West Hertfordshire Teaching Hospitals NHS Trust

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 third 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.

The hospital was inspected again in September 2016 and was rated requires improvement overall. It remained in special measures

Part of the inspection was announced taking place between 30 August and 1 September 2017 during which time Watford Hospital, St Albans Hospital and Hemel Hempstead Hospital were all inspected. Unannounced inspections of all three hospitals were undertaken on the 12 September 2017.

The key questions for safe, effective, responsive and well led were rated as requires improvement. Caring was rated as good.

Four services were rated as requiring improvement overall and eight rated as good. One was rated inadequate.

This was an improvement on the inspection we carried out in September 2016, where five services were rated as requiring improvement, five rated as good and two were rated inadequate, although one of these services is no longer run by this trust.

Overall, we rated West Hertfordshire Hospitals NHS Trust as requires improvement because:

• The medical service was found to be in breach of Regulation 10; Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, due to patients not always being segregated from members of the opposite sex.
• The medical and surgical service was found to be in breach of Regulation 10; Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, due to personal identifiable information being on display on wards and patient sensitive information being discussed within earshot of non-authorised persons.
• The trust was in breach of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation: Regulation 11: Need for consent, as there was no evidence, that decision specific mental capacity assessments were always fulfilled when staff completed DNACPR forms.
• The medical and surgical services was found to be in breach of Regulation 12; Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, due to inconsistent risk assessment and reassessment of venous thromboembolism medicine risks.
• The medical service was found to be in breach of Regulation 12; Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, due to antibiotic regimes not consistently being assessed after 72 hours of initial treatment.
• The medical service was found to be in breach of Regulation 12; Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, due to a registered nurse not always delivering care and treatment in the deep vein thrombosis clinic.
• The outpatient service at St Albans City Hospital was in breach of Regulation 13; Safeguarding. The service was not fulfilling its mandatory duty to report cases of female genital mutilation (FGM) as all staff we spoke with were unaware of the trust policy on identifying and assessing the risk of FGM.
• The medical and surgical service was found to be in breach of Regulation 17; Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was due to nursing risk assessments not always being fully completed and patient information boards being openly displayed and discussed in sight or earshot of non-authorised persons. This meant that confidential information could be viewed or overheard. There were no robust systems in place to assess, improve and monitor performance and quality of services in the urgent care centre at Hemel Hempstead Hospital. There was no monitoring of waiting times to initial assessment of patients.
• The trust was in breach of Regulation 18 (1) Staffing. There was an insufficient number of nursing and medical staff on duty in the emergency department to ensure the safety of patients. Not all nursing staff who had direct contact with children in outpatient clinics had undergone level 3 safeguarding children training, which was not in line with national guidance. Compliance with fire safety training in the radiology department was worse than the trust target of 90%. Overall staff compliance was 76%. Nursing staff compliance was 40% for clinical staff and 80% for non-clinical staff.

