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Northwick Park Hospital Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 6 November 2019

Our rating of services stayed the same. We rated it them as requires improvement because:

  • Compliance rates for mandatory training and safeguarding training were below trust targets.
  • The Clinical Decision Unit (CDU) was still admitting patients against the admission criteria in order to help prevent breaches within the department. Patients were being held on CDU who required and were waiting for a bed within the hospital.
  • The emergency department still faced significant issues with ambulance turnaround which led to high numbers of black breaches due to the volume of patients the department received on a daily basis. However, the service had improved the way patients were offloaded to ensure patient safety. The department had introduced a streaming team to assess patients on arrival by ambulance. This ensured patients observations and early warning scores were taken and they were streamed to appropriate areas of the department.
  • People did not always have prompt access to the service when they needed it. Waiting times from referral to treatment and decisions to admit patients were not always in accordance with best practice recommendations relating to national standards.
  • Some medicine storage areas did not meet national guidance for security for controlled drugs
  • Records showed that temperatures had fallen outside of the recommended range for storing medicines and action had not always been taken by staff.
  • Managers did not always effectively appraise all staff’s work performance.
  • Nurse vacancy rates were high in the surgical service.
  • Not all formal complaints were responded to within the timeframe set by the trust.
  • The maternity service did not always control infection risk well. Hand hygiene was not consistently being undertaken. We observed areas were clean however we received information from one patient which suggested this wasn’t always the case.
  • Consultant obstetricians were attending handover in the morning but not in the evening. We were told by the trust that consultant obstetricians were available by telephone for the evening handover.
  • All staff told we spoke with in the maternity service told us that there appeared to be a shortage of staff
  • The service did not use monitoring results well to improve safety. We did not see evidence of use or knowledge of the Maternity Safety Thermometer
  • Some staff had a variable understanding of the mental capacity act (MCA) and deprivation of liberty safeguards DoLS.
  • There were systemic issues around culture within the maternity service. We were told that staff morale had deteriorated because of staffing pressures and that some staff were going off sick due to the culture of the organisation.
  • The maternity service did not have an open culture where staff could raise concerns without fear. Staff were not able to raise concerns without fear of reprisal.
Inspection areas

Safe

Requires improvement

Updated 6 November 2019

Effective

Requires improvement

Updated 6 November 2019

Caring

Good

Updated 6 November 2019

Responsive

Requires improvement

Updated 6 November 2019

Well-led

Requires improvement

Updated 6 November 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 31 August 2018

Our rating of this service stayed the same. We rated it it as requires improvement because:

  • Leaders had failed to manage the high demand for the service and high bed occupancy, the service was still struggling to cope. Leaders had failed to address the length of stay for elective patients at Northwick Park Hospital.
  • Four risks identified on the risk register in 2017 and 2016 concerned the environment none of which related to the aging estate which did not always provide the best environment for providing care. Following the previous inspection we reported the environment of the stroke wards needed improving. During this inspection we found the stroke wards environment still needed improving.
  • The risk register did not include some of the concerns we found during the inspection including staff levels across the wards, mandatory training compliance and the movement of patients at night.
  • Most staff in the medical services knew the trust values. However most staff we spoke with were unaware of the integrated medicines divisional strategy. This was similar to what we found at the last inspection.
  • Although the service had taken action to address staff shortages, those actions had to date not resulted in improvements in permanent staff numbers.
  • Although the trust had systems for identifying risks and plans to mitigate risks, this did not always translate to improvements within the service. For example, there were inconsistencies in relation to document completion across the wards, kitchens, sluices and clean utility rooms were locked or unlocked, out of date medicines.
  • A total of 7,138 patients were moved at night between 11.00pm and 8.00am during the period 1st January 2017 to 31st December 2017. This means the trust was not focussed on getting patients a bed on a ward for their speciality.
  • The trust informed did not have data for the last year (2017) showing whether ward moves were due to non-clinical reasons.
  • From January 2017 to December 2017 the average length of stay for medical elective patients at Northwick Park Hospital was 13.5 days, which was longer than England average of 5.8 days.
  • The trust took an average of 43.1 working days (mean) to investigate and close these complaints. The trust responded to 45.4% of complaints within the target period of 40 working days. This is not in line with their complaints policy, which states that 80% of complaints should be responded to within 40 working days
  • The service did not have enough permanent nursing staff to ensure the provision of safe care and treatment. However, the service used bank and agency staff to cover gaps in the staffing provision.
  • Mandatory training in key skills for nursing staff was below the trust targets of 85% in three of the 10 core training areas. The overall completion rate was 80%. This was similar to what we found at the last inspection.
  • Mandatory training in key skills for medical staff was below the trust targets of 85% in none of the nine core training areas. The overall completion rate was 38%. This was similar to what we found at the last inspection.
  • Safeguarding adults level 2 training for medical staff was below the trust target of 85%. The completion rate was 58%.
  • Hand hygiene compliance was variable across the medical wards was monitored across the wards. Compliance varied from between 100% to 50%.
  • Care records were not being completed consistently. Some staff did not understand how to use all parts of the care record and were adding signatures to care plans without highlighting the specific aspects of the plan that were relevant.
  • Out of date medicines including a controlled drug (CD) which was a liquid medicine was found. This had a four-week expiry after opening. There was no opening date or expiry date on the bottle.
  • The temperature of ward fridges were consistently being recorded at more than eight degrees which meant that fridge temperatures were out of range and medicines were not being stored at the correct temperature.
  • There was not a systematic approach to keeping trust policies and guidelines up to date, which meant the trust could not be assured that staff were working with the latest guidance. We found this was similar during the previous inspection.
  • Fluid balance charts and malnutrition universal screening tool MUST assessments were not being completed consistently. We found this was similar in during the previous inspection.
  • The number of qualified nursing staff who had an appraisal in the period was 72.3% which was below the trust target of 85%.
  • The number of medical staff who completed the training was 57.5% which was below the trust target of 85%. However there had been an improvement since the last inspection in the number of nursing staff (92.7%) completing Mental Capacity Act training in the period April 2017 to January 2018,
  • We observed that patients on beds were sometimes transported in public lifts which meant visitors waiting for lifts saw these patients, which unnecessarily compromised their privacy and dignity.
  • We observed phones were unanswered on some wards. We did not know who calls were from but two relatives said it was difficult to get an answer when they rang the ward.
  • Signage to wards was sometimes misleading, and had not been updated to reflect where wards had been relocated. There was no sign to Kingsley ward (the haematology ward) in the lifts or on the list of wards beside the map. There were no signs on lifts that were meant for staff use only.

However:

  • There was a clear governance structure. The integrated medical division was responsible for all medical services across the three hospital sites within the trust and was led by a divisional clinical director, divisional general manager and divisional head of nursing, who worked across all three of the trusts sites.
  • Patients were being continually being assessed using the National Early Warning System (NEWS). Staff were knowledgeable in responding to any changes in the observations which necessitated the need to escalate the patient to be seen by medical staff or the critical care outreach team.
  • Serious incidents (SIs) were discussed as part of the monthly medicine clinical divisional quality and risk meetings clinical governance. SIs were investigated, had an action plan and lesson learnt identified.
  • Northwick Park Hospital consistently achieved grade A for overall performance for the Sentinel Stroke National Audit programme (SSNAP) over the six audit periods from October 2015 to July 2017. On a scale of A-E, where A is best.
  • Patients prescribed pain relief to be given ‘when required’ were able to request this when they needed it. Patient notes recorded whether patients had been asked about pain.
  • There was effective multidisciplinary team (MDT) working in the ward areas. Relevant professionals were involved in the assessment, planning and delivery of patient care. We found this had improved since the last inspection.
  • We saw clinical staff treat people with dignity, respect and kindness during their stay on the wards. Staff were seen to be considerate and empathetic towards patients. Most of the patients we spoke with were positive about the staff that provided their care and treatment.
  • From March 2017 to February 2018 the Friends and Family Test (FFT) response rate for medical care at Northwick Park Hospital was 41%. This was based on 6,737 responses. This was higher than the England average of 25%.
  • Most of the wards had day rooms or visitors room which staff could use to break bad news or have confidential conversations with relative. We saw staff providing emotional support to patients and relatives.
  • Most patients we spoke with said they felt involved in their care. Relatives we spoke to were mostly happy with the care their relatives received and felt they had been kept involved with their loved ones’ treatment.
  • The service took account of the needs of different people. Staff had received training in dementia and there was a mental health specialist nurse who provided advice relating to patients with mental health needs and an activities co-ordinator. Patients had access to translation services and relatives of elderly patients stay overnight.
  • The care of the elderly wards Fielding and Hardy had been made more dementia friendly using the Kings Fund environmental assessment tool.
  • Dickens ward had recently been restructured when the ward became a frailty medical assessment unit where elderly patients would be discharged after a short stay. The ward was aiming for a high daily discharge rate
  • Staff felt valued, supported and spoke highly of their jobs despite the pressures; Staff told us there was good team work and peer support and it was better when fully staffed, but when short staff it could be very stressful and it made their job much harder.
  • There was a culture of honesty, openness and transparency. We saw evidence of senior staff carrying out duty of candour responsibilities
  • Staff felt valued, supported and spoke highly of their jobs despite the pressures; Staff told us there was good team work and peer support and it was better when fully staffed, but when short staff it could be very stressful and it made their job much harder.
  • There was a culture of honesty, openness and transparency. We saw evidence of senior staff carrying out duty of candour responsibilities.

Services for children & young people

Requires improvement

Updated 31 August 2018

Our rating of this service stayed the same. We rated it it as requires improvement because:

  • Mandatory training completion rates for nursing and medical staff were not meeting the trust target.
  • Processes and systems could not always be relied upon to protect children from abuse and harm. Children on the child protection register were not always identified, and arrangements for vulnerable patients between 16 and 18 years were not robust.
  • There was a lack of appropriate assessment for children with mental health concerns during nights and weekends, which meant they may stay in hospital longer than necessary.
  • Nursing vacancies were high across all areas of the service, with a high turnover rate between January and December 2017. This led to a high proportion of bank and agency staff being used to fill shifts.
  • Nutrition and hydration assessments were not always completed. We found gaps in feeding charts and the frequency of patient assessment reviews.
  • The pain tool, used by the service to assess and manage pain, was not consistently completed and reviewed.
  • The children and young people’s service did not have a nursing lead for patients with a learning disability or mental health concern. Advice was sought from the Children and Adolescent Mental Health Service Monday to Friday, but there was no support at night or weekends.
  • The service did not always provide a smooth and timely transition for patients moving between children and adult services. The trust did not have a transition policy and staff felt that guidelines required clarity.
  • Bed space capacity during the winter months was not meeting the increasing demand, particularly for patients with higher and more complex needs. The inpatient ward was providing high dependency care although this was not yet funded and there was no designated area.
  • Senior leaders of the trust were rarely seen on the children and young people’s wards. Medical staff told us there was no forum for them to raise ideas or concerns with the senior leadership team.
  • Audits were regularly undertaken within the service to check that guidelines were being followed. However, robust action plans were not always put in to place when gaps were identified.
  • The service did not have a forum for children and young people, and their carers, to provide feedback about the care and treatment received at the hospital.
  • Most staff within the children and young people’s service said that communication could be improved. In particular, staff said ward meetings did not always go ahead. Emails with a brief summary were sent out to staff who missed meetings.

