Homerton University Hospital

Updated 14 September 2023

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Homerton University Hospital.

We inspected the maternity service at Homerton University Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out an announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Homerton University Hospital is part of Homerton University Hospital NHS Foundation Trust; the trust serves a diverse and complex local population from Hackney, the City of London, and surrounding boroughs in East London. The hospital provides maternity care for approximately 6000 women and their babies each year during pregnancy, labour, birth and up until one month after birth.

A higher proportion of mothers were in the 2nd and 3rd most deprived deciles at booking compared to the national averages. The proportion of women and birthing people who were Asian or Asian British was 13% which was lower than compared to the national average and also lower for women and birthing people who were White at 50% compared to 66% nationally. Women and birthing people who were Black or Black British was higher at 13% compared to 7% nationally.

We did not review the rating for Homerton University Hospital. However, we did update the ratings for maternity services.

Updated 2 July 2020

We carried out a focused inspection of older people’s care at Homerton Hospital. This inspection looked specifically at the provision for care of elderly patients within medical care. The inspection was a response to concerns raised by members of the public, and from intelligence coming from stakeholders.

Elderly and frail patients were admitted to the hospital elderly care units (North and South). Each elderly care unit consisted of 28 beds each. This was previously a single 56 bedded ward, which had split since the time of the last inspection.

Patients were admitted to the elderly care units from the acute care unit (ACU), a 35 bedded short stay assessment unit which admitted patients from the emergency department.

Both the elderly care units and ACU were delivered under the division for integrated medicine and rehabilitation services (IMRS), which included the emergency department and community health services.

We visited these wards over two days during an announced inspection from the 28 to 29 January 2020. We also visited and spoke with staff in the discharge lounge.

We reviewed ten patient clinical records and observed care being delivered across the three wards. We spoke with eight relatives and carers, nine patients and 31 members of staff including divisional and local leadership, nurses, consultants, junior doctors, physiotherapists, pharmacists, dietitians, and administrative staff. We also reviewed the performance data and looked at trust policies and pathways for elderly care.

As this inspection was focused on care of elderly patients, the inspection was focused only on relevant Key Lines of Enquiry (KLOEs), and this is reflected in the report. For this reason, the report is not rated.

Care of the elderly wards at Homerton Hospital continued to provide safe care and treatment. Although these services were not rated, we found:

• The service provided mandatory training in key skills to all staff, including dementia awareness and safeguarding training.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Staff supported patients to make informed decisions about their care and treatment. Staff also followed national guidance to gain patients consent.
• The environment on the care of the elderly wards and areas was visibly clean and tidy.
• The service had enough staff with the right qualifications and experience.
• Staff recognised incidents and reported them appropriately. Managers investigated reported incidents and shared lessons learned with the whole team and the wider service.
• Doctors, nurses and other healthcare professionals worked together as a team to benefit patients and we observed that the MDT supported each other to provide good care.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
• The service was inclusive and took account of patients’ individual needs and preferences, including for elderly patients.
• Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care.
• Staff felt respected, supported and valued. They were focused on the needs of patients receiving care.
• However:
• On inspection we identified an issue that some patient records did not document falls assessments in care plans. While we noted that patients had been seen by a falls nurse and action had been taken, this was not always reflected in the patient records.
• At the time of inspection, care of the elderly wards did not have a dedicated practice development nurse.
• Where staff had to deliver difficult news, there were communal rooms on the wards and nearby where these conversations could be had. However, these multipurpose spaces were not particularly private and were often in use by staff or for ward activities. Following inspection, the trust stated that the sister’s office was the designated space for private conversations on the ward, however some staff were not aware of this.

Updated 24 April 2014

We spoke with 12 children, 15 parents, nine nurses, three managers, four doctors and received 11 comment cards. We found that children’s services were safe. Whenever possible, children were protected from avoidable harm.

There were effective systems in place to ensure the care delivered met children’s individual needs. Staff had appropriate training and followed standard operating procedures as well as relevant guidance to deliver care. Staff were caring and described as “loving”, “easy to talk to”, “very supportive, through a difficult time” and “willing to go the extra mile”.

The trust served a diverse population, was responsive to children’s needs, including services such as City and Hackney Young People's Services Plus (CHYPSPlus), which provides holistic health services for young people aged 11-19 years. Staff were aware of the trust’s values and vision, and felt supported by senior management. They told us they could report incidents without the fear of being blamed. 

