Tower Hamlets Local Involvement Network

Enter and View Visit

Royal London Hospital

Barts and the London Trust

Date and time: 24th March 2009, 10:00am

Areas Visited: The Neurosurgical Unit of Royal London Hospital, Whitechapel. AW4 (Fourth floor, West Wing). and Outpatients

Visiting team of Authorised THINk Members

Lead member- Dr. Amjad Rahi

Other members – Gaynor Tenen, Sybil Yates

Host organisation – Dianne Barham

Barts and the London Trust staff

Jane Canny - Head of Patient Quality

Project information reviewed

The core standards report of the Royal London Hospital (Barts and the London NHS Trust) submitted to the Healthcare Commission in 2007/08. The visit was intended to review the core standards relating to patient focus and accessible and responsive care to inform THINks Third Party Commentary to the Healthcare Commission as part of the Annual Health Check process.

Key visit objectives

To observe how well the core standards are met and also to gather relevant information in order to write a third party commentary for Annual Health Check 2008/09. The visit was intended to be preliminary in nature and would involve both observation of service and speaking to the service users

The visit was arranged through the Head of Patient Quality at BLT, Jane Canny. AW4 was suggested by Jane as the ward was reflective of the standard of environment expected of wards within the new hospital. It was felt that this may give THINk an opportunity to flag up both positive and negative issues of this new ward environment from the patient perspective.

Conversely the Outpatient services are in an older part of the hospital and will not be moving to new premises within the new build.

The Visit team made a very short informal unannounced visit to the Patient Advice and Liaison Service (PALS) at the beginning of our visit and a number of issues were highlighted by staff.

AW4

Background to AW4

AW4 is a forty nine bedded neurosurgical/neurology ward (one of the biggest neurosurgical units in the South East of England) with ten monitored beds, three two bedded rooms, six four bedded bays, and nine single side rooms.

There are two rooms designated for Video telemetry with the capacity to expand to three. Video Telemetry is the monitoring and recording of seizures for prescribing and diagnosis of epilepsy. The monitored unit is predominately step down from ITU and the major head injury patients and post op craniotomy.

EEG Room - the technicians provide service throughout the hospital on other wards.

There are close links with the multidisciplinary team and the physiotherapy Gym is situated on the unit. They have two MDT meetings a week, one for surgical patients and the other for Neurology. They are a tertiary referral centre for both emergency and elective surgery and neurology.

There are several specialist nurses affiliated with the unit, including those for Multiple Sclerosis, Epilepsy, Brain Tumours and Parkinson disease. Many of the patients have a tracheostomy. Sister Ayres is a member of the tracheostomy team and teaches how to care for these both in-house and for carers in the community.

The ward has two ward managers Sisters Jill Ayres and Grainne Mckenna. The Matron is called Amanda Payne. They have an establishment of forty seven Staff Nurses, eight Junior Sisters and 23 Health Care Assistants. They currently have vacancies for one band six nurse and four Health Care assistants and are advertising for a Teaching Sisters post.

A third of Staff nurses have specialist training in Neuroscience nursing and some have the high dependency course. The mentorship course is also well attended by staff and they are accredited to teach student nurses ranging from a first ward to a third year specialist placement. They also have medical students.

Staff on visit

Sister Jill Ayres – Ward Manager

Louise Crosby - Divisional Nurse

Authorised representatives’ observations;

The ward was very light, spacious and clean and had the appearance of being modern and well managed.
A list of all the patients currently on the ward was clearly displayed on the wall as you came onto the ward. THINk members felt that this might breach patient privacy and the some patients may not wish to visitors to see their information. It was suggested that perhaps a pull down screen could be used (similar to those in use at Mile End Hospital) when the info wasn’t needed.
Patient information andInfection control notices were clearly displayed
Soap dispensers were prominent and accessible when entering and leaving the ward and outside of every room.
Hoists were available for patients with physical disabilities and there was room for wheel chairs to be maneuvered alongside toilets for easy access.
No access to television or telephones.

Discussions with users;

THINk members spoke to three patients in AW4 Room B

Patients were complementary of the clinical care including the nurses, doctors and specialists.
They felt their diversity was respected and they were treated with dignity.
One user said that today was the first time that all the soap dispensers had been full.
One patient felt that the buffet style of service was unhygienic as people talked, coughed over and handled the food prior to their receiving it. Food could also be cold if you were at the opposite end of the ward from where the buffet trolley started.
There was a problem with a toilet in the room that staff had been trying to rectify for several of days.

Discussions with staff;

Although children under five were not permitted on the ward staff were flexible where there was a clear benefit to the patient and where it did not cause disruption to other patients on impair clinical care. Similarly visiting hours were not strictly adhered to.
Staff said that they were having some difficulty keeping soap dispensers available in all areas as visitors were taking them because of their alcohol content.
Response times from domestic services were often very slow with the prioritisation system difficult to understand.
It was felt that generally the response and repairs was slow with a lot of nurse time being spent chasing them up. This can have a negative effect on clinical care.
There seems to be a shortage of porters with clinical staff having to move patients, again taking them away from their real role of caring for patients.
Delays in getting beds cleaned and disinfected are also causing delays in getting people who are waiting elsewhere into the ward.
Staff felt that the increase in the number of smaller and single rooms led to:

a need for more staff as it was difficult for staff to always stay in touch with specialists, doctors and nurses without taking the time to seek them out specifically rather than crossing them frequently within the course of their work
a sense of isolation by patients and a feeling that there were fewer staff available
maintaining single sex rooms was a problem at times

Medical and Surgical Outpatient Departments

Background to Outpatient Department

The Department consists of: 20 Consultation Rooms, a four cubicle Dressings Clinic area, and a Minor Operating Theatre.

