You are here

Watford General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 1 March 2017

West Hertfordshire Hospitals NHS Trust provides acute healthcare services to a core catchment population of approximately half a million people living in west Hertfordshire and the surrounding area. The trust also provides a range of more specialist services to a wider population, serving residents of North London, Bedfordshire, Buckinghamshire and East Hertfordshire.

This was the second comprehensive inspection of the trust the first taking place in April and May 2015. It was rated as inadequate overall and went into special measures in September 2015.

Part of the inspection was announced taking place between 6 and 9 September 2016 during which time the hospitals that make up the trust, Watford General Hospital, St Albans Hospital and Hemel Hempstead Hospital were all inspected. Unannounced inspections were undertaken of Watford Hospital and Hemel Hempstead on the 19 September 2016.

We have rated Watford General Hospital as requires improvement overall. Medicine, emergency services, critical care, maternity and gynaecology and end of life care were all rated inadequate in September 2015. Emergency services remain inadequate, however, all, except critical care, maternity and gynaecology services and end of life care, which have now been rated good, have been rated as requires improvement. This means all these services, except emergency services and services for children and young people, have improved and provide a better service to their patients. There was one outstanding rating, caring within children and young people’s services.

Our key findings were as follows:

  • Most staff were aware of their roles and responsibilities in the management and reporting of incidents, however this was not consistent in all areas of the hospital. The hospital had a lower rate of incidents compared to the national average. This can be an indicator that not all incidents are being reported. In addition, feedback from incidents and evidence of learning from them was inconsistent throughout the hospital.
  • Duty of candour was poorly known amongst most trust staff and there was limited evidence that it had been applied routinely.
  • There had been one never event which occurred in the maternity service. A root cause analysis had been undertaken and there was evidence of learning from this event and actions taken to mitigate future risk.
  • There were effective safeguarding procedures in place for both adults and children. Staff had received appropriate training, in most departments. However, not all who dealt with children and young people were trained to level three, which is the expected standard.
  • Patients did not have their mental capacity assessed in accordance with the requirements of the Mental Capacity Act 2005 (MCA) and associated code of practice. There was no trust database relating to the total number of patients, the expiry of initial authorisation or the date of external assessment. This meant that patients were potentially being deprived of their liberty without appropriate authorisation made. Locally, some wards had understanding of those patients who were being cared for under a deprivation of liberty safeguard (DoLS). In addition, the Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) form did not prompt staff to complete a capacity assessment as part of the decision making process.
  • Provision for patients who had a mental health problem was poor in the emergency department.
  • The trust was making improvements to the organisation of outpatient clinics. However, clinics still frequently over-ran and some patients told us they had experienced long delays. The length of time patients waited to be seen was not monitored. The trust’s patient administration system had no facility for recording when patients were seen and the information was not collected manually.
  • There was a notable culture of acceptance regarding the waiting time breaches in the emergency department with many relating to time to see a clinical decision maker or receive treatment from a doctor. This had improved at the unannounced inspection.
  • The percentage of patients discharged, admitted or transferred within four hours was consistently around 83%, against a target if 95%.
  • The number of ambulance handover delays over 30 minutes totalled 2,535, putting the trust in the top quartile of all trusts in England. Between November 2015 and August 2016, the trust has had 2107 black breaches.
  • The percentage of patients leaving the department before being seen was higher, at 6.5%, than the England average of 3%.
  • The percentage of emergency admissions via A&E waiting from four to 12 hours from the decision to be admitted ranged from 12% to 44% against the England average of 8%.
  • Referral to treatment performance had been improving since the last inspection, and exceeding the target for some clinics. However, due to poor performance in certain clinics only 86% of patients met this target from May 2016 to September 2016.
  • Data for September 2016 showed that the trust had fallen below the national 93% target that all suspected cancers should be referred to a consultant and seen within two weeks; only 89.4% of patients were seen within this time period. For breast cancer, for the year to date only 76% patients had been seen within two weeks.
  • The Five Steps to Safer Surgery checklist were not consistently used; there was a mixture of five and three step processes in operation.
  • The management and storage of medications was not always safe. There was varied practice regarding the safe management and storage of patients own controlled drugs. Treatment room temperatures consistently exceeded recommended temperatures.
  • Staffing levels were below the trust targets. Mandatory training compliance did not meet the trust target of 90% in all subjects, including basic life support. Not all staff had received an annual performance appraisal. This was a concern we raised in our previous report.
  • Although we saw that all departments appeared to be clean, Patient-led assessments of the care environment (PLACE) audits for cleanliness and privacy and dignity were below the England average. We found that there was some poor practice around privacy and dignity in outpatients.
  • The Intensive Care National Audit and Research Centre (ICNARC) results 2016 showed the critical care unit had a higher than national average for delayed discharges of 14% compared to the national average of 5%. The trust was in the worst 5% of units for this element. On occasions the unit was unable to admit or discharge patients due to the unavailability of beds. This resulted in single sex breaches. Patients could be nursed in theatre recovery for over 10 hours whilst waiting for a bed either in the critical care unit (CCU) or on the ward. We found that patients experienced multiple moves within admission areas, and were frequently transferred between areas overnight.
  • Patients told us that the care they received was good and that they felt safe and in most departments. We saw patients were treated with dignity, respect. During our inspection the weather was hot; we saw that in most departments there was no provision for ensuring patients received extra fluids during this time.
  • Staff had undergone sepsis training and were able to recognise and treat sepsis according to national guidelines.
  • The numbers of MRSA, Methicillin Sensitive Staphylococcus Aureus (MSSA), and Clostridium difficile, reported between June 2015 and May 2016 were lower than the England average. Between June 2015 and June 2016 there were low numbers and prevalence rates of pressure ulcers, falls with harm and catheter acquired urinary tract infections reported.
  • The children’s emergency department was outstanding in terms of environment. Children and young people had a dedicated resuscitation area away from the adult department, which was set up with equipment and medicines for children. The medicines storage and management of medicines in the children’s emergency department was exemplary.
  • Relationships between staff, patients and relatives were strong, caring and supportive. Staff regularly went above and beyond for the children and young people who used their services and valued their emotional wellbeing
  • Staff treated all patients with kindness, dignity and respect. All patients and their carers that we spoke with told us that staff were kind, caring and included them in the planning of care and treatment.
  • Patients moving from children’s services to adult services were prepared in advance for the transition by individual specialist consultants and nurses.
  • Nursing staff completed local induction training when they joined the outpatient department. We saw the training programme which included training on the use of equipment within the department and a medicines competency assessment. Induction programmes were developed to meet the needs of different staff groups for example for trained nurses and healthcare assistants.

