to visit the unit and implement strategies to improve working relationships and leadership.

There were also areas of practice where the trust should consider making improvements:

• The trust should work with all staff groups and their representatives to assess how staff can feel more involved in major changes within the trust.
• The trust should review how governance systems can be made more open and effective in relation to project implementation and conflict management.

Professor Edward Baker

Chief Inspector of Hospitals

An unannounced inspection was undertaken by seven members of Care Quality Commission staff, a specialist adviser and an expert by experience (someone who has experience of care) on 26 February 2014. We visited eight wards: 4 East (Intensive Therapy Unit), 6 East (temporary re-enablement ward / winter pressure ward), 6 South (Stroke Unit and Neurology), 8 East (Respiratory Medicine), 8 West (Health services for elderly people), 9 North (Health services for elderly people), 10 South A (Acute Renal) and 10 North (Hepatology). We also met with the hospital’s PALS (Patient Advice and Liaison Service) and Complaints teams.

We spoke with 40 patients or their relatives and with 58 members of staff from a range of backgrounds, including medical, nursing and therapy. We looked at 33 sets of records relating to patients and analysed seven complaint responses.

Most of the patients we spoke with were positive about their experiences at the trust. Many told us they felt the staff were caring and had provided them with good support. A few felt there could be improvements. Most patients felt there was enough staff to meet their care needs. When we asked patients if they would feel confident raising concerns, most told us they would feel comfortable doing this.

The following are examples of comments we received from patients:

“Nurses are wonderful, couldn’t ask for nicer. Doctors are good as well.”

“The care had been very good. The nurses are very attentive.”

“Everything is right. They took care of me very well. Best hospital.”

“Quality of the care is simply outstanding.”

“Overall it is first class.”

“Not too good. It’s a bit noisy sometimes. I’ve known better hospitals.”

Where people did not have the capacity to consent, the provider acted in accordance with legal requirements. We saw that where they were required, capacity assessments and best interest meetings had taken place.

People experienced care, treatment and support that met their needs and protected their rights. We saw examples of care being planned appropriately and observed staff being very caring towards patients. Some care planning in the services for older people could be more personalised.

People were protected from the risks of inadequate nutrition and dehydration. We observed staff supporting patients with meals.

People were protected from the risk of infection because appropriate guidance had been followed. The wards we visited were mostly very clean.

There were enough qualified, skilled and experienced staff to meet people’s needs. In most wards we visited we saw examples of good leadership and motivated staff. On ward 8 East there were a number of vacancies but recruitment was underway.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Most staff we spoke with told us they felt adequately trained and supported in their roles.

There was an effective complaints system available. Comments and complaints people made were responded to appropriately. The trust was not meeting their timescales for replying to all complaints although this was being addressed.

Medicines were kept safely, and being stored securely for the protection of people who use the service.

As part of the inspection an unannounced visit was undertaken by eight members of CQC (Care Quality Commission) staff on 16 October 2012. On this day we looked at five areas of the trust: Health services for elderly people (in wards 8W and 9N), Maternity services, Phlebotomy, Paediatric services (ward 6N), and the emergency care pathway for patients (in the A&E and the Medical Admission and Assessment Unit). We conducted an additional visit, on 23 October 2012, to meet staff in the trust’s complaints and governance teams. In addition, we assessed all the data and information we hold on the trust.

Overall, we spoke with 58 patients or their relatives and with 46 members of staff from a range of medical, nursing, and therapy backgrounds.

In general, the patients we spoke to were very positive about their experiences at the trust. Most told us they felt the staff were caring and treated them with respect. They felt they were involved in decisions about their care and that there were enough staff to meet their care needs.

Most of the patients we spoke with told us they thought the hospital was clean.

The following are examples of comments we received from patients:

“The staff including the doctors and midwives have all been very friendly.”

“I have been using the service since 2009. The care is not bad I have no complaints.”

“Yes, it is good. I have no concerns.”

“Staff are there when I need them.”

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, patients we spoke to on our visit were positive about their care, treatment and support. Patients and their families told us they understood their care and felt involved in the decisions about their care. Patients are responded to in a timely manner and are happy to request assistance if they wanted to. Patients told us that they had a choice of food which was satisfactory and that they could get food and drinks 24 hours a day. We saw patients sitting comfortably and enjoying the meals they had at lunch. Staff check that patients have enough to eat and drink.

Women told us that were very happy with the care they received throughout the stages of pregnancy and overall they would rate their care experience as excellent or very good. Staff were considered kind and supportive and ensured women were involved in their care. They explained treatments’ risks and benefits in a way that was understood by women and their partners. All the women we spoke to were happy with the infant feeding support and advice they had been given by staff.

