All inspections: Northwick Park Hospital

Northwick Park hospital serves an ethnically diverse population mainly concentrated in the London Borough of Harrow. Northwick Park Hospital provides the following services:

•Urgent and emergency care

•Medical care (including older peoples care)

•Surgery

•Maternity and gynaecology

•Outpatients and diagnostics

•Critical care

•End of life care

•Children’s and young people services.

We inspected medical care and surgery core services at our inspection on 9, 10 and 11 February 2022.

Medical care at Northwick Park Hospital was last inspected in August 2018 when it was rated requires improvement for safe, effective, responsive and well led and good for caring. Medical care was rated as requires improvement overall.

At this inspection our overall rating of medical care stayed the same. We rated the service overall requires improvement. We rated safe, and responsive as requires improvement and good for effective, caring and well led.

Medical services involve assessment, diagnosis and treatment of adults by means of medical interventions rather than surgery. Medical care at Northwick Park Hospital provided care and treatment in the following disciplines: regional rehab unit; stroke; care of the elderly; cardiology; dermatology; genitourinary medicine (GUM) and sexual health; infectious disease; respiratory; rheumatology; endocrinology and diabetes; neurology and gastroenterology.

During this inspection we visited Fielding, Dryden, Crick, Darwin, Haldane, Hardy, Gaskell, Jenner and Fletcher wards. We also visited the discharge lounge and endoscopy. We spoke with 25 staff members and viewed 24 patient records. We also spoke with six patients.

We rated medical care at Northwick Park Hospital requires improvement overall because:

Indications of patients having venous thromboembolism (VTE) prophylaxis were not always specified on the prescription charts we viewed. This meant staff reading the prescription may not have information on patients VTE status.
Records were not always stored securely. We saw records cupboards were not locked when not in use on Darwin ward. This meant unauthorised people may have been able to access patients’ confidential information.
All staff did not consistently receive feedback from incidents. One member of staff on Darwin ward told us they were not aware of an incident that had happened on the ward.
We saw a ‘do not attempt cardiovascular resuscitation’ (DNAR) form on Herrick ward where it was unclear whether the patient’s DNAR had been cancelled. Staff were unable to tell us the reasons for the cancellation.
We saw a sharps bin in the discharge lounge stacked on top of another sharps bin. The sharps bin was open and had not been signed or dated. There was a risk of the sharps bin being knocked over and potentially causing harm to patients or staff.
We saw a wheelchair with broken foot straps on the discharge lounge. There was a risk that staff may have used the wheelchair, even though staff had reported the wheelchair to the medical engineering department.
The hospital was not meeting national standards in some areas of the myocardial ischaemia audit.

However:

The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service-controlled infection risks well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Surgery at Northwick Park Hospital was last inspected in November 2019 when it was rated good in safe, effective, caring and well led and requires improvement in responsive. Surgery was rated as good overall.

At this inspection our overall rating of surgery stayed the same. We rated the service overall as good. We rated safe, effective, caring, and well led as good and responsive as requires improvement.

We visited the following areas during our inspection: Gray ward, Eliot ward, Kingsley ward, surgical assessment units (SAU) on levels two, three, and four, the theatre assessment unit, the west London vascular and interventional service, the post anaesthetic care unit (PACU), the theatre recovery unit, the main theatre suite, and the discharge lounge. The service had 13 theatres, of which 11 were in use. One theatre was being refurbished and one theatre was being converted into a paediatric recovery.

To manage staffing and capacity during the COVID-19 pandemic, the trust had restructured surgical services and treatment pathways. Northwick Park Hospital provided non-elective surgery and patients underwent pre-assessment care at Central Middlesex Hospital. As part of our inspection of surgical care at Ealing Hospital and Northwick Park Hospital, we visited Central Middlesex Hospital to understand the pre-assessment pathway and the post-treatment therapy provided by allied health professionals. We have included the findings in our surgery report for Ealing Hospital.

We rated surgery at Northwick Park Hospital good overall because:

The service managed staffing well and maintained consistent levels of training and appraisals despite pressures on the service caused by COVID-19.
Services were demonstrably multidisciplinary, and staff had established a wide range of new working opportunities to support patient outcomes.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

Pharmacy cover on wards was limited due to short staffing. This meant pharmacists could not always join ward rounds and could not always review prescriptions daily.
The service did not have a coherent, overarching vision for what it wanted to achieve. Individual departments and divisions developed their own strategies in the absence of a trust-level approach.

