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The Whittington Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 8 July 2016

The Whittington Hospital has approximately 320 beds, and is registered across 3 locations registered with CQC: Whittington Hospital (includes community services) , Hanley Primary Care Centre (GP practice and community centre) and St Luke's Hospital (Simmons House) multi-disciplinary MH service for 13-18 year olds with emotional and mental health problems.

We carried out an announced inspection between 8 and 11 December 2015. We also undertook unannounced visits on 14, 15 and 17 December 2015.

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

This was the first inspection of Whittington Hospital under the new methodology. We have rated the trust as good overall, with some individual core services as requires improvement.

In relation to core services most were rated good with critical care and outpatients and diagnostics rated as requires improvement.

Our key findings were as follows:

  • During our inspection we found staff to be highly committed to the trust and delivering high quality patient care.
  • We saw staff provided compassionate care and patients were positive about the care they received and felt staff treated them with dignity and respect.
  • The trust had vacancies across all staff groups, but was recruiting staff and staffing levels were maintained in services through the use of bank and agency staff.
  • Staff were aware of how to recognise if a child or adult was being abused and received good support and training from the trust's safeguarding team.
  • The trust had an incident reporting process and staff were reporting incidents and receiving feedback. Learning was shared across ICSU’s which encompassed acute and community service.
  • The trust had promoted duty of candour and this was seen to be cascaded through the organisation.
  • We observed effective infection prevention and control practices in the majority of areas we inspected.
  • Patient care was informed by national guidance and best practice guidelines and staff had access to polices and procedures.
  • Patients had their nutritional needs met and received support with eating and drinking.
  • There was good team and multidisciplinary working across all staff groups and with clinical commissioning groups, voluntary organisations and social services to deliver effective patient care.
  • We found evidence of good compliance with the World Health Organisation (WHO) surgical safety checklist, with good completion of the three compulsory elements: sign in, time out and sign out.
  • There were processes in place to ensure staff attended training on the Mental Capacity Act 2005 and the majority of staff demonstrated a good practical understanding of this, with variability in some services,
  • Staff understood and responded to the needs of the different population groups the trust served and worked hard to meet the needs of individual patients.
  • Patients were largely treated in timely manner with the trust meeting national access targets and performing higher than the England average, with the exception of the cancer two week wait standard, although it was noted that improvements were being made against that standard.
  • The emergency department (ED) performed better than the average ED in England in the speed of initial assessment, the timeliness of ambulance handover, and the percentage of people staying for more four hours in the department. However, there were times when there were no in-patient beds available and patients remained in ED for a long time.
  • The trust had introduced the ambulatory care unit, which engaged stakeholders across the health and social care economy to avoid unnecessary hospital admissions and transfer their ongoing care needs to the most appropriate provider.
  • Patient flow out of theatres and critical care, impacted on patient movement and service capacity.
  • Executive and non executive members of the trust were visible in most areas, in both acute and community settings.
  • The trust had a clear vision and strategy, the development of this into local strategies were in place in some areas, but were still being developed in some cases.
  • Staff were positive about how their local and senior managers engaged with them.

We saw several areas of outstanding practice including:

  • Whittington Health NHS Trust worked with clinical commissioning groups (CCGs) and other providers to improve the responsiveness of emergency and urgent care services for local people. The Ambulatory Care Centre, which opened in 2014, provided person-centred hospital level treatment without the need for admission.
  • Within the Ambulatory Care Centre we observed good multidisciplinary working across hospital services, including diagnostics, care of the elderly physicians, therapists, pharmacists, and medical and surgery specialities to provide effective treatment and care.
  • Elderly care pathways had been well thought out and designed to either avoid elderly patients having to go to ED or if they do, making sure that their medical and social care needs are quickly assessed.
  • Within the ED there was outstanding work to protect people from abuse. The lead consultant and nurse for safeguarding coordinated weekly meetings attended by relevant trust wide staff to discuss people at risk and to make plans to keep them safe.
  • Within children and young people’s services responsiveness was demonstrated through close working arrangements with community-based services including the ‘hospital at home’ service which ensured that children could expect to be cared for at home via community nursing services.
  • The trust provided ‘Hope courses’ for patients who had been on cancer pathways to get together outside of hospital, and hear from motivational speakers including talks on personal wellbeing, nutrition and recovery care.