• There had been three never events in the trust, all at the Watford site between June 2016 and June 2017. These were all unrelated and had happened in different departments.
• In the ED at Watford General Hospital, there were differences in opinions between the leaders. This caused dysfunctionality and it meant that the directorate leaders’ relationships in some cases had broken down. The culture within the department had not improved to a sufficient level since our last inspection. Several staff formally raised concerns to us regarding the ongoing poor culture within the service. The concerns with this culture had not been adequately addressed by the trust. This had lowered staff morale. In addition, there were concerns within the safety and responsive domain, with regards to staffing levels, lack of staff trained in ALS/PILS, response times and breaches of national targets. Although caring and effective were good, safe, responsive and leadership was rated inadequate. This led to an overall rating of inadequate for this service.
• We were not fully assured that the consultant body within the ED were working the hours required to safely staff or manage the emergency department.
• Only 66% of nursing staff in the ED and children’s emergency department had received Paediatric Intermediate Life Support Training.
• The middle grade ratio of the department was 3% against an England average of 15%. There was a lack of medical middle grade cover on the rota overnight and at weekends.
• The percentage of patients leaving the ED before being seen was higher, at 5%, than the England average of 3%.
• The time to initial assessment for self-presenting patients from March to August 2017 averaged between 31 and 55 minutes. This is significantly outside of the recommendation from the Royal College of Medicine (RCEM) which recommend that patient’s initial assessment is undertaken within 15 minutes of arrival.
• On average between July 2016 and June 2017, 65-78% of ambulances that attended Watford General Hospital experienced delays of more than 30 minutes to hand over a patient.
• Between July 2016 and June 2017 the trust reported 3211 “black breaches”. This was an increase on prior year.
• Between June 2016 and May 2017 the trust monthly percentage of patients waiting between four and 12 hours from the decision to admit until being admitted for this trust was worse than the England average.
• Complaints were investigated and responded to in line with trust policy. However learning and outcomes from complaints were not always effectively implemented in ED to improve care.
• There were differences in opinions between the leaders within the service causing this dysfunctionality and it meant that the directorate leaders’ relationships in some cases had broken down.
• The culture within the ED had not improved to a sufficient level since our last inspection. Several staff formally raised concerns to us regarding the ongoing poor culture within the service. The concerns surrounded that the negative culture had not been adequately addressed by the trust. This had lowered staff morale.
• The children’s emergency department was not clearly included in the vision, strategy or direction for either responsible division. The department was not part of an integrated governance approach to ensure all aspects of the service were included between the two responsible directorates.
• We were not assured that all risks were being adequately identified, placed on the risk register and escalated accordingly.
• There was variable compliance with infection control and prevention practices, in some departments, with staff not consistently washing their hands at the appropriate points, or using hand sanitiser when exiting or entering clinical areas.
• Flood and fluid charts were not always completed, in some areas, as details of total input and output were missing.
• Flow through the hospital did not appear to always be managed effectively, with escalation areas used frequently.
• Clinical specialities did not always meet the national average referral to treatment times.
• The Vanguard theatre in St Albans City hospital did not allow for waste and dirty linen to be removed without travelling outside or through a clean area.
• Imaging, diagnostics and dietetics and speech and language therapy services were available Monday to Friday from 9am to 5pm in St Albans. If support was required outside of these hours, for example for an x-ray or scan, it was undertaken at the Watford Hospital site. Patients were transferred to the Watford site via non-emergency ambulance transport.
• Pharmacy support was available on site at St Albans Monday-Friday but there was no on site support at weekends. Medicines and support were supplied from the Watford site.
• Those who had surgery cancelled were not always treated within the following 28 days in line with guidance.
• Theatre five and the recovery area within surgery services at Watford General Hospital, did not meet national guidance with regards to Department of Health Building Note Guidance 26 (2004) and the Royal College of Anaesthetists (RCOA) guideline; the provision of paediatric anaesthesia (2017).
• The day surgery unit at Watford General Hospital did not provide appropriate facilities. Patients were sometimes cared for on the Emergency Surgical Assessment Unit (ESAU) and in recovery overnight because there were not enough beds on the wards.
• Surgery services were not engaged in the implementation of the National Local Safety Standards for Invasive Procedures (LocSSIPs).
• Audits of the Five Steps to Safer Surgery audited the completion of the paper form only. There were no observational audits to assess how well the team participated in the steps.
• The surgery audits on the trust’s audit register were nearly all behind schedule.
• Patients’ records were not always available at pre-operative assessment.
• The route to administer the painkiller Paracetamol was not clearly documented on some patients’ prescription charts.
• Patients did not always get the written information they needed about their treatment.
• Systems and processes related to the maintenance of equipment in the critical care department were not always effective. We found five items of equipment that had not been serviced appropriately. We raised this issue and it was addressed during our inspection.
• Staff were not clear how often the contents of the difficult airway trolley in the critical care unit, should be checked.
• The unit did not meet the guidance for the provision of intensive care services (GPICS 2015) standard of 50% of nursing staff having a qualification in critical care. This was 42% at the time of the inspection.
• Despite actions being taken in conjunction with the trust regarding delayed discharges, this remained an issue for many patients in the critical care service. This also reflected in the increasing number of mixed sex accommodation (MSA) breaches, from June 2016 to May 2017, there were on average 10 each month.
• Delayed discharges from critical care appeared to impact the services ability to always admit critically ill patients in a timely manner.
• Divisional level mortality and morbidity meetings included critical care services but local review minutes were brief and actions to be taken were not always clear.
• There were risks to the provision of the critical care service we found were not included in the risk register. For example, the delays with servicing equipment.
• The microbiologist was available on call and attended the critical care unit three times a week. This did not meet the daily requirement as stated in GPICS (2015).
• The emergency caesarean section rate had been significantly higher than the national average. However, the trust had introduced a number of initiatives to address this and the latest delivery figures showed caesarean section rates were declining.
• The trust’s perinatal mortality rate was worse than trusts of a similar size and complexity and the number of full term babies admitted unexpectedly to the neonatal unit had increased since our previous inspection. A quality improvement plan had been developed to address this, although the service was compliant with the majority of recommendations made in the MBRRACE-UK perinatal audit report.
• Due to bed pressures, patients from other medical specialities were cared for on the gynaecology ward. This meant there were times when gynaecology patients were cancelled on the day of their planned surgery. The high number of medical outliers had had a detrimental effect on staff morale.
• Although staffing levels and skill mix was planned and reviewed so that patients received safe care, staffing levels were generally below planned levels in both maternity and gynaecology. Bank and agency staff were used to meet staffing needs whenever possible.
• Medicines, specifically vitamin K given to babies at birth, were not always documented in line with national guidance. The trust took immediate action to address this concern. However, there had been improvement in the storage and management of medicines.
• Not all equipment in the maternity department had evidence of annual safety testing.
• Operating theatre and recovery arrangements did not consider adequately the specific needs of children.
• Standards of cleanliness and hygiene were not consistently maintained on Starfish ward. We raised this at the time of the inspection and senior staff immediately addressed the issues.
• The information technology system for the paediatric diabetes service was not fit for purpose and required the clinical team to spend extensive periods of time on non - clinical activities.
• Results from the Picker 2016 national inpatient survey for children’s services were worse than the trusts previous survey in 2014. Results were worse than average compared to similar trusts in 2016.
• The children’s service took an average of 47 days to investigate and close complaints compared to the trust standard of 25 days.
• Children’s services were incorporated into the trust clinical strategy 2015 - 2020 and the children’s services strategy 2017. However, not all staff in the service were clear about the longer term development of children’s services at the trust.
• Although efforts were being made by the service to engage children and carers in feedback about the service, response rates around the Friends and Family Test were consistently low.
• At our previous inspection in September 2016, there was insufficient space, in the neonatal unit, which did not reflect current guidelines. This was still the case. During our inspection we saw a thematic review had been undertaken which had identified the unit to be safe in the interim and mitigating arrangements were in place to manage patient flow and safe staffing levels on a daily basis.
• Children who were moved from inpatient wards to the operating theatre travelled along a corridor that was not fit for that purpose. However, a risk assessment was in place and a health and safety review had been undertaken to mitigate the risks to children and young people.
• The trust had systems in place to identify risks, this was not always effective. We were not assured the trust was aware of the risks for the end of life care and mortuary services.
• We saw evidence that learning from incidents was shared across Watford General Hospital, Hemel Hempstead and St Albans Hospital; however, this learning was predominantly within divisions and did not include services provided by different divisions. For example, staff in the main outpatient department which was run by the medical division were unaware of any learning from the never event that occurred in ophthalmology, which was run by the surgical division.
• In outpatients, the World Health Organisation (WHO) five steps to safer surgery checklists had not been completed consistently for patients who had undergone minor surgery with local anaesthetic.
• Not all band 5 nursing staff who had direct contact with children in outpatients had received level three safeguarding children training.
• Patients attending the clinic for the first time and identified as having a learning disability or living with dementia were not always flagged in the patients’ records or referral letter. This meant adjustment could not be made prior to their attendance to facilitate their journey through the outpatient department.
• Risks that were identified during both the previous and most recent inspections, such as missing records were not on the departmental risk register.
• Significant progress had been made with trust governance since our last inspection in 2016. The architecture had been strengthened through review of the committee structure. However, the quality assurance framework lacked maturity and with that so did the processes in place to identify, manage and mitigate risk.
• There was a lack of understanding with regards to both controls assurance and correlation between the risks identified between the board assurance framework and corporate risk.

Overall this meant that the board could not be fully assured that all risks were identified, managed and mitigated.

