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Whipps Cross University Hospital Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 15 December 2016

Whipps Cross University Hospital in Waltham Forest is part of Barts Health NHS Trust, the largest NHS trust in the country, serving 2.5 million people across Tower Hamlets and surrounding areas of the City of London and East London.

Whipps Cross University Hospital provides a range of general inpatient services with 636 beds, outpatient and day-case services, as well as maternity services and a 24-hour emergency department and urgent care centre. The hospital has various specialist services, including urology, ENT, audiology, cardiology, colorectal surgery, cancer care and acute stroke care.

Waltham Forest is in the most deprived quintile of local authority districts and about 25%  of children (14,500) live in poverty. The population includes 47.8% BAME residents.

We returned to inspect this location (and the Royal London location) to follow up on our previous inspections of Barts Health NHS Trust in 2014 and 2015 where we found a number of concerns around patient safety and the quality of care. Following the last inspection, significant changes were made to the leadership of the organisation at both an executive and site level.

We carried out an announced inspection between 26 and 29 July 2016. We also undertook unannounced visits on 2 and 4 August 2016.

We inspected eight core services: Urgent and Emergency Care, Medicine (including older people’s care, Surgery, Critical Care, Maternity and Gynaecology, Services for Children, End of Life, and Outpatients and Diagnostic Services.

Overall, we rated this hospital as inadequate. The surgery and end of life care services were rated inadequate because of concerns around safety, responsiveness and leadership. We found important improvements had been made in maternity and gynaecology and services for young people since our last inspection. The other four core services were rated as required improvement.

Our key findings were as follows:

Safe:

  • There was no dedicated place of safety room in the emergency department for patients with psychiatric conditions.
  • Infection prevention and control procedures were not strictly adhered to, increasing the risk of infection for patients. We found poor infection control practice in the surgery service.
  • The incident reporting process was inconsistently applied. We found limited evidence of learning from incidents or complaints.
  • Staff did not always record actions taken or learning points for incidents. The knowledge of incidents and awareness of shared learning was inconsistent.
  • The trust did not provide all patients with one-to-one care during labour which is recommended by the Department of Health.
  • Staff had a good understanding of the trust's safeguarding policy and procedures and how to protect patients from abuse. The children’s service had good arrangements in place to keep children and young people safe.

Effective:

  • The use of clinical audits was inconsistent across the core services. We found that some services were undertaking little auditing to identify improvements they could make to patient care.
  • We found that there was good compliance with local and national guidance in the treatment of patients.
  • The hospital participated in the National Care of the Dying Audit in May 2015 and in 2016. The hospital performed worse than the England average in most areas for both audits. The service had been slow to start actions and make changes to improve end of life care for patients.

Caring:

  • Most staff were caring and compassionate in their delivery of care.
  • Most patients and relatives we spoke with were satisfied with the care and support they received and felt that staff took the time to include them in decisions about their care.
  • We found many examples of a lack of compassion towards patients nearing the end of their lives.

Responsive:

  • Emergency department performance against the national four hour target for treatment and discharge was well below the national 95% target at around 85%.
  • The trust suspended monthly mandatory 18-weeks referral to treatment time (RTT) reporting from September 2014 onwards. This followed the identification of significant data quality concerns relating to the accuracy, completeness and consistency of the RTT patient tracking list.
  • The average length of stay at Whipps Cross University Hospital was in line with the England average for both elective and non-elective admissions.
  • At trust level the percentage of patients whose operations were cancelled and not treated within 28 days was worse than the England average between the first quarter of 2013/14 to quarter four of 2015/16. However, this had improved from around 30% in quarter three of 2014/15 to around 10% in quarter four of 2015/16.

Well led:

  • Changes to the leadership structure of the trust, including at site level, were beginning to make a positive impact on the improvement of standards but the pace was too slow. Most staff spoke optimistically of the new leadership structure.
  • Governance and risk management was generally well managed. We observed many good managers who had a clear understanding of the issues they faced in their service areas.
  • In some services there was a lack of understanding of the vision and strategy of the whole organisation. Local hospital plans and visions were generally well understood.
  • We found pockets of poor culture with evidence of bullying and inequality.
  • We were unable to find any areas of outstanding practice at Whipps Cross Hospital.

There were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must improve bed management, theatre management and discharge arrangements to facilitate a more effective flow of patients across the hospital and to improve theatre cancellation and delayed discharge rates. This should include improving flow of patients into and out of critical care.
  • The trust must improve compliance and awareness of trust infection prevention and control policies and processes to ensure surgical staff do not wear theatre scrubs and clogs outside the operating theatres. Additional, the trust should review its infection control policies for ensuring infectious patients are effectively and safely managed in ward areas.
  • The trust must improve compliance with venous thromboembolism (VTE) assessments.
  • The trust must work towards improving the organisational culture to reduce instances of unprofessional behaviours and bullying and ensure all staff feel sufficiently supported by their managers.
  • The trust must ensure all patients are treated in a caring and compassionate manner, and ensure their privacy and dignity is maintained.
  • The trust must ensure that patients' pain levels are monitored and acted on appropriately and that pain relief is provided to patients when required.
  • The trust must ensure there are sufficient numbers of qualified, skilled and experienced staff employed and deployed to meet the needs of patients. This should include ensuring staff have the right skills to recognise and manage the deteriorating patient.
  • The trust must ensure all staff receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.
  • The trust must ensure governance systems are embedded in practice to provide a robust and systematic approach to improving the quality of services. This should capture relevant elements of good governance including an adopting a positive incident reporting culture where learning from incidents is shared with staff and embedded to improve safe care and treatment of patients.
  • The trust must ensure staff on the wards receive sufficient handover including patients' infectious status.
  • The trust must ensure all patients are screened for malnutrition as required by NICE guidelines.
  • The trust must ensure that patients needing urgent referrals or follow up appointments for assessment or treatment are followed up promptly.