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

Importantly, the trust must:

  • Within the Emergency Department (ED) there was not sufficient consultant cover and there were vacant middle grade medical posts, covered by locum (temporary) doctors, which poses a risk to delivery of care and training staff.
  • Within acute outpatient departments the hospital must improve storage of records and ensure patient’s personally identifiable information is kept confidential.
  • Within the acute outpatient setting, improve disposal of confidential waste bags left in reception areas overnight.
  • Within surgery and theatres review bed capacity to ensure patients are not staying in recovery beds overnight.
  • Within critical care the trust must review capacity and outflow of patients. We observed significant issues with the flow of patients out of critical care and found data suggesting 20% of patient bed days were attributed to patients who should have been cared for in a general ward environment. This led to mixed sex accommodation breaches, a high proportion of delayed discharges from critical care and a number of patients discharged home directly from the unit
  • Within critical care the service must review governance processes and use of the risk register. We were concerned there was a culture of underreporting incidents and near misses and the importance of proactive incident reporting should be promoted.
  • Within critical care staff did not challenge visitors entering the unit and we were concerned patients could be at risk if the unit was accessed inappropriately.
  • Within maternity services the department must ensure the information captured for the safety thermometer tool is visible and shared with both patients and staff in accessible way.
  • Within maternity the service must ensure the safety of women undergoing elective procedures in the second obstetric theatre and agree formal cover arrangements.
  • Within palliative care the service did not meet the requirement set by the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care related to number of palliative care consultant working at the hospital.
  • Within palliative care services staff were not always aware of patient’s wishes in regards to their ‘preferred place of death’. They did not always record and analyse if patients were cared for at their ‘preferred place of care’.

In addition the trust should:

  • Take further action to improve safe nurse staffing levels across the surgery service, particularly within main operating theatres and recovery.
  • Improve consistency of labelling medical equipment that is clean across surgery wards and operating theatres.
  • Ensure healthcare assistants on surgery wards are given competency appropriate tasks and supervision at all times.
  • Improve bed management across the hospital to ensure post-operative patients are allocated to a ward in a safe and timely way.
  • Ensure all recorded risks in the surgery service are addressed in a timely way.
  • Improve engagement with consultant surgeons and anaesthetists working in the surgery service.
  • Improve leadership support and capacity within operating theatres.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 8 July 2016

Effective

Good

Updated 8 July 2016

Caring

Good

Updated 8 July 2016

Responsive

Requires improvement

Updated 8 July 2016

Well-led

Requires improvement

Updated 8 July 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 8 July 2016

We rated the service a Good because our main concerns were limited to safety issues within the service. 

Patient risk assessments were undertaken in a timely and comprehensive manner. Across both services medical, midwifery and nursing staff provided safe care; staffing levels were in line with national averages and were regularly reviewed.

Staff delivered evidence-based care and treatment and followed NHS England and the National Institute for Health and Care Excellence (NICE) national guidelines and policies and procedures were accessible to staff. Staff were competent and understood the guidelines they were required to follow

There was multidisciplinary working that promoted integrated care. The audit programme monitored whether staff followed guidelines and good practice standards.

Staff were caring and thoughtful, and treated women with respect. Patients’ confidentiality and privacy were protected. All the patients and relatives we spoke with gave positive feedback about their care and how staff treated them. Women and their partners felt involved with their care and appropriate explanations were given to them.