However:

• Leadership within the trust was strong, supportive and visible. The leadership team understood the challenges to service provision and actions needed to address them. Continued improvement had been made to ensure staff and teams worked collaboratively. There was a positive culture, which was focused on improving patient outcomes and experience. Staff were proud to work at the trust.
• Staff knowledge of duty of candour was evident. Most services were able to demonstrate where the duty of candour had been applied following incidents. However, we found when reviewing complaints, trust wide, there was often lack of evidence that candour had been applied.
• Lessons from incidents were mostly being learnt trust wide.
• We observed good hand hygiene practice, in ED.
• Safeguarding of vulnerable adults and children training compliance had improved in ED since the last inspection.
• ED had significantly improved the management and treatment of patients with sepsis. The ‘sepsis six’ pathway was well embedded and audit results demonstrated good outcomes for patients diagnosed with sepsis.
• Policies and pathways for conditions including stroke and chest pain were in place, which reflected National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine (RCEM) guidelines.
• Pain was assessed on arrival in ED and levels of pain for children were checked at stages throughout their time in the children’s emergency department.
• Excellent pathways of care were established within the children’s emergency department.
• Staff in both adult and children’s ED had received training in understanding learning disabilities and patients with complex needs.
• There were a number of outstanding innovations in the children’s emergency department to support the needs of parents, children and younger people.
• The leadership, culture and staff satisfaction within the children’s emergency department was very positive.
• Staff engagement within ED had improved since the last inspection.
• The medicine service shared details of incidents and used these to identify any learning, sharing information across the service, through local team meetings, peer support meetings and formal mortality review meetings.
• Safety thermometer data was used to identify areas for improvement and changed the way in which the service provided targeted training.
• Personal protective equipment was used by staff appropriately.
• Equipment used across all clinical areas in the medical wards was clean and ready for use. There was an adequate supply for the management of patient care and welfare.
• Patients nursing and medical notes were stored securely, in the medical wards and information was contemporaneous and accurately reflected patient care.
• Staff mandatory training was overall above the trust target of 90%.
• There were processes in place to escalate patients appropriately when their clinical condition changed or deteriorated. There were support networks in place to provide support out of hours.
• The medical wards ensured adequate staffing levels. Locum doctors and agency nursing staff supplemented staffing numbers and were integrated into the trust using generic templates and checklists.
• Some staff on the medical wards had completed a training exercise in line with the major incident policy.
• National guidance and protocols to manage patient care and treatments were reflected in service policy and procedures.
• Patients’ pain and nutritional needs were well managed.
• The trust had achieved the highest rating for the Sentinel Stroke National Audit Programme (SSNAP) for one year.
• The Hospital Standardised Mortality Ratio (HSMR) for the twelve-month period from January 2016 to December 2016 the HSMR was lower than expected at a value of 93 (better) compared to 100 for England. For the twelve-month period from January 2016 to December 2016, the Summary Hospital-level Mortality Indicator (SHMI) was lower (better) than expected at a value of 90 compared to 100 for England.
• Staff training was inclusive of all staff working across the service and focused on staff development and patient safety. Internal and external courses were readily available to all staff on the medical wards.
• Multidisciplinary team working was inclusive of all professions and patient centred.
• The medical service was provided over seven days, with some services such as dietetics and clinical investigations requiring a referral out of hours or at weekend.
• There was a clear process in place for the completion of mental capacity assessments and Deprivation of Liberty Safeguards (DoLS) referrals with alignment to specific issues and detail. This was an improvement since the last inspection.
• All staff treated patients in a respectful and in a considerate manner. Discussions were open and inclusive. Patients and their relatives were included in decision making about treatment and care.
• Patients and their relatives felt that they were involved with care and treatment plans.
• The medical division was involved with trust wide development plans to realign services to other clinical areas.
• Staff on the medical wards were aware of their roles in line with the trust escalation plan.
• The service had reduced the number of inpatient moves to other wards, since our last inspection.
• Staff were able to access services to ensure patients with specialist needs were addressed. This included interpreters, patient advocates, specialist equipment such as pressure relieving mattresses and patient passports/ “This is Me” to inform care.
• Complaints that arose in the medical wards, were managed effectively with responses made to complainants in a timely manner and in line with trust policy.
• There was clear leadership across the speciality. (Medicine.) Team and clinical leads were accessible and respected by all staff.
• Local managers on the medical wards were enthusiastic about improving their ward, team and sharing knowledge.
• Staff were aware of the trust’s vision and aims.
• Staff were committed to the trust and had pride in their role.
• Locum staff were included in all activities and felt valued and supported.
• Surgery services followed national guidance in order to provide effective treatment and care. Surgical specialities participated in national audits and used the results to make improvements to treatment. Outcomes for surgical patients were similar to or better than the national average.
• Surgery services had taken action to improve access to unplanned and planned treatment.
• Referral to treatment times had improved since our last inspection and were similar to the England average. The emergency surgical assessment unit provided timely review from appropriately skilled medical staff and consultants.
• Surgery services leaders had a clear understanding of risks and how these were mitigated and monitored. They took action to resolve risks by making the business case for funding.
• Leaders were driving standardisation so that surgical patients received consistent treatment and care. There were a number of initiatives to improve care and treatment, such as cross-site meetings to review reasons for cancelled operations.
• There was a culture that supported the reporting and learning from incidents in the surgical departments. This was used to improve services and make them safer.
• Staff asked for feedback from patients and relatives to check they were satisfied with their care. Surgery services provided a timely and responsive investigation of complaints. Action was taken to improve services based on feedback and complaints.
• In surgery consent to treatment was taken in line with expected standards.
• Staff protected the rights of people with a mental health condition in the surgical departments. There was an effective and patient centred process to make sure people were kept safe without depriving them of their liberty.
• Patients we spoke with in the surgical wards, commented on the caring, attentive, and compassionate service they received.
• Staff spoke positively about working within surgery and felt local and senior managers were approachable. Nursing and theatre staff told us they had opportunities for professional development. Practice development support was available to all surgical ward and theatre staff. Doctors in training were receiving appropriate training and support.
• In critical care, leaders fostered a culture where patient safety was the highest priority. This was supported by an active incident reporting culture, maintenance of healthcare records, medicines management and the appropriate level of monitoring for patients.
• The critical care service was provided in appropriate facilities to care for critically ill patients and relatives and visitors had access to appropriate areas of the unit.
• In critical care, as well as attending mandatory training, completing competencies and underwent annual appraisals of their development needs, staff also received support from the unit’s professional development nurse.
• The critical care unit contributed to the Intensive Care National Audit and Research Centre (ICNARC) that monitored patient outcomes and mortality indicators. The annual report for 2016/17 showed the unit was performing as expected (compared to other similar services) in all the indicators, except for two related to delayed discharges.
• Despite the delays encountered with discharges from the critical care unit, patients were not being transferred out to wards in the hospital overnight nor transferred to other units as a result.
• The critical care unit nursing and medical staffing was in line with guidance for the provision of intensive care services (GPICS 2015).
• The critical care unit had an active research and development programme and patients’ care and treatment was assessed and delivered according to national and best-practice guidelines.
• There were low infection rates in the critical care unit and good adherence to infection prevention and control policies, including use of handwashing and personal protective equipment.
• Patients were treated with dignity, respect and kindness. The critical care team were committed to involving patients and their relatives in care and treatment decisions.
• In maternity and gynaecology staff understood their responsibilities to raise concerns and report patient safety incidents. 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 shared with staff and changes were made to the delivery of care because of lessons learned.
• A dedicated team of midwives provided support, care and treatment to women who were thought to be in vulnerable circumstances. Staff understood their responsibilities for safeguarding vulnerable adults, children and young people and were confident to raise concerns. There was effective engagement with other professionals and teams to ensure women in vulnerable circumstances were protected. A female genital mutilation (FGM) clinic had been established, which provided tailored care, treatment and support to women with FGM.
• Staff had the right qualifications, skills, knowledge and experience to do their job within maternity and gynaecology. There were systems in place to develop staff, monitor competence and support new staff. Mandatory training compliance figures had improved and generally met the trust target.
• Systems were in place for assessing and responding to risk in the maternity and gynaecology departments. Staff received multidisciplinary training to help them manage emergencies.
• Women’s care and treatment was planned and delivered in line with current evidence-based practice. National and local audits were carried out and actions were taken to improve care and treatment when needed.
• Performance outcomes and measures were regularly monitored and reviewed within maternity and gynaecology. Action was taken to improve performance.
• Woman had access to care and treatment in a timely manner. Gynaecology referral to treatment times were generally better than the England average.