In addition the trust should:

  • The trust should improve its performance against the national four hour target for treatment and admission/discharge in ED.
  • The trust should ensure staff always have access to reliable equipment to minimise potential delay to treatment.
  • The trust should ensure mixed-sex accommodation breaches are reported without any delays and as required by NHS England guidance.
  • The trust should consider the use of an acuity tool to manage capacity on delivery suite.
  • The trust should ensure that the latest version of the 'Do Not Attempt Cardio Pulmonary Resuscitation' (DNACPR) forms are used throughout the hospital.
  • The trust should improve access to chaplaincy service to meet people’s spiritual and emotional needs.
  • The trust should ensure the needs and preferences of patients and their relatives are central to the planning and delivery of care at the hospital.
  • The trust should ensure the physical environment is fit for purpose,
  • The trust should ensure children with learning disabilities are identified on presentation to the hospital and facilities to support these children improved.
  • The trust should ensure patients are fully involved in decisions about their care and treatment.
  • The trust should ensure that records are complete, accurate and do not contain variances and discrepancies.
  • The trust should improve the availability of medical records and reduce the requirement for the need for temporary notes.
  • The trust should implement a systematic approach to the assessment of individual risks to the health, safety and welfare of patients.
  • The trust should review medical staffing at night in medical services and nurse staffing on acute assessment unit.
  • The trust should ensure care plans reflect the individual needs of patients, with particular focus on those with complex needs.
  • The trust should ensure compliance with the Mental Capacity Act (2005) and Deprivation of Liberty safeguards (DoLS).
  • The trust should ensure more patients are clinically assessed within the 15 minute national target.
  • The trust should ensure nursing staff caring for patients requiring tracheostomy care are sufficiently trained.
  • The trust should ensure all staff that provide care and treatment to children have the appropriate training.
  • The trust should ensure the emergency theatre is compliant with the surgical safety checklist process.
  • The trust should ensure there are effective systems in place to ensure patient records are tracked and available when required.
  • The trust should ensure that timely arrangements are in place to replace ageing diagnostic imaging equipment identified as at risk of failure.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 15 December 2016

Effective

Requires improvement

Updated 15 December 2016

Caring

Requires improvement

Updated 15 December 2016

Responsive

Inadequate

Updated 15 December 2016

Well-led

Inadequate

Updated 15 December 2016

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 15 December 2016

Infection prevention and control procedures were not strictly adhered to, increasing the risk of infection for patients. Medicines and cleaning fluids were not always stored safely and in line with national guidance.

The provision of compassionate care was not consistent and patients’ privacy and dignity were not always maintained. Communication with patients and their relatives, particularly relating to discharge was variable in quality and timeliness.

A clear management structure and clinical governance framework had been put into place but needed to be further developed to realise the full benefits.

A positive culture of reporting and learning from incidents, along with the daily safety huddles and ward safety briefings, facilitated the escalation of concerns and dissemination of learning.

Staff completion of mandatory training was good and there was access to clinical support and clinical guidelines based on best practice to enable the development and maintenance of staff knowledge and skills.

Urgent and emergency services (A&E)

Requires improvement

Updated 15 December 2016

Patients were taking too long to be initially reviewed against the 15 minute target.

There were not enough doctors in the department with only 4.5 WTE consultants currently in post, which fell short of the 9.4 WTE consultants they should have.

There was no dedicated place of safety room which could be used by patients detained under the Mental Health Act or with psychiatric conditions.

Patients received compassionate care and were treated with dignity and respect. Staff provided appropriate emotional support to patient.

There was clear and effective leadership at all levels and across all staff groups. There were systems in place to identify and manage risk.

Surgery

Inadequate

Updated 15 December 2016

The incident reporting process was inconsistently applied. We found limited evidence of learning from incidents or complaints.

Surgical site infection data was not effectively captured and used to inform the service and drive improvement. Surgical services did not have a well embedded working relationship with the infection prevention and control team. There was also poor communication and understanding between the wards, recovery and acute assessment unit in relation to handovers.

Not all patients were screened for malnutrition as required by NICE guidelines.

We saw little evidence that local clinical and quality audits were regularly carried out. Specialist surgical clinical governance meetings (apart from theatres) were not well embedded, and were poorly attended.

We found staff to be committed, dedicated, caring and motivated to deliver care and treatment to patients.