Referral to Treatment Times (RTT) for gynaecology patients were routinely above 90%. Appropriate arrangements were in place for patients who could not make informed decisions about their care. Systems were in place to support patients who had a learning disability. Complaints were dealt with effectively and improvements made, where necessary

Whilst there were established local governance and risk management arrangements, safety risks we identified in our inspection had not been addressed. The leadership team was not yet fully established and the vision and strategy of the service was not formal and plans to expand the service had not been fully communicated to staff.

There was limited assurance about safety of women undergoing elective procedures in the second obstetric theatre. Safety information, including staffing levels, was not displayed in any public area. Incidents were reviewed and learnt from, though there were some gaps in ensuring all actions listed on serious incident investigations were completed. Equipment was not readily available in the community and resuscitation equipment was not always checked. Mandatory training rates were, in some areas, well below the trust’s levels of expected compliance.

Medical care (including older people’s care)

Good

Updated 8 July 2016

We rated Medical care (including older people's care) as good overall because most patients were kept safe while they are being cared for at The Whittington Hospital. Patients who are at risk of deteriorating were monitored and systems were in place to ensure that a doctor or specialist nurse was called to provide the patient and ward staff with additional support. The trust had an open culture and had systems that allowed them to learn from clinical incidents. The medical wards had enough doctors and nurses to keep people safe.

We found that care on medical wards was provided in line with national and local best practice guidelines. Audits were being undertaken and there was good participation in national and local audits that demonstrated good outcomes for patients. Patient morbidity and mortality outcomes were well within what would be expected for a hospital of this size and complexity and no mortality outliers had been identified. Although there was a good knowledge of the issues around capacity and consent, the levels of staff training in these areas was low.

Patients received compassionate care and were treated with dignity and respect. Most of the patients and relatives we spoke with said they felt involved in their care and were complimentary about the staff looking after them. One person told us: “It’s great, they look after me well here. They are so nice and take an interest in how I am getting on”. The medical division had good results in patient surveys and results indicated an improvement in the views of patients over the last 12 months.

The medical division is effective at responding to the needs of its patients from all parts of its community. The hospital operational management team had a good understanding of status of the hospital at any given time. Bed availability was well managed. Elderly care pathways had been well designed to ensure that elderly patients were assessed and supported with all their medical and social needs. The hospital had designed pathways that if possible kept patients out of the emergency department (ED). The Ambulatory Care Unit and Hospital at Home provided effective alternate pathways for GPs and other referrers.

The Medicine, Frailty & Networked Service Integrated Care Service Unit (ICSU)is well led. Divisional senior managers had a clear understanding of the key risks and issues in their area. The division had an effective meeting structure for managing the key clinical and non-clinical operational issues on a day to day basis. Staff spoke positively about the high quality care and services they provided for patients and were proud to work for the hospital. They described the hospital as a good place to work and as having an open culture. The most consistent comment we received was that the hospital was a friendly place to work and people enjoyed working with their teams.

Urgent and emergency services (A&E)

Good

Updated 8 July 2016

We gave an overall rating for the urgent and emergency services of good because:

Some aspects of these services were outstanding. The multi-disciplinary working within the services, with other departments within the hospital and with external organisations put the patient at the centre of care and treatment. The Ambulatory Care Centre for adults provided an innovative service to patients, with access to diagnostic, therapeutic and specialist medical and surgical services in one place.

The emergency department (ED) performed better than the average ED in England in the speed of initial assessment, the timeliness of ambulance handover, and the percentage of people staying for more four hours in the department. However, there were times when there were no in-patient beds available and patients remained in ED for a long time.

The timeliness and quality of medical review was sometimes compromised because of the low number of consultant posts and the difficulty recruiting middle-grade doctors. Consultants worked hard to maintain standards in the ED, to review patients with complex needs, and to provide supervision and training to junior and middle grade doctors in training. This was not sustainable with the current consultant numbers. The nursing numbers and skill mix on ED were suitable. Nurses of all grades received excellent training and development opportunities.

