All inspections: Ealing Hospital - Care Quality Commission

Ealing Hospital serves an ethnically diverse population mainly in the London Borough of Ealing. Ealing hospital provides the following services:

•Urgent and emergency care

•Medical care (including older peoples care)

•Surgery

•Outpatients and diagnostics

•Critical care

•End of life care

•Children’s and young people services

We inspected medical care and surgery core services at our inspection on 9, 10 and 11 February 2022.

Medical care at Ealing Hospital was last inspected in August 2018 when it was rated and inadequate for safe and requires improvement for effective, caring, responsive and well led. Medical care was rated as requires improvement overall. A follow up inspection of medical care services was carried out in January 2019 but the rating was not reviewed because of the limited focus of the inspection.

At this inspection our overall rating of medical care stayed the same. We rated the service overall as requires improvement. We rated safe, responsive and well led as requires improvement and effective and caring as good.

During our inspection in February 2022 we visited seven integrated medicine division wards, and the ambulatory care unit, and the discharge lounge.

Medical services involve assessment, diagnosis and treatment of adults by means of medical interventions rather than surgery. Medical care at Ealing Hospital provided care and treatment in the following disciplines: stroke; care of the elderly; cardiology; dermatology; genitourinary medicine (GUM) and sexual health; infectious disease; respiratory; rheumatology; endocrinology and diabetes; neurology and gastroenterology.

The number of admissions for the three specialties most admitted to in the division of integrated medicine at Ealing Hospital between 1 November and 31 January 2022 were : general internal medicine (GIM), with 1039 admissions in the period or 83% of total admissions; cardiology with 120 admissions, or 10% of total admissions in the period; and geriatric medicine with 30 admissions, or 2% of total admissions in the period.

Gastroenterology was not part of the integrated medicines division; it was a specialty in the St Mark's division. In the period 1 November to 31 January 2022 there had been 581 admissions in gastroenterology.

We spoke with eight patients and one relative. We reviewed 10 sets of patient records. We also spoke with 28 members of staff, including qualified nurses, matrons, consultants, doctors, senior managers, and support staff.

We rated medical care at Ealing Hospital requires improvement overall because:

The service did not always have enough nursing and support staff to keep patients safe. The service was mitigating the staffing risks during twice daily safety huddles. However, there was a 22% vacancy rate for band 5 nurses.
We found a drawer in the catheterization labs with a range of out of date equipment and a monitor in the catheterization labs which did not have a servicing date. We also found out of date equipment on a resuscitation trolley in the acute medical unit (AMU). There was a risk that staff could inadvertently use out of date equipment.
On Ward 6 South, we found discrepancies in the use of Waterlow scoring. This is a tool used for pressure area risk assessment. This meant that patients’ level of risk of developing pressure ulcers may not be accurately assessed and timely actions taken.
Medical staff mandatory training in resuscitation was 72.2%. This was less than the 80% standard. This meant some staff may not have up to date skills in resuscitation.
There was a lack of seamless services between the trust and other NHS providers of mental health care for patients temporarily on an acute ward waiting for transfer to a mental health facility. There was a risk of delays in patients care and treatment as a result of a lack of clarity about the responsibility for clinical decision making whilst the patient was an inpatient in the acute hospital.
Due to a shortage of registered mental health nurses, the service had a policy of cohorting patients assessed as requiring enhanced observations or one to one care in a bay. However, we saw cohorted bays were not always observed by staff. There was a risk to patients if they were assessed as requiring enhanced observations or one to one care and this was not provided in accordance with their assessed needs at all times.
The patient electronic record could only display a maximum of two patient needs on screen. This had led to staff not placing a magnetic identifier for the confusion care pathway above a patient’s bed. The lack of a visual prompt for staff led to a patient not receiving a scheduled review after 72 hours. There was a risk that without a visual prompt, staff working on the bay may not be aware of patients’ needs, unless they fully consulted patients’ electronic records.
Records were not always stored securely. We found a patient’s ‘adult inpatient care needs assessment’ booklet next to the reception area in the acute medical unit (AMU). We saw a computer in the endoscopy reception which was unattended and not locked. There was a risk that unauthorised people could have accessed confidential patient information.
Staff told us the trust’s senior executive team and some ward leaders were not visible at Ealing Hospital, as they were based off-site at Northwick Park Hospital.
The signage enabling patients and visitors to navigate around the hospital was confusing for patients and visitors.
Staff on the Older Persons Short Stay Unit (OPSSU) were using a printed copy of the infection prevention and control policy. There was a risk that staff may use an out of date policy instead of using the most up to date policies on the trust’s intranet.
We saw a cracked shower chair and shower chairs with chipped enamel on the OPPSSU. This could pose a patient safety and infection control risk as microorganisms can thrive in cracked surfaces.
Domestic staff on the acute medical unit (AMU) was not aware of control of substances hazardous to health regulations (COSHH), including the trust’s policies and guidance on COSHH.
The trust was a large provider of cancer services but staff told us they did not have a local cancer strategy. This meant there was a potential risk that cancer services were not aligned to local commissioning and provision of services to support people during and after their cancer treatment.

