Whittington Health NHS Trust

Whittington Health was established in April 2011 bringing together Islington and Haringey community services with Whittington Hospital’s acute services to form a new Integrated Care Organisation (ICO). Whittington Health provides acute and community services to 500,000 people living in Islington and Haringey as well as other London boroughs including Barnet, Enfield, Camden and Hackney.

The 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 Whittington Health NHS Trust acute hospital, including the right 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.

We inspected Whittington Health NHS Trust CAMHS services, Whittington Health community services for adults, children and young people and families, and patients receiving end of life care.

This was the first inspection of Whittington Health NHS Trust 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. Community end of life care and community dental services were rated as outstanding.

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 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:

At the Whittington Hospital:

• 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 he 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.

• At Whittington Health community sites:

• Community teams told us they felt very integrated with the trust hospital services, GPs and nurses. We found examples of shared assessments within community settings, for example joint podiatry and diabetes assessments.

• Within community dental services we received consistently positive responses from patients, some describing the services as “Life changing” and others rating services as five-star on the NHS Choices website.

• Within community end of life care we found the service provided outstanding, effective services to children, young people and their families. We saw examples of very good multidisciplinary working and effective partnerships with the local GPs, other providers and hospices.

• Within community end of life care services we observed exemplary care, delivered with respect and dignity. Everyone we spoke with told us they had entirely positive experiences of the service.

• Within community end of life services there was a commitment to offering an equitable service across the three boroughs. Data was collected on the patient’s preferred place of death and discussed at a specialist network level.

• The service worked well with the local hospice to make the best use of day care and hospice at home services in response to patient need.

• The children’s community palliative care service, Lifeforce, was exceptionally well led. The service was committed, adaptable and flexible to meet the needs of the patients and their families. The term going, ‘over and above’ was used on many occasions to describe the team’s approach to their work.

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

Importantly, the trust must:

Trust wide:

• Review bed capacity to assess capacity across medicine, surgery and critical care to ensure patients are appropriately placed within the correct specialism and enhance hospital flow.

At the Whittington hospital site:

• 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, departments improve disposal of confidential waste bags were 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 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’.

At CAHMS inpatient services

• Improve ligature risk assessments and the identification of associated risks

Professor Sir Mike Richards

Chief Inspector of Hospitals

We rated community services for adults as good overall because;

• All community staff were aware of the trust’s incident reporting processes and there were mechanisms in place to learn from incidents. District Nurses (DNs) were aware of their duty to report pressure ulcers. Community services across the trust were described to us as high demand in relation to capacity. The DN service had a high staff turnover rate but there were a number of measures in place that managed the safety issues that arose from this. Staffing pressures and low team morale were more acutely felt in some teams and this had an effect on the service.
• Current evidence based guidance, standards and published best practice were identified and used in the delivery of care. The trust had done much to improve staff competency through a number of positive initiatives although some essential items needed further development. We found good and widespread examples of multidisciplinary working and clear understanding of care pathways among the community teams.
• We found compassionate and respectful care was present in all interactions we observed, in what were busy teams working in what were challenging environments.
• The trust’s integrated care approach was designed to meet the wide ranging needs of different patient groups. Community services were provided by staff groups who were generally culturally and ethnically representative of local populations. The DN services were observed to be very supportive of the older patients they visited and understood the needs of working with this patient group.
• The trust’s vision and values around providing integrated patient centred care were reflected by the community staff we observed and spoke with. Community staff felt well supported by the managers of community services.
• There were governance processes and lines of reporting to the executive team on quality for all three directorates with community services, with risk and quality issues discussed in local team meetings.
• All staff reported that meeting demand with current capacity was a challenge, which was only set to increase with further development of integrated community services within the trust. Community staff generally felt there was a lack of understanding of their role by both trust leaders and their professional counterparts who were hospital based.

We gave an overall rating for the community health services for children, young people and families of requires improvement because:

The use of a combination of paper and electronic records led to problems such as notes being mislaid. Records were not always available to clinicians when needed and details from paper notes were not always added to electronic records. This meant there was a risk that staff might not see important patient information.

The management of medicines required improvement as some vaccines were found to be past their expiry date, and processes and equipment for transporting medicines to schools was not always adequate.

The care environment and facilities did not always meet the needs of children. Many pieces of equipment were worn and tired.

The transition pathway from children’s to adult services was not clear.

There were long waiting times for children with autistic spectrum disorder and attention deficit hyperactivity disorder referrals.

There was no management for administrative staff since the previous manager had left and there was no plan in place at the time of inspection.

However,

Staff showed a good level of understanding of the incident reporting process, and of safeguarding processes.

Staff followed national and local guidance and delivered good outcomes for patients.

There was good multidisciplinary team working.

Most care pathways were well laid out.

Staff treated people who use the service with respect and kindness. Staff communicated with people in a way they could understand. Children and their parents or carers were involved in their care and treatment.

The service had a system for recording, managing and responding to complaints.

