University Hospital Lewisham

Updated 24 January 2024

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at University Hospital Lewisham.

We inspected the maternity service at University Hospital Lewisham 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.

University Hospital Lewisham is based in Lewisham, Southeast London and is part of the Lewisham and Greenwich NHS Trust and the Southeast Local Maternity and Neonatal System (LMNS). The hospital provides maternity services to women living across the boroughs of Lewisham, Greenwich, and Bexley.

The maternity service at University Hospital Lewisham included a range of antenatal, intrapartum, and postnatal care and comprises of a maternity day assessment unit, antenatal clinic, maternity wards, triage unit, delivery suite, maternity led unit, home birth service and a community midwifery service. Additional antenatal and postnatal services are provided at the sister site, Queen Elizabeth Hospital in Woolwich. From July 2022 to June 2023, there were 3,124 deliveries at the hospital.

We last carried out a comprehensive inspection of the maternity service in September 2018.

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.

We did not review the rating of the location, therefore our rating of this hospital stayed the same. University Hospital Lewisham overall rating is requires improvement.

We also inspected the other maternity services run by Lewisham and Greenwich NHS Trust. Our reports are here:

Queen Elizabeth Hospital – https://www.cqc.org.uk/location/RJ231

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited the maternity theatres, maternity assessment (Triage), labour ward, birth centre, day assessment unit, the antenatal and postnatal wards and antenatal clinics.

We spoke with 40 multidisciplinary staff, 2 women and birthing people and 2 birthing partners and or relatives.

We reviewed 8 patient care records, 8 Observation and escalation charts and 8 medicines records.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection .

Updated 3 July 2020

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

• The service provided mandatory training in key skills to all staff, but compliance for nursing and medical staff was below the trust target of 90%.
• Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse but compliance for safeguarding training for medical and nursing staff was below the trust target of 90%.
• The service controlled infection risk well. They kept equipment and the premises visibly clean, but hand hygiene was variable across the wards.
• Staff undertook risk assessments for each patient, but documentation showed these were not completed consistently so staff could not be assured appropriate action was taken to remove or minimise risks.
• The service used systems and processes to safely prescribe, administer, record and store medicines. However, audits found wards were not always compliant with the trust's policy.
• Staff kept detailed records of patients’ care and treatment. Records were clear, but not always up-to-date. However, patient confidentiality was not always respected.
• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. However, audits found wards were not always compliant with the trust's policy.
• Staff assessed and monitored patients regularly to see if they were in pain, but pain relief was not always given in a timely way.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance. However, only 67.7% of medical staff had an appraisal which was below the trust target of 90%.
• Staff supported patients to make decisions about their care and treatment. They followed national guidance to gain patient’s consent. They knew how to support patients who lacked capacity to make their own decisions. However, compliance for Mental Capacity Act and Deprivation of Liberty Safeguards training was 76.1% for medical staff and nursing staff was 72.2% which was below the trust target of 90%.
• People could access the service when they needed it and received the right care promptly. However, some patients were being discharged at night and some patients were experiencing a delayed discharge.
• Leaders and staff engaged with patients but the take up of the Friends and Family tests across the wards was low and it was not clear if the plan for staff engagement had been implemented.

However:

• The service had enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed staffing levels and skill mix, and gave bank and agency staff a full induction.
• The service managed patient safety incidents well. Staff recognised incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team. 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 best practice.
• Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients.
• Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They 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.
• Staff provided emotional support to patients, families and carers to minimise their distress. They understood patient's personal, cultural and religious needs.
• Staff supported patients, families and carers to understand their condition and make decisions about their care and treatment.
• The service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others to plan care.
• The service 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 service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
• Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills.
• The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. Leaders and staff understood then and monitored progress.
• Leaders operated effective governance processes. Staff were clear about their roles and had regular opportunities to meet, discuss and learn from the performance of the service.
• Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact.

Updated 17 August 2017

• There was strong evidence of good learning from incidents including sharing of methods cross-site to reduce errors across both sites. All areas we saw were clean and regular audits supported this process.
• Good hand hygiene was maintained rigorously including the introduction of specialist hand gel door dispensers in the neonatal unit to prevent infection. Patients and parents were positive about the compassionate care that they received and we observed kind and respectful care during the inspection.
• Changes had been made to patient pathways, such as the introduction of ward reviews, and referrals to the hospital at home team which had decreased length of stay. There were a low number of formal complaints made about the service and response rates to complaints received were within the agreed timescales. Since the last inspection there had been clear progress in developing cross-site governance structures, risk management and learning.