London North West University Healthcare NHS Trust is one of the largest integrated care trusts in the country, bringing together hospitals and community services across Brent, Ealing and Harrow.

London North West University Healthcare NHS Trust operates hospital services from three main hospital sites:

Northwick Park Hospital
Ealing Hospital
Central Middlesex hospital.

The trust employs more than 9,000 clinical and support staff and serves a diverse population of approximately one million people. The trust was last inspected in 2019 and was rated requires improvement overall.

The trust provides, urgent and emergency care, medical care, surgery, critical care, maternity, gynaecology, children and young people services, end of life care and outpatient services.

The trust provides a range of community services including: dental services, sexual health services, paediatric audiology, musculoskeletal specialist and end of life care.

We inspected one core service at Northwick Park Hospital.

Our inspection was unannounced to enable us to observe routine activity. Before the inspection we reviewed information we had about the trust based on the intelligence we had received.

We carried out an unannounced inspection of the maternity service on 25 and 26 October 2021 at Northwick Park Hospital to follow up the concerns we identified at our previous inspection of the service in April 2021 where we had rated safe and well led as inadequate.

Maternity Services:

Our rating of this maternity services at Northwick Park Hospital improved. We rated this service as Requires Improvement overall at this inspection. We rated safe, responsive and well led as Requires Improvement. We rated effective and caring as Good. We rated it as requires improvement because:

The service did not always have enough midwifery staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. Waiting times were longer for women across maternity services when staffing levels were low.
Mandatory training compliance was still not in line with the trust target of 85%. At 84% compliance, this did not meet the trust target of 85% but was an improvement on previous compliance.
Staff did not always observe control measures to protect women, themselves and others from infection. Some equipment marked as clean had surface dust.
There was some out of date equipment on resuscitation trolleys and cold cots had been out of operation for two months.
We saw loose triage log sheets which could become detached from women’s notes and meant that information could be misplaced. Records when staff had spent ‘Time alone’ with women were still not always being recorded at every antenatal appointment.
We found an open trolley on the delivery suite which contained two drugs vials. There was a risk that unauthorised people could have access to the vials.
Antenatal classes had been reduced as a result of the logistics of providing classes during the COVID-19 pandemic and staff availability. We were told that videos and online classes had been planned, but these had not been implemented.
The triage policy was to admit women on their third call in 24 hours to explore any concerns. However, there was no system of recording the time at which women with concerns had previously called.
Staff on the maternity day assessment unit (DAU) told us there was no clear policy or pathway for women that should go to triage and women that should go to DAU.

However:

New interim leaders had the skills and abilities to run the service. The new managers understood and managed the priorities and issues the service faced. However the trust needed time to embed this improved leadership and also to forge a period of stability by making permanent appointments to the leadership team.
In response to external reviews of the service, managers had produced a maternity improvement plan, this was reviewed and updated weekly.
There had been improvement in doctors, nurses and other healthcare professionals working together as a team to benefit women.
Work was in progress to ensure staff completed and updated risk assessments for each woman and took action to remove or minimise risks.
Staff on triage used the modified early obstetric warning score (MEOWS).
Work was in progress to monitor domestic abuse being assessed at all antenatal appointments.
Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
The service had information boards which carried updates for staff on the maternity risk register.
Policies and clinical guidelines we viewed were up to date and had dates for review.
The service made sure staff were competent for their roles. Managers appraised staffs’ work performance and held supervision meetings with them to provide support and development.
The service had recently employed an audit midwife and a risk midwife to ensure monitoring of patient outcomes and benchmarking of service provision.
It was easy for people to give feedback and raise concerns about the care they received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
Staff understood and respected the personal, cultural, social and religious needs of women and how they may relate to care needs.

Professor Edward Baker Chief Inspector of Hospitals

How we carried out the inspection:

We visited maternity services at Northwick Park Hospital on 25 to 26 October 2021. During the inspection we visited the labour ward, postnatal and antenatal areas, admission triage area, day assessment unit and theatres. We conducted interviews with staff members on the 25 and 26 October 2021. We spoke to 31 staff including service leads, matrons, midwives, medical staff and maternity care assistants. We also reviewed the trust’s performance data and looked at trust policies for the maternity service. You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/whatwe-do/how-we-do-our-job/what-we-do-inspection.