• Women were positive about their care and treatment. They were treated with kindness, dignity and respect. Women felt involved in their care and were given an informed choice of where to give birth. Actions were taken to improve service provision in response to complaints and concerns received.
• In the children and young people’s service staff were confident to report incidents and staff were encouraged to raise concerns. 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 risk and prevent incidents from reoccurring. This was an improvement from our previous inspection in September 2016 where feedback from staff had been mixed as to whether incident reporting was encouraged.
• At our previous inspection in September 2016 there had been a significant division of staff concerning opinion and practice in the neonatal unit. Some staff felt this might have had an impact on patient care. Following a thematic review and implementation of the recommendations there was evidence of good local leadership from clinicians and managers. Consultants in the neonatal unit were working well together.
• There was clear and visible leadership from the divisional clinical lead, clinicians, the lead nurse, matrons and managers who were approachable and fully engaged with providing high quality child centred care.
• At our previous inspection in September 2016 staff did not always follow the correct security procedures for entering and exiting the neonatal unit, Starfish and Safari (children’s) wards. During our inspection we observed it was not possible to enter or leave the ward and unit without being challenged by staff who always followed the correct security procedures.
• At our previous inspection in September 2016 there was no safety thermometer on Starfish ward which was contrary to guidelines issued by the NHS. A safety thermometer was implemented in April 2017 which reported 100% harm free care on Starfish ward for the period April to July 2017.
• At our previous inspection in September 2016, children who showed signs of deterioration were not always escalated to a senior nurse or doctor. During our latest inspection we saw in patient records that patients were appropriately escalated to either the nurse in charge or the doctor, whichever was indicated.
• At our previous inspection in September 2016, there were gaps in management and support arrangements for staff, such as mandatory training and appraisal. During our latest inspection all staff in children’s services were achieving 93% for mandatory training and appraisal.
• At our previous inspection in September 2016, there were a high number of cancellations of outpatient appointments for children. Children’s services had reduced cancellation rates for appointments less than six weeks. There was an improving picture for cancellations over six weeks.
• We observed the majority of staff in the children’s departments, followed best practice guidance for infection control to reduce the risk of infection through staff washing their hands, using personal protective equipment and following sterile techniques.
• Suitable arrangements were in place for the management of medicines which included the safe ordering, prescribing and dispensing, recording handling and storage of medicines. There was a paediatric pharmacist in post.
• Staff treated children with kindness, dignity and respect. All parents and children we spoke with told us how “wonderful” the service was and staff always went the ‘extra mile’ when caring for children and families. There was a strong child centred culture across the service and staff told us how “proud” they were to work in the children and young people’s service.
• Staffing levels were safe for the number and acuity of children. There were effective measures in place to ensure that when there was increased activity, staff numbers increased. There were sufficient medical staff in post to provide 24 hour, seven day a week care for babies, children and young people.
• There were practice nurses in post to identify and deliver individual and service wide training needs. Staff had the relevant experience, knowledge and qualifications to care for and treat patients.
• There was effective multidisciplinary team working. This included, safeguarding services, mental health services, dieticians, physiotherapists and occupational therapist, play specialists and pharmacists. There were effective working relationships with other trusts, tertiary services and external organisations.
• There were systems in place to protect patients who were receiving care at the end of life from harm and in addition, a good incident reporting culture.
• Medicines were provided in line with national guidance. We saw good practice in prescribing anticipatory medicines for patients who were at the end of life.
• The trust had a replacement for the Liverpool Care Pathway (LCP) called the ‘individualised care plan for the dying patient’ (ICPDP). The document was embedded in practice on the wards we visited.
• The service had produced a detailed action plan to address the shortfalls and issues raised by the national care of the dying audit of hospitals (NCDAH) 2014 to 2015. Local audits were in place to measure the effectiveness and outcomes of the service.
• Do not attempt cardio-pulmonary resuscitation (DNACPR) records we reviewed were signed and dated by appropriate senior medical staff.
• Relatives were happy with the care their relatives had received and felt involved in their care planning at the end of their life. Staff demonstrated compassionate patient centred care throughout the inspection.
• Care and treatment was coordinated with other services and other providers. The specialist palliative care team had good working relationships with discharge services and their community colleagues. This ensured that when patients were discharged their care was coordinated.
• All adult wards had compassionate care champions who were trained in providing end of life care and were a direct link to the SPCT.
• The SPCT saw 91% of patients within 24 hours of referral.
• The trust had an executive and a non-executive director on the trust board with a responsibility for end of life care.
• There was a clear vision and strategy for end of life care.
• Since our previous inspection in September 2016, an outpatient quality improvement plan (QIP) had been implemented. This included all issues raised during the previous inspection and we found that 14 out of 15 had been completed in August 2017. Performance data had improved since the plan was implemented and the service was performing in line with their planned trajectory.
• There was a positive incident reporting culture across the outpatient services provided. We saw robust departmental learning from a recent never event.
• Our last inspection in September 2016 highlighted issues with non-compliance with hand hygiene and lack of hand hygiene audits in outpatients at Watford general Hospital. We found this had improved during our inspection in August 2017. Good standards of hand hygiene were maintained and the department was compliant with hand hygiene audits.
• Patient records were stored securely in locked rooms and trolleys. This was an improvement since our last inspection.
• Radiation protection in the diagnostic imaging department was robust and supervisors were appointed in each clinical area. Medical physics experts and radiation protection supervisors actively worked with staff to provide advice and ensure compliance with safety standards.
• Nurse staffing levels were appropriate with minimal vacancies and staffing levels met patient needs.
• Staff in all departments were aware of the actions they should take in case of a major incident.
• Risk to patients on the waiting list for outpatient appointments was discussed at weekly meetings. Clinical assessments were conducted if patients waited 30 weeks or more for outpatient services.
• Care and treatment was delivered in line with evidence-based guidance, standards, and best practice.
• The diagnostic imaging department was working towards the Imaging Services Accreditation Scheme (ISAS).
• There was a comprehensive clinical audit programme in the radiology department to monitor compliance with trust policy and Ionising Radiation (Medical Exposure) Regulations (IR(ME)R). Results showed consistent compliance and actions taken to improve.
• Multidisciplinary meetings were held in various specialties within the outpatients department so that all necessary staff were involved in assessing, planning and delivering patient care.
• Patients were treated with compassion, kindness, dignity and respect.
• Chaperones were available throughout the outpatient and diagnostic imaging services. Information on the chaperone policy was displayed in clinical rooms and waiting areas.
• Patients we spoke with felt well informed about their care and treatment.
• Our last inspection identified issues with patients being treated in the corridor in dermatology. During inspection, there was a dedicated room for wound care. This was an improvement.
• Improvements had been made in the ophthalmology department to maintain patient confidentiality. During our previous inspection, two orthoptists shared a clinic room and saw patients at the same time, which did not maintain confidentiality. At this inspection we found that clinic rooms were no longer shared.
• During our last inspection, we were not assured that patients had timely access to treatment as the trust performed worse than the England average for the percentage of patients receiving an outpatient appointment within 18 weeks of referral. However, this had improved and had met the England average from April 2017 onwards.
• The trust had improved its performance for cancer waiting times and was meeting the national standard in four out of five measures.
• Patients had timely access to diagnostic imaging services and the percentage of patients waiting more than six weeks was lower than the England average.
• Diagnostic imaging services were available seven days a week and patients were able to change appointments to suit their needs.
• Outpatient specialties held additional evening and weekend clinics to reduce the length of time patients were waiting.
• Our last inspection identified issues with lack of written information for patients prior to their appointment, for example, what to expect on the day. During this inspection, we saw letters contained detailed information for patients. This was an improvement.
• Poor communication between medical and nursing staff was highlighted at our previous inspection for example, clinics were held that nursing staff were unaware of. During this inspection, staff said this had improved.
• Staff completed a weekly monitoring of waiting lists and clinics flexed to meet any changes in demand or noted increased numbers.
• A new cardiac suite had been opened and magnetic resonance imaging (MRI) was available seven days a week to meet the needs of patients.
• There was good awareness of the needs of patients with a learning disability and dementia. ‘Twiddle muffs,’ as promoted by the dementia society, were introduced for patients living with dementia attending the diagnostic imaging department to assist with restlessness.
• Some outpatient departments had developed services, such as one-stop clinics, in order to better meet the needs of patients and improve service provision.
• Staff felt that managers were visible, supportive and approachable.
• All staff we spoke with felt respected and valued. The culture across outpatient and diagnostic imaging services encouraged openness, candour and honesty.
• Patients, relatives and visitors were actively engaged and involved when planning services. People were encouraged to provide feedback and we saw their comments used to improve. Clinical leads led an outpatient user group to gather information on patient experience.
• Leadership of the diagnostic imaging department was focused on driving improvement and delivering high quality care to patients. Radiology governance and risk management processes were robust and effective.
• There were high levels of staff satisfaction, and individuals were proud to work for the trust.