We saw an area of outstanding practice in the children’s emergency department where children were seen promptly.

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

Importantly, the trust MUST:

  • Ensure that care for patients with mental health issues in the emergency department is safe by ensuring that they are cared for in a safe environment, that their safety is risk assessed, and that staff are suitably trained to meet their needs, as well as keep staff safe from harm.
  • Ensure governance quality systems, including the reporting of incidents, duty of candour, completion of local audits, learning from incidents and complaints and ensuring the risk register is up to date.
  • Ensure that observations of patients who could be acutely unwell are undertaken in a timely way and escalated as required.
  • Ensure the timely completion of patient records.
  • Ensure that patients who have been in the emergency department for more than six hours are reviewed by a senior clinician and are risk assessed.
  • Ensure that there is a provision for the offering of regular drinks to patients during their time in the emergency department.
  • Ensure that there are appropriate systems in place to track the patients and the expiry of those being treated under a deprivation of liberty safeguards.
  • Ensure that staff completing ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms where a person lacks capacity to make an informed decision or give consent act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.
  • Ensure that all staff caring for patients less than 18 years of age has completed safeguarding level 3 training.
  • Ensure the safe management of medicines at the hospital complies with Home Office 2016 guidelines on the security of controlled medicines. This includes patients’ own medication.
  • Ensure that there are procedures in place for the safe management of temperatures within treatment rooms and areas where temperature sensitive medications are stored.
  • Prescriptions for syringe pumps must comply with the trust’s prescribing standards.
  • Ensure that mandatory training compliance meets trust targets of 90%, including blood transfusion training.
  • Devise an action plan to address the shortfall between appraisal rates and the trust target and make sure that the trust target is reached.
  • Ensure staff in outpatients comply with the trust’s hand hygiene policies.
  • Ensure treatment rooms where invasive procedures take place are clean.
  • To improve the percentage of patients to be seen within 18 weeks of referral from a GP for an outpatient appointment.

  • To improve the percentage of patients waiting to see a consultant with a suspected cancer to meet the national target of 93%.

