Queen Mary's Hospital for Children, Carshalton

General Services Information

Hospital Questions

• How many single rooms are available to NHS patients at this hospital: 6

• Of these how many have an ensuite toilet: 1

• Of these how many have an ensuite toilet and shower or bath: 1

• Does this hospital operate an accident and emergency unit:

• How many specialist palliative care beds are available at this hospital: 0 The Trust palliative care team see palliative care patients across all wards and assess, advise and support patients, relatives and medical staff whenever required.

• Does this hospital have a named private unit/service:

Trust Questions

• Does the Trust treat private patients:

Patient Safety

Trust Questions

• Is there a system for recording operations that resulted in a foreign body being left post surgery:

• What is the reporting system for a foreign body being left post surgery: Never Event - escalation in accordance with Trust SI (Series Incidend) procedure to Medical Directors

• Is there a system for recording operations that were cancelled due to missing notes:

• What is the reporting system for operations that were cancelled due to missing notes: Reportable via Trust Clinical Incident System in line with the Trust escalation process for non clinical cancellations.

• Is there a system for recording operations that resulted in wrong site surgery taking place:

• What is the reporting system for operations that resulted in wrong site surgery taking place: Never Event - escalation in accordance with Trust SI (Series Incidend) procedure to Medical Directors

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in a foreign body being left post surgery: 1

• During the period 01 April 2010 - 31 March 2011, how many operations were cancelled due to missing notes: 0

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in wrong site surgery taking place: 0

• How many incident investigations using a full Root Cause Analysis did were carried out in 2010/11: 552

• What percentage of patient safety incidents resulting in severe harm or death had a full RCA initiated/completed: 100%

• What percentage of acute inpatients have a track and trigger warning system in place for the duration of the admission: 91-99% Validated by audit - Policy to undertake assessments on all admissions using the Trusts Early Warning Alert System (EWAS) tool

• What percentage of patients are risk assessed for venous thromboembolism on admission: 31-60% The Trust recorded a figure of 39% electronically in March 2011, though a casenote audit in Medicine identified significantly better performance. The trust has made significant improvement in VTE assessment recording since March. July figure was 73%

• Compliant with all relevant NPSA safety alerts issues in 2010/11 (you can find a full list of alerts issued at http://www.nrls.npsa.nhs.uk/resources/?p=3). :

• Does the Trust have a policy for providing educational programmes on using and interpreting clinical indicators:

• Does the Trust have a designated member of staff who supports teams in locating and analysing safety and quality data? (support):

• Is safety and quality data available on a central platform and actively disseminated to users:

Infection Control

Trust Questions

• Does the Trust employ an antibiotic pharmacist:

• Does the Trust operate a pre-admission assessment clinic or equivalent system where patients are screened and results returned in advance of the day of admission:

• Elective patient groups screened at the pre-op assessment clinic: All elective surgical

• Are all oncology patients screened at the pre-op assessment clinic: YES Inpatients only

• Are all chemotherapy patients screened at the pre-op assessment clinic: YES Inpatients only

• Are all elective neurosurgery patients screened at the pre-op assessment clinic: Not Applicable

• Are all patients with past history of MRSA screened at the pre-op assessment clinic:

• What method of MRSA screening is used when screening at admission: Other (please specify) Culture based in 24-48hours/ Molecular or other method result in less than 24 hours

• On admission, does topical suppression take place immediately: Only for patients undergoing joint replacement surgery admitted as an emergency from nursing/residential home

• Does the Trust have at least one accident and emergency unit:

• Are all patients admitted through A&E screened:

• Is screening done according to individual risk assessment: According to national guidelines - all medical and surgical

• Does the Trust have a dedicated isolation ward:

• How many beds does it contain: 19 Capacity of 14 + 5 beds. I unit on each acute site.

• Does the Trust have an isolation policy:

• Where medically appropriate, are patients with C Diff isolated in single rooms as a matter of priority:

• Does the Trust have a policy to guide the use of metronidazole and vancomycin for C.difficile infected patients:

• Does the Trust routinely isolate all patients with diarrhoea:

Stroke Medicine

Hospital Questions

• Does the hsopital have a specialist stroke unit:

Trust Questions

• Does the Trust have a specialist stroke unit or units: Units at St Helier and Epsom

• Is the Trust part of a stroke care network:

• Details: Epsom is part of the Surrey cardiac and stroke network. St Helier is part of the South London cardiac and stroke network

• How many emergency admissions with a primary diagnosis of stroke (ICD10 codes I60 - I64) did the Trust receive in the financial year (period 01 April 2010 - 31 March 2011): 312

• Of these, what was the number of patients given a Computerised Tomography (CT) scan within 24 hrs of admission: 234

• Is thrombolysis for stroke patients provided 24 hours per day and 7 days a week :

• Are there any formal arrangements with neighbouring hospitals for the emergency transfer of stroke patients who would benefit from thrombolytic treatment:

• These arrangements are with: St Helier hospital is part of the London model where all stroke patients are initially admitted to one of 8 hyperacute stroke units in London and then repatriated locally. From July 2010 the majority of our patients are initially admitted to the HASU (Hyperacute stroke unit) at St George's Hospital, Tooting. Epsom hospital has a formal arrangement for primary divert of potential thrombolysis patients to either St George's Hospital or Royal Surrey County Hospital Guildford Epsom hospital is starting day time thrombolysis on 5th September 2011 (Monday to Friday) with a future aspiration to providing 24/7 thrombolysis via telemedicine as part of the Surrey Stroke network.

Trauma & Orthopaedics

Trust Questions

• Does the Trust offer a trauma service:

• Does the Trust have a dedicated trauma list available 24 hours a day for the duration of the week, (Sunday to Sunday): Dedicated trauma list Monday to Saturday with patients treated on the priority list on Sunday, if clincally required. 7 day trauma list has commenced.

