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Northwick Park Hospital Requires improvement

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Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 June 2016

Northwick Park Hospital is in the London Borough of Harrow. It is part of the London North West Healthcare NHS Trust whichis one of the largest integrated care trusts in the country, bringing together hospital and community services across Brent, Ealing and Harrow. Established on 1 October 2014 from the merger of North West London NHS Trust and Ealing Hospitals NHS Trust, and employing more than 8,000 staff it serves a diverse population of approximately 850,000.

The trust runs Northwick Park Hospital, St Mark’s Hospital, Harrow; Central Middlesex Hospital in Park Royal and Ealing Hospital in Southall. It also runs 4 community hospitals – Clayponds Rehabilitation Hospital, Meadow House Hospital, Denham unit and Willesden Centre - in addition to providing community health services in the London Boroughs of Brent, Ealing and Harrow.

At the end of the financial year 2014-15 the trust had a deficit of £55.9 million.

We carried out this inspection as part of our comprehensive acute hospital inspection programme for combined acute hospital and community health based trusts. We inspected Northwick Park Hospital, Ealing Hospital and the following community health services: community services for adults; community services for children, young people and families; community inpatient services; community services for end of life care and community dental services.

The announced part of the inspection took place between 19-23 October 2015 and there were further unannounced inspections which took place between 3-7 November 2015.

Overall we ratedNorthwick Park Hospitalas requires improvement. We rated end of life care as good.We rated the followingservices as requires improvement: Urgent and emergency care, medical care including care of the elderly, surgery, critical care, maternity and gynaecology, acute services for children,and outpatients and diagnostic imaging.

Overall we rated caring at thehospital as good but safety, effective, responsive and well-led as requires improvement.

Our key findings were as follows:

  • The merger of the trust had been protracted and subject to delay. This had had a negative effect on performance and leadership.
  • We saw overall disappointing progress in merging systems and processes at the trust. To most intents and purposes Ealing and Northwick Park appeared to be operating as separate entities and community health services appeared disengaged from the rest of the trust.
  • There appeared to be substantial duplication of support functions at both main sites. There appeared to have been lack of control over spend of administrative, non-staff, and nursing staffing budgets with little rationale over nursing numbers on wards.
  • A new chief executive had recently been appointed earlier in 2015. She was in the process of building a new executive team and by the time of our inspection only one member of the previous substantive executive team was in post. This meant that the new executive team were in the process of getting to grips with their respective functions.
  • All staff working at the hospital were dedicated, caring and supportive of each other within their ward and locality. There was a high degree of anxiety and uncertainty borne out of the merger.

  • There appeared to be a lack of firm information provided to staff about the effects of Shaping a Healthier Future - to reconfigure services in north west London - despite the chief executive holding regular briefing session. This added to staff anxieties.

  • We saw several areas of good practice or progress including:

  • a newly opened emergency department at Northwick Park

  • a refurbished and child friendly ward for children's care called Jack's Place.
  • caring attitudes, dedication and good multi-disciplinary teamwork of clinical staff.
  • good partnership working between urgent and emergency care staff and London Ambulance staff.
  • good induction training for junior doctors.
  • research projects into falls bundles, stroke trials and good cross site working in research.
  • Staff told us there were good opportunities for training and career development.
  • We found the specialist palliative care team (SPCT) to be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner.
  • The play specialists in services for children demonstrated how they could make a difference to the service and its environment in meeting the needs of the children and young people. This includedan outstanding diversional therapy approach for children and young people, which was led by the play specialist and school tutor.