St Albans City Hospital, was rated requires improvement overall, although surgery was rated good.

This was because:

• There was no initial clinical assessment of adult patients in the minor injuries unit. This had not improved since our last inspection and meant that patients’ condition was at risk of deteriorating while they waited for treatment.
• Although children were assessed quickly during our inspection, the trust could not provide assurance that this took place consistently.
• Staff did not use an early warning scoring system in order to identify deteriorating patients.
• There remained a lack of monitoring of patient outcomes, performance measures and compliance with evidence-based protocols.
• X-ray services were not always available when patients needed them.
• There was no job description for the lead nurse role meaning that their responsibilities were unclear. The matron of the unit also managed a neighbouring emergency department and an urgent care centre that was several miles away. This left little time for direct clinical leadership of the MIU.
• There was a lack of understanding of the risks that could affect the delivery of good quality care. We raised this with the trust at our last inspection. There had been some improvements but not all risks had been added to the risk register.
• The vanguard theatre did not allow for waste and dirty linen to be removed without travelling outside or through a clean area.
• Imaging, diagnostics and dietetics and speech and language therapy services were available Monday to Friday from 9am to 5pm. If support was required outside of these hours it would be at the Watford hospital site. If a patient required diagnostic imaging, for example an x-ray or scan, outside of these hours they would have to be transferred to the Watford site via non-emergency ambulance transport.
• Pharmacy support was available on site Monday-Friday but there was no support at weekends, but this was available from the Watford site
• Those who had surgery cancelled were not always treated within the following 28 days in line with guidance.

However:

• Within surgery, there were clear processes in place for reporting incidents and providing feedback. Learning from incidents was shared across all areas.
• ‘Test your care’ nursing care indicators were consistently high and meeting trust targets.
• Written records were consistent across areas, clearly maintained with risk assessments and nursing/medical records easy to locate. Records were stored securely throughout our inspection.
• Improvements had been made in relation to standardisation of World Health Organisation safer surgery checklists and compliance with these met the trust target.
• Infection control practices had improved since the previous CQC inspection and audits demonstrated good levels of compliance.
• There was a dedicated orthopaedic ward and a dedicated general surgical ward to manage patient’s specific needs.
• Policies were up to date in line with guidance from the National Institute for Health and Care Excellence (NICE) and other professional associations.
• Care bundles were embedded in patient care to improve patient outcomes.
• Significant work was being carried out in relation to enhanced recovery. Enhanced recovery pathways were used to improve outcomes for patients in general surgery, breast, urology, orthopaedics and ear nose and throat (ENT). Outcomes for enhanced recovery were collected and monitored within the service.
• The average length of stay for patients was better (shorter) than the England average.
• The re-admission rate for elective patients were slightly better than the England average overall. However, the re-admission rate for elective orthopaedic patients was slightly worse than the England average.
• The service continuously reviewed and improved patient outcomes through participation in national audits including the elective surgery Patient Reported Outcome Measures (PROM) programme, the National Joint Registry and surgical site infection audits.
• Staff told us they had opportunities for personal development and to enhance their skills. Practice development support was available to all staff.
• All staff provided a caring, kind, and compassionate service, which involved patients and their relatives in their care. All the feedback from patients and their relatives was positive.
• Staff provided emotional support to patients and staff directed patients to clinical nurse specialists for support where required.
• Patients’ and relative feedback was sought on the care they received to ensure they were satisfied with the care provided.
• Changes in senior leadership had led to positive operational and cultural changes within surgical service.
• Senior managers had a clear understanding of risks to the service and how these were being mitigated and monitored.
• All staff spoke positively about working within the service and felt local and senior managers were approachable.
• Staff understood the trust's vision and values and portrayed these in their day to day role.
• Cross site working occurred to improve risk and quality management within the service.
• The service demonstrated a drive to improve clinical services and supported innovations.