• Does the Trust offer an orthopaedics service:

• Do all the Trust's orthopaedic ward/team have a linked geriatric team with whom they have regular meetings at least once a week:

• Does the Trust run a pre-operative patient education session/class for patients to attend prior to Total Knee Replacement (TKR) and Total Hip Replacement (THR)? : The Trust provides a DVD and offers an open day visit to all our patients. This visit is managed by the Director of nursing/Elective Orthopaedic Centre and pre operative nurse lead.

• Does the Trust have a standardised anaesthetic protocol for Total Knee Replacement (TKR) and Total Hip Replacement (THR) patients:

• Audited percentage compliance to this protocol: 94

• Estimated percentage of the Trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery: 95

• Does the Trust have a specialist orthopaedic physiotherapy service which is available 7 days a week:

• How many patients' discharge's delayed due to lack of physiotherapy services at weekends - estimated figure: 15

• Are patients for total knee replacement (TKR) and total hip replacement (THR) admitted prior to the day of surgery: We do not routinely admit patients prior to the day of surgery but in very rare circumstances (less than 1%) this may be necessary, i.e. for clinical optimisation.

• Are patient records routinely recorded using a specific multi-disciplinary team THR/TKR pathway document:

• Is this data used to monitor compliance with the agreed pathway:

• Is criteria-based discharge used:

• Are patients routinely phoned in the first 48 hours after discharge to check on their progress:

Paediatrics

Hospital Questions

• Does the hospital have a paediatrics service:

Trust Questions

• Is the Trust's elective paediatric surgery carried out only by designated surgeons with at least six months training in a specialist unit:

• Do the Trust's anaesthetists with responsibility for paediatric anaesthesia participate in at least one paediatric list per week:

• Is a paediatrician on site (SpR or higher) 24 hours per day, 7 days per week:

• Are at least two registered children's nurses on duty 24hours per day in each children's ward:

• Is there a designated facility on site for parents or guardians to stay overnight:

Palliative Care

Trust Questions

• Does the Trust provide a palliative care service:

• How is specialist palliative care delivered at the hospital: Other (please specify) A multi-disciplinary specialist palliative care team / Referral to community based hospice(s)

• Does the hospital's specialist palliative team includes: A consultant in palliative medicine,A palliative care nurse,Counsellor(s),Other (please specify) Social Worker with Counselling skills / LCP Facilitator /Chaplaincy input

• Is the Trust's specialist palliative care team available 24 hrs a day seven days a week: 24/7 Telephone advisory service available by palliative Medicine consultant to the Trust clinical teams.

• Are facilities provided to support relatives and carers who wish to stay with a patient in hospital:

• Does the Trust routinely survey and evaluate the views of patients and bereaved relatives and carers regarding the delivery of care on the end of life programme:

Maternity Care

Maternity Sites

• St Helier Hospital - Midwife Led

• How many women gave birth in the unit during the year? (not including home births): 500

• How many babies were born in the unit during the year? (not including home births): 500

• Number of antenatal rooms: 4

• Total antenatal beds: 4

• Number of assessment area rooms (for monitoring and / or induction): 0

• Total delivery beds: 4

• Number of postnatal rooms: 0

• Total postnatal beds: 0

• Number of rooms in obstetric high dependency unit: 0

• Total obstetric high dependency beds: 0

• Amenity rooms; Are women able to book a single room in advance of their birth: Once in labour women can book amenity room

• Epsom General Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 2495

• How many babies were born in the unit during the year? (not including home births): 2076

• How many women were booked for a home birth: 72

• How many women had a home birth? (not including births at home by accident): 38

• Number of antenatal rooms: 14

• Total antenatal beds: 32 Includes single beds

• Number of assessment area rooms (for monitoring and / or induction): 3

• Total assessment area beds: 11 Including Maternity Assesment Unit

• Total delivery beds: 6

• Number of postnatal rooms: 1

• Total postnatal beds: 2

• Number of rooms in obstetric high dependency unit: 1

• Total obstetric high dependency beds: 3 These beds also use as Recovery

• Amenity rooms; Are women able to book a single room in advance of their birth: Once in labour women can book amenity room

• If women can pay for a single room what is the average cost per night (GBP): 150

• St Helier Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 2044

• How many babies were born in the unit during the year? (not including home births): 2568

• How many women were booked for a home birth: 80

• How many women had a home birth? (not including births at home by accident): 45

• Number of antenatal rooms: 19

• Total antenatal beds: 53 Includes single beds

• Number of assessment area rooms (for monitoring and / or induction): 3

• Total assessment area beds: 12 Including Maternity Assesment Unit

• Total delivery beds: 8

• Number of postnatal rooms: 0

• Total postnatal beds: 0

• Number of rooms in obstetric high dependency unit: 0

• Total obstetric high dependency beds: 0

• Amenity rooms; Are women able to book a single room in advance of their birth: Once in labour women can book amenity room

Trust Questions

• Do all women have a choice about where they receive their antenatal appointments (i.e. at hospital or local health centre):

• Are NHS antenatal classes available (e.g. Parentcraft):

• Available during the daytime (until 5pm):

• Available in the evenings (after 5pm):

• Available at weekends (Saturday and/or Sunday): Home birth workshops available at weekend.

• Available for women only groups:

• Available for other groups:

• Also available for: Teenage/young women's classes

• Are all women routinely offered ultrasound scans:

• Scan 1 available between: 12-13 weeks + 6 days

• Scan 2 available between: 19 weeks + 3 days - 20weeks + 6days

Trust Statistics

Trust Questions

• You can view various measures relating to the Trust's performance by clicking the following link: Epsom and St Helier University Hospitals NHS Trust