Updated 24 April 2014

Patients’ needs were being met by the service, and patients were cared for in a supportive way. There were criteria for admission to the unit run by the intensive care staff and the critical care outreach team. Patients received safe care and were treated according to national guidelines and evidence-based practices. Patients and their families told us they felt the unit was safe and the care they received was “excellent”.

Staff used clinical governance methodologies such as audits to monitor the quality and outcomes of their patients. They reported incidents so they could improve on the quality of care patients received. There were processes to ensure patients received care and treatment that was as risk free as possible, and other processes to prevent the spread of infection and monitor risk.

Updated 2 July 2020

End of life care encompasses all care given to patients who are approaching the end of their life and following death. It may be given on any ward or within any service in a trust. It includes aspects of essential nursing care, specialist palliative care, and bereavement support and mortuary services.

The specialist palliative care team are a multidisciplinary team that work across the wards and alongside ward staff and doctors as an advisory team and in the delivery of direct patient care. It is comprised of a senior nurse, lead nurse, a palliative consultant, clinical nurse specialists, a social worker and an end of life care facilitator. The role of the team includes assessment and care planning for patients with complex palliative care needs, treatment, medication, symptom control and emotional and psychological support for patients and their relatives and loved ones. They provide a five day a week face to face palliative care and end of life care service for patients and support to staff. A 24-hour telephone advice line is available from a consultant in palliative medicine. The team carry out holistic assessments in partnership with nursing and medical teams. The trust use an individualised care plan to tailor care for dying patients in the last weeks or last days of life.

During 2018/19, there were 436 patient deaths at the hospital. Current data showed that 65 to 70% of patients who died in the hospital were seen by the SPCT. There are no inpatient palliative care beds. The SPCT received 561 referrals in 2019.

We spoke with a total of seven patients and relatives. We also spoke with 37 members of staff, which included ward managers, nurses and healthcare assistants, ward doctors and specialist support staff such as occupational and physiotherapy staff. We also spoke with senior managers, mortuary staff, chaplaincy, bereavement coordinators and all members of the specialist palliative care team, end of life care team and key senior managers at the trust.

We observed care and treatment within the wards and reviewed 26 care records that included 11 Do Not Attempt Cardio-Pulmonary Resuscitation forms.

At the last inspection we found patients received safe end of life care and there were systems in place to ensure patients were kept safe. People were given information and support to make decisions about their care as inpatients and they were involved in discharge planning. Staff received appropriate training and support and understood the good practice guidelines and pathways in place. The service was well led by an experienced palliative care team that was respected and valued by medical, nursing and other colleagues in the hospital.

We rated it as good because:

• All members of the specialist palliative care team demonstrated appropriate awareness and understanding of safeguarding processes. Staff used equipment and infection control measures to protect patients, themselves and others. Equipment and the premises were kept clean. Risk assessments considered patients who were deteriorating and in the last days or hours of their life. The use of electronic patient records was fully embedded and records we saw were up to date and accessible. All members of the specialist palliative care team had a specialist understanding of medicines used for symptom control.
• The service provided effective care and treatment. It was based on national guidance and evidence-based practice. Patients had enough food and drink and were assessed and monitored regularly to see if they were in pain. We encountered positive multidisciplinary working for the benefit of patients. We reviewed 11 DNACPR forms that were in place at the time of our visit and found them completed to a high standard.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. The service understood patients’ personal, cultural and religious needs. Patients, families and carers supported to understand their condition and involved in making decisions about their care and treatment.
• The specialist palliative care team’s assessments and daily handovers considered patient risk and the holistic needs of patients. The team worked closely with community teams, the community palliative care team and maintained good links with the local hospice. The mortuary and bereavement teams understood patients’ cultural needs after death and the bereavement office was co located in the mortuary suite, enabling good access to services for relatives. The borough registrar was located in the hospital two full days and three half days a week, thus better facilitating the process for prompt funeral arrangements.
• There was a leadership structure and clear lines of accountability in place for different aspects of end of life care. There were governance structures in place to manage the performance and risks of the service. There was a positive drive to improve the culture of the hospital and make end of life care everyone’s business, which was linked to the end of life care strategy.