London North West University Healthcare NHS Trust is one of the largest integrated care trusts in the country, bringing together hospitals and community services across Brent, Ealing and Harrow. London North West University Healthcare NHS Trust operates hospital services from three main hospital sites:

• Northwick Park Hospital

• Ealing Hospital

• Central Middlesex hospital.

The trust employs more than 9,000 clinical and support staff and serves a diverse population of approximately one million people. The trust also provides a range of community services in the London Boroughs of Brent, Ealing and Harrow. The trust was last inspected in 2019 and was rated requires improvement overall.

The trust provides, urgent and emergency care, medical care, surgery, critical care, maternity, gynaecology, children and young people services, end of life care and outpatient services. The trust also provides a range of community services including: diabetic eye screening, district nursing, falls services, family dental, musculoskeletal specialist and physiotherapy services and many more. We inspected two core services at Northwick Park Hospital.

Our inspection was unannounced to enable us to observe routine activity. Before the inspection we reviewed information we had about the trust based on the intelligence we had received.

We carried out an unannounced focused inspection of the emergency department at Northwick Park Hospital on 19 and 20 April 2021, in response to concerning information we had received in relation to the care of patients in this department. We also took into account nationally available performance data and concerns we had received about the safety and quality of the services. At the time of our inspection, the department was under adverse pressure due to the COVID-19 pandemic.

We carried out an unannounced focused inspection of the maternity service on 19 and 20 April 2021 at Northwick Park Hospital in response to concerns we had received in relation to the care of mothers and babies in the department.

Focused inspections can result in an updated rating for any key questions that were inspected if we inspect the key question in full across the service and/or we had identified a breach of a regulation, and issued a requirement notice or taken action under our enforcement powers. In these cases, the ratings will be limited to requires improvement or inadequate.

Following this inspection, under Section 31 of the Health and Social Care Act 2008, we sent the trust a letter of intent to take urgent actions as we believed people would or may be exposed of risk to harm.

Maternity services:

We rated this service as inadequate at this inspection. Overall, we rated safe, and well-led as inadequate. The ratings in effective, caring and responsive stayed the same. In maternity we found:

Mandatory training compliance was not in line with the trust target of 85%. Medical staffing compliance was poor and not on the service’s risk register.
We were not assured the trust had effective systems in place to ensure that medical and midwifery staff had the competence, skills and experience to safely care for and meet the needs of women and babies within all areas of the maternity service.
Staff did not always complete and update risk assessments for each patient and did not always remove or minimise risks. We found domestic violence was not always documented.
We found that the triage function was not using Maternity Early Obstetrics Warning Systems (MEOWS) scoring in the records we reviewed and was relying on clinical judgement to escalate patients. The triage area had not been audited since 2018 and we were not assured women were seen in a timely way.
The service did not always manage patient safety incidents well. We were not assured incidents were always reported in a timely way and that lessons learned were always shared amongst the whole team and the wider service. When things went wrong, there were concerns that there was a lack of transparency through fear of being blamed.
We were not assured the leaders had the skills and abilities to run the service. We were concerned that leaders within the service were not effective at implementing meaningful changes that improved safety. The governance structure and leadership team were new and had not embedded practice to implement change at the time of the inspection. Leaders said it was still very early in the process.
We found policies that were not up to date to ensure staff deliver high quality care according to evidence-based practice and national guidance.
We found doctors, nurses and other healthcare professionals did not always work together as a team to benefit women. We were not assured they supported each other to provide good care.
The service did not have a good culture and there were multiple allegations of bullying. There were mixed views regarding whether staff felt respected, valued and supported.
We were not assured staff were always focused on the needs of the women receiving care, and whether the service promoted equality and diversity in daily work.
We were not assured all leaders were aware of the challenges to the service. Some leaders did not know what was on the service’s risk register and there were long standing issues which had not been addressed. Some staff said leaders were not visible and did not act in a timely way to address issues within the service.
We were not assured risk management was robust and identified all risks within the service.
Staff understood how to protect women from abuse however safeguarding training compliance was not always meeting the trust target and domestic violence assessments were not documented in all women’s notes.

