Wednesday, January 30, 2013

CQC Report on Queens A&E copied below

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Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 1
Inspection Report
We are the regulator:
Our job is to check whether hospitals, care homes and care
services are meeting essential standards.
Queen's Hospital
Rom Valley Way, Romford, RM7 0AG Tel: 01708435000
Date of Inspections: 05 December 2012
29 November 2012
28 November 2012
Date of Publication: January
2013
We inspected the following standards to check that action had been taken to meet
them. This is what we found:
Care and welfare of people who use services
Action needed
Staffing
Action needed
Records
Action needed
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Details about this location
Registered Provider Barking, Havering and Redbridge University Hospitals NHS
Trust
Overview of the
service
Queen's Hospital is part of Barking, Havering and Redbridge
University Hospitals NHS Trust. It offers acute services for
all major specialities to a large and diverse population and
includes an accident and emergency department. The Trust
runs a joint cancer centre with another London hospital, and
is a regional neuroscience centre. We visited the accident
and emergency department.
Type of service Acute services with overnight beds
Regulated activities Diagnostic and screening procedures
Family planning
Maternity and midwifery services
Surgical procedures
Termination of pregnancies
Treatment of disease, disorder or injury
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Contents
When you read this report, you may find it useful to read the sections towards the back
called 'About CQC inspections' and 'How we define our judgements'.
Page
Summary of this inspection:
Why we carried out this inspection 4
How we carried out this inspection 4
What people told us and what we found 4
What we have told the provider to do 5
More information about the provider 5
Our judgements for each standard inspected:
Care and welfare of people who use services 6
Staffing 9
Records 10
Information primarily for the provider:
Action we have told the provider to take 11
About CQC Inspections
12
How we define our judgements
13
Glossary of terms we use in this report
15
Contact us
17
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Inspection Report | Queen's Hospital | January 2013 www.cqc.org.uk 4
Summary of this inspection
Why we carried out this inspection
We carried out this inspection to check whether Queen's Hospital had taken action to meet
the following essential standards:
·
Care and welfare of people who use services
·
Staffing
·
Records
This was an unannounced inspection.
How we carried out this inspection
We looked at the personal care or treatment records of people who use the service,
carried out a visit on 28 November 2012, 29 November 2012 and 5 December 2012,
observed how people were being cared for and checked how people were cared for at
each stage of their treatment and care. We talked with people who use the service, talked
with carers and / or family members and talked with staff.
What people told us and what we found
The accident and emergency department (known as the Emergency Department) has not
met most of the national quality indicators as a result of extensive delays in the care of
patients. Five percent of patients who need to be admitted to the hospital are waiting for
more than 11 hours in the department. The Trust should be aiming to transfer 95% of
patients who are being admitted to wards within four hours of their arrival.
This has led to poor care for patients in the 'Majors' area where seriously ill patients are
cared for. The 'Majors' environment is unsuitable for patients to be nursed in for long
periods of time for a variety of reasons such as, lack of privacy/dignity, no washing
facilities, no storage space for personal belongings and no bedside tables. There is a
limited range of food and drink available.
We found that many patients, who were there for a long period of time, including overnight,
were nursed on trolleys when they should have been moved onto a bed. This
increases the risk of them developing pressure damage, dehydration, and an increase in
falls.
There are not enough consultant or junior doctors to provide medical care for the number
of people who attend Queen's ED. In the 'Majors' area there are not enough nurses to
provide adequate care for patients.
The Emergency Department Medical Unit (EDMU) had the names, dates of birth and
diagnosis of patients on 'white boards' which were visible to both the public and other
patients.
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You can see our judgements on the front page of this report.
What we have told the provider to do
We have asked the provider to send us a report by 09 February 2013, setting out the
action they will take to meet the standards. We will check to make sure that this action is
taken.
Where we have identified a breach of a regulation during inspection which is more serious,
we will make sure action is taken. We will report on this when it is complete.