Updated 17 August 2017

• There was a positive incident reporting culture, and learning from incident investigations was generally shared with staff in a timely manner.
• The environment was clean, infection rates were low and staff complied with infection prevention and control practices. Nursing staffing levels met national standards.
• Systems were in place to ensure the safe supply and administration of medicines.
• Records were safely secured and contained documentation in accordance with national and local standards.
• Care and treatment was delivered in line with national guidelines and best practice guidance.
• There was an ongoing programme of clinical audit which included measurements of patient outcomes.
• Interactions between staff and patients were individualised, caring and compassionate. Patients and their relatives felt they were treated with dignity and respect.

Updated 11 January 2019

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

• At the last CQC inspection, we found there was poor completion of a patient’s end of life care plan in nursing notes. During this inspection, we found there were still inconsistencies.
• The trust did not have a rapid discharge pathway in place and did not routinely record hospital patients preferred place of death which was reported at the last CQC inspection in March 2017.
• There was no formal assessment in place to assess the efficacy of anticipatory drugs.
• Shortages of ward staff meant there were low numbers of end of life care link nurses as well as occasional poor patient care.
• Patients did not always receive their controlled drug analgesia as prescribed or on time.
• There was just one fit for purpose concealment trolley which caused delays in transfer of bodies from wards to the mortuary.
• Principles of Care for Dying Patients and use of the end of life care plans were not fully embedded in practice.
• There was no succession planning for the current end of life care strategy 2016 - 2019.

However:

• Consideration of the patient’s spiritual needs had considerably improved since the time of the last inspection.
• Palliative and end of life care patients were no longer sent to the discharge lounge and there was a standard operating procedure which ensured this.
• There was improved representation of end of life care at trust board level since the time of the last CQC inspection.
• A separate end of life care risk register was introduced since the time of the last CQC inspection.
• There were an increased number of clinical nurse specialists in the specialist palliative care team.
• Patients and their relatives spoke positively about the care they received and commented on the sensitivity shown to them by all staff; including mortuary staff and members of the chaplaincy.

Updated 24 January 2024

Updated 17 August 2017

• Many patients complained about the waiting times in the outpatient clinics. They said they had not been given any update information about waiting times.
• There was a lack of shared working across the trust within outpatients. Not all staff were aware of how to use the electronic reporting system.
• The environment in general diagnostic imaging was not fit for purpose. Some equipment was in urgent need of replacement.
• There was a shortage of radiographers and radiologists.

Updated 3 July 2020

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

• We found the service had worked to rectify the problems we highlighted at the last inspection and this had led to improvements for both staff and patients.
• The service had improved and was continuing to improve upon the numbers of permanent staff and had enough staff to keep patients safe.
• The service controlled infection risk well and had improving figures for surgical site infections. Staff assessed patients risks and routinely recorded these risks. Medicine management had significantly improved since our last inspection. They managed safety incidents well and demonstrated learning from these. Staff collected safety information and used it to improve services.
• The service provided care and treatment in line with national guidelines and best practice and had mechanisms in place to ensure new guidance was added to applicable policies. Patients were given enough food and drink and had their pain assessed and pain relief given accordingly. Staff worked together seven days a week to deliver joint up care for patients and gave patients advice on how to lead a healthy life. Staff supported patients to make decisions about their care and always gained consent before carrying out any procedure.
• Staff treated patients with kindness and respected their dignity. Staff took account of patient individual needs and made sure they understood their conditions and helped them to make informed decisions about their care.
• The service was planned to meet the needs of local people and took account of patients individual needs. Most people could access the care they needed promptly and within national targets, those that could not were monitored for any signs of deterioration. It was easy for patients to make a complaint and these were taken seriously, and lessons were learnt.
• Leaders understood and manged the issues the service faced and were in the process of redefining a new vision and strategy to move forwards with. There had been improvements to the culture of the service since our last inspection and staff reported tensions between services no longer existed. Staff were clear about their roles and accountabilities and leaders were working to engage more with staff about any necessary changes to the service.