However:

The service controlled infection risk well. Staff used equipment and control measures to protect women, themselves and others from infection. They kept equipment and the premises visibly clean.
The service used systems and processes to safely prescribe, administer, record and store medicines. Medicines were stored securely in all the clinical areas we visited.
Following the external reviews of the maternity services, the trust had developed a Maternity Improvement Plan based on recommendations from external reviews which incorporated suggestions from the engagement work that was ongoing with staff.

Urgent and emergency services:

We did not rate this service at this inspection. The previous overall rating of requires improvement remains. In urgent and emergency services we found:

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
The service generally controlled infection risk well. Staff wore the right personal protective (PPE) to keep themselves and others safe from cross infection. Patients had an assessment of their infection risk on arrival at the department and staff allocated them to the correct areas.
The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The service had enough medical staff to ensure safe care was provided at all times
Staff mostly kept detailed records of patients’ care and treatment. Records were clear, up to date and stored securely.
The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
Patients could access the service when they needed and were able to access treatment promptly. The trust had significantly improved their patient handover and treatment time performance.
Leaders had the skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff.
Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
Leaders and teams used systems to manage performance effectively. They identified and escalated most relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events.

However:

Senior leaders were not aware of all of the risks in the department. We were told that staff were responsible for changing the filters on masks and the leadership team did not monitor this or have oversight of this. Therefore, we were not assured the filters were changed in a timely manner as per guidelines which could create a risk for both patients and staff.
Patient safety checklists were not consistently filled in for three sets of records that we reviewed.
Nursing staffing vacancies remained a challenge for the department. The service acknowledged that there were vacancies particularly for band five nursing staff. The department leaders had been working on recruitment in order to improve this vacancy rate. Managers regularly reviewed and adjusted staffing levels and skill mix, and regular bank and agency staff were used to fill gaps.

Professor Edward Baker Chief Inspector of Hospitals

How we carried out the inspection

We visited the emergency department at Northwick Park Hospital on 19 April 2021. We visited all areas of the emergency department including the paediatric emergency department. We conducted interviews with staff members on 19 April 2021 and 20 April 2021.

We reviewed 23 patient care records and observed the care provided. We spoke with 24 staff members including nurses, matrons, practice development nurses, junior doctors, middle grade doctors, coordinators, consultants, healthcare assistants, senior leaders, administrative staff and one patient.

We also reviewed the trust’s performance data and looked at trust policies for the emergency department.

We visited maternity services at Northwick Park Hospital on 19 April 2021. During the inspection we visited the labour ward, postnatal and antenatal areas, admission triage area, day assessment unit and theatres. We conducted interviews with staff members on 19 April 2021 and 20 April 2021. We spoke to 39 staff including service leads, matrons, midwives, medical staff and maternity care support workers.

We also reviewed the trust’s performance data and looked at trust policies for the maternity service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Our rating of services stayed the same. We rated it them as requires improvement because:

Compliance rates for mandatory training and safeguarding training were below trust targets.
The Clinical Decision Unit (CDU) was still admitting patients against the admission criteria in order to help prevent breaches within the department. Patients were being held on CDU who required and were waiting for a bed within the hospital.
The emergency department still faced significant issues with ambulance turnaround which led to high numbers of black breaches due to the volume of patients the department received on a daily basis. However, the service had improved the way patients were offloaded to ensure patient safety. The department had introduced a streaming team to assess patients on arrival by ambulance. This ensured patients observations and early warning scores were taken and they were streamed to appropriate areas of the department.
People did not always have prompt access to the service when they needed it. Waiting times from referral to treatment and decisions to admit patients were not always in accordance with best practice recommendations relating to national standards.
Some medicine storage areas did not meet national guidance for security for controlled drugs
Records showed that temperatures had fallen outside of the recommended range for storing medicines and action had not always been taken by staff.
Managers did not always effectively appraise all staff’s work performance.
Nurse vacancy rates were high in the surgical service.
Not all formal complaints were responded to within the timeframe set by the trust.
The maternity service did not always control infection risk well. Hand hygiene was not consistently being undertaken. We observed areas were clean however we received information from one patient which suggested this wasn’t always the case.
Consultant obstetricians were attending handover in the morning but not in the evening. We were told by the trust that consultant obstetricians were available by telephone for the evening handover.
All staff told we spoke with in the maternity service told us that there appeared to be a shortage of staff
The service did not use monitoring results well to improve safety. We did not see evidence of use or knowledge of the Maternity Safety Thermometer
Some staff had a variable understanding of the mental capacity act (MCA) and deprivation of liberty safeguards DoLS.
There were systemic issues around culture within the maternity service. We were told that staff morale had deteriorated because of staffing pressures and that some staff were going off sick due to the culture of the organisation.
The maternity service did not have an open culture where staff could raise concerns without fear. Staff were not able to raise concerns without fear of reprisal.

