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

• The hospital improved its rating of effective since the last inspection, but the ratings for each of the other key questions remained the same.
• We inspected Urgent and emergency care during this inspection to check if improvements had been made. Our rating of the service went down. We rated it as requires improvement because safe, effective, responsive and well-led required improvement, and caring was good. The rating for safe, responsive and well-led went down, and the ratings for each of the other key questions remained the same.
• We inspected Surgery during this inspection to check if improvements had been made. Our rating of the service stayed the same. We rated it as requires improvement because safe and responsive required improvement, and effective, caring and well-led were good. The rating for well-led improved and the ratings for each of the other key questions remained the same.
• We inspected the Medical care (including older people’s care) service in October 2017 because we had concerns about the quality of the service. Our rating of the service improved. We rated it as good because safe and responsive required improvement; well-led was good, and caring and effective were outstanding. The ratings for effective, caring and well-led improved and the ratings for each of the other key questions remained the same.
• We inspected the Outpatients and diagnostic imaging service in May 2017 to check if improvements had been made. Our rating of the service improved. We rated it as requires improvement because safe, responsive and well-led were required improvement, and caring was good. The ratings for responsive and well-led improved; the rating for safe went down. We did not rate effective.

We visited Charing Cross Hospital on 22nd January and went to the Accident and Emergency Department (A&E), the Clinical Decision Unit (CDU) and two general medical wards, one of which was specifically for care of older people and one which had beds where the majority were designated for care of older people. We also spoke with staff on the wards and departments we visited, observed care being delivered and spoke with patients and family members. We also spoke with members of the Dementia Care Team in the Trust including the medical lead and a dementia specialist nurse. We received further information from the Trust during the inspection. We looked at treatment records for patients of which we checked six records for people who had dementia and spoke with staff who worked in discharge planning and the hospital social work team.

We looked specifically at people the care and treatment of people who were admitted to hospital and had either diagnosed dementias or identified cognitive impairments who may have been admitted to the hospital for a number of reasons.

Most people we spoke with told us that they were happy with the service they received in the hospital. One person told us “they [the nursing staff] are always there for me” and another person told us “I’m looked after absolutely perfectly”. Most care we observed was delivered by nursing staff in a kind and responsive manner. We saw that family members were involved in discussions about their relatives by looking in the notes and by speaking with family members.

We saw that the hospital had a process to ensure that people with dementia who had different support needs were identified on admission and provided with care and treatment which met their individual needs. We tracked people’s paths through the hospital and found that this was effective. People’s assessments of needs included their medical history and social needs however there was some variation in the quality and detail of information about people’s social histories and preferences.

Most of the staff we spoke with had received a minimum of one day training specifically related to dementia care and they all spoke positively about this.

There were systems put in place by the provider on a ward and Trust-wide level to monitor the quality of dementia care provided.

People told us what it was like to be a patient in Charing Cross Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

We visited five wards during our visit and observed lunchtime on three wards. The wards were chosen as the majority of the patients were older people.

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

We spoke with more than 20 people and their relatives. They were generally positive about the hospital regarding the information they received about their care and treatment, ward environment, choice of menu, facilities and their surroundings. They were very positive about their experience of staff. One person said they “couldn’t ask for more” and another described Charing Cross Hospital as a “magnificent organisation” and had the highest praise for the hospital.

We saw positive feedback from relatives about the care given to their family members, for example the relative being “treated with great respect and treated seriously” and being made welcome when visiting.

We visited ten wards and departments and spoke to patients who were using the service. The majority of patients we spoke with were happy with the care they were receiving. They felt involved in their discharge arrangements and gave some examples of how the pre-admission preparation for some planned procedures had helped them throughout their stay.

Patients also told us that they found the hospital to be clean and saw staff washing their hands and using gel appropriately.

Imperial College Healthcare NHS Trust provides acute and specialist healthcare for a population of around two million people in north west London and the surrounding areas. The trust has five hospitals Charing Cross, Hammersmith, Queen Charlotte’s & Chelsea, St Mary’s and the Western Eye. Charing Cross Hospital is an acute general teaching hospital located in Hammersmith, London.

