Since our last inspection of acute services at Homerton University Hospital NHS Foundation Trust in 2014 and 2015, the trust had addressed or shown improvement for most of the previously reported concerns and requirement notices, for which we commend them. There were evident improvements in a number of areas, for example the introduction of maternal early warning scores and greater use of audit, and improved record keeping in surgery.

Across all services, the staff we spoke with knew how to report incidents and could give examples of learning from them. There was an open culture of incident reporting and a willingness to learn from incidents. Learning from incidents was shared with staff using a variety of different methods and was embedded in trust governance processes.

There were comprehensive, clearly defined and embedded processes to protect people from abuse. Staff were knowledgeable about safeguarding and were confident to escalate concerns. There were well-developed care pathways for ‘at risk’ patients, for example in maternity services and the emergency department.

There was good compliance with infection prevention and control across the hospital, although we saw inconsistent hand hygiene carried out by doctors and midwives in maternity services. All areas of the hospital we inspected were visibly clean, tidy, and clutter free. Patients, relatives, staff and managers we spoke with consistently told us they were satisfied with cleaning services in clinical areas. Equipment was well maintained.

The trust had improved the storage of medicines and Controlled Drugs in clinical areas and operating theatres. Staff were aware of policies and protocols in relation to the administration of medication and we observed adherence to these protocols. Staff recorded administration of medication and performance was maintained through audits.

The trust had introduced measures to better anticipate and manage patient risks. For example national early warning score (NEWS) in surgery and modified early warning score (MEWS) in maternity to assess and escalate deteriorating patients. Staff had good knowledge of what to do in the event of a patient deteriorating. There were good protocols in place for the recognition and management of sepsis in ED and the surgery service consistently met the 95% trust target for venous thromboembolism (VTE) risk assessments showing improvements from the last inspection.

Staffing was well managed in medical care and the emergency department. Although many services relied on bank and agency doctors and nurses to staff wards, local and divisional leadership mitigated the risks associated with temporary staff well.

Across services, patient care was delivered in line with good practice and evidence-based guidance from relevant bodies. Trust policies were reviewed regularly and new clinical guidelines were disseminated to staff appropriately.

There were good opportunities for education and development across services. Doctors in training were very positive about the support and teaching they received from senior clinicians.

Throughout our inspection, we saw consistent evidence of effective multidisciplinary team (MDT) working across all disciplines and wards. The delivery of patient care included all relevant healthcare professionals and their input was reflected in patient records. Ward staff worked closely with staff across acute and community services as well as practitioners in the local health economy.

Staff demonstrated compassion to patients and their relatives in all of the services we inspected. Staff included patients in decision making so they understood their care and treatment. Patients and their relatives spoke very highly of the kindness and compassion shown to them by staff.

People using the trust’s services were treated with dignity and respect. Patients told us they felt listened to by health professionals and felt informed and involved in their treatment and plans of care. Trust staff provided patient-centred support on wards, in clinics and in patients’ homes. For example, the surgical rehabilitation team visited patients in their homes for up to two weeks post discharge.

The trust’s services were responsive to the needs of people using them and adapted provision to meet the diverse and specific needs of the local community, including tailored clinics and support services for different populations. The integrated nature of the trust’s acute and community services facilitated the integrated delivery of care for patients between inpatient wards and community teams.

The trust had introduced a dementia identifier to support patients across the hospital. This was considered good practice by the Alzheimer’s Society and all staff received a dementia awareness training session.

The trust delivered a broad range of surgical services including a number of highly specialised services such as the Homerton Anal Neoplasia service (HANS), which was the only one of its kind in the UK and one of very few in the world. The hospital was also a regional centre for bariatric surgery. The service was actively involved in clinical research and in regional teaching of bariatric surgery doctors in training.

The emergency department used innovative standard operating procedures designed to be responsive to the needs of ‘at risk’ patients and patients with complex needs.

There was an effective system for bed management across the hospital, from the assessment unit and throughout the wards. Admissions and potential discharges were discussed daily in the consultant-led morning white board rounds, which informed the site managers and emergency department of bed availability throughout medical wards.

There were pockets of outstanding leadership within services at the trust, notably in the trust’s emergency department. The senior leadership of the emergency department was a dynamic and cohesive group with a high level of interaction and good communication across all staff groups. Each member of staff we spoke with told us the leadership team was supportive, visible and encouraging.

There was a clear governance structure within the division for Integrated Medicine and Rehabilitation Services (IMRS) and staff at all levels were clear about their roles and what they were accountable for. The divisional structures were well managed by the leadership triumvirate and communication from divisional leadership down to ward level was clear. The divisional leadership had oversight of clinical governance and operational governance through monthly divisional meetings. Departmental risks were widely understood and staff described the same risks as those identified by the leadership team. Measures were in place to mitigate identified risks.

Senior leaders and managers of services had, for the most part, a good understanding of risks to the service and these were appropriately documented in risk management documentation with named leads and actions.

During the inspection most staff we spoke with felt they were listened to by service and trust leadership and felt they could approach managers if they needed support.

The trust had responded to address whistleblowing incidences in both theatres and pre-operative assessment areas. At the time of our inspection, the trust’s interventions and development work were ongoing.

However,

There were some challenges with staffing in the maternity service. Consultant numbers were lower than expected for a unit this size and there had been a long running issue about whether to appoint a new consultant and how to attract more middle grade doctors. This meant there were not always consultant-led elective caesarean sections or consultant ward rounds. Midwifery skill mix arising from the high proportion of newly qualified midwives was a concern considering the high acuity of women using the service.

