We inspected The Royal Brompton Hospital over two days and visited 11 wards and departments, including the Paediatric and Adult Outpatients Departments. The specialist advisor accompanying us was a specialist in paediatric cardiology care. We followed the patient pathway from the intensive care departments through to the wards. We spoke with patients, families or carers and staff in every area we visited. We also spoke with senior management staff including the Chief Executive, Director of Nursing and Governance and the Director of Performance and Trust Secretary, as well as three non-executive members of the trust board.

Our overall impression was of good standards of cleanliness in the hospital. We found all grades of staff open and friendly and there was strong leadership provided in the wards and departments we visited. Staff told us that the management teams were supportive and provided on-going training. They described communication with management staff as good. They were proud to work for The Royal Brompton & Harefield Foundation Trust and wanted to tell us about their roles.

Patients’ we spoke with had had a positive experience of care and treatment at the hospital. They were treated with dignity and respect, were complimentary about staff, understood their care and treatment and said there were sufficient staff to meet their needs.

During the inspection we visited six inpatient wards at the Royal Brompton hospital. We also visited the adult and children’s outpatient departments. Patients who used the service told us that they were given information about their care and treatment before they underwent procedures. They said that staff was "very professional", "welcoming" and "very attentive”. The majority of patients told us that staff were “fantastic” and that the overall care at the Royal Brompton hospital had been “excellent”.

Patients told us they where knew the name of the staff member looking after them. Some people had regular visits to the Royal Brompton hospital for ongoing treatments, comments from patients included “the staff are so welcoming, home from home” and “I am provided with excellent care from staff”. The patients informed us that prior to discharge staff would discuss all relevant areas of ongoing care and support required, including medication that is discussed with the pharmacist.

Patients reported that they were aware of how to complain if they wanted to. The majority of people told us that they would initially discuss any issues with staff on duty. We observed that information on how to make a complaint was on display in all areas we visited. This included how to make a complaint through the Patient and Liaison Services (PALS) located at the Royal Brompton hospital.

Overall, patients were extremely positive about the healthcare provided at the Royal Brompton hospital. Comments from patients included ‘excellent care’, ‘Staff are wonderful’ ‘The best hospital I have stayed in’.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

Our rating of services improved. We rated it as good because:

• The ratings of safe, responsive and well-led have improved, the ratings of effective and caring have stayed the same.
• Our rating for surgery and critical care services improved to good and the rating for children services stayed the same as good overall.
• The hospital had successfully implemented improvements highlighted during last inspection regarding the use of the safer surgery checklist, cleaning processes within theatres, safeguarding children training in recovery, theatre staffing and management and culture issues within theatres.

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

• The service had suitable premises and equipment and looked after them well.

• Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.

• The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time. However, we found that the surgical service did not always follow best practice when storing medicines.

• Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to all staff providing care.

• The hospital had enough staff with the right qualifications, skills, experience and training to keep patients safe from avoidable harm and abuse, and to provide them with the care and treatment they needed. Ward managers matched staffing levels to patient need and could increase staffing when care demands rose. All staff understood their responsibilities to safeguard patients from abuse and neglect, and had appropriate training and support.

• The hospital 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 service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.

• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.

• Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.

• Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.

• The service made sure staff were competent for their roles. Except in surgery, managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.

• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.

• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. The unit had since introduced an animal therapy policy to enable dogs to be safely allowed on the unit for patients who wished to have them visit.

• Staff provided emotional support to patients to minimise their distress.

• Staff involved patients and those close to them in decisions about their care and treatment.

• The trust planned and provided services in a way that met the needs of local people.

• People could access the service when they needed it. Waiting times from treatment were and arrangements to admit, treat and discharge patients were in line with good practice.

• The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.

• The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.

• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. However, staff survey results within surgery showed dissatisfaction in various areas.

• The trust used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.

However,

• We observed a few lapses in strict adherence to infection control procedures within critical care. Although the hospital controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.

• Although the service provided mandatory training in key skills to all staff. The trust target was set at a comparatively low 70% or 80% depending on the mandatory training module and the compliance rates for mandatory training for some staff groups were below these trust targets.

• Although staff had training on safeguarding children and adults, the trust target was set at a comparatively low 75% and the compliance rates for mandatory training for some staff groups were below trust targets.

• Managers did not always effectively appraise staff’s work performance.

• There was no ratified strategy for critical care and children and young people services.