The surgical service worked towards reducing hospital-acquired pressure ulcers with the surgical wards achieving good results.

Patients’ pain was assessed and managed effectively.

Intensive/critical care

Requires improvement

Updated 15 December 2016

Staff did not always record actions taken or learning points for incidents. The knowledge of incidents and awareness of shared learning was inconsistent. Learning points from mortality and morbidity meetings were not consistently followed up.

ICNARC data for April 2015 to December 2015 suggested the unit had higher than expected mortality levels (compared to similar units nationally). Senior staff were not fully aware of the latest ICNARC clinical audit data results.

The unit was failing to comply with a number of the ‘London quality standards’ for adult critical care. Not all patients were seen and reviewed by the consultant in clinical charge of the unit at least twice a day, seven days a week.

The acute response team (ART) was not able to provide a 24-hour, seven-day service and plans to provide this cover did not seem sustainable. There was poor oversight of the acute response team as it was not managed within the department and division. The team’s activity was not monitored to ensure the team responded to all referrals promptly.

All staff we spoke with demonstrated a good awareness of policies and how to access them. They had a good understanding of their responsibilities with regards to safeguarding patients from harm or abuse.

Staff worked to meet individual needs, for example through translation services, communication tools, and individualised patient diaries, which were used to record patient’s likes and dislikes as well as religious and spiritual beliefs.

Relatives told us the staff were helpful and gave them regular updates and that they felt suitably involved in their loved one’s care.

Maternity and gynaecology

Good

Updated 15 December 2016

Patients and their relatives spoke highly of the care they received in both the maternity and gynaecology services

Staff planned and delivered care to patients in line with current evidence-based guidance, standards and best practice. 

We found all areas of the maternity and gynaecology service we visited to be visibly clean and well maintained.

There were good clinical multidisciplinary working relationships. Leaders were visible and approachable.

Services for children & young people

Good

Updated 15 December 2016

Staff members demonstrated and were encouraged to adopt an open and transparent culture about incident reporting.

Patients were safeguarded from the risk of abuse and we saw that staff fully understood how to activate as necessary the trust’s local safeguarding policies and could describe national best practice guidance.

Children's services participated in a range of local and national audits, including clinical audits and other monitoring activities.

Nursing staff levels did not always meet national standards in the majority of clinical areas including the neonatal unit.

The environment in which children were cared for within Acorn, the general paediatric ward, was in the main appropriate, although residential accommodation for the parents was basic..

End of life care

Requires improvement

Updated 15 December 2016

We observed some patients were visibly in pain, but staff did not respond to this by providing them with adequate analgesia.

There were examples of lack of compassionate care. One patient looked dirty with stains all down the front of their nightwear and staff had neither noticed it nor took any actions to wash and care for the patient.

There was little support provided by the chaplaincy service for people’s spiritual and emotional needs. The needs and preferences of patients and their relatives were not central to the planning and delivery of care at this hospital.

The hospital participated in the National Care of the Dying Audit in May 2015 and in 2016. The hospital performed worse than the England average in most areas for both audits. The service had been slow to start actions and make changes to improve end of life care for patients.

End of life care training was provided during induction but there was no mandatory ongoing end of life care training for consultants.

The trust had developed a draft strategy for the end of life.This had not been linked with other services such as therapy services and chaplaincy.

However;

Medicines were stored and managed safely for end of life patients. Records were complete and accessible and enabled information to be accessed to support patients’ welfare.

There was access to syringe driver equipment and they were in line with national standards.

Outpatients

Inadequate

Updated 15 December 2016

Incidents were not always reported or actioned in line with trust policy. Staff and managers had different views on what should be reported and what actions should be taken when incidents were reported.

Risk registers did not reflect all areas of concern. Risks relating to radiology and diagnostic equipment breakdown were on the risk register, however there was no mention of the impact on patients when appointments were cancelled, or co-ordinated systems in place to ensure patients were appropriately re-booked.

The outpatient department was not tracking all patient health records. The location of medical records was often unknown and resulted in delays or temporary notes being used.

The appointment centre and central booking call centre had a shortage of skilled staff and operating systems that were not working effectively for patients. As a result, patients and staff were often unable to contact the call centre when they needed to.

The trust did not have a robust enough system of audit in place or effective enough means for measuring quality. Reporting turnaround times in radiology and diagnostics were not meeting best practice guidance. Over 25% of radiology and diagnostics patients had not had scans or x-rays reported on within the recommended timescales.

We observed a lack of leadership which led to some staff feeling demotivated, high levels of stress and work overload. This resulted in poor cooperation between teams and staff reluctant to raise concerns.

We saw that records were securely stored.

Medications that were prescribed were managed safely. In outpatients, radiology medicines were stored in locked cupboards in the department. Lockable medicines fridges were in place, with daily temperature checks recorded.

There was evidence of treatment across outpatient’s services that were delivered in line with national guidance and best practice. Staff had access to provision of evidence-based advice, information and guidance. Staff with specialist skills and knowledge supported their colleagues to provide advice or direct support in planning or implementing care. Teams made appropriate referrals on to specialised services to ensure that patients’ needs were met.