Despite many improvements in areas of weakness identified in the previous inspection, there remained a few areas where tighter control was needed, for example, ensuring emergency boxes on the delivery suite were immediately restocked after use, and that records of triage and baby observations were correctly maintained at all times.

Some women told us concerns about their experience of triage, and also said the level of activity on the postnatal ward meant they did not receive as much support from staff as they felt they needed.

In surgery and maternity services, mandatory training completion rates for medical staff was below the trust target of 90%. Nursing staff in the surgery service also did not meet trust targets for most mandatory training modules. However, senior leaders acknowledged this and were working to address this.

The trust did not provide specific training for staff in understanding their responsibilities under the Mental Capacity Act (MCA) or Deprivation of Liberty Safeguards (DoLS). The principles of MCA and DoLS were covered in the mandatory safeguarding training course, but staff understanding of the MCA and DoLS was variable across wards.

The capacity of the trust’s adult safeguarding team was limited due to vacancies and high workload. This meant that the safeguarding team was not always able to provide comprehensive support to all services. At the time of inspection the post for the trust lead nurse for safeguarding adults and learning disability acute liaison was unfilled and had been for the last six months. This created a current gap in the provision of services for patients with learning disabilities.

On medical wards recording of capacity assessments and decisions on DoLS was not consistently documented in patient records and patient notes used limited contextual information rather than using the specific MCA records sections. In some cases it was not sufficiently clear if patients had received a capacity or DoLS assessment.

There were frequent late starts in operating theatres. The service did not collect data for the number of ‘on the day’ list changes with reasons despite list changes contributing to late starts in theatres.

Governance processes in the Surgery, Women and Sexual Health division (SWSH) required improvement. Some of the maternity risks we identified were not recorded on the service risk register and there were inconsistent governance structures across surgical specialities. The divisional management team was aware of varied agendas and quality of reporting and there were plans to address this as part of the ongoing governance review.

The maternity service did not proactively benchmark outcomes for women against national or pan-London standards and did not have plans for reducing rates of caesarean section. Consultant obstetricians’ engagement with the local maternity network was limited, although we were told this was likely to grow.

There were very few facilities for relatives in the surgical wards. Staff told us they used the staff room or office to communicate sensitive messages with families.

We visited the Maternity and the Elderly Care Units and spoke with patients, relatives and staff from medical, nursing and other backgrounds. Patients and relatives were predominantly positive about their experiences.

One patient on the Maternity Unit told us, “I’ve never had any problem. That is why I keep coming here. The midwives know exactly what they are doing but there should be more midwives on the delivery ward.” Another patient said, “the midwives are very nice. They offered to show me and help me with breastfeeding. There was more than enough staff and I felt really supported.”

A patient on the Elderly Care Unit said, “the nurses are looking after me nicely, and encourage me to eat and get strong. They come and make sure that I am comfortable. The food is good, mostly. Another patient told us, “sometimes it’s good, sometimes it’s bad. It depends on the staff. They always talk to me with dignity and respect. They do their cleaning good, its always clean."

We found patients received care that met their needs and was delivered in a respectful manner.

Patients told us they felt safe and knew how to make a complaint.

There were adequate staffing levels to meet patients’ needs and staff received training, support and supervision.

Systems were in place to monitor the quality of the service and respond to issues that needed improvement.

We carried out this inspection on 15 November and 22 November 2011, visiting the following wards and departments:

Aske Ward (elderly care), Edith Cavell Ward (gastroenterology/rheumatology), Lamb Ward (respiratory/general medicine) and Lloyd Ward (endocrinology/haematology/general medicine); the Delivery Suite and Birthing Centre, Templar Ward (postnatal care) and Turpin Ward (antenatal care); Starlight Ward (paediatrics); the Accident and Emergency Department and the children's Accident and Emergency Department; the Regional Neurological Rehabilitation Unit and a range of outpatient clinics. We also talked to the hospital-based social work team and visited the Patient Advice and Liaison Services office.

This inspection focused on the acute services provided by the trust at Homerton University Hospital. In the course of the inspection we spoke to around 40 patients and relatives, 30 members of staff, reviewed 15 patient records and observed the environment in all the areas we visited.

Most patients and their relatives said they received a very good level of care, treatment and support. Patients described Homerton as a 'good hospital'. People generally praised the staff and said that they explained and answered questions about their care and treatment. Very few people we spoke to had complaints about the service they had received.

Our observations of care and discussions with patients and staff identified some specific issues around patient experience in the Regional Neurological Rehabilitation Unit. We recognised that this service was achieving positive outcomes and helping people's recovery and rehabilitation but felt that at times the trust did not do enough to protect people's dignity on this unit.

People were positive about the Homerton University Hospital and praised the staff as caring and hard working. Patients told us that staff treated people with kindness, for example when helping people to eat. People had generally been given enough information but medication was sometimes an area where people wanted to know more. People said that they and their families had been involved in decisions and they had received helpful support from professionals. People felt able to raise any issues and said that staff had always listened even if the problems were not fully resolved.

Most of the people we spoke to said there was a choice of meals and the food was good. One person did not find the hot meals appetising but could find things they liked from the cold options. At the time of our visit, patients reported a lack of choice of kosher meals. One patient said they had to wait too long for lunch and we also observed this. Patients said that staff checked they had enough to eat. Two people mentioned that they were weighed regularly and their fluid intake was being checked. One of the patients we spoke to had initially been admitted to the ward after tea time. The nurses had brought them some food so they did not go hungry. None of the other patients we interviewed had missed a meal.