Action the hospital SHOULD take to improve

  • Review the arrangements for the collection of blood samples from the emergency department.
  • Provide training to staff in dementia awareness, learning disabilities and complex needs.
  • Review the escalation plan for the emergency department and make this effective in practice.
  • Review staff training and knowledge on the Mental Capacity Act and DoLS.
  • Review ambulance offload and handover times in the emergency department.
  • Limited numbers of staff in the emergency department had been trained in safe breakaway. No staff members had received training in ethical control and restraint. Consider increasing the number of staff in the emergency department who have been trained in safe breakaway, and in ethical control and restraint.
  • Consider learning and outcomes from complaints.
  • Consider developing a vision and strategy for the future of the emergency department.
  • Consider lack of staff engagement across the emergency department and work towards improving this.
  • Reduce the number of patient moves out of hours within admissions and ward areas.
  • Consider undertaking a risk assessment in relation to the lack of a dirty utility area in the emergency surgical admissions unit.
  • Review processes and practice so that venous thromboembolism risk assessments are consistently completed and repeated according to trust policy and that the proforma used to complete assessments is fit for purpose.
  • Consider further training for staff around Deprivation of Liberty safeguards to ensure that all staff are aware of when it is appropriate to consider an application to meet patients’ needs and protect their rights when necessary.
  • Review processes so that patients are discharged from the critical care unit (CCU) within four hours of the decision to discharge to improve the access and flow of patients within CCU.
  • Consider how to meet the needs of patient requiring admission to CCU at all times.
  • Review the microbiologist input to the ward rounds on CCU to review patients care daily, in line with the Guidance for the Provision of Intensive Care Services 2015 (GPICS).
  • Take actions to reduce the incidence of single sex breaches in CCU.
  • Review procedures and practice so that all medicines are administered and documented in accordance with trust policy and national standards.
  • Review the process for obtaining tablets for patients to take home to reduce high volumes being received in pharmacy during the afternoon which they are unable to action in a timely manner.
  • Review procedures and practice so that modified obstetric early warning score observation charts are completed and acted on in accordance with trust policy.
  • Take the required actions to meet the 62 day referral to treatment time for patients with suspected gynaecological cancers.
  • Review the consultant cover in palliative care staffing levels. The consultant cover in palliative care staffing levels were below the National Institute of Health and Care Excellence (NICE) guidelines, commissioning guidance for palliative care published collaboratively with the association for palliative medicine of Great Britain and Ireland, Consultant Nurse in Palliative Care Reference Group, Marie Curie Cancer Care, National Council for Palliative Care, and Palliative Care Section of the Royal Society of Medicine, London, UK.
  • Within end of life care, the service should collect effective information on the percentage of patients who were discharged to their preferred place within 24 hours.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 1 March 2017

Effective

Requires improvement

Updated 1 March 2017

Caring

Good

Updated 1 March 2017

Responsive

Requires improvement

Updated 1 March 2017

Well-led

Requires improvement

Updated 1 March 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 1 March 2017

Overall, we rated the maternity and gynaecology service as good for effective, caring, responsive and well-led and requires improvement for safe. The service was judged to be good overall because:

  • Staff were confident to report incidents and there was a robust governance and risk management framework in place to ensure incidents were investigated and reviewed in a timely way. Learning from incidents was cascaded to staff and actions were taken to minimise risks and prevent incidents from reoccurring. This was an improvement from our previous inspection in April 2015.

  • Safeguarding vulnerable adults, children and young people was given sufficient priority. Staff understood their responsibilities and were confident to raise concerns. A dedicated team of midwives had been established to provide support, care and treatment to vulnerable women.

  • Medical, nurse and midwifery staffing levels and skill mix were planned, implemented and reviewed regularly. Despite high levels of midwifery staff vacancies, staffing levels were sufficient to protect people’s safety. Bank and agency staff were used to ensure staffing needs were met. However, staffing levels was the most cited reason for stress and low morale amongst staff and remained the service’s biggest risk. The trust were taking action to address staffing vacancies.

  • Consultant cover was in line with national guidance. Access to medical support was available seven days a week throughout the service.

  • The service regularly monitored and reviewed performance against locally agreed standards, which were in line with national recommendations. Actions were taken to investigate and address issues related to performance.

  • We saw effective multidisciplinary working across the service.

  • Feedback about the service was largely positive. Patients were treated with dignity, respect and kindness. Staff cared about the services they provided and spoke positively about improvements that had been made since our previous inspection.

  • The service had introduced a gynaecology ambulatory care unit, which reduced the demand for beds on the gynaecology ward.

  • Perinatal mental health services had been developed to ensure women with complex mental health needs received sensitive and appropriate care. Combined obstetric and psychiatric run clinics were available and a public event was held to publicise the importance of mental health care and raise awareness in the wider local community.

  • Governance arrangements were effective and there was a clearly defined strategy and governance structure in place.

  • Leadership was knowledgeable about quality issues and priorities, understood the challenges and were taking action to address them. The service was well represented at board level and leadership within the service was strong, supportive and visible.

However, we also found:

  • Medicines were not always managed and stored safely. Medicines in the anaesthetic room were not always stored securely, which meant there was a risk they could be removed by unauthorised persons and staff would be unaware. Patients own controlled drugs were not handled in a way to ensure they were safe and secure and there were inadequate controls in place to prevent misuse. Furthermore, the treatment rooms where medicines were stored consistently exceeded recommended temperatures. The trust was taking action to address this.

  • Mandatory and midwifery specific training compliance did not meet the trust target of 95% in all topics covered, including adult basic life support and only 7% of midwifery staff were compliant with blood transfusion training. This meant there was a risk that staff did not have up-to-date knowledge in order to protect patients, visitors and staff from potential harm.

  • Not all staff had received an annual performance appraisal. This was a concern we raised in our previous report.

  • We were unable to determine how effective the service was in delivering care and treatment in line with national guidance because the majority of planned audits were outstanding at the time of our inspection. However, an effective framework had been established to ensure policies and guidelines were reviewed to reflect current national guidance.