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

  • There was limited sparse medical cover on eHDU out of hours and at weekends, which meant there was frequently no doctor immediately available on the unit. Consultants responsible for eHDU and Dryden HDU were not intensivists and processes for escalating surgical patients were unclear. Additionally, less than the recommended proportion of eHDU nurses had critical care qualifications.
  • There was a lack of expert support from consultant radiologists at weekends, which impacted on the accuracy of clinical diagnosis being achieved. Risks related to patient safety and service delivery had not always been identified and agreed timelines for resolution had not always been identified. Thisled to scans being reported by specialist registrars (SpR’s) and amended by consultants on Mondays. They reported an apparent 25% amendment rate, with missed pathologies.
  • Surgical staff were not always reporting incidents. Consultants and other surgical staff told us they did not routinely complete incident reports for issues or concerns as the forms were said to be “too laborious” and nothing was done to change the problems highlighted.
  • Access to services and patient flow through the ED at Northwick Park to wards in the hospital was poor and patients experienced long waits in the HDU and assessment unit areas.
  • The performance dashboards for ED showed that compliance with achieving the mandatory targets, including the 4 hour treatment target, had been poor over the previous 12 months.
  • The emergency department participated and performed poorly in the College of Emergency Medicine audits on pain relief, renal colic, fractured neck of femur and consultant sign-off; and there were no clear action plans drawn up by the department indicating what actions were taken as a result of the audits.
  • Compliance with safeguarding training was poor particularly among medical and dental staff.
  • The trust target was to have 95% of staff having completed mandatory training. Trust data, as of March 2014 – July 2015, showed compliance with the target was poor in many areas.
  • We saw examples of poor infection control practice such as linen left on a bin when a nurse was putting gloves on, staff wearing nose rings and hooped earrings that were not covered and name badges that were made of paper.
  • There was a poor environment on the stroke wards at Northwick Park Hospital.
  • There were poor handovers between ED and the wards at Northwick Park with MRSA screening and medicines management not always clear or complete in the handovers.
  • Nutrition and hydration was poorly managed on Northwick Park medical wards with poor assessments, choice of food and support for those that needed it.
  • In surgery, several groups of patients had no formally defined pathway, which impacted on their safety.
  • The National Bowel Cancer Audit for 2014 indicated that data completeness for patients having major surgery was poor at 30%, compared with an England average of 87%.
  • There was a lack of formal escalation process for surgical patients who deteriorated on eHDU aside from the support provided by the outreach team.
  • Handovers to the consultant taking over care of eHDU patients on a Monday morning was completed by the weekend on call anaesthetic registrar rather than a consultant to consultant handover. Staff highlighted this as a concern as there wasarisk important information could be missed.

  • In maternity and gynaecology, there were safety concernsrelated to midwife shortages, not having safety thermometers on display and some staff reporting that they did not get feedback after reporting incidents.Staff raised concerns about one midwife covering the triage and observation areas at same time during times of pressure.

  • We were concerned that some of the risks we identified were not on the risk register, such as the room used for bereaved women on the delivery suite at Northwick Park Hospital with a lack of sound proofing from the ward.
  • Staff on wards outside of the end of life team had a poor understanding of end of life care and the trust LDLCA - Last days of life care agreement. Concern was raised that doctors and nurses on the wards did not recognise deteriorating and dying patients.
  • Signage for outpatient clinics was in some cases poor and or stopped short of providing clear directions for patients.
  • In outpatients and diagnostic imaging, poor patient experience was due to overbooking clinics, lack of capacity in outpatients and lack of availability of medical records in time for clinics.
  • In OPD, we were concerned incidents were not always appropriately recognised, escalated or investigated and lessons learned were not widely shared
  • The pre-inspection information identified some concerns around consultant cover in haematology. Some of the facilities were not suitable to meet the needs of patients, for example, the haematology day care service.
  • Audits showed hand hygiene was a concern with some wards either not submitting audits or scoring less than 90%.
  • We had concerns with medicines given by night staff. Drug rounds were arranged so night staff had a round at the start and two at the end of their shift with a potential increased risk of error.
  • All types of therapy visits on wards were unscheduled meaning patients could miss their therapy if they were away from their bed or in pain.
  • Trust wide there weretemperature control issues across sites in rooms where medicines are stored.
  • The above list is not exhaustive and the trust should address these and the rest of the issues outlined in our reports in its action plan.

