Great Ormond Street Hospital

Updated 22 January 2020

Great Ormond Street Hospital for Children NHS Foundation Trust is a tertiary specialist children’s hospital and has the largest paediatric centre in the UK for intensive care, cardiac surgery, neurosurgery, cancer services. nephrology and renal transplants. Children are also treated from overseas in the International and Private Patients’ (IPP) wing.

There are more than 50 different clinical specialties at Great Ormond Street Hospital (GOSH). It provides surgery, medical care, critical care, end of life care, outpatients services, and child and adolescent mental health services. The hospital has 418 beds including there are 42 critical care beds, seven inpatient mental health beds and three-day case mental health beds.

Between March 2018 to February 2019, the trust had 40,349 elective admissions of which 26,583 were day cases and 13,766 were elective and 3,038 non-elective admissions. On a weekly basis on average 4,673 patients were seen in the outpatient’s department.

We carried out the unannounced core service inspection on 01-03 October 2019. We inspected the core services of critical care, surgery and child and adolescent mental health services at Great Ormond Street Hospital (GOSH). During our inspection we spoke with 31 children and young people. 150 staff, 18 carers/relatives.

We observed care and looked at a wide range of documents including patient records, policies, standard operating procedures, meeting minutes, action plans, prescription charts, risk assessments and audit results. Before our inspection, we reviewed performance information from, and about, the trust.

Updated 22 January 2020

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

• The service provided mandatory training in key skills in line with trust targets.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse, and they knew how to apply it.
• Staff knew how to assess, monitor and manage patient risk. Staff identified and quickly acted upon children and young people at risk of deterioration.
• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
• The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance.
• Staff assessed and monitored children and young people regularly to see if they were in pain and supported those unable to communicate using suitable assessment tools. Children and young people were given pain relief in a timely way.
• Staff actively monitored the effectiveness of care and treatment. Opportunities to participate in benchmarking, peer review and research were proactively pursued. They used the findings to make improvements and achieved good outcomes for patients.
• The continuing development of staff skills, competence and knowledge was recognised as integral to ensuring high quality care. Staff were proactively supported to acquire new skills and share best practice.
• Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide high quality, effective care.
• Staff treated all children, young people and their families with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
• Staff took time to interact with children, young people and their families in a respectful and considerate way.
• Staff provided emotional support to children, young people, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs. There was access to a range of services to support children and young people who were frightened, confused or phobic about aspects of their care and treatment.
• Children and young people and parents were treated as important partners in the delivery of care.
• The service planned and provided care in a way that met the needs of children, young people and their families served. They pro-actively liaised with services and with others in the wider system and local/national organisations to manage the discharge care pathway and plan future care.
• The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
• The culture of the services provided were centred on the needs and experiences of children, young people and their families who used services. The service had an open culture where children, young people, their families and staff could raise concerns without fear.
• Staff felt respected, supported and valued. The services promoted equality and diversity in daily work and provided opportunities for career development.
• Leaders operated effective governance processes, throughout the service. However, the planning and implementation of the electronic patient record did not meet the individual needs of all services. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.
• Leaders and staff actively and openly engaged with children, young people and their families, staff, equality groups, the public and local and national organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.

However;

• The service did not always use systems and processes to safely store, record or destroy medicines in line with legislation.

Updated 22 January 2020

Our rating of this service stayed the same. We rated it as good because:

• The service generally controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection.
• Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
• There were significant vacancies in the nursing workforce, but critical care wards were mitigating this risk to avoid any negative impact on patient care.
• Patient records for the critical care wards were entered on an electronic records system. All ten sets of patient records we reviewed were fully completed and stored securely.
• The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them using the trust’s systems and processes. Managers investigated incidents and shared lessons learnt with the whole team and the wider service.
• During the inspection we saw staff treating patients with dignity, kindness, compassion, courtesy, and respect. Staff explained their roles and any care they deliver to patients and family members, including being considerate to patients who were not conscious, during any interactions.
• Family members spoke very positively about the care their child received in critical care and how they were treated by the staff on the wards.
• Family liaison sisters provided keyworker support for families experiencing a bereavement or those needing additional support.
• The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to assist patients access services.
• Families could access the family liaison service, a service staffed by senior nurses who worked across PICU and CICU. The family liaison service provided practical and emotional support to patients, parents, and other family members.
• It was easy for people to give feedback and raise concerns about the care they received. The service treated concerns and complaints seriously, investigated them, involving family members and shared lessons learnt with all staff.
• Staff we spoke with stated that the directorate leadership team were visible on the wards and approachable. We observed that critical care staff interacted well with the ward leadership team during the inspection and that they were approachable.
• At the time of our last inspection it was identified that there were tensions between nurses and doctors on the critical care wards. During this inspection we found an improved relationship between doctors, nursing, and allied health professionals (AHP). Staff were very positive about their colleagues and we observed a collaborative working culture in place between the various disciplines.
• Prior to the inspection we were informed that there had previously been some tensions within the nursing workforce. However, on inspection staff were positive about the nursing leadership. Staff stated that they felt there was now improved morale and that it felt like a different working atmosphere.
• There was an effective corporate governance framework in place which oversaw service delivery and quality of care. The service had systems and processes to identify risks, plan to eliminate or reduce them, and cope with both the expected and unexpected.
• The service was committed to improving services by learning from when things went well or wrong, promoting training, research and innovation. The critical care research team was embedded within the running of the service and was involved in numerous local, national, and international clinical and academic research projects.

However:

• We observed inconsistent staff compliance with IPC best practice guidance in relation to hand hygiene.
• Resuscitation equipment on critical care wards was not consistently checked, which was not in line with guidance from the Resuscitation Council.
• Critical care wards had a significant turnover of its nursing workforce, which meant that since our last inspection many experienced staff had left the service.
• The availability of pharmacy cover on critical care wards fell below the levels recommended by the Society of Critical Care Medicine. Staffing for pharmacy, a known risk, was on the directorate risk register.
• On PICU we saw medicines cupboards and fridges within the medicine’s room were unlocked. We also found some expired medicines which had not been segregated from medicines still in use.
• We were told by staff that medicine related incidents had increased since the implementation of electronic prescribing, which was also on the board assurance framework (BAF).
• At the time of our inspection all critical care wards had beds closed which was impacting on their ability to admit children requiring intensive care. Staff on the critical care wards and the directorate leadership team stated that this was due to the wards not having sufficient staff to meet the critical care staffing level standards. Data provided by the trust demonstrated that between the 02 and 30 of September 2019, of the 19 PICU beds, 13 to 15 beds were open. Similarly, 15 to 17 of the 21 cardiac intensive care beds (split across Flamingo and Alligator), were open.
• Availability of beds was a significant factor in the number of refused admissions to critical care wards. Staff we spoke with stated that the number of refused admissions was higher than the national average.
• Delayed discharges for clinically fit patients from PICU to the wards was a recognised issue and on the directorate risk register. It was acknowledged that these delayed transfers were having a negative impact on flow and capacity. To mitigate this risk there were daily bed management reviews in critical care. In September 2019, the trust had commenced a project focusing on internal trust discharges which involved clinical leads. This continued to be an issue and update notes on the directorate risk register stated that step down capacity on the wards was limited due to the lack of available nursing staff.
• Although staff were positive about their colleagues across all disciplines and the change in morale, staff were frustrated about some of the decisions taken by the trust. Particularly in relation to a change in the specialist nurse bank rates. All members of the multi-disciplinary team were aware of the impact this had had on the morale of the nursing staff. Many staff felt that this could have been a contributing factor in staff turnover in the past 12 months.