Hemel Hempstead Hospital was rated requires improvement overall, although outpatients and diagnostic imaging were rated good.

This was because:

• At Hemel Hempstead Hospital there had been several improvements in assessing and responding to patient risk within the urgent care centre. All patients were assessed by a triage nurse, usually within 20 minutes of arrival. This compared well to our last inspection when patients were waiting up to two hours for an initial clinical assessment.
• Staff used an early warning scoring system to identify patients at risk of deterioration.
• All practitioners had undertaken further training in the assessment and treatment of sick children and there was always access to a specialist children’s nurse if necessary.
• There was good multi-disciplinary working and the unit met 18 of the 19 standards set out in the Royal College of Medicine (RCEM) report on “Unscheduled care facilities” 2009.
• We observed staff maintaining patients’ privacy, dignity and confidentiality. They demonstrated empathy towards patients who were in pain or distressed and were skilled in providing reassurance and comfort.
• Almost all patients (99%) were treated, discharged or transferred within four hours, with an average time to treatment of 27 minutes.
• An escalation plan had been introduced that provided support to the unit if patients were waiting more than two hours for treatment.
• Staff engagement had improved and clinical staff were encouraged to attend monthly clinical governance meetings.
• Since our previous inspection in September 2016, an outpatient quality improvement plan (QIP) had been implemented for issues raised. Performance data had improved and the service was performing in line with their planned trajectory.
• There was a positive incident reporting culture across the services provided. All staff we spoke with knew how to report an incident and details of recent incidents and learning.
• Radiation protection in the diagnostic imaging department was robust.
• The main outpatient department had no nursing vacancies at the time of our inspection.
• Since our previous inspection in September 2016, the availability of patient notes had improved.
• Medical records were comprehensive, legible, accurate and up-to-date. They were stored safely in a locked office or in lockable trolleys when being used in clinics.
• Medicines and prescription pads were stored securely in all areas we visited.
• Waiting lists for outpatient appointments were reviewed weekly. Risk assessments and individual treatment plans were completed for patients who waited 30 weeks or more. At the time of our inspection, no clinical harm had occurred to patients because of waiting over 30 weeks.
• In outpatients care and treatment was delivered in line with evidence-based guidance, standards and best practice. Pathways were in place for the management and treatment of specific medical conditions that followed national guidance.
• There was a local audit programme in the outpatient department that included monitoring compliance with best practice.
• The diagnostic imaging department was working towards the Imaging Services Accreditation Scheme (ISAS).
• There was a comprehensive clinical audit programme in the radiology department to monitor compliance with trust policy and Ionising Radiation (Medical Exposure) Regulations (IR(ME)R).
• Clinics were run by specialists in their field and staff were supported to develop based on their professional and clinical interests. Multidisciplinary meetings were held to assess, plan and deliver co-ordinated patient care.
• The outpatients department communicated regularly with patients’ GPs and worked with the trust’s GP liaison manager to share information.
• Staff understood their responsibilities for obtaining consent and making decisions in line with legislation, including the Mental Capacity Act (MCA) 2005.
• Patients were treated with kindness, dignity, respect and compassion. Staff were considerate of people’s personal, cultural, and religious needs.
• Chaperones were available throughout the outpatient and diagnostic imaging services.
• Staff communicated with people so that they understood their care, treatment and condition. Patients we spoke with felt well-informed about their treatment and could explain what would happen next.
• Staff recognised when people needed additional support to help them understand and took action to meet their needs.
• Patients we spoke with described being offered emotional and social support.
• During our last inspection, we were not assured that patients had timely access to outpatient treatment. The service was found to be in breach of Regulation 12 of the Health and Social Care Act Regulations 2014: Safe care and treatment, due to being worse than national standards for waiting times. During this inspection, we found that most waiting times had improved to meet national standards.
• The trust had improved its performance for cancer waiting times and was meeting the national standard in four out of five measures.
• Patients had timely access to diagnostic imaging services and the percentage of patients waiting more than six weeks was lower than the England average.
• Services were planned and delivered to take into account different people’s needs. This had improved since our previous inspection with the introduction of written information in languages other than English.
• The main outpatient department was working towards gaining a Purple Star accreditation for the care and treatment they provided to patients with a learning disability.
• The phlebotomy service engaged with people in vulnerable circumstances and took actions to overcome barriers when people found it difficult to access services.
• Leaders and staff across outpatient and diagnostic imaging services were continuously striving for improvement. In addition to the QIP, local leaders had further plans to improve services.
• The culture in across outpatient and diagnostic imaging services encouraged openness, candour and honesty. All staff we spoke with felt supported, respected and valued.
• Patients, relatives and visitors were actively engaged and involved when planning services. People were encouraged to provide feedback and we saw their comments used to improve.
• Leadership of the diagnostic imaging department was focused on driving improvement and delivering high quality care to patients.

However:

• During our previous inspection, we found that not all staff working in clinics that saw children had the appropriate level of safeguarding training. This was still the case at the inspection in August 2017.