We gave an overall rating for end of life care as outstanding because;

Whittington Health had their own children’s palliative care service called Lifeforce. The service was a multi-disciplinary team delivering care and support to families who have a child with a life limiting or life threatening condition living in the boroughs of Camden, Haringey and Islington. We found that the service were providing a very high quality of care to the children and families on their caseload. The few areas where there was room for improvement was recognised by the team and plans were in place to make further improvements.

Staff were aware of the processes for reporting any incidents and there was a strong culture of learning from incidents and complaints to improve the quality of the service provided. Staff were fully aware of the safeguarding policies and procedures and could clearly tell us what they would do if they had any concerns. Staff reported there was good access to further training specific to their roles and all mandatory traning targets had been met. We observed risk assessments and emergency care planning. These were managed on an individual basis as needs changed.

Standard documentation based on the ‘Together for Short Lives’ protocols was used across the service and was shared with relevant stakeholders.

Relatives reported that they found staff very caring and supportive and we reviewed some excellent feedback especially from the services’ exceptional Memory Day event. Patients’ needs were looked at on an individual basis and the service showed us and we observed good examples of responsive care.

Staff were very passionate about their roles and local leadership was excellent. Staff felt supported in their roles and could discuss any issues they had with senior leaders. The teamwork was evident throughout the visit and staff often mentioned how they supported each other. The supervision offered by the team psychology members was essential in enabling staff to provide effective end of life care in difficult circumstances. All the staff we spoke with had been in their roles for many years and were justifiably proud of the end of life care they provided, whilst always looking for further improvements to be made.

We gave an overall rating for the community dental service of outstanding because:

Feedback from people who used the service, and those close to them, was continually positive about the way staff treated people. Patients and their relatives told us that staff went the extra mile and the care they received exceeded their expectations. Staff provided care with compassion. They communicated with patients in a way they could understand and enabled them to manage their own oral health and care when they could.

The service was well-led and had a clear, patient-centred vision. Leaders worked with other organisations to improve care outcomes and tackle health inequalities.

There was a clear and effective governance structure. Staff were well supported by their managers, and managers encouraged, listened to and acted on staff feedback.  Staff were proud of the service they provided and spoke highly of the culture.

Staff had the knowledge, skills and competence to carry out their roles and responsibilities effectively. Many dentists and nurses had additional dental qualifications, for example four dentists were specialists in special care dentistry. We saw examples of effective multidisciplinary working and evidence-based care and treatment. Staff obtained consent to care and treatment in line with legislation and guidance.

The service was responsive to the needs of patients. Staff provided home visits for patients who were unable to attend clinic. There were hoists, wheelchair platforms and a bariatric chair available. The service had a walk-in urgent dental clinic which provided care for patients with an urgent dental problem such as pain, swelling or bleeding.

There were systems in place for identifying, investigating and learning from patient safety incidents. Staff understood their responsibility to raise concerns and report incidents and near-misses and managers supported them to do so. Procedures were in place to keep patients safe from abuse. We found good practice and procedures in place for cleanliness, hygiene and infection control.

Information about the service

Simmons House was an in-patient adolescent psychiatric unit, for young people between 13 and 18 years of age. It consisted of a mixed gender 12 bed unit.

The unit could admit patients in an emergency or for a planned longer outcome-focussed admission of between six and nine months. The length of stay at Simmons House depended on the young person's needs and collaborative aims and goals.

Adolescents and their families or carers received an individually planned and structured treatment package combining as needed the following; Psychiatric assessment and medication, nursing input and care, family therapy, individual therapy and individual psychology, occupational therapy and group work and education.

The service was commissioned by NHS England and took patients from across the country. The admitted patients had a variety of mental health needs.

Before the inspection visit, we reviewed the information that we held about these services.

During the inspection visit, the inspection team: Visited the unit and looked at the quality of both the environment and observed how staff were caring for young people. Spoke with six young people who were patients at Simmons House. Spoke with one parent/carer. Spoke with the two managers. Spoke with 12 members of staff including doctors, nurses, therapy staff and support workers. Attended and observed one handover meeting.

We also looked at 12 drug charts. Looked at seven care records for young people. Looked at a range of policies, procedures and other documents relating to the running of the service.

We gave an overall rating for the specialist community mental health services for children and young people of good because:

• Young people and their families were treated as partners in their care. Staff treated young people and their families with compassion, dignity and respect.

• Managers supported staff to deliver effective care and treatment. Staff adopted a multi-disciplinary and collaborative approach to care and treatment. There were good working relationships with other agencies.

• The team had clinicians working in schools across the borough; this meant that the service was accessible.

• There were clear processes in place to safeguard young people and staff knew about these. Incident reporting and shared learning from incidents was apparent across the services.

• The service accepted referrals from a range of professionals and young people could refer themselves to the service.

• There were systems in place to manage referrals and the service provided an advice line to potential referrers.

• However, we also noted the waiting times for appointments were too long. The service had a transformation plan and had received funding for additional staff to assist in reducing waiting times.

• There was strong leadership at the local team level, which promoted a positive culture. There was a commitment to continual improvement across the services