Importantly, the trust must:

  • provide expert support from consultant radiologists at weekends.
  • ensure effective processes for reporting, investigating and learning from incidents, and ensure all staff always report incidents.
  • provide sufficient trained and experienced medical and nursing cover on eHDU at all times including out of hours and at weekends to ensure immediate availability on the unit.
  • Weissued the trust with a Section 29 (A) warning notice in relation to the three " must do" items listed immediately above requiring substantial improvements.
  • The above list is exhaustive and the trust must pay attention to remedy all other issues raised in the report.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 21 June 2016

Effective

Requires improvement

Updated 21 June 2016

Caring

Good

Updated 21 June 2016

Responsive

Requires improvement

Updated 21 June 2016

Well-led

Requires improvement

Updated 21 June 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 21 June 2016

We found concerns regarding the safety arrangements in the maternity services.These related to midwife shortages, not having safety thermometers on display and some staff reporting that they did not get feedback after reporting incidents.

Staff shared concerns with us about the environment, temperature and faulty equipment in the Day Assessment Unit.(DAU).

The records we reviewed showed venous thromboembolism (VTE) assessments were carried out and maternity early warning score (EWS) assessments were being completed. Gynaecology was also completing EWS. There were up-to-date evidence-based guidelines in place, however we were not able to find evidence that ‘Fresh eye’ checks were being recorded every hour for women during labour.

We did observe good practice in terms of effective multidisciplinary team working, multidisciplinary handover on delivery suite and that staff had the right skills, qualifications and knowledge for their role.

Some women experiencing pregnancy loss were being cared for in a room without sound-proofing. This meant that women in the room could hear the sounds of babies crying and this could cause distress. However, people told us they were consistently treated with dignity, kindness, and respect throughout the services.

We requested the current percentages of women seen in the labour ward within 30 minutes by a midwife, and the percentage seen by a consultant within 60 minutes, to determine timeliness of assessment. This information however was not being recorded.

Most of the people using the service told us that did not know who to make a complaint. Between October 2014 to September 2015 the service received 64 complaints. 13 of these were still open and being investigated at the time of the inspection. Some complaints had been open for over two months.

The Trust had a clear vision and strategy however the staff we spoke with did not demonstrate awareness or understanding of it. The trust vision and strategy was not visible throughout the wards and corridors. We saw the services' business plan for 2015 – 2016. It did not include the vision of the service.

Medical care (including older people’s care)

Requires improvement

Updated 21 June 2016

Medical services at NPH required improvement across all key questions other than caring which we rated as good. The biggest concerns were the flow of patients through the medical wards, staffing levels, nutrition and the environment’s safety and responsiveness to patient needs.

Governance and leadership also required improvement. Although there was some risk awareness and a strategy going forward, cross site working was in its infancy and performance was not fully monitored.

Other areas of concern including patient record completion, mandatory and competency based training. A number of areas of where understanding and performance was limited or variable included adherence to the Mental Capacity Act or engagement with staff and the public.

However, most of the patient feedback we received was positive including involvement in care and privacy and dignity. Patients who deteriorated or were in pain were well managed and patient harm was being actively reduced. Complaints were responded to and acted upon.

There was a supportive leadership at ward and department level but there was an impression the divisional leadership were acute pathway focused. There were also some unclear reporting lines in care of the elderly.

Urgent and emergency services (A&E)

Requires improvement

Updated 21 June 2016

Theemergency department (ED) had not achieved the four-hour national target of 95% of all patients seen within four hours from July 2014 to June 2015, an average of 90% of patients were seen within the four-hour target time. Patients often waited for long periods before staff moved them to an appropriate ward or department once a decision to admit hadbeen made. Access to services and patient flow through the ED to wards in the hospital was poor and patients experienced long waits in the HDU and assessment unit areas.

The physical layout of the department and waiting times for admission and discharge to or from the EDordid not ensure the safety of patients in the department.

The leadership team within the department demonstrated innovation, and encouraged learning and listening across all grades of staff. There was a clear local management structure in the department. However, the senior management within the trust did not appear to be working closely together to meet the strategic objectives of the department.