  • The normal (non-assisted) delivery rate was 54%, which is lower than the England average of 60%. However, the elective caesarean section rate was 11%, which is in line with the England average.

  • The service did not meet the 85% standard for patients with suspected gynaecological cancer who commenced treatment within 62 days following urgent GP referral. However, the service did meet the target for patients on an incomplete pathway who waited less than 18 weeks to start treatment.

Medical care (including older people’s care)

Requires improvement

Updated 1 March 2017

  • The service did not have an overview of the number of patients who were cared for under a deprivation of liberty safeguards authorisation. This included no trust database relating to the total number of patients, or the expiry of initial authorisation or the date of external assessment. This meant that patients were potentially being deprived of their liberty without appropriate authorisation.
  • The management and storage of medications was not always safe. There was varied practice regarding the safe management and storage of patients own controlled drugs, and treatment room temperatures consistently exceeded recommended temperatures. There was limited evidence to support actions taken to address elevated temperatures.
  • Mandatory training compliance did not meet the trust target of 90% in all subjects including basic life support, which meant that patients might be at risk when appropriately trained staff were not on duty.
  • When there were insufficient side rooms available, patients with confirmed MRSA were nursed in shared bays, in line with trust policy. However, systems were in place to reduce the risk of cross infection.
  • The service had variable performance in national audits, and did not have action plans in place to address service results in the National Diabetes Inpatient Audit (NaDIA), Sentinel Stroke National Audit Programme, Heart Failure Audit or the National Lung Cancer Audit.
  • Patients experienced multiple moves within admission areas, and were frequently transferred between areas overnight.

However we also found:

  • There had been a number of positive changes to improve the safe delivery care and treatment within medical services since our last inspection.
  • The Hospital Standardised Mortality Ratio (HSMR) and Summary Hospital-level Mortality Indicator (SHMI) figures were better than expected.
  • The service had an established seven-day working across the service which included dietitians, pharmacy and therapy staff.
  • Staff were aware of the Mental Capacity Act (MCA 2005) and Deprivation of Liberty safeguards (DoLS). Staff demonstrated awareness of their roles and responsibilities in escalating concerns and preventing harm and accurately recorded assessments and rationales for decisions made. Locally, wards had understanding of those patients who were being cared for under a deprivation of liberty safeguard (DoLS).
  • Patients were treated with dignity, respect and kindness during interactions with all staff.
  • Nursing staff utilised support networks for patients with emotional or mental health issues and completed joint ward rounds to ensure that all aspects of the patient’s physical and mental health were addressed during reviews.
  • Data collected through patient satisfaction audits was generally positive and regularly shared within teams.
  • Non-medical wards used to care for medical patients at times of high activity used admission criteria to ensure patients’ needs could be met. The exception of this was the gynaecology and surgical wards, where patients admitted were identified as clinically stable by medical staff prior to transfer.
  • The service worked collaboratively with local authorities and agencies to assist with patient pathways through hospital and discharge.

  • Staff had assisted with the development of the trust vision. This was also reflected within the service aims and objectives.
  • There were robust systems in place to identify and manage risk and risk registers were reviewed and updated regularly. There was clear escalation processes with reporting between ward, service and trust board. All staff demonstrated good knowledge of local risks.
  • The service had a robust audit calendar in place and regularly monitored and benchmarked performance to ensure practice was safe and within trust and national targets.
  • Nursing and medical staff were positive about the teams they worked in and the services they provided. Staff felt supported and encouraged to develop themselves and services.

Urgent and emergency services (A&E)

Inadequate

Updated 1 March 2017

  • Duty of candour was not evidenced by the service. Blood samples were not being routinely collected and taken to the laboratory for testing. We found that records were not always thoroughly completed.
  • The mental health room was located in the main area of the department. The room had been risk assessed in June 2016 for the risk of ligatures and patient self-harm.
  • Training records provided showed that 0% of doctors had received conflict resolution training. Limited numbers of staff in the department had been trained in safe breakaway.
  • The deployment of medical staff throughout the medical department did not ensure that the skill mix was safe in all areas of the department.
  • There was a clear protocol for staff to follow with regards to the management of sepsis.
  • Fluid rounds and drinks provision for patients had not increased despite the warm temperatures in the department. Pain levels were not routinely scored or monitored. There was a lack of local audit activity in the service. Not all medical staff could articulate Mental Capacity Act or Deprivation of Liberty Safeguard requirements. No training was provided in dementia awareness. Staff had not received training in understanding learning disabilities and complex needs
  • The percentage of patients leaving the department before being seen was higher, at 6.5%, than the England average of 3%. The percentage of emergency admissions via A&E waiting four to 12 hours from the decision to admit ranged from 12% to 44%, against the England average of 8%.. Learning and outcomes from complaints were not widely known throughout the department.
  • There was a lack of vision, robust strategy or direction for the emergency department. There was a poor culture noted amongst some of the medical staff which was impacting on the safe running, and communication within the department. This culture and behaviours witnessed, disempowered the nursing staff and lowered staff morale. However during the unannounced visit we observed that the culture of nursing staff had improved and nurses were being empowered to make positive changes.

