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Northwick Park Hospital Requires improvement

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


Inspection carried out on 02 July to 15 August 2019

During a routine inspection

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 carried out on 09 January 2019

During an inspection looking at part of the service

We undertook this focused inspection to follow up on the concerns identified in two Section 29A Warning Notices served in July 2018, following an inspection of the trust in June 2018. We Judged that the requirements of the warning notice had been met. The warning notices set out the following areas of concern, where significant improvement was required:

In maternity there were several concerns which we listed in our warning notice:

  • We were not assured that there were robust systems in place to ensure that all the correct staff were bleeped on an ongoing basis.

  • We were not assured that there was a system in place to ensure that the correct staff were bleeped at all times.

  • We were not assured that systems were in place to ensure that unauthorised persons could not gain access to the maternity surgical theatres via use of the staff/theatre lift.

  • We observed that the doors to the delivery suite from the theatres were not controlled by a secure access system.

  • We were notified that the main doors to the maternity unit could be forced opened, allowing unauthorised persons to enter the building.

In critical care we found two concerns, which we listed in our warning notice:

  • We were not assured that there were sufficient handwashing facilities to mitigate the risk of cross-contamination.

  • We were not assured that the beds within critical care were appropriately located to enable staff to perform emergency lifesaving care and treatment.

Our key findings were as follows:

In maternity we found:

  • Several improvements had taken place since the comprehensive inspection report published in August 2018.

  • The main security issues in maternity had been addressed.

  • The maternity service had installed new outer main doors which could not be opened by force.

  • The estates team reconfigured the lifts in maternity to prevent public access into the theatres corridor.

  • New doors had been installed between the delivery suite and theatres to improve the overall security within the maternity department.

  • Access to the building and in particular to the delivery suite was controlled by 24 hour receptionists in the delivery suite who were able to monitor visitors via security camera.

  • Security staff told us that they patrolled the building regularly to check on and remove any unauthorised persons who may have gained access to public corridors.

  • A member of the estates team told us that they were continuing to review security systems in this area of the trust to see what further improvements could be made.

  • Switchboard tested the bleep system twice a day and recorded and acted upon the outcomes.

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

  • All information to the public regarding tailgating, which lifts to use and the closing times of the maternity link corridor was in English only. Senior staff we spoke with told us that work was in progress to get the signs translated into up to 3 other commonly spoke languages.

  • It was still possible, because of the need to ensure safe evacuation of the building for members of the public to allow access to the building by pressing an access button. This was mitigated by the secure access systems into the maternity unit itself.

  • There was no nominated list of relatives or friends or equivalent that an expecting mother could set up to control the people visiting the maternity department.

In critical care we found:

  • The removal of two beds in critical care and the repositioning of the remaining furniture to allow staff to deliver emergency lifesaving care and other treatment effectively was completed promptly and efficiently.

  • Additional hand washing facilities have been inserted into critical care to mitigate the risk of cross contamination.

In addition the trust should:

  • Continue to ensure robust security measures are in place across the trust.

  • Look at further ways of verifying and controlling people entering and exiting the maternity department building.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 5th June to 7th June 2018

During a routine inspection

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

  • We rated caring at Northwick Park hospital as good. We rated safe, effective, responsive and well-led as requires improvement.
  • Critical care improved from requires improvement to good.
  • Maternity went down from requires improvement to inadequate.
  • Urgent and emergency services, medical care, surgery and children and young people’s services remained as requires improvement.
  • We rated well-led as inadequate in medical care and maternity.
  • We rated safe as inadequate in maternity services.

Inspection carried out on 19-23 October 2015; unannounced visits between 3-7 November 2015

During a routine inspection

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