Specialties treated within the area: Plastic surgery, Colorectal surgery, Hepatobilary surgery, Hepatology, Respiratory Medicine, Gastroenterology, Nephrology, Neurology, Neurosurgery, Haematology, Vascular surgery, Urology, General surgery, General Medicine.

There are Minor Theatre lists run by the General and Plastic Surgeons plus the Dermatology department have the use of the Theatre.

Staffing: Senior Sister, Sister, 10 Staff Nurses and six Nursing Assistants.

The computer based appointments system is still causing major problems with multiple people being booked for the same appointment and people being booked into the wrong clinics at the wrong times.

Staff on visit:

Matron Tosh Denholm

Elaine Wall - Divisional Nurse

Authorised representatives’ observations;

The general look and feel of Outpatients is of a building that is need of maintenance and repair with paint peeling off windows and old worn out furniture. Although we visited at a quiet time of the day it still felt very noisy and chaotic. Members felt that the poor environment led to a perception of poor or less than modern treatment and care. Signage was not clear and it could be difficult to find your way to all the various areas covered by Out Patients.

Hand wash was available but not as obvious or as well used. However many of those that were there had locking systems so that they weren’t taken by people looking to drink it due to its alcohol content.

Infection control board clearly displayed with data broken down by professional group.

Discussions with users;

THINk members spoke to three patients waiting in the out patients area. Patients were generally happy with the clinical care that they had received. Their concerns were:

lack of car parking facilities
long waitingr periods (half an hour or more) without any explanation as to why or how long the delays were likely to be

Discussions with staff;

Although there are private consultancy rooms patients are still reporting that they do not feel they are being treated with dignity and respect on their patient surveys. This may be down to the environment of the consultancy rooms.

Staff feel under pressure to make up for the poor environment with the quality of care which can bring added stress to a busy job.

Of the around about 1,000 patients booked into medical outpatients, 20-30% are DNA (did not attend). The sense from staff is that local people don’t think it’s wrong not to turn up. Should there be education around this issue or should it be made easier to cancel appointments e.g. designated phoneline.The current phone line only operates restricted hours and asks you to leave a message and then no one rings back.

The major issue for out patients has been the implementation of the new computer booking system for scheduling appointments. It has allowed two appointments to be made at the same time, has booked people into clinics that are not scheduled or at the wrong time. GPs are losing confidence in the system.

There is a shortage of parking particularly for disabled patients. There is concern that there is a plan to rectify this when the new hospital is completed.

The pedestrian crossing at the front of the hospital can be very dangerous as it can get very crowded and the island in the middle of the road isn’t wide enough for everyone.

Language line is very good and well used.

It can be difficult to find you way to out patients and around the various parts of the hospital where outpatient services are. It can also be difficult for those with physical disabilities to know the best route for them to take coming from the disability parking area.

Patient Advice and Liaison Service

We undertook an informal visit to the PALS office. It was noted that

the office needs to be more identifiable
although paitent information leaflets are easily available it isn’t clear exactly how you might go about making a complaint: an electronic version might be an easier option for some patients
there is no interview room that would enable staff to conduct private discussions with people wanting to raise what can sometimes be very private issues.
Summary

Patients were generally complementary of nurses and medical staff with staff considered to be welcome, open and prepared to listen. Overall patients were positive about their experience.

Overall the standard of cleanliness was good. Both patients and staff noted that the hand wash bottles outside rooms had a tendency to disappear. It was thought they were being stolen for their alcohol content. This is both extremely dangerous for the people drinking it but is also leading to hygiene and safety issues on the wards.

Food was still an issue for some patients who felt that the buffet style of service was unhygienic as people talked, coughed over and handled the food prior to their receiving it. Food could also be cold if you were at the opposite end of the ward from where the buffet trolley started. The choice of food was generally considered good but several patients said they preferred the food and system at Hommerton where you were able to select from a menu a couple of days before and then your food came pre packaged on individual trays.

Staff, but also patients, had noted that the response of domestic services could be very slow. One of the toilets on a ward in AW4 had not been working for a couple of days and staff had to chase the issue up on several occasions.

Patients in Outpatients were mainly concerned about waiting times – both the length of wait and the fact that they were often not kept updated as to how long delays were and why there were delays. There was also concern about the lack of parking and whether there were plans to have more parking with the new hospital.

Recommendations

a system for ensuring that hand wash dispensers are secured or locked should be implemented throughout the hospital
staff should ensure that patients who are having to wait are informed of why and how long waits are likely to be.
consideration should be given to the perception of staffing levels within the new hospital wards where patients may feel more isolated – possibility of more volunteers etc to have a presence on wards
that patients be sent a map of the hospital with their appointment letter indicating where the particular area is they are going to visit.
a map should be produced indicating the easiest disability routes through the hospital
that the Patient Advice and Liaison Service has access to a private interview room