However we also found that:

  • During our unannounced inspection, we noted that improvements had been made to the assessment ‘pit stop’ process and there were no longer delays in assessment.
  • There was a notable culture of acceptance regarding the breaches in waiting times. However, during our unannounced inspection we noted that there had been a change in levels of acceptance of breaches, and the number of breaches had reduced. The four hour performance for the department had also improved.
  • The time patients waited to see a doctor was too long consistently during the inspection, despite a full rota of medical staff. However, we found that this had improved significantly during our unannounced inspection.
  • The escalation plan did not work during our inspection because staff did not accelerate the situation within the department in a timely way. However, during our unannounced inspection we observed that a formal process had been put in place for escalating department risks and we observed this being used effectively by nursing staff.
  • We were concerned that the resuscitation department was frequently left without sufficient senior clinical oversight during times when the department was busy. During the unannounced inspection, we found that one consultant or senior clinician was based in this area.
  • The children’s emergency department was outstanding in terms of environment. Children and young people had a dedicated resuscitation area away from the adult department, which was set up with equipment and medicines for children and young people up to the age of 16 years. The medicines storage and management of medicines in the children’s emergency department was exemplary. Staffing levels within the adult and children’s department were at a safe establishment level. Policies and pathways were written in line with the National Institute for Health and Care Excellence (Nice) and Royal College of Emergency Medicine (RCEM) guidelines. The service took part in all national audits. Excellent MDT working was observed.
  • We received feedback on site where the majority of service users shared positive experiences of using the service. The friends and family test results were consistently above the England average. The children’s department had a range of distraction methods and sensory items to support the individual needs of children whilst they had treatment. Children could watch films, play with toys or play on a games system to support them during their time in the department.

Surgery

Requires improvement

Updated 1 March 2017

  • Not all staff received feedback after reporting incidents
  • There was no separate recovery area in theatres for children and young people.
  • Not all staff involved in the assessment, treatment, and care of children and young people had received the appropriate level of safeguarding children training.
  • Theatre five had a scrub area that was not compliant with Department of Health, Health Building note guidance HBN 26 ( 2004).
  • The emergency surgical admissions unit (ESAU) did not have a dirty utility area.
  • Venous thromboembolism (VTE) assessments were being completed on admission, but not consistently repeated in line with best practice.
  • Junior nursing staff we spoke with were not able to explain when a Deprivation of Liberty Safeguard (DoLS) application was appropriate.
  • Staff were unaware of the trust vision and strategic objectives.
  • The Five Steps to Safer Surgery checklist were not consistently used; there was a mixture of five and three step processes in operation.

However we also found that :

  • All policies were current and followed the appropriate guidelines, such as National Institute for Health and Care Excellence (NICE).
  • Staff understood the importance of reporting incidents and had awareness of the duty of candour process. The team meeting minutes reviewed shared learning from incidents.
  • The environment was visibly clean and staff followed infection control policies.
  • Patient notes had documented risk assessments undertaken.
  • There were competency frameworks for staff who worked in all surgical areas.
  • Patients told us staff requested their consent to procedures and records seen demonstrated clear evidence of informed consent.
  • The hospital had a nurse led pre-assessment clinic, which provided choice to patients regarding their appointments.
  • There was a sense of pride amongst staff working in the hospital.
  • The service recognised the views of patients and carers.
  • Staff working within the service felt supported by their managers
  • Ward sisters had access to leadership programmes.
  • Patients told us that the care they received was good and that they felt safe.

Intensive/critical care

Good

Updated 1 March 2017

  • Staff were encouraged to report incidents and were confident in reporting incidents and were aware of the importance of duty of candour.
  • There was access to appropriate equipment to provide safe care and treatment.
  • The environment was visibly clean and staff followed the trust policy on infection control practices.
  • The service had procedures for the reporting of all new pressure ulcers, and slips, trips and falls and actions were taken. Staff were aware of safeguarding procedures to keep patients safe.
  • Medical staffing was appropriate and there was good emergency cover. Care was consultant led.
  • Nursing and medical handovers were well structured.
  • Safe staffing levels were being achieved by the use of bank and agency staff.
  • Staff had completed their mandatory training.
  • Policies and procedures were accessible, and staff were aware of the relevant information. Care was delivered in line with best practice guidelines.
  • Patients’ pain, nutrition and hydration was appropriately managed.
  • Care bundles (evidence-based procedures) were in place for the use of ventilators and central lines.
  • Patients in the unit were screened for delirium using a recognised screening tool.
  • A practice development nurse was in post.
  • Staff had awareness of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS).
  • Staff were caring and compassionate to patients’ needs, and treated patients with dignity and respect. Patients spoke highly of the care they had received.
  • Between June 2015 and May 2016, the trusts Friends and Family Test, were consistently above 95% for each month.
  • Patients were kept up-to-date with their condition and how they were progressing and people were aware of how to make complaints.
  • The unit offered a monthly coffee, cake and chat session for relatives past and present to meet medical, nursing and allied professionals.

