You are here

Whipps Cross University Hospital Inadequate

Inspection Summary

Overall summary & rating


Updated 17 March 2015

Whipps Cross University Hospital is part of Barts Health NHS Trust and provides acute services to a population of approximately 350,000 living in Waltham Forest and surrounding areas of East London and Essex.

The trust employs around 15,000 whole time equivalent (WTE) members of staff with approximately 836 nursing and midwifery staff working at Whipps Cross University Hospital.

We inspected this location as a direct response to concerns raised from a number of sources, stakeholders, patients, local politicians and indicators which we consistently monitor. We spoke with over 185 patients and relatives, and 400 members of staff.

Overall, we rated this hospital as 'inadequate'. We found urgent and emergency care, medical care (including care for older people), surgery, services for children and young people, outpatients and diagnostic imaging and services for those patients requiring end of life care were inadequate. Significant improvements are required in these core services.

We found that maternity and gynaecology and critical care require improvement.  

We rated this hospital as inadequate for safe, effective, responsive and well-led and rated caring 

as requires improvement.  

Our key findings were as follows:

  • There was a culture of bullying and harassment and we have concerns about whether enough is being done to encourage a change of culture to be open and transparent.
  • Morale was low. Some staff were reluctant to speak with the inspection team, when staff did some did not want the inspection team to record the discussions in fear of repercussions.
  • The decision in 2013 to remove 220 posts across the trust and down band several hundred more nursing staff has had a significant impact on morale and has stretched staffing levels in many areas. We observed the reorganisation had a damaging impact on staff and the service provided.
  • Staffing was a key challenge across all services and the environment was not conducive to recruitment and retention and the sustainability of services.
  • The implementation of IT systems had impacted on patient safety and care. The trust recognised there had been issues and were attempting to resolve them. However patients were struggling to get appointments and be recognised as needing care and treatment. 
  • Patients, staff and stakeholders including Commissioners, MPs, Royal Colleges, Health Education England and local branches of h

    Healthwatch continue to raise concerns about the quality of the service provided.


  • There were not enough nursing and medical staff to ensure safe care was provided.
  • Handovers between medical staff were unstructured and did not ensure relevant staff were aware of specific patient information or the wider running of the hospital. 
  • There was limited learning from incidents. Staff did not have the time to report incidents, were not encouraged to report incidents and were not aware of any improvements as a result of learning from these incidents. Some senior staff were unaware of serious incidents and action plans that involved them leading the required change.
  • There were low levels of compliance with mandatory training. It was not always evident that learning from the training was embedded.
  • Medicines management required improvement in some areas including, but not limited to the storage and administration of medicines. There was an inconsistent use of opioids across wards.
  • Patients nearing the end of their life were not identified, and their needs therefore were not always assessed and met.
  • The application of early warning systems to assist staff in the early recognition of a deteriorating patient was varied. The use of an early warning system was embedded within the surgery, while in A&E and medical care areas, its use was inconsistent. the National Early Warnings System had not yet been implemented in the hospital.
  • Theatre ventilation was not adequately monitored.


  • The use of national clinical guidelines was not evident throughout the majority of services. An end of life pathway to replace the existing Liverpool Care Pathway had not been introduced. National guidance for the care and treatment of critically ill patients was not always followed.
  • Medical patients pain relief was managed.
  • The management of patients nutritional and hydration needs varied. In the National Care of the Dying Audit patients' nutrition and hydration requirements being met was rated worse than the England average.

  • Patient outcomes in national audits were similar to or below the performance of other hospitals.
  • We were told that actions had been taken to raise staff awareness of the Mental Capacity Act 2005 and deprivation of liberty safeguards. Records showed mental capacity was recorded and families were involved however we found most staff we spoke with lacked an understanding of the Mental Capacity Act and deprivation of liberty safeguards.
  • The trust was working towards seven day working. Job planning for medical staff had started. Access to fundamental diagnostic and screening tests out of hours was limited. There was no critical care outreach team after 5pm or at weekends.


  • Improvements were required to ensure staff were always caring and compassionate and treated patients with dignity and respect at all times.
  • In September 2014, 194 of 210 (92%) respondents to the friends and family test were 'extremely likely' or 'likely' to recommend the inpatient service.