We undertook this focused inspection to follow up on the concerns identified in two Section 29A Warning Notices served in July 2018, following an inspection of the trust in June 2018. We Judged that the requirements of the warning notice had been met. The warning notices set out the following areas of concern, where significant improvement was required:

In maternity there were several concerns which we listed in our warning notice:

We were not assured that there were robust systems in place to ensure that all the correct staff were bleeped on an ongoing basis.
We were not assured that there was a system in place to ensure that the correct staff were bleeped at all times.
We were not assured that systems were in place to ensure that unauthorised persons could not gain access to the maternity surgical theatres via use of the staff/theatre lift.
We observed that the doors to the delivery suite from the theatres were not controlled by a secure access system.
We were notified that the main doors to the maternity unit could be forced opened, allowing unauthorised persons to enter the building.

In critical care we found two concerns, which we listed in our warning notice:

We were not assured that there were sufficient handwashing facilities to mitigate the risk of cross-contamination.
We were not assured that the beds within critical care were appropriately located to enable staff to perform emergency lifesaving care and treatment.

Our key findings were as follows:

In maternity we found:

Several improvements had taken place since the comprehensive inspection report published in August 2018.
The main security issues in maternity had been addressed.
The maternity service had installed new outer main doors which could not be opened by force.
The estates team reconfigured the lifts in maternity to prevent public access into the theatres corridor.
New doors had been installed between the delivery suite and theatres to improve the overall security within the maternity department.
Access to the building and in particular to the delivery suite was controlled by 24 hour receptionists in the delivery suite who were able to monitor visitors via security camera.
Security staff told us that they patrolled the building regularly to check on and remove any unauthorised persons who may have gained access to public corridors.
A member of the estates team told us that they were continuing to review security systems in this area of the trust to see what further improvements could be made.
Switchboard tested the bleep system twice a day and recorded and acted upon the outcomes.

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

All information to the public regarding tailgating, which lifts to use and the closing times of the maternity link corridor was in English only. Senior staff we spoke with told us that work was in progress to get the signs translated into up to 3 other commonly spoke languages.
It was still possible, because of the need to ensure safe evacuation of the building for members of the public to allow access to the building by pressing an access button. This was mitigated by the secure access systems into the maternity unit itself.
There was no nominated list of relatives or friends or equivalent that an expecting mother could set up to control the people visiting the maternity department.

In critical care we found:

The removal of two beds in critical care and the repositioning of the remaining furniture to allow staff to deliver emergency lifesaving care and other treatment effectively was completed promptly and efficiently.
Additional hand washing facilities have been inserted into critical care to mitigate the risk of cross contamination.

In addition the trust should:

Continue to ensure robust security measures are in place across the trust.
Look at further ways of verifying and controlling people entering and exiting the maternity department building.

Professor Edward Baker

Chief Inspector of Hospitals

Our rating of services stayed the same. We rated it them as requires improvement because:

We rated caring at Northwick Park hospital as good. We rated safe, effective, responsive and well-led as requires improvement.
Critical care improved from requires improvement to good.
Maternity went down from requires improvement to inadequate.
Urgent and emergency services, medical care, surgery and children and young people’s services remained as requires improvement.
We rated well-led as inadequate in medical care and maternity.
We rated safe as inadequate in maternity services.