However:

• The service was not meeting its mandatory training targets for most modules and although staff were routinely assessing risks to patients’ they were not always acting on these risks as set out in trust policy.
• The service was not always ensuring patient privacy was maintained and did not ensure all paper records were kept securely.
• The service was meeting its national targets for getting patients treated on time but 298 patients had been waiting over 40 weeks for their operation

Updated 11 January 2019

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

• There was a clear leadership structure. The emergency departments came under different directorates. The adult emergency department was part of the acute and emergency medicine (AEM) division and the paediatric emergency department part of the children and young persons (CYP) division. At a local level the adult emergency department (ED) was led by the clinical director. There was a clear clinical leadership presence in the department.
• The operating plan set out a clear vison for the ED at University Hospital Lewisham (UHL) which included service improvements.
• There was an emergency department education strategy for all nursing grades which set out the opportunities for further learning and development. Nursing staff told us there were opportunities for them to progress.
• There was a culture of honesty, openness and transparency and staff told us there was learning from mistakes. Staff felt valued, supported and spoke highly of their job; there was good team work and peer support.
• Risks for the ED were incorporated on their divisional risk registers with details of the actions to mitigate them and regular review.
• In the paediatric ED, staffing levels complied with the Royal College of Paediatrics and Children’s Health (RCPCH) by having a minimum of two children’s nurses in the ED 24 hours a day seven days per week. All nursing staff were registered children’s nurses.
• The records reviewed showed the ED used the National Early Warning Score (NEWS) system to detect deterioration in adult patients. As part of the quality assurance in the ED the nurse in charge of majors checked all patients every four hours.
• Mental health liaison nurses were available to assess patients 24 hours a day seven days per week.
• Staff we spoke with were aware of how to report incidents. Staff told us that learning from incidents was shared.
• The ED participated in national audits to improve the care and treatment provided to patients. They also acted in response to the audit findings.
• The trust was participating in the national commissioning for quality and innovation (CQUIN); improving services for people with mental health needs who present to A&E to reduce attendances by frequent attenders.
• The trust had a comprehensive emergency department education strategy which set out the additional training requirements for nurses, emergency nurse practitioners (ENP) and advances clinical practitioners (ACP).
• The trust had a service level agreement with a neighbouring mental health trust detailing the service provision and staffing availability of the mental health liaison team.
• Consultants were available seven days a week in the both departments and on-call if required.
• Staff provided treatment and care in a kind and compassionate way and treated people with respect.
• People told us the staff were very friendly and helpful. All the patients we spoke with were happy with their care and raised no concerns. In the paediatric ED one parent told us the treatment of their child is ‘always very impressive’.
• The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was consistently better than the England average from May 2017 to April 2018.
• The emergency department had a relative’s room where families could go to discuss issues with medical staff or amongst themselves relating to loved ones care or emotional support.
• Staff took time to ensure patients and their families understood treatment. We observed doctors speaking respectfully and professionally about next steps for patients.
• The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment is no more than one hour. The trust met the standard over the 12 month period from June 2017 to May 2018, and was consistently better than the England average over the same time period.
• The ED had taken steps to address flow through the department. Patients attending the ED were streamed to GP services which were available seven days per week or the Urgent Care Centre that was available 24 hours per day 365 days per year.
• The ED could refer patients directly to the acute admissions unit AMU and the frailty unit which meant patients did not need to be assessed by a medicine consultant prior to admission.
• Four recently reconfigured cubicles enabled the department to accommodate mental health patients awaiting admission. The department also has a psychiatric assessment room for patients requiring a Mental Health assessment.
• Complaints were investigated and closed in line with the trust policy complaints being responded to within 25 working days of receipt. The ED took an average of 15 working days to investigate and close the complaints.

However

• Whilst the ED was meeting the Royal College of Emergency Medicine (RCEM) recommendations that consultants should provide 24 hour 7 days a week cover. The service did not have a minimum of 16 hours of consultant presence 7 days per week. This was similar to what we found at the last inspection.
• Mandatory training was below the trust target of 85% for medical staff in all 10 mandatory training courses and nursing staff in seven of the 14 mandatory training courses made available to them.
• Whilst nursing staff reported that rapid tranquilisation was rarely administered to mental health patients in the ED department. Staff did not know if the trust had a rapid tranquilisation policy.
• Some aspects of medicines management was safe. In the adult ED we found there were no records of the FP10s in stock and that no action was taken when fridge temperatures were out of range.
• On the inspection we saw evidence of good practice in relation to hand hygiene and compliance to the trust policy of bare below elbows. However, the trust’s own internal audit data compliance varied from between 100% and 73%.
• Appraisal rates of nursing staff for the period April 2017 to March 2018 was below the trust target of 90%.
• There was little information for patients attending the emergency department about quality and performance.
• Whilst privacy and dignity was maintained; curtains and screens were used in majors and resus areas. We observed that patients queuing to be streamed at the entrance of the ED could be overheard when discussing their health issues with the streaming nurse which compromised patients’ dignity and respect.
• The ED did not have specific arrangements to meet the needs of patients with dementia or means of identifying people with dementia by means of an identity band or special sticker.