  • The average bed occupancy for from May to October 2014 was 91%. This impacted on the flow of patients throughout the hospital. Patients were cared for in recovery, or transferred out of critical care for non clinical reasons.  
  • Patients well enough to leave hospital experienced significant delays in being discharged because of documentation needing to be completed. During our inspection an estimated 30 patients were well enough to leave hospital but remained because their continuing health care assessments had not been completed. Staff that previously completed this paperwork were no longer in post because of the restructure.
  • Operations were often cancelled due to a lack of available beds.
  • The average length of stay (ALOS) was high, the trust recognised this issue was impacting on patient care and had taken some action to address it. 
  • The hospital was persistently failing to meet the national waiting time targets. Some patients were experiencing delays of more than 18 weeks from referral to treatment (RTT). The trust had suspended reporting activity to the department of health and had started a recovery plan.
  • Many patients experienced delays in their treatment as a result of lack of planning to introduce the electronic patient records system or when transport arrangements had changed. Patients complained that they were unable to get in touch with the hospital.
  • Capacity issues within the hospital led to a high proportion of medical “outliers” (patients on wards that were not the correct specialty for their needs) . The result of this was that patients were being moved from ward to ward on more than one occasion, this impacted on their treatment, delayed their stay in hospital and were on occasion transferred late at night.  


  • Staff told us that the executive team were not visible.
  • Morale was low. The 2013 NHS Staff Survey for the trust as a whole had work related stress at 44%, the joint highest rate in the country for an acute trust. 32% recommend it as a place to work, which is third lowest in the country.
  • Nursing staff who were previously supernumerary to the shift were no longer there to provide leadership and guidance.
  • There were a number of vacant managerial posts and interim staff in post making it difficult for staff to be well-led.  
  • The application of clinical governance was varied, with some services lacking any formal, robust oversight. Risk registers were poorly applied in some clinical areas which led to some risks not being recorded and or escalated.
  • The trust was £13.3 million off its financial plan at the end of September 2014, the year end forecast outturn was revised from £44.8 million to a deficit of £64.1 million. £2 million additional costs were specifically associated with the deployment of IT systems at Whipps Cross University Hospital as the deployment had been unsuccessful  and it had been necessary to invest significant resources to address problems in outpatients booking and scheduling.

We saw some areas of outstanding practice including:

  • Pain relief for children and adults was effectively managed. 
  • The Great Expectations maternity programme had led to a reported better experience for women. There had been a reduction in complaints regarding staff behaviour and attitude and an increase in women's satisfaction of the maternity service.

However, there were also areas of poor practice where the trust needs to make improvements.

The hospital must ensure:

  • Safety and effectiveness are a priority in all core services
  • Services are be well-led.
  • Adequate steps are taken to meet the fundamental needs of patients.
  • There are appropriate levels and skills mix of staffing to meet the needs of all patients.
  • Bank and agency staff are fully inducted to ensure they can access policies, be aware of practices and provide care and treatment in the areas they are required to work in.
  • Complaints are investigated in a timely manner and patients are involved and action taken.
  • Robust assessment and monitoring of the quality of the service.
  • Patients leave hospital when they are well enough. Average length of stay was higher than medically necessary.
  • Procedures for documenting the involvement of patients, relatives and the multi-disciplinary team ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNA CPR) forms are followed at all times.
  • Accurate records are available for the majority of patients attending outpatient appointments.
  • Safeguarding procedures are improved and followed.
  • All staff understand the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
  • Equipment is ready for use and appropriately maintained.
  • The environment is adequately maintained to protect patients.
  • Medications are stored safely.


Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas



Updated 17 March 2015



Updated 17 March 2015


Requires improvement

Updated 17 March 2015



Updated 17 March 2015



Updated 17 March 2015

Checks on specific services

Medical care (including older people’s care)


Updated 17 March 2015

Safety was not a sufficient priority. There were frequent staff shortages and a reliance on agency and locum staff that increased the risk to patients. The handovers did not cover all aspects of patient care, or ensure that staff were aware of how the service was performing. The medical services were not responsive to patient needs.