  • There were appropriate arrangements for meeting the needs of people who may not have English as their first language.
  • Staff were aware of the ICNARC data and some information was displayed on staff noticeboards.
  • Strong leadership, commitment and support were evident.
  • A strong supportive teamwork and culture was evident within the unit with improved communication between divisions.

However, we also found that:

  • Staff caring for young people aged 16 to 18 years of age were not always trained to level 3 in safeguarding children. This did not meet the Royal College of Paediatrics and Child Health (RCPCH) guidelines or those contained in the Intercollegiate Document (March 2014).
  • The unit contributed to the Intensive Care National Audit and Research Centre (ICNARC) database and indicators were generally similar to other units apart from delayed discharged which was higher than the average.
  • The ICNARC results 2016 showed the unit had a higher than national average for delayed discharges of 14% compared to the national average of 5%. The trust was in the worst 5% of units for this element. On occasions the unit was unable to admit or discharge patients due to the unavailability of beds within the trust, which resulted in single sex breaches. Patients could be nursed in theatre recovery for over 10 hours whilst waiting for a bed either in the critical care unit (CCU) or on the ward
  • Although this was highlighted on the CCU and trust risk register, there was no evidence that an effective plan was in place to address this.
  • A microbiologist did not visit the unit during the inspection period.
  • The safety of medication management was not always maintained.
  • The trust’s clinical strategy 2016-2020 did not include any specific reference to critical care.

Services for children & young people

Requires improvement

Updated 1 March 2017

Overall we rated the services for children and young people as requires improvement because:

  • Incidents were reported inconsistently. The service did not ensure that staff complied with the policy and procedure for reporting incidents.

  • Not all staff were involved in debriefing session outcomes.

  • Information flows were not always robust.

  • Feedback was mixed from staff as to whether incident reporting was encouraged. Whilst some doctors and nurses saw the value of raising concerns, some were afraid or discouraged from raising concerns and felt they may be blamed when reporting incidents.

  • The service cancelled some governance meetings. Staff who could not attend did not always receive minutes from these meetings.

  • There was a significant division of staff concerning opinion and practice within the neonatal unit. Some staff felt this might have had an impact on patient care. An external thematic review of this had been commissioned by the service.

  • There were gaps in management and support arrangements for staff, such as appraisal and professional development. Not all nursing staff were up to date with their appraisals.

  • Not all nursing and medical staff were up to date with mandatory training.

  • Patients who showed signs of deterioration were not always escalated to a senior nurse or doctor as recommended in the trust guidelines.

  • There was not a paediatric safety thermometer in use.

  • There were high numbers of cancellations of outpatient appointments for children especially in epilepsy and cardiology.

  • The neonatal unit lacked sufficient space to operate in accordance with current guidelines.

However, we also found:

  • Staff provided skilled and competent patient centred care.

  • Staff treated all patients with kindness, dignity and respect. All patients and their carers that we spoke with told us that staff were kind, caring and included them in the planning of care and treatment.

  • A carer support team was in place that supported carers and patients’ families. Regular activities were arranged for patients. Play therapists were an important part of the ward team ensuring that nervous patients or those with additional needs received the support required.

  • Staff regularly went ‘above and beyond’ to provide individualised care for patients. In feedback from patients and carers, we saw that consultants: “Always listen well, explain difficult information clearly and care very professionally”.

  • Nurse leaders and matrons were highly visible, approachable and fully engaged with providing patient centred, excellent care.

  • Staff knew how to report safeguarding concerns.

  • Nursing staff knew how to report incidents and understood their responsibilities in reporting incidents and near misses.

  • Nursing staff shared lessons learned in a variety of ways. Individual nurses were sensitively supported with their learning, skills and development where required, following incidents.

  • Staff understood about risk and risk assessments, which were generally thorough and updated frequently. Discussions about risk at multi-disciplinary team meetings were detailed and individualised.

  • Patients had their care assessed, planned and delivered in a clear and consistent way. Patient records we checked were accurate and up to date. Nursing staff had completed care plans and assessments. There was regular and well documented monitoring of symptoms and pain in patients.

  • Information technology was used to access results and x-rays. Safeguarding information was available to the specialist safeguarding nurses via a community based electronic records system.

  • The environment and equipment were visibly clean, well maintained and serviced. Environmental checks were done regularly. Beds and side rooms were thoroughly checked, cleaned and stocked between every patient.

  • Doctors and nurses were all compliant with “arms bare below the elbow” policy and hand hygiene. There were adequate places to wash hands and apply hand gel.

  • Starfish and Safari wards shared a playroom and adolescents’ room, which were attractively designed and well equipped.