• We could not be assured that the service was fulfilling its mandatory duty to report cases of female genital mutilation (FGM) as all staff we spoke with were unaware of the trust policy on identifying and assessing the risk of FGM.
• Hand hygiene and environmental infection control audits were not carried out in the phlebotomy department.
• Compliance with fire safety training in the radiology department was worse than the trust target of 90%.
• Staff compliance with Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS) training was below the trust target.
• There were no seven-day outpatient services provided at the time of inspection. Some ad-hoc Saturday clinics had been provided, but this had not taken place since March 2017. There were no plans to introduce evening or weekend clinics.
• Friends and Family Test scores for outpatient services across the trust were worse than the England average from January to June 2017. This had improved in July 2017.
• Five out of 16 specialties were not meeting the England overall performance for patients being seen within 18 weeks of referral.
• During the previous inspection, it was raised that hearing loops were not in use to aid people with hearing impairment. This was still the case at the most recent inspection.
• Staff were not always informed in advance if a new patient had mobility issues, a learning disability or dementia. This meant adjustments could not be made prior to their attendance to facilitate their journey through the department.
• At the time of inspection, there was only one risk on the outpatient department risk register. This was related to clinics being overbooked. However, during our inspection we identified other risks that should have been recognised.
• In the urgent care centre risks that we had identified at previous inspections did not feature on the risk register.
• There was no medical oversight of the UCC. The matron was also responsible for a neighbouring emergency department and a minor injuries unit that was several miles away. This left little time for active clinical leadership in the UCC.

We saw several areas of outstanding practice throughout the trust including:

• At Watford General Hospital, the “iSeeU” initiative provided women who were separated from their babies at birth the opportunity to use face-time technology to see their baby receiving care and treatment on the neonatal care unit.
• The pilot Phoenix team provided a case loading service for women with uncomplicated pregnancies who wanted to give birth at home or at the birth centre. The team sent a congratulations card to every mother who was part of their team once they had delivered their baby.
• There were a number of outstanding innovations in the children’s emergency department to support the needs of parents, children and younger people. This included support from voluntary groups charities and volunteers to tackle important issues such as mental health and suicide awareness.
• The set up and design of the children’s emergency department as an environment to children was outstanding as it enabled the service to undertake interventions on children quickly. The design and space for a district general hospital was unique and was modelled on the set up of the tertiary children’s units.
• We observed outstanding care interactions provided by staff to children in the emergency department and in the children’s observation bay.
• The pathways of care in the children’s emergency department, their effective use within the department on patients was outstanding.
• The trust had implemented a focused recruitment programme for band 5 (junior) nurses was in place to provide a “grow your own” concept at Watford hospital. The approach had enabled the trust to enhance their current nursing establishments and had allowed the progression of band 5 nurses using a quality improvement approach. This had provided independent career development opportunities for the nursing team and supported link roles within the service and the wider children’s network.
• The diagnostic imaging service monitored its compliance by auditing best practice relating to patients receiving chest radiography. Guidance from the Royal College of Radiologists (RCR) states that it is best practice to undertake chest radiographs on patients in the poster anterior (AP) upright position, apart from when this is not appropriate due to immobility or ill health. Following an audit performed within the diagnostic imaging department, staff embraced the importance of change in practice especially in difficult casualty situations.
• An electronic referral pathway had improved the care for infants with prolonged neonatal jaundice. The pathway had been developed in partnership with GPs, health visitors, community midwives and local commissioners. This had resulted in a reduction in the referral to appointment time (under 48 hours) and the overall time for parents to receive their child’s results was two weeks from referral.
• At Hemel Hempstead Hospital the phlebotomy service engaged with people in vulnerable circumstances and took actions to overcome barriers when people found it difficult to access services. For example, phlebotomists carried out home visits for housebound patients who were on blood-thinning medicines. Patients who are on blood-thinning medicines must be assessed regularly to monitor their condition and assess dosage of the drug. Phlebotomists conducted finger-prick tests in housebound patients’ homes to facilitate their access to treatment. This also reduced the need for these patients to have blood tests, which is beneficial if the patients are elderly as taking blood can be difficult and distressing. In the urgent care centre at Hemel Hempstead Hospital, staff had taken photographs of the unit in order to compile a book to help communicate with people who had cognitive impairment. This consisted of photographs that illustrated common practices in the unit such as having an X-ray taken or a dressing applied. This helped people to understand the treatment that had been planned for them.
• The enhanced recovery care of patients at St Albans was working effectively to improve patient outcomes. Staff managing the enhanced recovery care pathways were proactive and passionate about improving patient care.
• The enhanced recovery care of patients at St Albans was working effectively to improve patient outcomes. Staff managing the enhanced recovery care pathways were proactive and passionate about improving patient care.
• The phlebotomy service engaged with people in vulnerable circumstances and took actions to overcome barriers when people found it difficult to access services. For example, phlebotomists carried out home visits for housebound patients who were on blood-thinning medicines. Patients who are on blood-thinning medicines must be assessed regularly to monitor their condition and assess dosage of the drug. Phlebotomists conducted finger-prick tests in housebound patients’ homes to facilitate their access to treatment. This also reduced the need for these patients to have blood tests, which is beneficial if the patients are elderly as taking blood can be difficult and distressing.

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

Importantly, the trust MUST:

• Ensure governance quality systems, including the reporting of incidents, identification of risk and management of risk registers provide assurances that ED runs safely and effectively.
• The trust must ensure that the staffing levels on duty are based on acuity, and ensuring the numbers on duty for nursing, medical and support staff are sufficient to ensure safe care within ED.
• The trust must ensure that appropriate action is taken to improve the culture within the ED.
• The trust must ensure that where a person lacks capacity to make an informed decision or given consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice. A formal decision specific mental capacity assessment must be undertaken of the patient’s ability to understand this decision and to participate in any discussions.
• Ensure that all staff caring for patients less than 18 years of age in outpatients complete safeguarding children level three training.
• Ensure staff in outpatient services are aware of the trust policy and fulfil the mandatory reporting duty for cases of female genital mutilation.
• Ensure that World Health Organisation (WHO) five steps to safer surgery checklists are completed in their entirety within outpatients.
• Ensure that infection prevention and control standards are maintained in rooms where minor operations are performed.
• Ensure that all risks within the outpatient department are included in the departmental risk register.
• Ensure staff within the radiology department are up-to-date on fire and evacuation training.
• Ensure that venous thromboembolism reassessments for admitted patients are repeated and recorded in line with national guidance on both the medical and surgical wards.
• Ensure that patient personal identifiable information on medical and surgical wards is not displayed or discussed openly within earshot of unauthorised persons.
• Ensure that all staff caring for patients under 18 years of age complete safeguarding children level 3 training.
• Ensure staff in outpatient services are aware of the trust policy and fulfil the mandatory reporting duty for cases of female genital mutilation.
• Monitor compliance with hand hygiene and environmental infection control in the phlebotomy department.
• Ensure that all risks relating to outpatient services are identified, recorded and managed on the departmental risk register.