Patients did not always leave hospital when they were well enough and bed occupancy was regularly over 85%. Patients with complex needs were not always identified, or given access to specific services to cater for these needs.

Performance was between average and poor in national audits. There was a lack of local audits in some areas and a lack of seven-day working.

Although patient feedback was mostly positive, there were concerns with patient involvement in a number of areas and patient survey results were variable.

The medical services were not well-led. There were gaps in the governance arrangements at a middle-management level and the strategy to achieve the vision was unknown.

Urgent and emergency services (A&E)


Updated 17 March 2015

There was no clear vision for the department and monitoring arrangements were not always effective and did not promote improvements from shared learning.

We found that the access and flow did not work well, recognising this was partially linked to the availability of beds throughout the hospital. We saw that there were delays in patients being assessed and in handovers taking place for patients who arrived by ambulance.

Incidents were not always managed effectively in terms of reporting and improving patient outcomes. We also saw examples of patients who had received sub-optimal care during their time in the department.

Due to the high volume of agency and locum staff, there were inconsistencies in the application of trust processes and protocols.

Although most of the patients reported that staff were caring, we made some observations and saw some documentation which indicated patients did not always receive fundamental care and treatment which respected basic rights or their dignity.



Updated 17 March 2015

The service did not protect patients from risks of avoidable harm and abuse.

We identified high numbers of outstanding nursing vacancies, the poor skills mix throughout wards, a high volume of agency staff usage and a high patient volume that had a negative impact on the service. Some wards often relied on recently qualified, or agency staff.

Some agency staff did not have full access to the electronic record-keeping systems, which presented challenges in caring for patients and reporting incidents. We found inconsistencies in incident reporting throughout the service. Staff told us they did not have time to report incidents and that they would not escalate issues of inappropriate staff skills mix of staff shortages, due to fears of repercussions from senior staff. They had rarely received feedback from the incidents they reported to senior staff. Staff commented that they were not sufficiently supported by their seniors. Daily consultant-led care was not embedded.

We found inadequate surgical and medical cover which

that resulted in some unnecessary delays in obtaining some pain relief and clinical reviews, which had an impact on patient discharges. Patients who had undergone surgery were being cared for in the recovery area for extended lengths of time, because of

due to a shortage of surgical beds on the wards. Patients were occasionally transferred to clinical areas that were inappropriate given the complexity of their patients’ needs.

Patient flow within the service was poorly managed, which often led to operation cancellations, delays in treatment, and patients being cared for in inappropriate clinical areas. Operating data was collected in a number of ways by different staff, including handwritten lists, diary notes, theatres lists, and via an electronic system. There was no process to coordinate this information meaningfully in order to monitor the impact of frequent cancellations, or delays, on patients’ clinical outcomes.

We found that a number of medical patients were cared for on surgical wards, surgical patients were cared for on non-surgical wards and we identified that this was common practice. The lack of relevant

meaningful and accurate data and undeveloped governance systems within surgical services meant senior managers did not have a grip on the day-to-day running of the service.

Intensive/critical care

Requires improvement

Updated 17 March 2015

There was poor access and flow within the department and no designated area for patients who required high dependency care, although there was a business case in place for this. Surgical procedures were frequently cancelled and occupancy levels higher than the England average.

There were no clear arrangements in place for learning lessons and meetings were not well attended.

Staff did not feel well supported and there was a high use of agency nurses who did not always report for their shift.

The majority of medical records had been updated and recorded relevant information although nursing records were not contemporaneous notes and instead only recorded variations to expected standards of care.

Restraint guidance was not clear and not always applied in line with legislation.

Staff reported low morale and it was their perception that there was a bullying culture within the trust.

Maternity and gynaecology

Requires improvement

Updated 17 March 2015

We found committed staff and examples of good practice, such as close multi-disciplinary working. There had been improvements since our last inspection, but further work was needed.

Maternity and gynaecology services had taken action to address challenges in meeting the demand for their service. This included improvements to induction of labour and elective caesarean section procedures. Further action was needed to understand the demand for inpatient maternity services and how to make the best use of resources to meet this demand.