  • Staffing levels were safe for the number and acuity of patients. There were effective measures in place to ensure that when there was increased activity staff numbers increased. Medical staff had the relevant experience, skills and qualifications to care for and treat patients. There were practice development nurses in post to identify and deliver individual and service wide training needs.

  • Medicines and drugs were stored, prescribed and administered safely. There was a paediatric pharmacist in post.

  • Staff received specialist and mandatory training to enable them to fulfil their roles effectively.

  • There was effective multidisciplinary team (MDT) working. This included pharmacists, mental health services, dietitians, safeguarding services, physiotherapists and occupational therapists. MDT working was effective both internally and with partners in other trusts and organisations.

  • Patients moving from children’s services to adult services were prepared in advance for the transition by individual specialist consultants and nurses.

  • The service was planning development of specialist services including diabetes, epilepsy, oncology and gynaecology.

  • There was a clear governance structure in place; detailed responsibilities were documented in the governance policies that covered both the trust and the service.

  • There was participation in both local and national audit. Audit was routinely used to monitor, inform and develop practice.

End of life care

Good

Updated 1 March 2017

We rated end of life care services as good for safe, caring, responsive and well led and requires improvement for effective. We found that:

  • Staff within the end of life care service understood their responsibilities for ensuring patients were protected from the risk of harm. The service had systems in place to recognise and minimise patient risk. There was evidence that learning from incidents had been implemented within the service.

  • The trust had safety precautions and systems in place to prevent and protect patients and staff from a healthcare-associated infection. Trust infection control guidelines were up to date and reflected national guidance.

  • There were sufficient SPCT CNS at Watford hospital. The staffing levels were above National Institute of Clinical Excellence (NICE) guidelines, commissioning guidance for palliative care, published collaboratively with the association for palliative medicine of Great Britain and Ireland, Consultant Nurse in Palliative Care Reference Group, Marie Curie Cancer Care, National Council for Palliative Care, and Palliative Care Section of the Royal Society of Medicine, London, UK.

  • The service carried out an audit on preferred place of death for patients known to SPCT. The service used the audit to evaluate the quality of the information collated in the care plan and tailored training needs.

  • The trust had a replacement for the Liverpool care pathway called individualised care plans for the dying person (ICPDP). The ICPDP was embedded on all wards across the trust.

  • The SPCT provided seven-day face-to-face access to specialist palliative care.

  • Patients were supported and treated with dignity and respect.

  • Feedback from patients and those close to them was positive about the way staff treated people.

  • The service was collecting information on the percentage of patients who died in their preferred location. 82% of patients had died in their preferred place of death.

  • There was joint working between the SPCT and the medical teams at the hospital to support non-cancer patients.

  • The hospital had leaflets available for example coping with dying and procedures to be undertaken after the death of a patient for relatives or friends.The leaflets were available in a number of different languages and formats.

  • A chaplaincy team provided spiritual and pastoral care and religious support for patients, relatives and staff across the trust.

  • There had been no complaints about end of life care from July 2015 to July 2016.

  • The trust had executive and non-executive board representatives for end of life care that provided representation and accountability for end of life care at board level.

  • The trust had a three-year end of life care strategy; the strategy was presented to the trust board in July 2016. The strategy was realistic to achieve the priorities and delivering good quality care.

However:

  • Patients did not have their mental capacity assessed in accordance with the requirements of the Mental Capacity Act 2005 (MCA) and associated code of practice. There was no formal mental capacity assessment of the patient’s ability to understand this decision. The DNACPR form did not prompt staff to complete a capacity assessment as part of the decision making process.

  • The temperatures of treatment rooms where medicines were stored were consistently above the recommended storage temperature of 25°C and the trust were not following their own policy of reducing the expiry dates of medicines in line with the increased temperatures.

  • When medicines were prescribed to patients, who required them to be administered via a syringe pump the prescription did not always include an infusion solution (diluent) either on the prescription or on the administration records.

  • There was sufficient consultant in palliative care provision at the trust. The consultant in palliative care staffing levels met the National Institute of Health and Care Excellence (NICE) guidelines, commissioning guidance for palliative care, published collaboratively with the association for palliative medicine of Great Britain and Ireland, Consultant Nurse in Palliative Care Reference Group, Marie Curie Cancer Care, National Council for Palliative Care, and Palliative Care Section of the Royal Society of Medicine, London, UK.

  • Bereaved relatives’ views and experiences were gathered through the trust’s bereavement questionnaire. The service used these views to shape and improve the end of life care service. However, the response rate was low at 10%.

Outpatients

Requires improvement

Updated 1 March 2017

  • At our previous inspection in 2015 we found that patients’ records were not securely stored in the cardiology and ophthalmology outpatient departments which meant there was a risk of unauthorised access to personal, clinical information or of clinical information being lost. At this inspection we found patient records were securely stored in lockable cupboards in cardiology and lockable trolleys in the ophthalmology clinic areas.

