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Inspection Summary


Overall summary & rating

Good

Updated 15 August 2016

This was the first inspection of Barnet Hospital under the new methodology. We have rated the hospital as Good overall with all core services rated as Good. 

Barnet Hospital is a Good Hospital providing good levels of care and treatment across all of the eight core services we inspected.

We carried out an announced inspection between 2 and 5 February 2016. We also undertook unannounced visits during the following two weeks.

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

Our key findings were as follows:

  • Staff were proactive in reporting incidents and we saw evidence of learning taking place as a result of incidents. Learning was shared with all staff via safety briefings and posters were displayed within the department.
  • Staff we spoke with were aware of their responsibilities to protect vulnerable adults and children. All staff were fully aware of the duty of candour and were able to give examples of how they applied this requirement in practice.
  • The needs of people living with dementia were being met, staff showed good understanding of the condition. The environment was good for patients living with mental ill health.
  • We found where patients were unable to consent to restraint, no mental capacity assessment had been undertaken and no best interest decisions had been recorded. This meant that patients had their liberty restricted without hospital staff being able to evidence that the patient did not have the capacity to agree to the treatment plan.
  • The trust used a combination of National Institute for Health and Care Excellence (NICE) and Royal College guidelines to direct the treatment they provided and policies, procedures and local guidance were being reviewed to ensure they met NICE guidance. However following the acquisition of Barnet Hospital by the Royal Free Hospitals NHS Foundation Trust staff were still able to access the policies and procedures from the Barnet and Chase Farm NHS Hospitals Trust which could lead to confusion.
  • Where risks were identified such as falls and pressure area management there were action plans to resolve or manage them in a timely fashion.
  • The theatre recovery area is regularly used  to accommodate patients overnight.
  • There was very effective multidisciplinary team working between doctors, nurses, physiotherapists and other allied health professionals. The electronic patient record allowed information to be shared proactively between staff groups to ensure good coordination of patient care.
  • Staff were supported by their managers and there was a culture of openness to learn and develop services. They were also supported by managers and the education team to develop their knowledge and skills to improve the quality of care provided to patients.
  • The trust met the Royal College of Paediatrics and Child Health (RCPCH) standards for paediatric consultant staffing levels and nursing levels were generally complaint to both Royal College of Nursing (2013) and British Association of Perinatal Medicine standards (2011) for staffing children’s wards and neonatal units .
  • There was generally good access and flow within the children’s service. Patients received evidenced based care and treatment and good multi-disciplinary working existed between the children’s services, external providers and the child and adolescent mental health service (CAMHS).
  • The Royal Free London NHS Foundation Trust and it’s staff recognised that provision of high quality, compassionate end of life care to it’s patients was the responsibility of all clinical staff that looked after patients at the end of life. They were supported by the palliative care team, end of life care guidelines and an education programme.
  • The palliative care team was highly thought of throughout the hospital and provided support and education to clinical staff. The team worked closely with the practice educators and link nurses at the hospital to provide education to nurses and health care assistants. Medical education was led by the medical consultants and all team members contributed to the education of the allied healthcare professionals.
  • The outpatient and radiology departments followed best practise guidelines and there were regular audits taking place to maintain quality.

  • The trust had consistently not met the referral to treatment time standard or England average since April 2015.

  • There had been a deterioration in the 62 cancer wait times compared with the national standard.

  • The hospital cancelled 35% of outpatient appointments in the last year. From October to January 34% of short notice cancellations were due to annual leave, which was not in line with trust policy.

We saw several areas of outstanding practice including:

  • We observed dynamic nursing leaders who supported clinical environments are were essential in the development and achievement of best practice models.
  • The neonatal unit at Barnet hospital was very well equipped and offered outstanding levels of compassionate care delivered by all grades of staff from across the whole of the multidisciplinary team .
  • The neonatal unit had level 2 UNICEF accredited baby friendly status where breast feeding was actively encouraged and mothers are given every opportunity to breast feed their babies.

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

Importantly, the trust must:

  • The trust must take action to ensure compliance with The National Patient Safety Agency (NPSA) alert PSA001 issued 31st January 2011.
  • The trust data base of clinical guidelines and procedures hosted via “freenet” should be updated as soon as possible.
  • The recovery area ambiance of theatre must be altered to protect children from witnessing upsetting sights and hearing frightening sounds.
  • Theatre recovery staff must be receive PILS training.
  • The trust must address the issue of the day surgery unit being used to accommodate patients overnight.
  • The trust must ensure the 62 day cancer wait times are met in accordance with national standards.