However:

  • All areas within the children and young people’s service were visibly clean, and we found infection control protocols were adhered to.
  • Paediatric early warning scores were routinely recorded to identify patients that may be deteriorating.
  • We saw evidence of good multidisciplinary working throughout all areas of the children and young people’s service. Psychosocial and complex case meetings discussed the social and psychological wellbeing of patients.
  • We observed compassionate care being provided across all areas of the children and young people’s service by nursing and medical staff.
  • Children and their carers felt fully involved in their care and treatment. Doctors and nurses explained procedures in a relaxed and child friendly manner.
  • Transitional care was provided on the neonatal ward, enabling mothers to stay with their baby whilst receiving hospital care, and preparing for discharge.
  • The service had won a national patient experience network award for its’ use of technology and actively engaging with adolescent users of the diabetes services. This had led to a reduction in patient non-attendance at the diabetes clinics.

Critical care

Good

Updated 25 March 2019

  • We have not reviewed the rating for this service because of the limited focus of this inspection. The rating therefore remains good overall.

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 and diagnostic imaging

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.

Surgery

Good

Updated 6 November 2019

Our rating of this service improved. We rated it as good because:

  • The service controlled infection risk well.
  • The service provided care and treatment based on national guidance and monitored the effectiveness of care and treatment.
  • Staff cared for patients with compassion and took account of patients’ individual needs.
  • The average length of stay for elective surgery was shorter than the England average.
  • At the last inspection, we saw the service had received instruction from Health Education England that the surgical senior house officers (SHO) could not take referral calls from urgent care centres on weekends and that a surgical registrar must lead this. At this inspection we saw the senior team had put in place suitable strategies to meet the staffing requirement.

However

  • Some medicine storage areas did not meet national guidance for security for controlled drugs
  • Records showed that temperatures had fallen outside of the recommended range for storing medicines and action had not always been taken by staff.
  • Compliance rates for mandatory training and safeguarding training were below trust targets.
  • Managers did not always effectively appraise all staff’s work performance.
  • Nurse vacancy rates were high.
  • Waiting times from referral to treatment were not always in line with national standards.
  • Not all formal complaints were responded to within the timeframe set by the trust.

Urgent and emergency services

Requires improvement

Updated 6 November 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Safeguarding level three compliance was still below the trust target of 85%. However, the department showed us staff had been booked onto courses in order to improve this. Staff knowledge of safeguarding was also good and we found patients were appropriately safeguarded.
  • The Clinical Decision Unit (CDU) was still admitting patients against the admission criteria in order to help prevent breaches within the department. Patients were being held on CDU who required and were waiting for a bed within the hospital.
  • The department still faced significant issues with ambulance turnaround which led to high numbers of black breaches due to the volume of patients the department received on a daily basis. However, the service had improved the way patients were offloaded to ensure patient safety. The department had introduced a streaming team to assess patients on arrival by ambulance. This ensured patients observations and early warning scores were taken and they were streamed to appropriate areas of the department.

  • Due to capacity issues patients were still being cared for on trolleys in the corridor which meant private conversations could be overheard. These patients were cared for by nurses allocated to the pit stop. Investigations such as blood tests were also being carried out in the corridor. Whilst this helped improve patient safety as they were being seen faster, it did not maintain privacy and dignity.
  • Some doctors told us they were unable to attend training on a regular basis due to department being busy and workload.
  • People did not always have prompt access to the service when they needed it. Waiting times from referral to treatment and decisions to admit patients were not always in accordance with best practice recommendations relating to national standards.
  • The departments performance for Department of Health’s target of 95% of patients admitted, transferred or discharged within four hours of arrival was poor. However, significant improvements had been made and performance was no longer consistently below the England average. The trust were continuously working with NHS Improvement to improve their performance. The trust had been above the England average for six months.
  • Black breaches and ambulance turn around were still significant issues for the department. However, a new streaming and offloading process had been put into place to improve patient experience and safety. There were plans to audit this in the future.