Overall, patients we spoke to on our visit were positive about their care, treatment and support. Patients and their families were involved in their care but sometimes staff tended to talk to their family members about the care and treatment instead of themselves. Patients would also like to be responded to more quickly. Patients told us that they had a choice of food which was satisfactory and that they could get food and drinks 24 hours a day. However staff did not always check that patients had enough to eat and drink. Patients would also like the opportunity to wash their hands before mealtimes.

Our rating of services went down. We rated it them as requires improvement because:

• We rated safe, responsive and well-led at this hospital as requires improvement and we rated effective and caring as good.
• We rated three of the five services inspected, during this inspection, as requires improvement overall.
• Many of the issues identified during the previous inspection, which impacted on the safety and responsiveness of the service, had not been yet been addressed by the hospital’s leadership team.

• Mandatory training for staff in key skills, including safeguarding, fell below the trust’s target for compliance.

• Staff did not consistently follow best practice when prescribing, giving, recording, storing and disposing of medicines. Documentation indicated patients did not always receive the right medication at the right dose at the right time. Medicines management was inconsistent and audits repeatedly found areas of unsafe practice in relation to documentation and storage. Medicines were not always stored securely and managed appropriately.

• Services did not always have sufficient numbers of staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. Nurse vacancy rates and turnover rates were significantly higher than trust targets and services relied on temporary staff to fill shifts.

• Standards of nursing documentation were inconsistent and persistent concerns about the performance of agency nurses had not been addressed. The impact of short staffing and lack of specialty team cover at weekends was evident in the inconsistencies and errors we found in some patient documentation, including important medicine administration records. There was a hybrid system of record keeping: part paper, part electronic which led to some delayed or missed information being available to clinicians.

• We were not assured that there were effective systems and processes in place to prevent avoidable patient safety incidents from reoccurring. Although the hospital generally managed patient safety incidents well, evidence of completed actions in response to serious incidents, was not always robust. There were gaps in the outcomes divisional teams thought they had achieved and the information understood or used by staff delivering care.

• Equipment was not always well looked after or safely maintained. Not all equipment was up to date with planned preventative maintenance and staff in some services reported frequent equipment failures. This did not meet recommended standards. There were a number of incidents reported relating to the loss or missing surgical instruments after an operation. Whilst instruments were checked at the end of an operation, some instruments would be missing when arriving at the sterile services department.

• People did not always have prompt access to the service when they needed it. Waiting times from referral to treatment and decisions to admit patients were not always in accordance with best practice recommendations. There was an increase in the number of patients being cared for overnight in the recovery area in the operating theatres due to a lack of suitable beds. Delays in theatres meant patients sometimes had to wait a long time on the day of their procedure. Long waits in A&E were a regular occurrence due to lack of capacity to meet service demand.

• Best practice guidelines for care and treatment of patients with additional support needs were not consistently followed. Staff did not always use or access specific communication aids for patients with a learning difficulty and were unfamiliar with hospital passports. Some staff said they regularly struggled to meet the needs of patients with mental health conditions whilst they were waiting for a mental health bed placement. Some staff told us their training was insufficient to meet patient needs.

• Whilst the trust had effective systems for identifying risks and planning to reduce them, risks were not always being dealt with in a timely way. Some department level risks had not been identified or adequately addressed. Not all risks identified during our inspection were on the hospital’s risk register; therefore we were not assured that senior leaders had appropriate oversight of these issues.

• Whilst the majority of staff felt the culture of the organisation had improved and described the leadership team as accessible and supportive, there remained a culture of bullying within the operating theatres.

However:

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

• The hospital generally controlled infection risk well. Staff kept themselves, equipment, and the premises clean. They used control measures to prevent the spread of infection.

• The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff delivered care and treatment in line with national guidance.

• Staff worked together as a team to deliver effective, patient-centred care and improve patient outcomes. Treatment was planned and delivered in line with current evidence-based guidance and patients were supported by staff to take ownership of their own recovery.

• Staff treated patients with kindness, dignity and respect. Patients were involved as partners in their care and were supported by staff to make decisions about their treatment.

• Most staff felt well supported by managers and told us that they encouraged effective team working across the hospital. Senior staff were visible, approachable and supportive. Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. Most staff spoke positively about their local leadership and line management and said relationships were supportive.

• The trust was committed to improving services by learning, promoting training, research and innovation. Staff were positive about the support they received to challenge existing practice and try out new ideas.