  • Embedding of fresh eyes for review of CTGs
  • Ensure that emergency drugs such as Sodium Bicarbonate and Adrenaline are removed from the Rescusitaires.

In addition the trust should:

  • The trust should ensure the swab, needle and instrument policy is ratified and new practices are embedded in all relevant departments across all sites.
  • The trust should ensure a safer surgery policy is produced and ratified.
  • The trust should ensure that there is an electronic system in place to flag patients who may require additional support.
  • The trust should ensure fridges are replaced on Damson ward.
  • The trust should ensure appropriate storage of medicines in the day surgery unit.
  • The trust should introduce the use of POSSUM scoring.
  • The trust should ensure the call bells in theatres are improved to be louder.
  • The trust should ensure that RTT is met in accordance with national standards and England averages.

  • The trust should ensure all staff interacting with children have the appropriate level of safeguarding training.

  • The trust should ensure security of prescription forms is in line with NHS Protect guidance.

  • Ensure emergency medication is stored safely and access to these drugs is controlled.
  • The hospital should ensure that all staff undertake mental capacity assessments and record best interest meetings to ensure that they can evidence that staff are working the legal framework of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberties Safeguards (DoLS) training.
  • Ensure that good standards hygiene practices are followed in clinical areas such as hand hygiene and bare below area.
  • The trust performance in the National Safety performance improves to meet the England average.
  • The trust ensures that staff mandatory training on the medicine wards meets the trust target of 95%.
  • Arrangements around equipment storage should be reviewed so that shower rooms are not used.
  • The ward environments for individuals living with dementia should be improved.
  • Improve antenatal risk assessments.
  • Undertake a maternity acuity staffing assessment to identify staffing requirements for the merged service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 15 August 2016

Effective

Good

Updated 15 August 2016

Caring

Good

Updated 15 August 2016

Responsive

Good

Updated 15 August 2016

Well-led

Good

Updated 15 August 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 15 August 2016

A single management team oversaw the main maternity site at Barnet Hospital and a small birthing centre at Edgware Hospital.

At Barnet Hospital w

We saw examples of safety incident reporting systems, audits concerning safe practice, and compliance with best practice in relation to care and treatment.

Staff planned and delivered care to patients in line with current evidence-based guidance, standards and best practice. For example, we observed that staff carried out care in accordance with National Institute of Health and Care Excellence (NICE) and Royal College of Obstetricians and Gynaecologists (RCOG) guidelines.

The ratio of clinical midwives to births was one midwife to 29 women which is slightly higher than the national average of one to twenty eight women. The trust provided evidence of one-to-one care during labour which is recommended by the Department of Health. Women confirmed that they had one to one care in labour and told us they felt well informed and were able to ask staff if they were not sure about something.

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

At Edgware Birth Centre we saw examples of safety incident reporting systems,audits concerning safe practice, and compliance with best practice in relation to care and treatment. Staff planned and delivered care to patients in line with current evidence-based guidance, standards and best practice. For example, we observed that staff carried out care in accordance with National Institute of Health and Care Excellence (NICE) guidelines.The trust provided evidence of one-to-one care during labour which is recommended by the Department of Health.

However,

the named midwife model was not yet in place.

Care and treatment did not always reflect current evidence-based guidance.Staff had access to and used evidence-based guidelines to support the delivery of effective treatment and care. However, some of these guidelines were out of date.

The management structure was top heavy with more band seven midwives than band six midwives.

Senior management and trust board members were not visible. Management had made important changes to the service without consultation.

Medical care (including older people’s care)

Good

Updated 15 August 2016

There was a positive culture of incident reporting. There were established processes for investigating incidents, and there was a range of forums for staff to receive feedback and learn from investigative outcomes.

Staff were aware of their role in relation to safeguarding children and adults and knew how to access the safeguarding team for advice and guidance.

The hospital achieved an ‘A’ rating in the Sentinel Stroke National Audit Programme (SSNAP) for their performance in January to March 2015 and April 2015 to June 2015 and scored above the England average in the Myocardial Ischemia National Audit Project (MINAP), National Diabetes Inpatient Audit (NaDIA), and National Heart Failure Audit.

There was an effective multidisciplinary approach to care and treatment with good communication between the teams.

People were cared for by staff who were kind, caring and compassionate in their approach. Patients and their relatives were positive about their experiences of care and the kindness afforded them. We observed staff being friendly towards patients and treating them and visitors with understanding and patience.

Patients told us they were involved in decisions about their care and treatment and were given the right amount of information to support their decision making. Emotional support was provided by staff in their interactions with patients.

