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

• We inspected Urgent and Emergency services during this inspection as we wanted to see what improvements and changes had been made to the service. We rated the service overall as requires improvement, although the rating for effective improved from requires improvement to good.
• We inspected Medical care (including older people’s care) and found the service had improved from requires improvement to good since out last inspection in 2016. The rating for effective improved to good.
• We inspected Surgery and found the service had overall improved from requires improvement to good since our last inspection in 2016. However, the rating for well led went down one rating to requires improvement.

We undertook a visit to Beech Ward because we were following up on compliance actions the hospital had declared they were compliant with.

Members of staff told us they were pleased with the improvements made since our previous visit and that the matron carried out regular checks on how the ward was improving.. One member of staff told us “the ward is much better now, before patients weren’t being got up out of bed unless we got them up, now those who are well and able are got up every day by the nursing staff”.

Improvements in the ward were also reflected in the comments made by the majority of patients; although a minority of patients were less satisfied.

During our inspection a local MP was also undertaking a visit to the ward. The MP recognised improvements and that staff were “more attentive” and the patients “a little happier”.

We undertook a visit to Beech Ward because we had received concerning information from some current and former patients as well as their relatives. We had been told of some staff being unkind to patients as well as concerns regarding privacy and dignity issues, we were also told of patients waiting a long time for the buzzers to be answered (including whilst using the toilet at night). We were also told that sometimes staff shouted at patients and each other.

Our visit took place during a Saturday afternoon and evening, we talked to patients and their relatives about the care patients received. We also talked to staff about the issues. It was the perception of staff that they were 'stretched' because of shortfalls in staffing. They said they felt this had an effect on the care they were able to give. Some staff also felt this impacted on their stress levels which resulted in arguing amongst themselves. There were mixed perceptions about how patients were cared for, some staff felt care could be better, others considered care to be of a good standard.

Patients also had mixed views on the care they received. Some told us the care they received was good, patients and their relatives also commented that some staff were 'better than others'. One patient told us; "Some staff are not lovely, some shout" another told us; "All the staff are friendly”.

Patients and their relatives told us that although they were supposed to get out of bed most days, in accordance with their care chart, this did not always happen and sometimes they stayed in bed all day.

Some patients felt buzzers were answered quickly, within about 15 minutes. Other patients and some staff told us that it can take a long time for buzzers to be answered. Staff said that it was difficult to always answer the buzzers when they were busy.

We were told by staff and management that following a serious complaint the trust had already started to tackle the concerns and take action to address the situation.

We carried out this inspection in the maternity unit in response to concerns raised with us by a member of staff. The inspection was unannounced and took place during the evening so that we could talk to staff from both the day and the night shifts. We spoke with eleven members of staff. On this occasion we did not speak to patients as we were following up very specific concerns which could not have been answered by talking to patients.

Most staff told us that there was a range of appropriate equipment available both in the ward and in the two theatres. They also told us that equipment was checked to ensure that it was kept in working order. For example one member of staff said, “There is enough equipment and people are not at risk from a lack of, or faulty equipment.”

Staff also told us that staffing levels and skill mixes were usually okay. They acknowledged that on occasions staff were transferred between hospitals to cover shortages but said that this did not place patients at risk. One member of staff said, “Sometimes staff have to move between hospitals because they are short staffed but I don’t feel that this leaves patients at risk. It sometimes makes it harder for the staff left behind as they are busier than usual.” A midwife told us that they could usually provide one to one care for women in labour.

Most patients and their relatives told us that they were very satisfied with the care and treatment that they received at King George Hospital. Patients said that they were treated in a polite and respectful manner and that their dignity and privacy was promoted well. Patients told us that they received straight forward information and had been able to make decisions about their treatment and discharge planning. Patients told us that they were offered a wide choice of food and sufficient quantities. There were mixed opinions regarding how appetising the food was. People told us that food was served at the right temperature and that they were given support.

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.