Updated 8 January 2016

Parents we spoke with could not praise the quality of the care and support given by GOSH any higher. One parent wrote in an email, “GOSH and the healthcare professionals involved in our child’s care are leading the world in paediatric care.” All staff across the hospital were found to be compassionate, caring and considerate and wanted to do the best they could for children and their families.

We found that care and treatment was safe, evidenced based and followed accepted standards and professional guidance. There were clear care pathways for children being cared for in the hospital and community and all parties involved in the child’s care were included in these plans.

There was excellent multidisciplinary team working in palliative and end of life care services which included chaplaincy and dedicated psychological and social support teams. An ethics committee safeguarded C&YP interests in the event of a conflict in care and treatment.

Children and their families were given the choice as to whether they wished to receive end of life care at the hospital, at home or in a hospice. The service took into account individual circumstances and needs and supported them in their decisions without judgement.

End of life and palliative care was well-led. The team were thought of highly by colleagues within the hospital and by other professionals from around the world.

The team were passionate about continually improving the service, which included training programmes for nurses and GPs from hospitals

Updated 8 January 2016

Patients in medical care services were protected from abuse and avoidable harm. There were enough trained and experienced doctors, nurses and other staff to react if patients deteriorated.

The service was treating many patients that could only be treated at very few other hospitals if any. Multi-disciplinary teams were well coordinated to ensure the best outcomes for patients.

The patients we spoke with were all very positive about the care they had received. One patient told us, “ It’s better than being in school, I come in three times a week. I love dancing with the staff”. Another patient told us, “ I have to come in for a check up every two years. It's a very good service, the doctors are brilliant and they’re good at listening and explaining things”.

Medical care services at the hospital were very responsive to the needs of patients. We found many examples where staff had made a special effort to meet the needs of patients.

The trust’s core vision of “The child first and always” was well recognised and owned by staff. The newer version of “always welcoming, always helpful, always expert and always one team” was less well recognised. Staff were focused on delivering high levels of care to patients.

Updated 8 January 2016

The NICU at GOSH had very good systems and processes in place to protect babies from harm and these included reporting and learning from incidents. Nurse staffing levels were in line with national guidance and staff had access to a range of training both internally via the GOSH education department and at local universities. The needs of the babies and theirmothers or carerswere met by skilled and experienced staff including breast-feeding experts. The staff members were accustomed to caring for babies with co- morbidities. Policies were based on NICE and other relevant national guidelines. NICU shares data with the British Association of Perinatal Medicine. There was a formal escalation process in place for managing deteriorating babies and outwith NICU in the high dependency unit care staff have been trained in its use and knew how to effectively use theclinical site practitioner service and the hospital at night team.

The capacity and flow of babies through the NICU was managed by collaborative working with other providers across London and further afield. The team of senior medical team co-ordinated the Intensive Care Outreach Network (ICON) which worked closely with the site practitioner team. Nursing staff felt supported by the senior nursing team and were able to raise concerns without fearof retribution. The staff members we spoke with were fully aware of the new chief executive and his plans for the future direction of the Trust. Interprofessional working was fully embedded within NICU.

Updated 6 April 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated safe, responsive and well-led as good. The rating of responsive and well-led had improved since our last inspection. Our overall rating of this service improved. We rated it as good because:

• We saw evidence of the use of national clinical guidelines and a culture of evidence based practice in the specialties we observed in outpatients.
• The service made sure staff were competent for their roles. All nurses in the outpatients department had an appraisal within the last year. Staff told us they found it of benefit to take time out and reflect on their work and possible career development.
• Staff cared for patients with compassion. We saw several examples of staff from all disciplines being supportive and kind to patients and their relatives. We saw staff comforting patients and carers and a high level of engagement with children and young people.
• Patients and their relatives felt included in their plan of care. Patients told us nurses and clinicians spoke directly with them rather than just to their parents and carers. They felt included in discussions about their treatment and staff took time to ensure they understood what was discussed.
• The service took account of patients’ individual needs. There were link nurses for patients with a learning disability, who staff and patients could contact for advice and support. Reasonable adjustments were made to provide a better patient experience for learning disabled patients.
• The department supported people to be as engaged in their own health and wellbeing as possible. For example, speech and language therapists ran a group once a month for parents of children who recently had a cleft palate repair. Advice and information was shared about speech development, good oral hygiene and diet.
• Staff we spoke with were very positive about the current leadership team and told us their biggest strength was their honesty and visibility. Staff told us there was good teamwork and they felt valued and got recognition for their work.
• There was general consensus amongst managers and staff about what the department’s top risks were. These included increasing demand on services and capacity in clinics, as well as the unplanned for arrival of inpatients from other hospitals to the outpatients department. Staff told us risks were discussed at meetings and managers shared information about what was being done to mitigate these risks.
• Leaders developed a business strategy which was designed to increase the efficiency of the department and enhance patient experience. For example, providing extra space for clinics that had become too full.
• The trust returned to reporting in January 2017 in agreement with commissioners with noticeable improvements to the quality of the data. This showed that the trust’s referral to treatment time (RTT) for non-admitted pathways was similar to the England overall performance. Data on RTT for admitted pathways showed that 91% of patients were seen within 18 weeks with the between August and December 2017.

However:

• We observed inconsistent adherence to infection prevention and control practice and recent hand hygiene results were poor. Hand hygiene audits from January to December 2017 demonstrated that the average compliance rate was 78%, with results varying between 50% and 96%. We observed doctors were not always ‘bare below the elbow’.
• We noted there were no single use tourniquets in use which increased the possibility of infection.
• We found inconsistencies in fridge temperature monitoring; we also saw that ambient temperature monitoring was not taking place in areas where medicines were being stored. There was no action plan in place to address this issue.
• Patient-identifiable information was left unattended in consulting rooms. This created the risk of confidential patient information being accessed inappropriately.

Updated 22 January 2020

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

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills and understood how to protect patients from abuse. Staff kept detailed, up to date records of children and young people's care and treatment. The service-controlled infection risk well. Staff knew how to assess, monitor and manage patient risk. The service managed patient safety incidents well. Staff recognised and reported incidents and near misses.
• All staff were actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking, peer review and research were proactively pursued. The continuing development of staff skills, competence and knowledge was recognised as integral to ensuring high quality care. Staff worked well together for the benefit of patients. Staff advised patients on how to lead healthier lives and supported them to make decisions about their care. Key services were available seven days a week.
• Staff respected patient’s privacy and dignity. They provided emotional support to patients, families and carers and helped them understand their conditions. Patient and parent feedback was consistently positive. Children and young people told us staff treated them well and with kindness. Parents told us that staff went the extra mile and that the care their child received exceeded expectations.
• The service planned and delivered care, in collaboration with other organisations, to meet the needs of patients. Staff took account of children, young people and their parents' individual needs and preferences. The trust made it easy for children, young people and parents to give feedback and used this information to improve care and services provided.
• Leaders had the skills and knowledge to deliver effective services. They supported and encouraged staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued and were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• In theatres, systems to ensure equipment was maintained and safe to use were not effective.
• Not all medicines were stored safely or destroyed in line with legislation.
• Discharge summaries and clinic letters were not always sent to the patient’s GP in a timely manner.
• Staff were unclear whether information leaflets were available in different languages and formats.
• The service was looking at ways to improve access, as referral to treatment times were below the England average.

Updated 8 January 2016

Young people were being treated with dignity, respect and compassion. Clinical teams supporting care were committed to supporting young people requiring transitional services. We found examples of excellent care pathways for young people with specific long-term health needs transitioning to adult services.

We saw evidence of trust wide “Transition to Adult Health Services Integrated Care Pathway” (ICP) audit and re-audit of “transition arrangements for young people”.However, we found that there was no overall responsibility or leadership for transitional services in the trust at board level.