Medical specialities planned their services to meet the needs of the local population. They responded to the needs of an ageing population and were developing services to improve the experience of patients living with dementia.

There was good leadership and management within the medical directorate with strategies on how the services were to develop. Managers were visible and approachable. Staff were proud to work for the trust and enthusiastic in their work.

There was an appropriate system of clinical governance in the medical directorate that identified quality and risk issues. Trends could be readily identified and learning was disseminated to staff.

We found where patients were unable to consent to restraint, no mental capacity assessment had been undertaken and no best interest decisions had been recorded. This meant that patients had their liberty restricted without hospital staff being able to evidence that the patient did not have the capacity to agree to the treatment plan.

Rates of harm free care as monitored by the National Safety Thermometer were displayed and showed wards scoring between 76.9% and 90.7%, which was below the England average of 94%.

Adequate personal protective equipment (PPE), hand washing facilities and hand gel were available for use at the entrance to the wards / clinical areas and standards of hand washing and cleanliness were regularly audited. However we observed poor infection control and hygiene practices.

Compliance with mandatory training for the medicine directorate was 75.1% for medical staff and 85.4% for nursing which was below the trust target of 95%.

The trust used a combination of National Institute for Health and Care Excellence (NICE) and Royal College guidelines to direct the treatment they provided and policies, procedures and local guidance were being reviewed to ensure they met NICE guidance. However following the acquisition of Barnet Hospital by the Royal Free Hospitals NHS Foundation Trust staff were still able to access the policies and procedures from the Barnet and Chase Farm NHS Hospitals Trust which could lead to confusion.

Urgent and emergency services (A&E)

Good

Updated 15 August 2016

Staff were proactive in reporting incidents and we saw evidence of learning taking place as a result of incidents. Learning was shared with all staff via safety briefings and posters were displayed within the department.

Staff we spoke with were aware of their responsibilities to protect vulnerable adults and children. All staff were fully aware of the duty of candour and were able to give examples of how they applied this requirement in practice.

The trust utilised a range of policies and guidelines, which were based on national guidance. Staff were aware of these guidelines and had received appropriate induction and training to carry out their roles.

There was very good evidence of multi-disciplinary working within the department and all members of the MDT worked well together.

The ED provided compassionate care and staff ensured patients were treated with dignity and respect at all times. Patients spoke positively about the care they received and the attitude of motivated and considerate staff and were satisfied with the care they received.

The department had a good understanding of patient flow and managed the system well to ensure most patients accessed the appropriate care pathway for their needs.

The needs of people living with dementia were being met, staff showed good understanding of the condition. The environment was good for patients living with mental ill health.

Operational managers and clinical staff worked together as a team to manage the capacity in the hospital and address the challenges faced by the ED on a daily basis.

There was an open culture so staff could raise concerns. Staff sickness was low and there was a stable workforce within the department. There was clear leadership visibility with the department.

Surgery

Good

Updated 15 August 2016

The general environment was visibly clean and a safe place to care for surgical patients.

We found that services for surgery at Barnet Hospital were caring and compassionate and were well led.

There was a good approach to team work and a good team ethos to achieve the best care for patients. Senior staff were visible, available and supportive to all staff.

Staff were aware of the safeguarding policies and procedures and had received training. Most staff understood their responsibilities under the Duty of Candour and were able to provide examples.

Mandatory training was up to date and staff gave examples of specialist courses undertaken.

There was a good culture of reporting incidents and we saw evidence of changes to practice as a result of investigations, and there were robust systems in place.

Patients’ records were managed in accordance with the Data Protection Act 1998. Records were kept securely preventing the risk of unauthorised access to patient information.

All patients were treated with respect and dignity, and services were responsive to patient’s complex needs.

Staff were competent, knowledgeable and passionate about their specialties on both the surgical wards and in the theatre department.

Wards and departments undertook frequent audits such as environmental, theatre checklist, infection control, hand hygiene, falls and pressure areas. Clinical governance teams analysed the audits and fed the results back to staff.

Where risks were identified such as falls and pressure area management there were action plans to resolve or manage them in a timely fashion.

Recovery was used regularly to accommodate patients overnight.

Barnet hospital performed badly in the national emergency audit. (NELA)

Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) is widely used in the UK in surgery. It measures surgical outcomes based on a standardised scoring system. It provides the patient with as much information as possible to make fully informed consent. This was not being used at Barnet Hospital.

The trust was non-compliant with The National Patient Safety Agency (NPSA) alert PSA001 issued on 31st January 2011.