King George Hospital opened at its current site in Ilford in 1995 and provides acute and rehabilitation services for residents across Redbridge, Barking & Dagenham, and Havering, as well as providing some services to patients from South West Essex. The hospital has approximately 450 beds.

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 King George Hospital of three core services  – the Emergency Department (ED), Medical Care (including older people's care) and Outpatients & Diagnostics (OPD).

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

Our key findings were as follows:

Are services safe?

• The percentage of patients seen on arrival in the emergency department (ED) within 15 minutes between August 2015 and August 2016 averaged 70%.
• There was a lack of evidence that learning and understanding of treating patients with suspected sepsis was embedded within the ED.
• Patient records were not always kept secure.
• There was a high dependency on locum doctors and lack of senior medical staff in the ED.
• There were too few paediatric nurses in the ED.
• There were breaches in the fire resisting compartmentation across the hospital site, which had been caused by previous contractors drilling holes for data cables and services.
• Medical staff were failing to meet trust targets for completion of mandatory training, across all topics.
• Staff completion rates in basic life support were below the trust target, due to a lack of external training sessions. There were low levels of resuscitation training in the ED.
• There were poor levels of hand hygiene compliance observed in the ED and in OPD.
• Although a comprehensive induction programme was in place for all new diagnostic imaging staff, some new staff members did not know where to find the Local Rules.
• The air handling unit in paediatrics and minor injuries had been out of service for at least three weeks prior to this inspection.
• There had been an improvement in the reporting of incidents and the sharing of lessons from these 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 had improved, with prescription charts being used correctly and processes being correctly followed and audited. Medication in the emergency and OPD were found to be appropriately stored.
• Nursing staff demonstrated an awareness of safeguarding procedures and how to recognise if someone was at risk or had been exposed to abuse.

Are services effective?

• There was a backlog of National Institute for Health and Care Excellence (NICE) guidance that was awaiting confirmation of compliance across the trust.
• Fluid charts were not always filled out and some patients did not like the food, or found it hard to eat.
• Patient outcomes in care of the elderly were limited by the lack of consultant geriatricians to lead improvements within the service.
• In the Lung Cancer Audit 2015, the trust was below expected standards for three key indicators relating to process, imaging and nursing measures.
• 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.
• There was a lack of effective seven day working across the hospital.
• The trust had updated all of their local policies since the last inspection, and these were regularly reviewed.
• Nursing and medical staff completed a variety of local audits to monitor compliance and improvement.
• Pain was assessed and well managed on the wards, with appropriate actions taken in response to pain triggers. There was a dedicated hospital pain team.
• The majority of staff received annual appraisals on their performance, which identified further training needs and set achievable goals.
• There was evidence of effective multidisciplinary working within wards and across departments. All members of staff felt valued and respected.
• Patients attending OPD received care and treatment that was evidence based.

Are services caring?

• Patients were cared for in a caring and compassionate manner by staff throughout their stay. Most medical wards performed in line with the national average in the NHS Friends and Family Test (FFT).
• Patients’ privacy and dignity was maintained throughout their hospital stay.
• Psychological support for patients was easily accessible and timely. Patients were routinely assessed for anxiety and depression on admission.
• The chaplaincy team offered comprehensive spiritual support to all patients, regardless of religious affiliation.
• Some patients and relatives felt that more could be done to involve them in their care, especially surrounding discharge.

Are services responsive?

