Our rating of Hammersmith Hospital stayed the same. We rated it as requires improvement because safe, responsive and well-led require improvement and effective and caring were good.

• The ratings for each of the key questions remained the same since our last inspection.
• We inspected Surgery during this inspection to check if improvements had been made. Our rating of the service improved. We rated it as good because effective, caring, responsive and well-led were good, and safe required improvement. The rating for responsive and 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 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 Outpatients and diagnostic imaging service in May 2017 to check if improvements had been made. Our rating of the service significantly improved. We rated it as good because safe, caring and well-led were good and responsive required improvement. The ratings for responsive improved and the rating for well-led significantly improved; the rating for safe went down. We did not rate effective.

We visited an acute medical assessment and care of the elderly ward, the emergency department and wards, and the heart attack centre (which took emergency admissions). We spoke to people in all the departments we visited.

People told us that they had been asked for consent to operations or procedures during their time in hospital. We saw that consent had been properly recorded. Where people lacked capacity, staff arranged assessments of mental capacity in line with current legislation and to ensure people’s safety and involvement.

Almost all the people we spoke with were positive about the quality of care and treatment they had received. They said staff took time to assess and meet their needs. We looked at patient records, which were clear, accurate and up to date. They included care and treatment plans, risk assessments and plans for safe discharge.

There were policies and procedures in place for staff to deal with foreseeable emergencies and any adverse incidents and staff had the necessary skills and experience to deal with emergencies.

There were sufficient skilled and experienced staff to meet people’s needs.. Patients told us that staff checked on them regularly and responded quickly when called. Staff told us they were generally satisfied with staffing levels. The hospital systematically adjusted staffing numbers and skill mix according to patient need.

There were clear policies and procedures for medical record keeping which staff followed.

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 Hammersmith 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 including renal, haematology, cancer and cardiology care and provides a regional specialist heart attack centre.

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 stayed the same, but there were some positive changes. The service was rated as requires improvement. We rated safe and responsive as requires improvement, and we rated effective, caring, and well-led as good.

Our key findings were as follows:

• Signage on site was poor and therefore, there were many visitors and members of the public lost and wondering how to get to their desired location.

• We found the environment on some wards was poor. Staff submitted requests for repairs but the work took a long time to be carried out. Some wards had identified the areas requiring repair as a potential infection prevention and control risk in their risk registers. Staff on one ward told us they had been able to make some changes, which improved patient observation but the environment remained on the directorate risk register.

• The trust was not monitoring compliance with the Faculty of Medicine’s Core Standards for Pain Management Guideline (2015).

• Liquid medicines on two wards did not have a date recorded for when they were opened.One of those medicines was used to relieve severe pain and should be used within 90 days of opening. Staff were not following the trust’s policy, which stated that the date of opening should be recorded.Ten boxes of medicines and fluids for intravenous administration were out of date on one ward. The expiry date of one medicine was nine months before our inspection.

• The results of the national diabetes audit showed patient experience was rated below the national average and the rate of foot assessments was worse than other services.

• Patients could not access the patient advice and liaison service at Hammersmith Hospital. The service was advertised as being available but the office was closed and the telephone number provided was not manned.

• Some cardiac patients were not able to access cardiac rehabilitation because the service did not have adequate capacity.

• Some patients experienced delays in receiving their chemotherapy medicines. Staff told us about one patient whose chemotherapy infusion could not be fully administered because it had exceeded the time period in which the medicine was effective. There were problems preparing some medicines on the Hammersmith site and these were being transferred from another site in the trust.

• Staff told us patient transport between sites was a problem and patients were unhappy about the length of time they waited for transport between sites and for going home after treatment.

• Staff told us executive directors did not often visit the site.The Chief Executive had met with senior staff to discuss the trust’s strategy. They said they valued receiving information because major changes were taking place, which affected the hospital.

However,

• The service managed patient safety incidents well. Staff received feedback from incidents they had reported. Learning from incidents was included in a staff bulletin, which was circulated to staff in the medicine and integrated care division.

• Results of patient safety monitoring were displayed on ward noticeboards for patients and visitors.

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

• Patients’ records were mostly electronic and staff described the benefits of medical staff being able to review test results or prescriptions from anywhere in the trust. Some wards were liaising with social services via email as part of planning patients’ discharge.

• Services participated in a wide range of national audits and benchmarked performance against other hospitals.

• Staff followed clinical guidelines and pathways, which were up to date and accessible on the trust’s intranet.

• Patients’ needs were planned and reviewed by multidisciplinary teams.Care of the elderly consultants worked with cardiology, renal and cardiac colleagues to plan the care provided to older patients.

• Governance arrangements were robust and had been revised to take account of recent changes in the management structure.

• The provider was working with commissioners and partners to plan services, which met the needs of the local population in Hammersmith and Fulham.

• Renal and haematology patients could contact the service day or night to discuss their symptoms and any care, which might be required.

• Patients with cardiac symptoms could access services at a new heart attack centre dedicated to provide specialist investigation and treatment.

• The complaints service was reviewed, resulting in improvements to the quality and timeliness of responses.

• Nurse managers described how services were co-ordinated and managed within the new multi-site divisional structure. They told us there was a site manager with responsibility for the operational co-ordination of services on the hospital site and between sites.

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

Importantly, the trust must:

• The trust must ensure all wards and departments follow the trust’s medicine management policies so that medicines are safe for administration to patients. In particular for date checking medicines and storing medicines in refrigerators.

• The trust must improve the proportion of medical staff completing mandatory training, level 2 adult safeguarding training in particular.

In addition the trust should:

• The trust should ensure patients and carers have the same access to the trust’s PALs service as patients on other sites.
• The trust should ensure the cardiac catheter lab complies with the World Health Organisation (WHO) safer surgery checklist.
• The trust should develop plans for addressing problems with the preparation of oncology treatments at the Hammersmith site and ensure staff and patients are informed. The trusts should also monitor the number of treatments adversely affected by delays in providing oncology medicines.
• The trust should clarify and implement a pathway for access to Level 2 beds for Haematology patients
• The trust should support clinicians and managers to develop the planned investigation unit and to review how specialty medicine beds and wards were configured across the site.
• The trust should improve signage and the environment on the wards by addressing the backlog maintenance programme.
• The trust should improve the provision of cardiac rehabilitation services.
• The trust should ensure patients with diabetes are able to access foot care.
• The trust should ensure all staff particularly those caring for older people fully understand and follow the requirements of the Mental Capacity Act (2005).
• The trust should ensure adequate overnight SHO rota cover for clinical haematology.
• The trust should review the recording of patients’ own controlled drugs to make sure stock levels and administration can be clearly documented.

Professor Ted Baker

Chief Inspector of Hospitals