Intensive/critical care

Good

Updated 15 August 2016

Staff were proactive in reporting incidents and there was evidence that learning from investigations had taken place consistently with an effective system in place to ensure all staff were aware of updates to practice.

We found good levels of cleanliness, infection control and hygiene across critical care and rates of hospital acquired infection were low.

Staffing levels were reviewed continually using an established nursing acuity tool staff to provide care and was in line with national guidance.

Patients on the critical care unit received effective care and treatment that met their needs. Their care and treatment was planned and delivered in line with national and local guidelines.

Patients were treated with compassion, dignity and respect and staff provided emotional support to patients and relatives. All of the patients we spoke with praised the staff for the care they provided and said that they would recommend the critical care services.

There was very effective multidisciplinary team working between doctors, nurses, physiotherapists and other allied health professionals. The electronic patient record allowed information to be shared proactively between staff groups to ensure good coordination of patient care.

Staff were supported by their managers and there was a culture of openness to learn and develop services. They were also supported by managers and the education team to develop their knowledge and skills to improve the quality of care provided to patients.

The leadership team had oversight of the issues affecting the unit but it was unclear what plans were in place to address these.

Services for children & young people

Good

Updated 15 August 2016

The trust met the Royal College of Paediatrics and Child Health (RCPCH) standards for paediatric consultant staffing levels. Nursing levels were generally complaint to both Royal College of Nursing (2013) and British Association of Perinatal Medicine standards (2011) for staffing children’s wards and neonatal units .

There was generally good access and flow within the children’s service. Patients received evidenced based care and treatment and good multi-disciplinary working existed between the children’s services, external providers and the child and adolescent mental health service (CAMHS).

Training provision to staff was good with meticulous recording of mandatory training enhanced by the implementation of a new on line data base to monitor staff compliance.

Children’s service were effectively supported by children’s critical care and neonatal retrieval services.

Staff were caring, compassionate and respectful. Staff we spoke with were positive about working in the service and there was a culture of flexibility and commitment.

The service was well led and a clear leadership structure was in place. Individual management of the different areas providing acute children’s services were well led. A governance system was in place and we saw that clinical risks identified. Feedback from staff, parents and children and young people was generally good.

Although services provided evidenced based care as identified within evidenced based clinical guidelines, many of these were out of date posing potential risks to patients.

The poor post-operative recovery facilities for children exposed them to potential hostile sights and sounds and recovery nursing staff were not PILS trained.

End of life care

Good

Updated 15 August 2016

They was a dedicated team providing holistic care for patients with palliative and end of life care (EOLC) needs in line with national guidance.

The hospital provided mandatory EOLC training for staff. A current EOLC policy was evident and a steering group met regularly to ensure that a multidisciplinary approach was maintained.

The Royal Free London NHS Foundation Trust and its staff recognised that provision of high quality, compassionate end of life care to it’s patients was the responsibility of all clinical staff that looked after patients at the end of life. They were supported by the palliative care team, end of life care guidelines and an education programme.

The palliative care team was highly thought of throughout the hospital and provided support and education to clinical staff. The team worked closely with the practice educators and link nurses at the hospital to provide education to nurses and health care assistants. Medical education was led by the medical consultants and all team members contributed to the education of the allied healthcare professionals.

Medical records and care plans were completed and contained individualised end of life care plans. Most contained discussions with families and recorded cultural assessments. The ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms were all completed as per national guidance. However there were inconsistencies in the documentation in the recording of Mental Capacity Act assessments.

There was evidence that systems were in place for the referral of patients to the palliative care team for assessment and review to ensure patients received appropriate care and support. These referrals were seen and acted upon within 24 hours.

The EOLC service had supportive management and visible and effective board representation. This had resulted in a well led trust wide service that had a clear vision and strategy to provide a streamlined service for EOLC patients.

Outpatients

Good

Updated 15 August 2016

The areas we visited were clean and tidy. Staff on the whole demonstrated good infection control practices.

Staff reported incidents and there were good systems of incident feedback to staff and to governance committees.

Records management was good and over a 12 month period almost 100% of complete medical records were available for clinics.

The outpatient and radiology departments followed best practice guidelines and there were regular audits taking place to maintain quality.

Staff contributed positively to patient care and worked hard to deliver improvements in their departments.

Staff felt supported by their managers and

stated their managers were visible and provided clear leadership.

The trust had consistently not met the referral to treatment time standard or England average since April 2015.

There had been a deterioration in the 62 cancer wait times compared with the national standard.

The hospital cancelled 35% of outpatient appointments in the last year. From October to January 34% of short notice cancellations were due to annual leave, which was not in line with trust policy.