• The ED failed to meet the four hour national indicator for treating or admitting patients.
• There was no viewing room in the ED where people could see their deceased relatives.
• The trust was consistently failing to meet national indicators relating to 62-day cancer treatment. This issue had been added to the corporate risk register and actions had been undertaken to improve performance.
• The trust was not meeting 18-week national indicators for non-urgent referral to treatment (RTT) times.
• The percentage of patients who did not attend (DNA) their appointment was above the England average.
• 13% of appointments were cancelled by the hospital. This was higher than the England average of 7.2%.
• NHS England suspended endoscopy screening invitations to the trust for eight weeks from July 2016. There was a risk of delayed diagnosis of bowel cancer due to inability to provide a full screening service to the local population.
• Staff across the hospital told us that they could not always discharge patients promptly due to capacity issues within the hospital or community provisions had not been put into place.
• Patient information leaflets were not standardly available in languages other than English. Although face-to-face and telephone translation services were available, many staff were not familiar with how to access these.
• The Patient Advice and Liaison Service (PALS) did not always respond to complaints in a timely manner.
• Diagnostic waiting time indicators were met by the trust every month between May and August 2016, meaning over 99% of patients waited less than six weeks for a diagnostic test.
• There had been an 88% reduction in the overall backlog of patients waiting over 52 weeks since May 2016.The hospital was using a range of private providers to assist in clearing the backlog of appointments where there were most demand for services.
• Ward-based pharmacists helped to facilitate discharges in areas where they were available. There was also a pharmacy discharge team who worked 11am to 4pm weekdays.
• Walk-in patients were streamed effectively in the ED, including back to their own GP.
• People living with dementia received tailored care and treatment. Care of the elderly wards had been designed to be dementia friendly and the hospital used the butterfly scheme to help identify those living with dementia who may require extra help. Patients living with dementia were nursed according to a specially designed care pathway and were offered 1:1 nursing care from healthcare assistants with enhanced training. A specialist dementia team and dementia link nurses were available for support and advice. There were also dementia champion nurses in the ED.
• Support for people with learning disabilities was available. There was a lead nurse available for support and advice. 
• There was a frail and older person’s advice and liaison team which worked closely with the ED.
• The environment of children’s ED was child friendly and well laid out.

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.
• Quality improvement and research projects took place that drove innovation and improved the patient experience. Regular audits were undertaken, overseen by a committee. The hospital facilitated a number of forums and listening events to engage patients in the development of the service.
• Most nursing and medical staff thought that their line managers and the senior team were supportive and approachable. The chief executive and divisional leads held regular meetings to facilitate staff engagement. However, some comments we received from staff reflected that they were not always happy with the management or leadership.

• The trust could not evidence how they maintained records to ensure they knew their locum staff had up to date training in sepsis management

• Many staff with whom we spoke were unclear about the future direction of the ED and the impact on job security.
• Monthly nurse staff meetings in the ED had become less frequent due to pressures of work.

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.

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

Importantly, the trust must:

• Ensure all patients attending the ED are seen more quickly by a clinician.

• Take action to improve levels of resuscitation training.

• Ensure there is oversight of all training done by locums.

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

• Take action to address the poor levels of hand hygiene compliance in ED.

In addition the trust should:

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

• Increase paediatric nursing capacity.

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

• Improve documentation of falls.

• Document skin inspection at care rounds.

• Document nutrition and hydration intake.

• Review arrangements for the consistent sharing of complaints and ensure that learning is always conveyed to staff.

• Make repairs to the departmental air cooling system.

• Ensure that all policies are up to date.

• Improve appraisal rates for nursing and medical staff.

• Ensure that consent is clearly recorded on patient records.

• Regularise play specialist provision in paediatric ED.

• Ensure that patient records are stored securely.

• Ensure staff and public are kept informed about future plans for the ED at King George hospital.

• Continue plan to repair breaches in the fire compartmentation as detailed on the corporate risk register.

• Continue to monitor hand hygiene and infection control across all medical 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.

• Increase staff awareness of the availability of interpretation services.

• Ensure leaflets detailing how to make a formal complaint are available across all wards and departments.

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

• Address the risks associated with non-compliance in IR(ME)R and IRR99 regulations.

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

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

• Ensure the OPD 62 day cancer waiting time is consistently above 85%.

• 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.

• Ensure diagnostic and imaging staff mandatory training meets the trust target of 85% compliance.

• Develop a departmental strategy in diagnostic imaging looking at capacity and demand and capital equipment needs.

• Improve staffing in radiology for sonographers.

Professor Sir Mike Richards

Chief Inspector of Hospitals