However:

  • The department had improved its compliance with mandatory training for medical staffing. The majority of mandatory training was meeting the 85% trust target.
  • Staff monitored patients who were at risk of deteriorating appropriately. Early warning scores were in use in both adult and paediatric areas. We also found recording of pain scoring had improved for paediatric patients.
  • The department had worked with the local mental health trust to improve risk management arrangements for mental health patients.
  • The department now had a Practice Development Nurse (PDN) in post to support staff with their learning and education needs.
  • The appraisal rate for nursing staff had improved and now met the trust target of 85%.
  • Patients, families and carers were positive about the care across the service and we observed compassionate and courteous interactions between staff and patients.
  • The Short Term Assessment, Rehabilitation and Reablement team (STARRs) provided intermediate care services for patients in Brent. The service provided a multi-disciplinary, holistic assessment of patients and supported early discharge.
  • Staff and managers were clear about the challenges the department faced. They explain the risks to the department and the plans to deal with them. The top risks were shared with staff via the clinical governance newsletter.
  • We found clinical governance arrangements were departmentally focused. There was a new a clinical governance team leading on urgent and emergency care services.

Maternity

Requires improvement

Updated 6 November 2019

We last inspected London North West University Healthcare NHS Trust maternity services in June 2018 and a focussed inspection was carried out in January 2019. We found maternity services were inadequate overall. The purpose of this inspection was to see if the services performance had been maintained or if any improvements had been made by the service since the previous inspection.

Our rating of this service improved. We rated it as requires improvement because:

  • The service provided mandatory training in key skills however there was some confusion among midwifery staff as to the correct length of mandatory training and its content.

  • The service did not always control infection risk well. Hand hygiene was not consistently being undertaken. We observed areas were clean however we received information from one patient which suggested this wasn’t always the case.
  • Consultant obstetricians were attending handover in the morning but not in the evening. We were told by the trust that consultant obstetricians were available by telephone for the evening handover.
  • The service had maternity staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. However all staff we spoke with told us that there appeared to be a shortage of staff.
  • The service did not use monitoring results well to improve safety. We did not see evidence of use or knowledge of the Maternity Safety Thermometer
  • Most risk assessments had been updated and completed for each patient. However we did not see evidence in any of the five records we reviewed that women had received CO (carbon monoxide) monitoring.
  • Some staff had a variable understanding of the mental capacity act (MCA) and deprivation of liberty safeguards DoLS.
  • There were systemic issues around culture within the maternity service. We were told that staff morale had deteriorated because of staffing pressures and that some staff were going off sick due to the culture of the organisation.
  • Leaders did not always have the integrity, skills and abilities to run the service. However they understood and managed the priorities and issues the service faced. They were not visible and approachable in the service for patients and staff. There were concerns about the lack of visibility and lack of regular daily contact with the senior leadership team of the maternity department.
  • The service did not have a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The maternity service had no formal strategy in place. We spoke with the senior leadership team of the maternity service who told us that the strategy for the forthcoming three years was to focus on the culture within the service and look at building better relationships with staffing groups.
  • Staff did not feel respected, supported and valued. The service did not have an open culture where staff could raise concerns without fear. Staff were not able to raise concerns without fear of reprisal. Staff raised concerns that there were not enough staff on shift.

However:

  • The issue we found at the last inspection with the third lift (designated for theatres) being able to be accessed by members of the public had been addressed. Swipe card access was now needed to get to the theatres, and if this lift did not work, then the public lifts could be rerouted to the theatres, however there would be a security guard to man the area and prevent unauthorised access to the theatre area.
  • The service had now ensured that direct access from the delivery suite to the theatres could now only be achieved with swipe card access. Since the automatic doors in the maternity reception had been replaced, there had been no further incidents of the doors being prised open.
  • We looked at the World Health Organisation (WHO) five steps to safer surgery checklist audit results from June 2018 to June 2019 and saw that compliance ranged between 92% and 100%.
  • Staff assessed and monitored women regularly to see if they were in pain, and gave pain relief in a timely way.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Patients and relatives we spoke with consistently told us about the kindness of the staff across maternity services.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers.
  • Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. The service had completed a staffing skills review however the trust indicated to us that this had resulted in some staff unhappiness