However:

The service managed safety incidents well and lessons were learnt from them.
Staff gave patients enough to eat and drink and gave them pain relief when they needed it.
Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to information.
Key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to raise complaints.
Staff understood the service’s vision and values, and how to apply them in their work and all staff were committed to improving services continually.

Surgery at Ealing Hospital was last inspected in August 2018 when it was rated requires improvement in safe, effective, responsive and well led and good in caring. Surgery was rated as requires improvement overall.

At this inspection our overall rating of surgery improved. We rated the service overall as good. We rated safe, effective, caring, well led as good and responsive as requires improvement.

We visited theatres, inpatient surgical wards, the theatre recovery unit and surgical assessment units.

To manage staffing and capacity during the COVID-19 pandemic, the trust had restructured surgical services and treatment pathways. Ealing Hospital provided elective surgery and patients underwent pre-assessment care at Central Middlesex Hospital. As part of our inspection of surgical care at Ealing Hospital and Northwick Park Hospital, we visited Central Middlesex Hospital to understand the pre-assessment pathway and the post-treatment therapy provided by allied health professionals. We have included the findings in this inspection report.

We rated surgery at Ealing Hospital good overall because:

The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

The service was not fully compliant with DHSC Health Technical Memorandum 07/01 and the Health and Safety Executive Health and Safety (Sharps Instruments in Healthcare) Regulations 2013 in relation to sharps waste.
The service had persistently high vacancy rates. At the time of our inspection the service had vacancies for 36 whole time equivalent (WTE) nurses. However, the number of nurses and healthcare assistants matched the planned numbers and vacancies were filled with bank and agency staff.

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

At our last inspection we found that the clinical decisions unit (CDU) was being used inappropriately to treat level two patients. Whilst the service assured us that this was no longer the case we did find that the area was being used as overflow for patients requiring inpatient beds and patients within the CDU could be there for over four hours and sometimes up to three days.
Our observation of patient records found that the grade of the clinician was not always clear and that the records were filled out inconsistently between different clinical areas.
There was poor Deprivation of Liberty Safeguards (DoLs) training rates amongst medical staff. Only 53% of medical staff had completed the training.
We found that the service still performed poorly in most of the Royal College of Emergency Medicine (RCEM) audits.
We found that improvements could still be made in relation to severe sepsis and shock management. The service audit revealed that with regards to 2019 compliance, only 54% of patients had their observations measured, this was down from 2017 compliance where 98% of patients had their observations measured.
Access to the service was not conducive to the overall patient experience. Patients had to wait for UCC triage before they were triaged in the emergency department.
Waiting times decision to admit and arrangements to admit, treat and discharge patients were not in line with national standards. The service did not meet Royal College of Emergency Medicine guidelines for median time from arrival to treatment.
The department’s 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 was continuously working with NHS Improvement to improve their performance. The trust had been above the England average for six months.
The trusts unplanned re-attendance rate to accident and emergency within seven days was worse than the national standard of 5% and consistently worse than the England average.

However:

At our last inspection we found that the service was still treating children instead of stabilising and transferring. At this inspection, we found that the service had overhauled its approach to paediatric patients presenting at the emergency department (ED). The service now had posters up both outside the service and within the waiting room letting patients know that they did not treat acutely unwell paediatric patients. If an acutely unwell paediatric patient presented at the service, they would stabilise and transfer to a neighbouring ED.
At the last inspection we found that staff in the ED were not trained in the adequate life support training. We found that this had changed since our last inspection. All staff were either trained in Immediate Life Support (ILS) or due to be trained.
At our last inspection we found that mandatory training rates were low – the 85% target was not met by medical staff in any modules and met by nursing staff in only three modules. The service had made efforts to ensure everyone completed mandatory training. At this inspection we found that the trust 85% target was met in all but one module by nursing staff and all but three modules by medical staff. Where there were gaps in training, we saw evidence that staff were placed on upcoming modules.
At our last inspection, we found there was high medical and nursing vacancy rates with no real improvement since the inspection before. We found that the service had made real efforts to improve its vacancy rate and figures provided whilst on inspection stated that the nurse vacancy rate was 10%.
At our last inspection we found that patient pain was not reassessed. At the time of this inspection we found that patient pain was reassessed at least every hour in line with RCEM guidelines.
Previously, the rates of medical staff training in mental capacity act (MCA) was quite poor (27%). Figures provided whilst on this inspection showed that 96% of clinicians were trained in MCA.
At our last inspection we found that patients were treated in corridors whilst waiting for a bed to become available. We saw no evidence of this whilst on inspection.
Previously, appraisal rates in the emergency department were lower than the trust target of 85%. In the year prior to our inspection, 87% of staff in the ED had received an appraisal.
It was reported at our last inspection that staff felt as though there was a lack of divisional and senior trust leadership presence. This was not the case whilst on inspection as staff spoke highly of management and knew members of the executive team by name.