Medicine and specialist medicine at Charing Cross Hospital sat under two directorates in the hospital; with the majority of the medical wards under the division of medicine and integrated care. The medical services include acute medicine unit (AMU), care of the elderly wards, specialist wards such as medical oncology, respiratory medicine, stroke unit, neurology, gastroenterology and endocrinology.

We plan our inspections based on our assessment of the risk to patients from care that is or appears to be less than good. We inspected the medicine and elderly care services because we had information giving us concerns about the quality of this service.

We last inspected the medicine and elderly care service in September 2014 as part of our comprehensive inspection program and rated the service as requires improvement. During that inspection we observed hospital discharges occurring after 10pm. We found that care plans for people living with dementia and diabetes were not used and we noted patients stayed in the hospital for longer than the national average. There were high vacancy rates among staff and it was not clear what the senior management was doing to address this.

During this inspection we found the overall quality of the medicine and elderly care services had improved and we rated it as good. We rated safe as requires improvement; effective and caring were rated as outstanding and responsive and well-led were rated as good.

Our Key findings were;

• The hospital participated in and used the outcomes from local and national audits for benchmarking, and to improve patient care and develop care and treatment pathways for the patients. All staff were actively engaged in activities to monitor and improve qualities and outcomes.

• The hospital was the second best performing hospital in the country among the trusts taking part in the Sentinel Stroke National Audit Programme (SSNAP) for the hyper acute stroke unit.

• The trust was consistently monitoring and improving their mortality rate and remained in the top five lowest-risk acute trust. The trust was the second lowest-risk acute trust in the 2016 Hospital Standards Mortality Ratio (HSMR) and the third lowest-risk acute trust in the Summary Hospital-level Mortality Indicator (SHMI).

• There was a strong, caring and visible-centred culture, which was fully rooted on all the medical wards visited. Staff we spoke to were highly motivated and inspired to offer care that was kind and promotes people’s dignity.

• Staff demonstrated in-depth knowledge of the principles of Deprivation of Liberty Safeguards (DOLS), safeguarding, consent and the Mental Capacity Act (2005) and we saw examples of these areas in practice.

• Staff were proactively supported to acquire new skills and share best practice to ensure continuous development of their skills, competence and knowledge.

• Staff actively sought, monitored and reviewed patient consent and processes to improve patient decision making about their care and treatment.

• Staff worked proactively and effectively as part of the multidisciplinary and multi-agency team to deliver patient centred care and improve patient discharges, access and flow.

• The service provided care that took account of people’s personal, cultural, social and religious needs into account.

• Patients and relatives gave positive feedback about the manner and attitude of staff. During inspection we saw people were treatment with kindness and respect by staff from all disciplines.

• There was emotional support, chaplaincy, support groups, psychologist and psychiatry support available to patients and their relatives.

• The service was planned and delivered to meet the needs of various patients in the local area.

• The medical wards were dementia friendly and there were dementia signs and activities for patients with dementia. The medical wards performed better than the England average on the 2016 patient led assessments of the care environment (PLACE) audit on the provision of care for people with dementia.

• The medical wards bed occupancy rate was better than the England average.

• The medical wards performed better than England average for the two weeks GP referral for breast symptoms.

• We noted improvement in the number of outliers, length of stay and discharges, and these were escalated to senior leads and discussed at their daily multidisciplinary team (MDT) meetings.

• The service had clear systems and processes, to ensure complaints were dealt with in a timely and appropriate manner. The trust recruited complaint investigator to handle complaint received in the hospital.

• Staff told us leaders were visible, accessible and supportive.

• There was a clear vision and strategy for the hospital. We saw the trust values were mirrored in staff actions and behaviours during inspection.

• The hospital welcomed views and input from staff and the local public which allowed a sense of engagement and empowerment from those involved in the service to help improve the quality of care and services been provided.

• We saw evidence of various initiatives, innovations and pathways developed in the hospital and trust to improve patient care and outcomes.

However:

• Staff did not follow the trust policies and national guidelines in the management and disposal of medicines, including controlled drugs and medical gases. We noted medicines errors that related to the use of controlled drug (CDs) during inspection. Staff were not following the trust policy in storing medicines at the right temperature and monitoring of the room temperature regularly. Controlled drugs were not secured and stored with other patients own property and equipment on Ward 8 South. We saw that expired medicines were not disposed and stored with other medicines on the wards.