The department had a caring and committed team of staff with a strong team ethos. Patients and relatives were all positive about the care they had received. Staff offered care that was kind, respectful and considerate. They responded to patients’ anxiety or distress with compassion and offered emotional support. However, due to the open nature of the area in which the ambulance crew handover of patients took place, those in the department and adjacent corridor could overhear patients’ confidential information being handed over by the ambulance crew. There was therefore limited privacy and dignity provided in this part of the patient experience.

Surgery

Requires improvement

Updated 21 June 2016

The reporting of incidents was not fully embedded in practice across all staff groups. Incident type was not always categorised correctly and there was a lack of awareness of outcomes from incident investigations , including never events.

There was a lack of expert support from consultant radiologists at weekends, which impacted on the accuracy of clinical diagnosis being achieved. Risks related to patient safety and service delivery had not always been identified and agreed timelines for resolution had not always been identified.

There was a lack of formalised admissions pathways for some surgical patients, including those with head injuries. The surgical wards had not been developed to address the needs of individuals living with dementia.

Patient surgical outcomes were monitored through audit and required improvements had been noted for hip fracture patients and those having an emergency laparotomy. Referral to treatment times were not being met in some surgical specialties. Theatres were not always effectively utilised and operating sessions started and finished later than planned, which impacted on patient discharges.

There was lack of assurance that staff had received Mental Capacity or Deprivation of Liberty Safeguard training.

Surgical staff reported a lack of support and engagement at trust board level.

The development of the surgical directorate strategic aims was in progress and would need time to be embedded into practice.

There had been limited opportunities for patients to contribute to the running of the surgical service, although they were able to feed back on their experiences.

Surgical directorate leaders understood their roles and responsibilities and the governance arrangements were set out to facilitate the monitoring of identified risks, reported safety concerns, patient outcomes and effectiveness of the service.

Staff demonstrated a commitment to delivering high standards across the surgical service and there was a culture of openness and transparency. The ward and theatre staff reported favourably on their immediate line managers, their approachability and support and felt valued and respected

Staff had the necessary skills and experience to ensure safe and effective patient outcomes and were supported appropriately.

Patients needs were assessed, treated and cared for in line with professional guidance, under the leadership of consultants. The multidisciplinary team and specialists supported the delivery of treatment and care. Patients reported positively with regard to the quality and standards of care they received from staff.

Where complaints were raised, these were investigated and responded to and where improvements were identified, these were communicated to staff.

Intensive/critical care

Requires improvement

Updated 21 June 2016

The critical care service requires improvement. Medical staffing on eHDU was not sufficient and care was provided by anaesthetists without critical care accreditation. Additionally, less than the recommended proportion of eHDU nurses had critical care qualifications. The provision of pharmacy staff within critical care did not meet recommended standards and multi-disciplinary working was variable across the service. There was little shared learning across the service or with other specialities within the hospital and a limited relationship with the critical care team at Ealing Hospital.

The critical care environments were not compliant with HBN0402 building notes and compliance with infection prevention and control measures was variable. Patient outcomes were not as good as those at similar units nationally and other local units. There was a high occupancy rate throughout critical care and there had been some elective surgery cancelled as a result of this. There were significant numbers of non-clinical transfers as well as out of hours discharges as a result of critical care bed shortfalls. Senior staff were aware of these issues and had sent reports with relevant data to the senior management team,however no steps were in place to address the shortfall in critical care beds.

There was a positive culture across critical care and a good clinical leadership presence. Managers within the service were aware of the risks on the individual units and these concerns were reflected on the relevant departmental risk register. There was an obvious desire to improve the quality of care delivered. Results from the Friends and Family Test and our Short Observational Framework for Inspection (SOFI) were positive and we received complimentary feedback from patients and relatives throughout the service. The service respondedto any negative feedback from patients and their visitors proactively.

Services for children & young people

Requires improvement

Updated 21 June 2016

Children and young people’s services at this trust were rated as requires improvement except for caring which was good. The safeguarding children’s procedures were robust with staff demonstrating how they were embedded into the service.