ED and ambulatory care took part in national and local clinical audits to monitor the effectiveness of care and treatment. The analysis of incidents, complaints and staff feedback contributed to initiatives to make services safer and more responsive. There was action to improve services, and the action monitored to assess their impact.

There was outstanding work in the ED to protect people from abuse. Staff were well-trained and aware of their responsibilities. The lead consultant and nurse for safeguarding coordinated weekly meetings attended by relevant trust wide staff to discuss people at risk and to make plans to keep them safe.

The Ambulatory Care Centre environment was bright and welcoming and there had been other improvements in the ED, but some areas required further renovation. There were some shortcomings in cleanliness and waste disposal on ED.

The leadership of the newly formed ICSU were clear about their purpose and were confident in achieving this. There was an exceptionally positive culture in ambulatory care, reflected in the views of staff and patients.

Surgery

Good

Updated 8 July 2016

We rated the surgical services as good overall because:

We found that the surgery service at Whittington Hospital was effective and caring. However, improvements were needed to ensure that the service was safe, well-led and responsive to patients’ needs.

The surgery service had a good overall safety performance with low rates of serious incidents and few surgical site infections. We found good processes for reporting and escalation of incidents and good sharing of learning from incidents. All of the clinical areas we visited were clean and there were good infection control systems in place. However, there were significant staffing pressures across the service, particularly around recruitment and retention of nursing staff.

The surgery service at Whittington Hospital was effective. There were good patient outcomes across surgical specialties. The trust performed well in national clinical audits. There were short length of stay and low readmission rates. There was good multidisciplinary team (MDT) working. There were enhanced recovery processes for different patient groups. Good learning and development opportunities were available to staff.

Staff across the surgery service were friendly, caring and professional. Patients told us that nurses and doctors had a caring approach and they were treated with dignity. There was good family involvement and we found a very good approach to partnership care and keeping family members engaged at all stages of the surgery process.

There was good provision and systems in place to support patient’s individual needs, including those with complex needs. Flow within the surgery system was well managed, particularly at the front end of the patient experience, from admissions through theatres and into recovery. However, flow was impacted by significant bed pressures on surgery wards. Surgery wards were used as overflow wards for medical patients.

We found a cohesive and supportive leadership team and there was a clearly defined strategic plan for the service. Leadership of the service was clinically led. Matrons were very visible on the ward and consultants provided clear clinical direction.

The escalation of risks was not robust. A number of identified risks were not addressed adequately or in a timely way. The service required investment by the trust to alleviate pressure and build capacity. There were some challenges with the organisation culture within the service, which impacted on staff morale.

Intensive/critical care

Requires improvement

Updated 8 July 2016

We rated critical care overall as requires improvement because;

There were significant issues with the flow of patients from critical care which meant 20% of patient bed days were attributed to level 1 and level 0 patients who should have been cared for in a general ward environment. This led to mixed sex accommodation breaches, a high proportion of delayed discharges from critical care and a number of patients discharged home directly from the unit. There was little evidence the critical care leadership team were pushing to address these issues and some senior staff failed to acknowledge the problems. The departmental risk register was sparse and did not contain matters identified during our inspection. We were concerned at an apparent under-reporting culture relating to incidents and near misses and senior staff on the unit did not recognise this.

We observed some occasions where patient privacy and dignity was not wholly maintained. Staff were not fully aware how to support people with specific needs such as those with a hearing impairment and staff knowledge of Deprivation of Liberty Safeguards (DoLS) was variable. Staff did not challenge visitors entering the unit and we were concerned patients could be at risk if the unit was accessed inappropriately.

The critical care unit contributed data to national and regional monitoring bodies, allowing outcomes to benchmarked. Patient outcomes were in line with or better than other similar critical care units and use of evidence-based practice was embedded throughout the unit. Safety thermometer results were good and we saw evidence demonstrating staff knowledge and understanding of safeguarding principles. Patient and visitor feedback about critical care was complimentary and staff routinely provided emotional support to patients and their relatives. There was a positive culture on the unit and staff spoke highly of the approachable and supportive leadership team.