• We found several boxes of unused medicines in the domestic waste bin, which were not disposed appropriately. We observed three bottles of used IV antibiotics still connected with the IV line on the worktable in the treatment and had not been disposed appropriately by staff.

• The trust compliance with mandatory training for medicine and the medicine specialities was 81.3 % for medical staff and 84% compliance for the nursing staff and allied health professionals, which was below their 90% target. Staff on medical wards were not meeting the trust targets for almost all modules of mandatory training, including safeguarding, information governance, health safety & welfare, MCA, consent, fire safety clinical and high risk area and resuscitation.

• Mandatory training rates for scientific and technical staff (31.4%) were significantly lower than the trust’s 90% target.

• There was personal protective equipment (PPE) and staff used it, however some medical staff did not wash their hands between patients.

• Resuscitation trolleys were not restocked and checked consistently by staff on the wards.

• There was a high usage of nursing bank and agency staff due to the high number of vacancies.

• There was poor signage on the wards and throughout the hospital. The signs were not updated to reflect the relocation of wards.

• The trust wide medical wards did not meet the NHS England national indicator for 18 weeks referral to treatment (RTT) times.

We saw several areas of outstanding practice including:

• Charing Cross Hospital medical care provided outstanding and effective medical care to patients. The hospital participated in and used the outcomes from local and national audits for benchmarking, and to improve patient care and develop care and treatment pathways for the patients. The hospital was the second best performing hospital in the country among the trusts that took part in the Sentinel Stroke National Audit Programme (SSNAP) for the hyper acute stroke unit.

• Staff actively engaged in activities to monitor the quality and outcomes of patients care and treatment.

• The trust’s performed higher or similar to the national averages for outcomes of patients on other national audits. These included the the Myocardial Ischemia National Audit Project (MINAP), Inflammatory Bowel Disease Programme (IBD) and the National Diabetes Inpatient Audit (Nadia)

• The trust was consistently monitoring and improving their mortality rate and remained in the top five lowest-risk acute trust. The trust was the second lowest-risk acute trust in the 2016 Hospital Standards Mortality Ratio (HSMR) and the third lowest-risk acute trust in the Summary Hospital-level Mortality Indicator (SHMI).

• Patients care and treatment were always consultant led and staff used evidence based best practice.

• Staff worked proactively and effectively as part of the multidisciplinary and multi-agency team to deliver patient centred care and improve patient discharges, patient care, access and flow.

• Patients’ medical and nursing records were available for all meetings and assessments, which meant that the most up to date information was considered when reviewing care and treatment.

• Without exception, patients told us they were treated with kindness, dignity, respect and compassion. There was a high standard of care provided for patients on the medical wards, and we saw that staff went to great lengths to respect and accommodate the wishes of patients and their loved ones. There was a strong, caring and visible-centred culture, which was fully rooted on all the medical wards visited. Staff we spoke to were highly motivated and inspired to offer care that was kind, respectful and promotes people’s dignity. Staff consistently considered peoples’ personal, cultural, social and religious needs and delivered kind and compassionate care.

• The Friends and Family Test (FFT) results showed the medical wards performed better than national average on the response rate and people who would recommend the service.

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

Importantly, the trust must;

• The trust must make sure that staff follows the trust’s medicine management policies concerning safe storage of medicines and medical gases.

• The trust must take action to ensure medical wards are meeting mandatory training including the resuscitation training requirements for their staff.

The trust should do the following;

• The hospital should review the recording of patients’ own controlled drugs to make sure stock levels and administration can be clearly documented.

• The hospital should ensure resuscitation trolleys are checked, restocked and recorded consistently.

• The hospital should ensure staff washes their hands between patients.

• The hospital should ensure compliance with appraisal and mandatory training meets the trusts target for safeguarding, consent and mental capacity act.

• The hospital should consider improvements to the hospital estate and facilities for the elevators, lifts and flooring of some wards areas.

• The trust should improve hospital signage, ensure it is up to date and provides clear information for visitors on how to access the wards.

• The hospital should review the facilities provided in ward day-room areas so they meet the needs of the patients using them.

Professor Ted Baker

Chief Inspector of Hospitals