Northwick Park Hospital is in the London Borough of Harrow. It is part of the London North West Healthcare NHS Trust whichis one of the largest integrated care trusts in the country, bringing together hospital and community services across Brent, Ealing and Harrow. Established on 1 October 2014 from the merger of North West London NHS Trust and Ealing Hospitals NHS Trust, and employing more than 8,000 staff it serves a diverse population of approximately 850,000.

The trust runs Northwick Park Hospital, St Mark’s Hospital, Harrow; Central Middlesex Hospital in Park Royal and Ealing Hospital in Southall. It also runs 4 community hospitals – Clayponds Rehabilitation Hospital, Meadow House Hospital, Denham unit and Willesden Centre - in addition to providing community health services in the London Boroughs of Brent, Ealing and Harrow.

At the end of the financial year 2014-15 the trust had a deficit of £55.9 million.

We carried out this inspection as part of our comprehensive acute hospital inspection programme for combined acute hospital and community health based trusts. We inspected Northwick Park Hospital, Ealing Hospital and the following community health services: community services for adults; community services for children, young people and families; community inpatient services; community services for end of life care and community dental services.

The announced part of the inspection took place between 19-23 October 2015 and there were further unannounced inspections which took place between 3-7 November 2015.

Overall we ratedNorthwick Park Hospitalas requires improvement. We rated end of life care as good.We rated the followingservices as requires improvement: Urgent and emergency care, medical care including care of the elderly, surgery, critical care, maternity and gynaecology, acute services for children,and outpatients and diagnostic imaging.

Overall we rated caring at thehospital as good but safety, effective, responsive and well-led as requires improvement.

Our key findings were as follows:

The merger of the trust had been protracted and subject to delay. This had had a negative effect on performance and leadership.
We saw overall disappointing progress in merging systems and processes at the trust. To most intents and purposes Ealing and Northwick Park appeared to be operating as separate entities and community health services appeared disengaged from the rest of the trust.
There appeared to be substantial duplication of support functions at both main sites. There appeared to have been lack of control over spend of administrative, non-staff, and nursing staffing budgets with little rationale over nursing numbers on wards.
A new chief executive had recently been appointed earlier in 2015. She was in the process of building a new executive team and by the time of our inspection only one member of the previous substantive executive team was in post. This meant that the new executive team were in the process of getting to grips with their respective functions.
All staff working at the hospital were dedicated, caring and supportive of each other within their ward and locality. There was a high degree of anxiety and uncertainty borne out of the merger.
There appeared to be a lack of firm information provided to staff about the effects of Shaping a Healthier Future - to reconfigure services in north west London - despite the chief executive holding regular briefing session. This added to staff anxieties.
We saw several areas of good practice or progress including:
a newly opened emergency department at Northwick Park
a refurbished and child friendly ward for children's care called Jack's Place.
caring attitudes, dedication and good multi-disciplinary teamwork of clinical staff.
good partnership working between urgent and emergency care staff and London Ambulance staff.
good induction training for junior doctors.
research projects into falls bundles, stroke trials and good cross site working in research.
Staff told us there were good opportunities for training and career development.
We found the specialist palliative care team (SPCT) to be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner.
The play specialists in services for children demonstrated how they could make a difference to the service and its environment in meeting the needs of the children and young people. This includedan outstanding diversional therapy approach for children and young people, which was led by the play specialist and school tutor.