However:

• The service did not have enough palliative medical staff to provide the right care and treatment in line with Royal College of Physicians guidance. The anticipatory drug chart identified four of the five symptoms recommended in NICE guidance but had omitted breathlessness from the chart. Space was provided for ‘other’ symptoms to be added which meant inclusion was down to user initiative. Although currently in working order, the mortuary fridges and freezers were 33 years old and consequently past their expected life span. There were no current plans for their replacement and the issue was not included on the trust risk register.
• Where DNACPR forms indicated that patients lacked capacity, a mental capacity assessment was not always completed. We were told that an audit of DNACPR had not been undertaken but data the trust extrapolated from other audits showed a low compliance rate. The palliative care service was a Monday to Friday service whereas guidance states the hospital service should be provided on site seven days a week. Plans for Saturday working were at the planning stage.
• Work was currently underway to improve the continuing healthcare fast track pathway where delays to discharge had been identified. Preference for patients’ preferred place of care and preferred place of death was being recorded. However, audits of these were not taking place. Nurses received training in dignity after death which we were told, had so far been ad hoc and the end of life care facilitator had been tasked with improving this. The trust had recently purchased a component for their electronic incident reporting system that could draw out themes relating to end of life and palliative care to improve learning. However, this was not yet embedded.
• There was a lack of spaces on wards to meet with relatives and patients for private or sensitive conversations. Chaplaincy provision, including office, multifaith prayer room, ablution room and resource area were all being provided from one small space. It was not possible to establish whether the number of chaplaincy hours allocated per week were in line with the NHS Chaplaincy Guidelines 2015 of 3.75 hours per week of chaplaincy care for every 35 patients.
• There was an aim to implement the Swan model of end of life and bereavement care by 1 April 2020. Most staff we spoke with had heard of its imminent introduction. However, at the time of inspection only one ward had been piloted and it was not clear how progress was being measured. The swan symbol featured on the cover of the strategy booklet. However, explanation of the Swan model of care for end of life or its implementation was not referred to within the strategy.

Updated 14 September 2023

Updated 24 April 2014

The outpatients department was a busy department and provided safe care. The department was clean and well maintained. When clinics were running late, patients were told how long the delays would be and given the reason for them. There were sufficient numbers of staff on duty.

The outpatients department generally met the Department of Health guidelines for ensuring patients received appointments within 18 weeks of referral. Patients told us staff were caring and explained their treatment to them. There were clear lines of leadership in the department and staff knew to whom to escalate concerns. 

Updated 10 August 2018

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

• Following our last inspection in February 2014 we issued one requirement notice requiring the service to take action to remedy breaches to Regulation 20 (1) (a), in relation to records and issued seven actions the provider should take to improve. During this inspection, the service had dealt with or shown improvement for most of the previously reported concerns.
• The trust had addressed the previous inspection’s requirement notice in relation to records through the implementation of electronic patient records (EPR) throughout the hospital. We reviewed 28 patient records and found all records were completed in a logical and comprehensive way with no gaps or inconsistencies.
• Staff were encouraged to raise concerns and to report incidents and near misses. The division effectively shared learning from incidents and good practice with staff through regular meetings.
• All of the areas we inspected were clean, tidy, and clutter free. Patients, relatives, staff and managers we spoke with consistently told us they were satisfied with the cleaning services in the ward and operating theatre areas.
• During our last inspection we identified concerns around the storage of medicines and controlled drugs. During this inspection we found this had improved and medicines and controlled drugs were stored securely in the clinical areas and operating theatres. A remote electronic system monitored fridge temperatures and if temperatures were out of range, the pharmacy team received an alert.
• The trust had clearly defined and embedded processes to keep people safe from abuse and staff demonstrated understanding of safeguarding processes and awareness on how to escalate and report safeguarding concerns.
• During our last inspection we found the trust did not use the nationally recommended early warning score for monitoring changes in a patient’s condition. During this inspection, we found this had improved as the trust had implemented the national early warning score (NEWS) to effectively assess and escalate deteriorating patients. Staff had good knowledge of what to do in the event of a patient deteriorating.
• During our last inspection we identified concerns around the consistent completion of venous thromboembolism (VTE) assessments. During this inspection, we found this had improved as the surgical service consistently met the 95% trust target for VTE risk assessments.
• The service demonstrated effective internal and external multidisciplinary (MDT) working, for example the service had links with the trust social worker and the homeless liaison officer as part of discharge planning.
• During our last inspection, we were told there was no orthopaedic medical cover based on site out of hours. During this inspection, we found the service had improved the onsite orthopaedic medical cover for out of hours with eight consultants who provided orthopaedic medical cover on call and remote support (off-site) from an orthopaedic senior doctor in training.
• People using the trust’s surgical 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.
• Staff provided patient-centred support in clinics and in homes. For example, the surgical rehabilitation team visited patients in their homes for up to two weeks post discharge.
• The service was responsive to the needs of people using it and had adapted to meet the diverse needs of the community it served.
• During the last inspection we found the trust did not have a dementia identifier which was considered good practice by the Alzheimer’s Society. During this inspection, we found this had improved as the trust had introduced a dementia identifier and all staff received a dementia awareness training session.