Where providers are not meeting essential standards, we have a range of enforcement
powers we can use to protect the health, safety and welfare of people who use this service
(and others, where appropriate). When we propose to take enforcement action, our
decision is open to challenge by the provider through a variety of internal and external
appeal processes. We will publish a further report on any action we take.
More information about the provider
Please see our website www.cqc.org.uk for more information, including our most recent
judgements against the essential standards. You can contact us using the telephone
number on the back of the report if you have additional questions.
There is a glossary at the back of this report which has definitions for words and phrases
we use in the report.
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Our judgements for each standard inspected
Care and welfare of people who use services
Action needed
People should get safe and appropriate care that meets their needs and supports
their rights
Our judgement
The provider was not meeting this standard.
People did not experience care, treatment and support that met their needs and protected
their rights.
We have judged that this has a major impact on people who use the service. This is being
followed up and we will report on any action when it is complete.
Reasons for our judgement
We visited the emergency department (ED) at Queen's Hospital because we had identified
major concerns about the care and welfare of patients during a previous visit in March
2012. We carried out this inspection to ensure they had made improvements, in relation to
concerns identified about meeting waiting times and delays experienced by patients in
receiving care and the quality of the care they received.
The ED monitors its performance times for dealing with all patients. For both patients who
are subsequently admitted and those who are not it aims to treat 95 % of them within four
hours. For those patients who do not require admission, since September 2012 the ED
has been meeting this target. However, for those patients who need to be admitted the ED
is not meeting the target and 5% of patients were in the ED for more than 11 hours before
admission.
The emergency department is subject to high levels of demand; it was originally built to
deal with up to 90,000 patients, it now sees around 132,000 patients per year. Although
other ED departments in London see more patients, in the financial year 2011/2012
Queen's Hospital had 2,686 'Blue Light' (very serious) ambulance cases which was more
than any other hospital in London.
The department consists of a separate paediatrics, resuscitation, rapid assessment and
treatment (RAT), Majors, Emergency Medicine Decisions Unit (EDMU), where ED patients
can be accommodated for up to 24 hours to assess their condition, and minor injuries area
which is co-located with the urgent care area.
We reviewed information provided by the London Ambulance Service (LAS) for the period
May to November 2012 relating to Queen's Hospital. The report showed that Queen's ED
was responsible for most of the ambulance diverts (when an ED has to close and non- life
threatening admissions and ambulances are diverted to other hospitals) in the North East
London region. For this six month period ambulances were diverted to other hospitals on
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16 occasions.
The LAS also records "black breaches" (those cases where it has taken over 60 minutes
from the time the ambulance arrives at a hospital, until both the clinical handover and the
patient handover has taken place). For the three month period from January to March
2012 there were 231 recorded "black breaches" at Queen's Hospital. This has recently
improved and for September to November 2012 52 "black breaches" were recorded,
although the Trust believes this figure should be lower and is currently in the process of
reconciling them.
Ambulance patients who are unwell and may need admission are assessed and directed
through to the 'Majors' area; this area consists of 25 bays, 23 used for beds with two bays
being used as a seating area with six seats; it also includes the five RAT cubicles.
Once the hospital has made a Decision to Admit (DTA), a patient they should be moved as
soon as possible from the ED to the main hospital wards or to the Medical Assessment
Unit. On our first day of the inspection at 11am there were 22 patients in the 'Majors' area.
For five of these it was noted that a DTA had been made and six patients had been in the
ED since midnight. One of the patients had been in the ED since 5pm the previous
evening. Patients told us the only drinks they had been offered was that morning with their
breakfast which was toast. One of the female patients we spoke to said she was very
thirsty and we could see that her mouth was dry, there was no information on her patient
records indicating that she her been given a drink since her arrival 11 hours previously.
On the second day of our inspection, at 1030am, there were 30 patients in the 'Majors'
area. Eighteen of them had been in the ED for more than six hours and ten had been in
the ED since before midnight. We examined the patient's records and found that for eleven
of them a DTA had been made and they were waiting for a bed in the medical admissions
unit or main wards in the hospital. Of the 10 patients who had been in since midnight, four
were still on a hospital trolley instead of a hospital bed. We spoke to four of the ten
patients who had been there since before midnight, we found that they had been given
drinks when needed. We noted that their dignity was not always being respected for
example curtains were not drawn when needed and in one case an elderly person's
underpants had been left hanging on the bottom of their bed.