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

There was limited sparse medical cover on eHDU out of hours and at weekends, which meant there was frequently no doctor immediately available on the unit. Consultants responsible for eHDU and Dryden HDU were not intensivists and processes for escalating surgical patients were unclear. Additionally, less than the recommended proportion of eHDU nurses had critical care qualifications.
There was a lack of expert support from consultant radiologists at weekends, which impacted on the accuracy of clinical diagnosis being achieved. Risks related to patient safety and service delivery had not always been identified and agreed timelines for resolution had not always been identified. Thisled to scans being reported by specialist registrars (SpR’s) and amended by consultants on Mondays. They reported an apparent 25% amendment rate, with missed pathologies.
Surgical staff were not always reporting incidents. Consultants and other surgical staff told us they did not routinely complete incident reports for issues or concerns as the forms were said to be “too laborious” and nothing was done to change the problems highlighted.
Access to services and patient flow through the ED at Northwick Park to wards in the hospital was poor and patients experienced long waits in the HDU and assessment unit areas.
The performance dashboards for ED showed that compliance with achieving the mandatory targets, including the 4 hour treatment target, had been poor over the previous 12 months.
The emergency department participated and performed poorly in the College of Emergency Medicine audits on pain relief, renal colic, fractured neck of femur and consultant sign-off; and there were no clear action plans drawn up by the department indicating what actions were taken as a result of the audits.
Compliance with safeguarding training was poor particularly among medical and dental staff.
The trust target was to have 95% of staff having completed mandatory training. Trust data, as of March 2014 – July 2015, showed compliance with the target was poor in many areas.
We saw examples of poor infection control practice such as linen left on a bin when a nurse was putting gloves on, staff wearing nose rings and hooped earrings that were not covered and name badges that were made of paper.
There was a poor environment on the stroke wards at Northwick Park Hospital.
There were poor handovers between ED and the wards at Northwick Park with MRSA screening and medicines management not always clear or complete in the handovers.
Nutrition and hydration was poorly managed on Northwick Park medical wards with poor assessments, choice of food and support for those that needed it.
In surgery, several groups of patients had no formally defined pathway, which impacted on their safety.
The National Bowel Cancer Audit for 2014 indicated that data completeness for patients having major surgery was poor at 30%, compared with an England average of 87%.
There was a lack of formal escalation process for surgical patients who deteriorated on eHDU aside from the support provided by the outreach team.
Handovers to the consultant taking over care of eHDU patients on a Monday morning was completed by the weekend on call anaesthetic registrar rather than a consultant to consultant handover. Staff highlighted this as a concern as there wasarisk important information could be missed.
In maternity and gynaecology, there were safety concernsrelated to midwife shortages, not having safety thermometers on display and some staff reporting that they did not get feedback after reporting incidents.Staff raised concerns about one midwife covering the triage and observation areas at same time during times of pressure.
We were concerned that some of the risks we identified were not on the risk register, such as the room used for bereaved women on the delivery suite at Northwick Park Hospital with a lack of sound proofing from the ward.
Staff on wards outside of the end of life team had a poor understanding of end of life care and the trust LDLCA - Last days of life care agreement. Concern was raised that doctors and nurses on the wards did not recognise deteriorating and dying patients.
Signage for outpatient clinics was in some cases poor and or stopped short of providing clear directions for patients.
In outpatients and diagnostic imaging, poor patient experience was due to overbooking clinics, lack of capacity in outpatients and lack of availability of medical records in time for clinics.
In OPD, we were concerned incidents were not always appropriately recognised, escalated or investigated and lessons learned were not widely shared
The pre-inspection information identified some concerns around consultant cover in haematology. Some of the facilities were not suitable to meet the needs of patients, for example, the haematology day care service.
Audits showed hand hygiene was a concern with some wards either not submitting audits or scoring less than 90%.
We had concerns with medicines given by night staff. Drug rounds were arranged so night staff had a round at the start and two at the end of their shift with a potential increased risk of error.
All types of therapy visits on wards were unscheduled meaning patients could miss their therapy if they were away from their bed or in pain.
Trust wide there weretemperature control issues across sites in rooms where medicines are stored.
The above list is not exhaustive and the trust should address these and the rest of the issues outlined in our reports in its action plan.

Importantly, the trust must:

provide expert support from consultant radiologists at weekends.
ensure effective processes for reporting, investigating and learning from incidents, and ensure all staff always report incidents.
provide sufficient trained and experienced medical and nursing cover on eHDU at all times including out of hours and at weekends to ensure immediate availability on the unit.
Weissued the trust with a Section 29 (A) warning notice in relation to the three " must do" items listed immediately above requiring substantial improvements.
The above list is exhaustive and the trust must pay attention to remedy all other issues raised in the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Northwick Park Hospital

All Inspections

9, 10 and 11 February 2022

During a routine inspection

25 October 2021 and 26 October 2021

During an inspection looking at part of the service

19 April 2021 and 20 April 2021

During an inspection looking at part of the service

02 July to 15 August 2019

During a routine inspection

09 January 2019

During an inspection looking at part of the service

Professor Edward Baker

5th June to 7th June 2018

During a routine inspection

19-23 October 2015; unannounced visits between 3-7 November 2015

During a routine inspection