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. The warning notices set out the following areas of concern, where significant improvement was required:

In urgent and emergency services:

We were not assured that the department had the appropriate environment and equipment to care for children. The paediatric resuscitaire had been left unplugged.
Paediatric medications were not managed and stored safely and were not assured that staff consistently knew where they were in the department.
Though there was no paediatric emergency service, the department was treating children who attended the department though they were equipped and registered only to stabilise and transfer paediatric patients.

In medical services:

We were not assured that risk was adequately assessed for service users on medical wards. There were incomplete and incorrectly tallied risk assessments in patient admissions booklets.
Staff did not follow policies and procedures to manage medicines in the care of the elderly ward and the acute medical unit (AMU). There were expired medicines on the wards and they were left unattended. Fridge temperature checks were not regularly recorded and no action was taken when temperatures went out of range. Medicines were left in drugs trolleys following administration and were not consistently disposed of.
There were not adequate numbers of suitably qualified staff on medical wards. Vacancy, turnover and sickness rates were above the trust target.
Medical outliers were not adequately tracked and were missed on ward rounds.

Our key findings were as follows:

The trust had made significant steps to address the concerns raised by CQC at the last inspection, including a detailed action plan, and had met the concerns raised in the warning notices.
The emergency department had moved all paediatric medications to the drugs cupboard and had ensured that all staff knew where they were.
The medical department had taken steps to improve nursing staff recruitment and retention and had improved the completion of patient notes.

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

There was still not adequate signage in the emergency department to alert patients that there was no paediatric service in the department.

Professor Edward Baker

Chief Inspector of Hospitals

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

Overall, we rated caring as good. Effective, responsive and well-led were rated as requires improvement. Safe was rated as inadequate.
Urgent and emergency services went down from requires improvement to inadequate.
We rated well-led in urgent and emergency care as inadequate.
Safe was rated as inadequate in urgent and emergency services and medical care.
Caring was rated as requires improvement in medical care.

Ealing Hospital is part of London North West Healthcare NHS Trust, which is 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 rated this hospital as requires improvement. We rated critical care, end of life care and outpatients and diagnostic services as good. We rated the following acute services provided by the hospital as requires improvement: Urgent and emergency care, medical care including care of the elderly, surgery, and services for children. and end of life care.

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 and also fears of service removal and potential job losses particularly at Ealing Hospital.

• 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, particularly at Ealing.
We saw several areas of good practice or progress including:
a good service overall for end of life care particularly at Ealing and in the community health service.
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 included an outstanding diversional therapy approach for children and young people, which was led by the play specialist and school tutor.
evidence of good antibiotic stewardship, particularly at Ealing pharmacy, with regular reviews of need; and the roll out of drug cabinets across certain parts of the trust with secure finger print access.
patient satisfaction data collected by iPAD by Ealing pharmacy.

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

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. Performance at Ealing had dropped since the merger.
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.
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.
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.
At Ealing ED we had some concerns around the care and treatment of children. There were insufficient children’s nurses employed to ensure they were consistently available at all times. Not all adult-trained staff had been trained in paediatric life support.
There were some aspects of poor morale of staff on the medical wards at Ealing.
There were some concerns with cleanliness and the state of repair or servicing of equipment and fixtures on medical wards at Ealing.
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.
We were concerned at the lack of provision for dementia care and inconsistent assessment of patients failing to direct them to a dementia friendly wards at Ealing. However, patients living with dementia were not specifically triaged to be admitted to this ward and some aspects of the ward were not dementia friendly.
In surgery at Ealing there was inadequate stock of some “bread and butter” items of equipment, such as endoscopic gastro-intestinal cartridges. Sets came back from the decontamination unit incomplete.
At Ealing OPD, the outpatients risk register identified five issues of concern including lack of capacity, temperature in the women’s clinic environment, lack of availability of complete medical records, overbooking clinics and absence of a dedicated plaster sink in the plaster room.
Trust wide there were temperature 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.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Ealing Hospital

All Inspections

9, 10 and 11 February 2022

During a routine inspection

02 July to 15 August 2019

During a routine inspection

9 January 2019

During an inspection looking at part of the service

Professor Edward Baker

5th June to 7th June 2018

During a routine inspection

19 - 23 October 2015; unannounced inspections between 3 - 7 November 2015

During a routine inspection