Services for children & young people

Good

Updated 8 July 2016

We rated services for children and young people as good overall because;

We saw that there were systems in place to ensure good governance and monitoring of standards for children, young people and infants who required acute medical care and surgical intervention and investigations.

Staff were proud to work for the trust and it was clear from speaking to parents that the public perception of the Whittington trust was very good. Inter-professional working was exemplary throughout children’s services.

Staff were aligned to, and supported the trust wide mission and vision. Leadership of individual aspects of children’s services was good with staff speaking positively about their immediate team leaders. The aspirations of the chief executive and his management team were fully supported by the staff.

End of life care

Good

Updated 8 July 2016

We rated End of Life Care as good overall because;

We found that staff providing end of life services were caring, the service was effective and well led. However, the safety of end of life services provided at Whittington Hospital required improvement. The end of life services also required improvement across the responsive domain.

Patients told us staff were caring and compassionate and that they were involved in planning their care and making decisions. We observed staff being respectful and maintaining patients’ dignity, there was a strong person centred culture. Patients in their last days were suitably assessed and their nutritional and hydration needs were met. Care and treatment was delivered in line with current evidence-based standards. Patients had appropriate access to pain relief. The trust had scored much better than the national average for clinical indicators in the national care of the dying audit. Palliative care and end of life team members were competent and knowledgeable.

There were no serious incidents relating to end of life care in the hospital. Staff received appropriate end of life training. They knew how to report concerns.

There was good end of life care awareness across the hospital. The trust appointed both, a non-executive lead, and an executive director to take lead and provide representation of end of life care at board level. Specialist palliative care team members felt supported in their work and worked well as a team. Staff were clear about their roles and their involvement in decision making and demonstrated a positive and proactive attitude towards caring for dying people.

However, not all staff had received adequate training including training in operating syringe pumps, Mental Capacity Act or training related to patients' deprivation of liberty. Patients DNR CPR forms were not always completed accurately. The trust did not meet the requirement set by the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care related to number of palliative care consultant working at the hospital and provision of seven day services. They did not monitor discharge times and if there were any obstacles to patient’s discharge. There was no formal rapid discharge pathway to ensure speedy discharge of patients who wished to die at home or another location. Staff did not always record and analyse if patients were cared for at their ‘preferred place of care’. The trust did not gather and analyse patients and relatives views in relation to end of life care to inform service delivery and planning.

Outpatients

Requires improvement

Updated 8 July 2016

We rated the outpatient services overall as requires improvement because;

Effective and safe systems were not always in place to monitor and manage risks to patients.

Outpatient staff showed an understanding of the need to report incidents, However, staff were not consistent in reporting incidents and they were not always reported in line with trust policy. This meant the trust did not have an oversight of all incidents that occurred within outpatient services.

We saw that learning from incidents was inconsistent across the specialities and learning from incidents was not shared across the outpatient department as a whole.

Patients’ personal identifiable information was not always kept confidential or stored securely. We saw patient personal information left on top of open trolleys in some clinics unobserved by staff and confidential waste and patient records left unsecured in reception areas overnight. This meant there was a risk of patient records and personal details being seen or removed by unauthorised people.

Systems and processes were not always reliable or appropriate to keep people safe. This meant there was a risk patients were waiting longer than appropriate to be seen.

Infection control standards required improvements. For example, we found risk assessments were not always completed and all nursing staff did not follow infection control processes.

Outpatient and diagnostic imaging services did not identify all risks to patients or effectively manage risks that had been identified.

Patients were not always treated with dignity and patient’s privacy was not always respected.

Trust-wide governance systems were not strongly established and there was a lack of adherence to, and knowledge of, policies and procedures.

Most patients were positive about the care they received.

Managers of outpatient departments were accessible and respected by staff.