• During the last inspection, we found lack of information on display for patients who wanted to raise a concern. During this inspection, we saw some improvement in signposting for patients in some surgical areas but not all.
• The trust had responded appropriately 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.
• Senior leaders and managers of the surgical service had a good understanding of risks to the service and these were appropriately documented in risk management documentation with named leads and actions.
• The trust delivered a broad range of surgical services including a number of highly specialist services such as the Homerton Anal Neoplasia service (HANS). It was the only one of its kind in the UK and one of very few in the world.
• The hospital was a regional centre for bariatric surgery. The service was actively involved in clinical research and in regional teaching of bariatric surgery doctors in training.

However:

• Medical and nursing staff in the service did not meet trust targets for most mandatory training modules. However, senior leaders acknowledged that the current method of monitoring compliance rates was not robust enough and they were currently addressing this.
• The NHS Friends and Family Test (FFT) response rate for surgery was 19% between December 2016 and November 2017, which was worse than the England average of 29%.
• During this inspection, staff and managers told us about frequent late starts in theatres. We requested trust data in order to investigate this further but found the trust did not collect the requested data. For example, the trust did not collect data for the number of ‘on the day’ list changes with reasons despite list changes contributing to late starts in theatres.
• 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.
• The trust had 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 NHS Staff Survey 2017 survey results showed the trust scored below the national average (86%) for this indicator with 76%.
• During our last inspection the trust was asked to consider introducing ‘patient safety at a glance’ boards across all wards to improve communication and safety. During this inspection we found the surgical wards did not display the NHS safety thermometer information for staff or patients to view.

Updated 10 August 2018

• The service performed consistently better than the England average for patients admitted, transferred or discharged within four hours between February 2017 and March 2018.
• Length of time for patient assessment from their arrival to the department was better than the overall England median.
• No patients waited more than 12 hours from the decision to admit until being admitted.
• The percentage of patients waiting between four and 12 hours from the decision to admit until being admitted was consistently better than the England average.
• 95% of patients between March 2017 and February 2018 would recommend the service to friends and family if they needed similar care or treatment.
• Staff demonstrated very good safeguarding awareness and were confident about how to escalate concerns.
• The department was clean and equipment well maintained. Staff followed infection control policies and adhered to ’bare below the elbows’ policy.
• There were good protocols in place for the recognition and management of sepsis.
• The service made sure staff were competent for their roles. Appraisals were up to date for all nurses and doctors.
• Staff knew how to report incidents and could give examples of learning from them.
• Treatment was delivered in accordance with National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine (RCEM) guidelines.
• There were many pathways in place which enhanced the patient experience in the department. Clinical pathways aim to promote organised and efficient patient care based on evidence-based medicine and aim to optimise outcomes.
• There was an active quality improvement programme in place which was monitored by two consultants.
• Doctors and nurses of all grades were given protected work time to participate in training.
• We saw staff being compassionate to patients and their relatives. Patients and relatives spoke highly of the kindness and compassion shown to them by staff.
• We saw staff communicated with and included people so that they understood their care and treatment.
• There was a separate waiting area and assessment area for children.
• There were innovative standard operating procedures designed to be responsive to the needs of ‘at risk’ patients or patients with complex needs.
• The senior leadership of the service 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.
• The department had a clear, achievable and sustainable five year strategy for medical and nursing staff.
• There was a robust governance structure in place, organised in such a way as to provide full oversight of each area of the department and anticipate potential issues.
• Patient safety, clinical effectiveness, patient experience, complaints and compliments were regularly discussed at all governance meetings.
• The service risk register was reviewed and updated at every governance meeting. Departmental risks were widely understood and staff described the same risks as those identified by the leadership team. Measures were put in place to mitigate identified risks.

However:

• Whilst consultant cover was not in line with Royal College of Emergency Medicine (RCEM) recommendations, we were assured that processes were in place to mitigate this risk with the provision of senior doctor presence in the department 24 hours a day seven days per week in accordance with RCEM guidance.
• There was a ‘toolkit’ of communication aids for to staff use with patients with learning disabilities, however some nurses we spoke with were not aware of this.