There were times of staff shortages in inpatient areas. The process for escalating concerns at these times was not always implemented effectively. The hard work and commitment of midwifery staff helped keep women safe, but this meant that midwives sometimes did not take a break in their 12 hour shift.

The change of patient record software earlier in the year had resulted in difficulties in accessing accurate data about activity in the maternity unit. There was manual verification of some data to make sure key performance indicators were reported accurately.

There was a focus on learning from serious incidents and complaints in women’s services and staff of all professions and grades reported incidents. There had been improvements in the way that complex complaints were dealt with to ensure that people were kept fully informed about investigations. Serious incidents were investigated and actions identified. The response to incidents not categorised as serious, and the process for monitoring the implementation of actions, required further work.

The women’s and children’s healthcare CAG was developing its clinical governance processes. This had promoted shared learning in women’s services, but attendance at trust meetings reduced the presence of senior managers at the site. Guidelines were being reviewed and updated, and there were regular audits, the results of which were shared with staff. Risk registers were regularly reviewed, with responsibility for actions allocated and monitored.

The women using the service said doctors and midwives gave them the information they needed when they attended antenatal appointments. We were told the midwives on the birth unit were “caring and compassionate” and one of the women who had given birth on the labour suite described her midwife as “brilliant”. A woman told us of the poor level of support she had received in recovery following a caesarean section.

The newly refurbished emergency gynaecology unit (EGU) was providing a responsive service to women, but the service was not open at weekends. Women undergoing gynaecological surgery did not always receive post-operative care from appropriately experienced staff.

A values and behaviour programme had been launched in maternity services at Barts Health NHS Trust to improve the way staff interacted with women and with each other and to improve the standard of care. Feedback from women using the service indicated that there had been improvements in patient experience. However, changes to staffing implemented by the trust, such as changes in the management structure, had lowered morale and some midwifery staff did not feel their voice was heard.

Services for children & young people


Updated 17 March 2015

Parents and children were generally satisfied with the care and felt they had been kept well informed. They told us staff were compassionate and caring.

There were concerns about how incidents were reported and acted upon and how learning was shared. Risks were not appropriately managed.

Patients on Acorn Ward did not always receive responsive care because of a lack of registered trained and experienced staff. Beds had been closed to make the service safer, however this was impacting on the rest of the hospital.

Services were not planned or delivered in a way that met the needs of children and young people. There was a lack of designated areas for children in areas they would visit across the hospital. There were avoidable delays in some treatments and transport between services. There was no evidence of learning and sharing from complaints, which would help other areas improve their practices.

While senior staff responsible for the care of young people, children and neonates had a vision for delivering high quality care to their patients, the service was not seen as a priority for the trust board.

End of life care


Updated 17 March 2015

While we found that staff were overall caring and committed to providing good care to patients at the end of life, we had concerns in all domains and rated this service as inadequate overall. Staffing issues had a major impact on the service’s ability to provide good care and we found examples where patients receiving end of life care were not being properly supported. The service was not able to understand how complaints or incidents might relate to end of life care, and the hospital was not measuring the quality of services delivered to patients receiving such care. Limited action had been taken in response to the 2013 review of the Liverpool Care Pathway (LCP) and at the time of the inspection the pathway had not been replaced. 50% of ‘do not attempt cardio-pulmonary resuscitation (DNA CPR)’ forms we reviewed had not been fully completed. We found a number of concerns that related to this service being well-led, with end of life care having no influence within the clinical academic group (CAG). There was a lack of strategy and resources that compromised the service’s sustainability.



Updated 17 March 2015

There were no effective systems for monitoring quality of the services and risks associated with its delivery. The hospital was unable to assess and respond to patients' risk as the data collection was unsatisfactory and the system used for monitoring patients' referral to treatment times and cancellations did not work effectively. The hospital was persistently failing to meet the national waiting time targets.

Staff felt disempowered and that they were unable to take initiative in order to improve the hospital’s performance. We observed lack of leadership which led to staff feeling demotivated. Many of the patients experienced delays in their treatment as a result of lack of planning when changes were introduced. There were problems with access to information as patients’ medical records were not delivered in a timely manner to outpatients clinics.

Although, we observed patients were treated with compassion, dignity and respect, patients did not always feel fully involved in decisions about their care and treatment.