  • Outpatient services had responded to many of the environmental issues identified at our previous inspection. Work was underway to provide new accommodation for cardiac patients and a new reception area had been built in the ophthalmology reception and waiting area.
  • Two treatment rooms in the dermatology department were not clean and the air conditioning in both rooms had not been working for some time. Staff were unable to evidence any progress on resolving this.
  • Nursing staff in outpatients were not auditing staff compliance with good hand hygiene practice and we did not see staff routinely using hand sanitisation gels in the ophthalmology outpatient department.
  • Endoscopes were cleaned before each use in the outpatient department. However, the equipment was not returned to the endoscopy department for checking and cleaning at the end of the clinic in line with best practice, as described in Health Technical memorandum 01-06 (HTM 01-06) Guidance on the Management and Decontamination of Flexible Endoscopes.
  • Treatment rooms in the ophthalmology outpatient department were fitted with locks during our inspection. However, we observed one door which led to a room where intraocular injections were being administered, was propped open, and there were no signs on the door to indicate when a patient was receiving treatment.
  • The system in place for maintaining medical equipment was not effective. Staff described frustration about equipment being not being adequately maintained.
  • Patients’ records were not always available for clinics. The trust was monitoring the situation and there had been an improvement since our last inspection. Information provided by the trust indicated that 94% of notes were available for clinics; however staff told us notes were often not available or arrived late.
  • There was a 25% vacancy rate for nursing staff in the main outpatient department and the turnover rate was 17% which was considerably higher than the other sites in the trust. The trust’s target for staff turnover was 12%.
  • Guidance had been developed for radiology staff to administer a medicine (Hyoscine Butylbromide) prior to treatment without a prescription. A patient group direction was in place (PGD). This meant that radiographers were aware of the risks and contraindications, when patients should not be given the medication as it could cause them harm.
  • PGDs were in place for nurses in the ophthalmology department who were able to administer medicines without a doctor’s prescription.
  • There was evidence that staff were following national clinical guidelines and participating in national audits.
  • Nursing staff completed local induction training when they joined the outpatient department. We saw the training programme which included training on the use of equipment within the department and a medicines competency assessment. Induction programmes were developed to meet the needs of different staff groups for example for trained nurses and healthcare assistants.
  • Clinic letters provided patients with very little information about the clinics or what to expect. Patients told us they would have appreciated more information about the clinic and about the difficulty parking, which many patients found frustrating.
  • Nursing staff told us there were good working relationships amongst the nurses but working relationships between medical and nursing staff was not always effective. They described how the poor communication culture meant they could not pass information on to patients if, for example, the clinic was running late.

However, we also found that:

  • Some services, for example, the diabetic service, had developed joint clinics with partners in primary care to support women who had developed diabetes in pregnancy. There were other examples of combined working in renal clinics and links with podiatry services. The service used videoconferencing to provide virtual clinics with community partners.
  • The trust was making improvements to the organisation of outpatient clinics. However, clinics still frequently over-ran and some patients told us they had experienced long delays. The length of time patients waited to be seen was not monitored. The trust’s patient administration system had no facility for recording when patients were seen and the information was not collected manually.
  • During our previous inspection in March 2015, we found that clinics were being cancelled at short notice. This was still happening, although staff told us that the clinical divisions were getting better at providing medical cover. The trust’s overall target for cancelled clinics was 8% and was 5% for clinics cancelled with less than six weeks’ notice. The overall cancellation rate for clinics had peaked in April 2016 at 14% which was a 3% increase on the mean of 11% over the previous 12 months. This improved in June 2016 reducing to 11%. The number of clinics cancelled at short notice had also improved to 3.9% in June 2016.
  • Staff told us communication between the clinics, consultants and their secretaries was poor and described examples of patients arriving for clinics that staff knew nothing about. In addition, clinics were cancelled at the last minute because there was no medical cover in place.
  • Data for September 2016 showed that the trust had fallen below the national 93% target that all suspected cancers should be referred to a consultant and seen within two weeks; only 89.4% of patients were seen within this time period. For breast cancer, for the year to date only 76% patients had been seen within two weeks.
  • Diagnostic imaging waiting times were good. The standard set by the trust was that 99% of patients referred for 15 diagnostic tests for example, ultrasound or a CT scan should wait no longer than six weeks. This standard, which was better than the national position of 98.2%, had been reached since April 2015.
  • A comprehensive information dashboard which included a range of performance indicators was under development but had not been rolled out for clinical and managerial use. Operational managers within the outpatient department were aware the information dashboard was being developed but were not aware of what this meant for the service.
  • There was a management structure in place. Responsibility for outpatients was shared between the clinical divisions and the outpatient department. Staff were not clear who they reported to.
  • In radiology, staff told us medical staff and radiography staff worked well together. Staff spoke highly of their managers.
  • The trust recognised the need to make improvements to outpatient services and had set up an improvement programme which had achieved some positive changes.