On the third day of our inspection we visited at 4pm and found there were 27 patients in
the 'Majors' area. Eleven of them had been at the hospital for more than four hours and
nine had been there for more than six hours. The longest time a patient had been there
was 14 hours and 43 minutes. Staff told us that nine of the patients were waiting to see
medical specialists from other parts of the hospital. All of the patients were lying on a
hospital trolley. Patients told us that they had been offered water throughout their stay and
sandwiches at lunchtime.
Over the three days of our inspection we spoke to a number of staff in 'Majors', they told
us that the area is not designed to provide ward type care, there is no meal provision other
than soup and sandwiches and no ward furniture, such as lockers and bedside tables, is
provided. Staff told us that we had visited at a particularly busy time but that it was often
very busy and what we had found on our inspection was typical for the ED. They told us
that the problem was the hospital wards were not making beds available so they could
transfer patients. In addition staff said that there were excessive delays in specialist
doctors from other parts of the hospital attending the ED to see patients. We examined
patient's medical notes and confirmed this to be the case; we found two examples where
patients had been waiting for more than seven hours to be seen by a specialist doctor.
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Staffing
Action needed
There should be enough members of staff to keep people safe and meet their
health and welfare needs
Our judgement
The provider was not meeting this standard.
There were not enough qualified, skilled and experienced staff to meet people's needs.
We have judged that this has a major impact on people who use the service. This is being
followed up and we will report on any action when it is complete.
Reasons for our judgement
We reviewed the number of nurses in the 'Majors' department, which was very busy
during the three days that we were inspecting. Staff also told us that the department was
usually very busy. We examined the staff rotas and observed the actual number of nurses
on duty. We found that there were always four nurses on duty in the 'Majors' area which,
for the number of patients they had to look after, meant their ratio ranged from one
registered nurse to 5.5 patients to one registered nurse for 7.5 patients. We were informed
that the baseline ratio for 'Majors' was a ratio of one registered nurse to six patients at
night and one registered nurse to five patients in the day.
We spoke to some of the nurses in the 'Majors' who told us, " we can cope with the
numbers if things are quiet, but when things get busy there are not enough nurses here".
With regards to medical staff, the Trust has 16 Consultants in the General ED to cover
both Queen's and King Georges Hospitals. They provide an on-site presence from 8am to
10pm Monday to Friday and 6 hours (as a minimum) on Saturdays and Sundays, at each
site. In addition there are two Paediatric Consultants. It currently has 11.6 permanent
consultants in post and provides the rest of the cover by employing locum staff. The Royal
College of Emergency Medicine would recommend that for the number of patients seen at
the ED at Queen's Hospital it should have 16 consultants to provide cover 16 hours a day,
seven days a week. The ED has a number of consultants working between 9am and 5pm
but after 5pm there is often only one consultant available until 10pm. Staff told us that
consultants do not finish their shift at 10pm until they are happy it is 'safe' to do so. After
10pm there is a consultant available on call. The ED at Queen's is under resourced for
consultants.
Additionally consultants need to be supported by a multidisciplinary workforce that reflects
the case mix and complexity of the workload. There are 29 doctor middle grade posts, of
which only 14 are filled. These doctors work a rolling shift pattern covering both King
George and Queen's Hospitals. The rest of the vacancies are filled by locums. The ED at
Queen's is under resourced for middle grade doctors.
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Records
Action needed
People's personal records, including medical records, should be accurate and
kept safe and confidential
Our judgement
The provider was not meeting this standard.
Records are not being kept securely
We have judged that this has a minor impact on people who use the service, and have told
the provider to take action. Please see the 'Action' section within this report.