The trust was placed into special measures in September 2015. Due to the improvements seen at this inspection, I have recommended to NHS Improvement that the special measures are lifted.

Professor Edward Baker

​Chief Inspector of Hospitals

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 Watford 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.

Overall, we rated West Hertfordshire Hospitals NHS Trust as requires improvement. The key questions for safe, effective, responsive and well led were all rated as requires improvement and caring was rated as good.

Our key findings were as follows:

• Whilst most staff were kind and caring we found concerns relating to staff attitude towards patients on the medical ward at Hemel Hempstead Hospital. In addition there were some examples in the outpatients department where patients’ privacy and dignity was compromised.

• There were systems and process in place for the assessment and response to risk however these were not consistently adhered to.

• Patients attending the emergency department were not consistently receiving treatment in a timely manner.

• There was no clear streaming process at the urgent care centre at Hemel Hempstead Hospital or the minor injury unit at St Albans City Hospital. This had not improved since the last inspection. It was raised with the trust who took actions to address this risk to patient safety. Also in these areas there was not a robust process to monitor arrival to initial clinical assessment or ensure all children were seen by a clinician within 15 minutes.

• There was no process in place for the safe storage of patients own controlled drugs. Also some room temperatures were higher than deemed appropriate for the safe storage of medicines and appropriate action had not been taken to address this.

• Not all relevant staff that required level three safeguarding children training had been identified as requiring this. There were areas in the trust that cared for patients aged 16 to18 years in which staff had not been trained to level three.

• Pain relief was not routinely checked or provided to patients in the emergency department.

• Regular fluids were not provided to patients in the emergency department, despite the high temperatures during the inspection.

• Records were not completed consistently in a timely manner.

• Whilst most staff were aware of their roles and responsibilities in the management and reporting of incidents, concerns and near misses, this was not consistent in all areas of the trust. Evidence of learning was inconsistent throughout the trust.

• Although there was a comprehensive duty of candour policy in place, staff knowledge was variable and processes were not robust, not all incidents that met the threshold were identified or managed appropriately.

• 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.

• Results from audits varied with a lack of clear action planning to address areas of weakness.

• There was not an effective process in place to monitor and review patient outcomes on the urgent care centre, minor injury unit or the medical ward at Hemel Hempstead.

• The access to the service and flow of patients through the trust was not effective. Medical patients were transferred numerous times often out of hours.

• The trust had a higher proportion of delayed transfers of care at 26.7%; this was nearly 10% higher than the proportion for all trusts in England.

• The emergency department was failing to meet a number of targets and breaches had become acceptable.

• The trust was not meeting the target of two weeks wait for suspected cancers, including possible breast cancer.

• Patients did not always have timely access to initial assessment or treatment with referral to treatment times below the England average.

• Complaints were not responded to in a timely way.

• Risks to the service had not all been identified by the trust, in particular on Simpson ward.

• Whilst the trust had a governance framework in place there were some areas of weakness. Both this and the divisional structure were relatively new so the processes were not yet fully embedded and it was too early to assess the impact.

• Most staff felt respected and valued however there were some areas where there was friction between staff disciplines and staff who felt uncomfortable speaking out.

• The trust had a relatively stable board since the last inspection so had been able to develop their skills and experience, although the chair and chief executive had both commenced in the intervening period.

• Staffing levels and skill mix was planned and reviewed using bank and agency staff when required to maintain safe care and treatment. The trust reported that they would have no consultant vacancies by October 2016.

• Care was mostly delivered in line with legislation, standards and evidence-based guidelines.

• The Summary Hospital-level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR) was lower (better) than expected. The trust was one of 17 trusts nationally with a lower than expected HSMR.

• The percentage of patients waiting less than six weeks for a diagnostic appointment was consistently better than the national average.

• The trust was working with stakeholders to ensure service were planned to take account of different people.

• The numbers of MRSA, 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.

• The urgent care centre and minor injury unit consistently met the target to admit, transfer or discharge 95% of patients within four hours of arrival at the unit.

We saw several areas of outstanding practice including:

• 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 trust reduced the mortality rate for hip fractures, from February 2013 to February 2016 from 12% to 4%, with a continuing downward trajectory, by reviewing their hip fracture care pathway. This pathway supported good communication between the emergency department and the orthopaedic service and there were dedicated “ring fenced” beds to support fast treatment.

• The trust has Hospital Standardised Mortality Ratio (HSMR) rates lower than expected, sustained for 18 months.

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 have 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

• Devise an action plan to address the shortfall between appraisal rates and the trust target and make sure that the trust target is reached.

• To ensure that there are effective streaming systems in place in the urgent care centre and minor injury unit and all staff have had appropriate training to carry out this process.

• Ensure there are processes in place to monitor arrival time to initial clinical assessment for all patients in the urgent care centre and minor injury unit.

• To establish a process so that all children are seen by a clinician within 15 minutes of arrival in the urgent care centre and minor injury unit.

• To ensure that there are effective processes in place in the urgent care centre and minor injury unit to provide clinical oversight for patients waiting to be seen.

• To ensure non-clinical staff in the urgent care centre and minor injury unit receive sufficient support or training to provide oversight to recognise a deteriorating patient.

• To ensure the urgent care centre and minor injury unit have direct access to a registered children’s nurse at all items and that paediatric competencies for emergency nurse practitioners are recorded as a part of their continuous professional development (CPD) in line with national recommendations.

• To ensure that effective governance frameworks, standard operating procedures and policies are in place to support service delivery urgent care centre and minor injury unit.

• To ensure that systems and processes are in place to monitor and review all key aspects of performance to identify areas for improvement and all potential risks in the minor injury unit and surgery at St Albans and the urgent care centre and Simpson ward at Hemel Hempstead.

• To ensure that staff are given training and support to understand the duty of candour statutory requirements.

• Plans must be put into place to ensure referral to treatment (RTT) times to continue to improve so that they are similar to or better than the England average.

• To ensure that the Simpson ward can meet the needs of patients with vulnerabilities, including those living with a dementia and those displaying difficult behaviours and to ensure the provision of activities to engage patients in meaningful stimulation.

• To review the admission and exclusion criteria for Simpson ward to ensure all referred patients have their needs met.

• 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%.

• To ensure all resident medical officers (RMOs) receive a trust induction.

• Actions on fire risk assessments in surgery at St Albans City Hospital must be completed and areas regularly monitored for future compliance 

• To ensure staff levels and competency of staff meets patient need at all times on Simpson ward.

On the basis of this inspection, I have recommended that the trust remains in special measures.

Professor Sir Mike Richards

Chief Inspector of Hospitals