We saw out of date policies in use and Control of Substances Hazardous to Health (COSHH) assessments not reviewed in line with policy changes implemented.

Staff shortages meant that staff hadto workextra shifts.

Senior staff had to physically seek out when children were admitted to an adult bed, as there was no flagging system. There were gaps in support arrangements for children with long term conditions e.g. epilepsy and no identified nurse specialist to support this group of patients who required information and support.

The service was not responsive in meeting the needs of children and young people when in the children’s accident and emergency department, as the waiting time was reported as too long by parents we spoke with.

Staff who wereasked about the trust strategy were not all aware of local or trust wide strategies.

The arrangements for governance and performance management did not always work effectively, as items on the risk register did not reflect all the areas that require improvement identified by the inspectors e.g. COSHH.

We raised concerns about the lack of neonatal resuscitation equipment and resuscitaire in the accident and emergency department.

The service had achieved 93% of children being seen within 18 weeks of referral for treatment with 7% of patients breached over 18 weeks which did not meet the target.

Feedback from family members and children or young people we spoke with was positive about the care provided. Parents said that staff went the extra mile for their children and staff engaged children and parents in individualised plans of care.

Services were planned and delivered to meet the needs of the diverse population.

End of life care

Good

Updated 21 June 2016

We found the specialist palliative care team (SPCT) to be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner.

The patients and relatives spoke positively about their interactions with the teams involved in their care.

The trust had responded to the withdrawal of the Liverpool Care Pathway. The trust used a holistic document which was in line with the five priorities of care, was called the ‘Last Days of Life Care Agreement' (LDLCA). However, this document was not compulsory to use across the hospital leading to difficulties in following some care plans.

Patients’ records and care plans were regularly updated, matched the needs of the patient and were relevant to EOLC.

There were some concerns raised by specialist staff and from our observations about whether all generalist nurses, doctors and consultants had the expertise to recognise dying; and had the skills to have difficult conversations about planning care for those at the end of their life.

The SPCT were focussed on raising staff awareness around EOLC. However they said that this should be a trust wide responsibility.

The trust had recently run a pilot training scheme for staff on the elderly care wards. However this is not yet part of mandatory training.

Staff were aware of their responsibility in raising concerns and reporting incidents.They were keen to report any incidents in relation to palliative and EOLC in order to drive improvement.

There were few complaints in relation to EOLC and staff told us they preferred to deal with concerns or issues at the time to try to deal with it prior to it becoming a formal complaint.All staff understood their role and responsibility to raise any safeguarding concerns.

We found that leadership of the SPCT was good at a local level, and all staff reported being supported by their line managers. The SPCT were able to communicate the trust's vision. However they were not always able to explain how this was going to be met. Cross site working was in its infancy and staff expressed a difficulty in doing more due to the difficulties in physically getting between the hospitals in the trust.

Outpatients

Good

Updated 21 June 2016

Outpatients and diagnostic imagingservices at Northwick Park Hospital did not consistently offer appointments within defined target times.

There was a system in place to highlight which patients had waited longest and should be prioritised for the first available appointments. The trust had attempted to reduce the backlog of patients waiting for appointments, but financial constraints meant that additional clinics had been stopped.

We found that management of risks associated with emergency situations in some areas within the outpatient services including haematology had not been appropriately recognised, assessed or managed.

We found that there were regular shortages of nursing staff of up to 20% in the outpatients departments.

We found the method for tracking medical records was not reliable. Notes were stored in the medical records department and were collected by medical records staff in preparation for outpatient clinics. Staff were not always aware of or have access to the incident reporting system through Datix.

We found limited evidence of the effectiveness of outpatient services and at times staff were not always caring or respectful of patients.

The services had begun to integrate across the three hospital sites following the merger in 2014, but there was more work needed.

We saw good evidence of how diagnostic services respond to patients’ needs and how outpatients track the progress of patients on the waiting lists for appointments.