Reasons for our judgement
The ED has an Emergency Department Medical Unit (EDMU) where patients from the ED
can be accommodated for up to 24 hours to assess their condition. The unit consists of
two wards with four bays in each. We looked at the unit in detail and found that it was full
with eight patients. However, only one of them met the criteria for an EDMU patient, all the
others were overflow from the Medical Assessment Unit (MAU) which is a ward that is not
part of the ED and can accommodate up to 60 patients for stays for up to 48 hours before
patients are either discharged or transferred to a main ward.
When we visited the EMDU, we found that patients' notes were securely stored in a
lockable trolley. However, we found that patient's names, dates of birth and a summary of
their diagnosis where written on large 'white boards' that were fully visible to the public and
other patients. We identified this issue to senior staff on the first day of our visit but found
the same situation when we returned on the second day.
This section is primarily information for the provider
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Action we have told the provider to take
Compliance actions
The table below shows the essential standards of quality and safety that
were not being
met
. The provider must send CQC a report that says what action they are going to take to
meet these essential standards.
Regulated activity Regulation
Treatment of
disease, disorder or
injury
Regulation 20 HSCA 2008 (Regulated Activities) Regulations
2010
Records
How the regulation was not being met:
To be advised
This report is requested under regulation 10(3) of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2010.
The provider's report should be sent to us by 09 February 2013.
CQC should be informed when compliance actions are complete.
We will check to make sure that action has been taken to meet the standards and will
report on our judgements.
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About CQC inspections
We are the regulator of health and social care in England.
All providers of regulated health and social care services have a legal responsibility to
make sure they are meeting essential standards of quality and safety. These are the
standards everyone should be able to expect when they receive care.
The essential standards are described in the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations
2009. We regulate against these standards, which we sometimes describe as "government
standards".
We carry out unannounced inspections of all care homes, acute hospitals and domiciliary
care services in England at least once a year to judge whether or not the essential
standards are being met. We carry out inspections of dentists and other services at least
once every two years. All of our inspections are unannounced unless there is a good
reason to let the provider know we are coming.
There are 16 essential standards that relate most directly to the quality and safety of care
and these are grouped into five key areas. When we inspect we could check all or part of
any of the 16 standards at any time depending on the individual circumstances of the
service. Because of this we often check different standards at different times but we
always inspect at least one standard from each of the five key areas every year. We may
check fewer key areas in the case of dentists and some other services.
When we inspect, we always visit and we do things like observe how people are cared for,
and we talk to people who use the service, to their carers and to staff. We also review
information we have gathered about the provider, check the service's records and check
whether the right systems and processes are in place.
We focus on whether or not the provider is meeting the standards and we are guided by
whether people are experiencing the outcomes they should be able to expect when the
standards are being met. By outcomes we mean the impact care has on the health, safety
and welfare of people who use the service, and the experience they have whilst receiving
it.
Our inspectors judge if any action is required by the provider of the service to improve the
standard of care being provided. Where providers are non-compliant with the regulations,
we take enforcement action against them. If we require a service to take action, or if we
take enforcement action, we re-inspect it before its next routine inspection was due. This
could mean we re-inspect a service several times in one year. We also might decide to reinspect
a service if new concerns emerge about it before the next routine inspection.
In between inspections we continually monitor information we have about providers. The
information comes from the public, the provider, other organisations, and from care
workers.
You can tell us about your experience of this provider on our website.
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How we define our judgements
The following pages show our findings and regulatory judgement for each essential
standard or part of the standard that we inspected. Our judgements are based on the
ongoing review and analysis of the information gathered by CQC about this provider and
the evidence collected during this inspection.
We reach one of the following judgements for each essential standard inspected.
Met this standard
This means that the standard was being met in that the
provider was compliant with the regulation. If we find that
standards were met, we take no regulatory action but we
may make comments that may be useful to the provider and
to the public about minor improvements that could be made.
Action needed
This means that the standard was not being met in that the
provider was non-compliant with the regulation.
We may have set a compliance action requiring the provider
to produce a report setting out how and by when changes
will be made to make sure they comply with the standard.
We monitor the implementation of action plans in these
reports and, if necessary, take further action.
We may have identified a breach of a regulation which is
more serious, and we will make sure action is taken. We will
report on this when it is complete.
Enforcement
action taken
If the breach of the regulation was more serious, or there
have been several or continual breaches, we have a range of
actions we take using the criminal and/or civil procedures in
the Health and Social Care Act 2008 and relevant
regulations. These enforcement powers include issuing a
warning notice; restricting or suspending the services a
provider can offer, or the number of people it can care for;
issuing fines and formal cautions; in extreme cases,
cancelling a provider or managers registration or prosecuting
a manager or provider. These enforcement powers are set
out in law and mean that we can take swift, targeted action
where services are failing people.
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How we define our judgements (continued)
Where we find non-compliance with a regulation (or part of a regulation), we state which
part of the regulation has been breached. We make a judgement about the level of impact
on people who use the service (and others, if appropriate to the regulation) from the
breach. This could be a minor, moderate or major impact.
Minor impact
people who use the service experienced poor care that had an impact on
their health, safety or welfare or there was a risk of this happening. The impact was not
significant and the matter could be managed or resolved quickly.
Moderate impact
people who use the service experienced poor care that had a
significant effect on their health, safety or welfare or there was a risk of this happening.
The matter may need to be resolved quickly.
Major impact
people who use the service experienced poor care that had a serious
current or long term impact on their health, safety and welfare, or there was a risk of this
happening. The matter needs to be resolved quickly
We decide the most appropriate action to take to ensure that the necessary changes are
made. We always follow up to check whether action has been taken to meet the
standards.
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Glossary of terms we use in this report
Essential standard
The essential standards of quality and safety are described in our
Guidance about
compliance: Essential standards of quality and safety
. They consist of a significant number
of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the
Care Quality Commission (Registration) Regulations 2009. These regulations describe the
essential standards of quality and safety that people who use health and adult social care
services have a right to expect. A full list of the standards can be found within the
Guidance about compliance
. The 16 essential standards are:
Respecting and involving people who use services - Outcome 1 (Regulation 17)
Consent to care and treatment - Outcome 2 (Regulation 18)
Care and welfare of people who use services - Outcome 4 (Regulation 9)
Meeting Nutritional Needs - Outcome 5 (Regulation 14)
Cooperating with other providers - Outcome 6 (Regulation 24)
Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)
Cleanliness and infection control - Outcome 8 (Regulation 12)
Management of medicines - Outcome 9 (Regulation 13)
Safety and suitability of premises - Outcome 10 (Regulation 15)
Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)
Requirements relating to workers - Outcome 12 (Regulation 21)
Staffing - Outcome 13 (Regulation 22)
Supporting Staff - Outcome 14 (Regulation 23)
Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)
Complaints - Outcome 17 (Regulation 19)
Records - Outcome 21 (Regulation 20)
Regulated activity
These are prescribed activities related to care and treatment that require registration with
CQC. These are set out in legislation, and reflect the services provided.
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Glossary of terms we use in this report (continued)
(Registered) Provider
There are several legal terms relating to the providers of services. These include
registered person, service provider and registered manager. The term 'provider' means
anyone with a legal responsibility for ensuring that the requirements of the law are carried
out. On our website we often refer to providers as a 'service'.
Regulations
We regulate against the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.
Responsive inspection
This is carried out at any time in relation to identified concerns.
Routine inspection
This is planned and could occur at any time. We sometimes describe this as a scheduled
inspection.
Themed inspection
This is targeted to look at specific standards, sectors or types of care.
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Contact us
Phone: 03000 616161
Email: enquiries@cqc.org.uk
Write to us
at:
Care Quality Commission
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
Website: www.cqc.org.uk
Copyright Copyright © (2011) Care Quality Commission (CQC). This publication may
be reproduced in whole or in part, free of charge, in any format or medium provided
that it is not used for commercial gain. This consent is subject to the material being
reproduced accurately and on proviso that it is not used in a derogatory manner or
misleading context. The material should be acknowledged as CQC copyright, with the
title and date of publication of the document specified.

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