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Barnet General Hospital Requires improvement

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

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 May 2019

Our rating of services went down. We rated it them as requires improvement because:

  • We rated safe and responsive at this hospital as requires improvement and we rated effective, caring and well-led as good.
  • We rated three of the four services inspected, during this inspection, as requires improvement overall.
  • Many of the issues identified during the previous inspection, which impacted on the safety and responsiveness of the service and had not yet been addressed by the hospital’s leadership team.
  • Mandatory training for staff in key skills, including safeguarding, fell below the trust’s target

    for compliance. However, staff we spoke with were aware of their responsibility to protect vulnerable children and adults.

  • Medicines were not always stored in accordance with published guidance. Although many aspects of medicines were managed safely, storage of medicines, and intravenous fluids, was not always safe or secure. Staff did not always monitor storage temperature accurately to ensure it was not harmful to medicines. In some areas there was a risk, due to lack of security measures, that unauthorised persons might gain access to, or tamper with medicines intended for patients.

  • Best practice guidelines for care and treatment of patients with mental health needs were not consistently followed. Not all staff understood how and when to assess whether a patient had the capacity to make decisions about their care. The trust policy on restraint was out of date and did not follow current best practice guidance.

  • The hospital did not always have sufficient numbers of staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. In some areas, there was a high turnover and vacancy rates amongst nursing staff and not always enough staff to ensure shifts were safe at all times.

  • 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. There were a high number of patient bed moves and discharges at night. Overcrowding in A&E was a regular occurrence due to lack of space and lack of capacity to meet service demand.

  • Whilst the trust had effective systems for identifying risks and planning to reduce them, risks were not always being dealt with in a timely way. Some department level risks had not been identified or adequately addressed. Not all risks identified during our inspection were on the hospital’s risk register; therefore we were not assured that senior leaders had appropriate oversight of these issues.

However:

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

  • The hospital generally controlled infection risk well. Staff kept themselves, equipment, and the premises clean. They used control measures to prevent the spread of infection.

  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.

  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers monitored the effectiveness of care and treatment and used findings to improve them.

  • Staff cared for patients with compassion, kindness and respect and provided emotional support to patients to minimise their distress. Patients and those close to them, were involved in decisions about their care and treatment.

  • Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The hospital engaged with patients, staff, and local organisations to plan and manage services.

  • The trust was committed to improving services by learning, promoting training, research and innovation.

Inspection areas

Safe

Requires improvement

Updated 10 May 2019

Effective

Good

Updated 10 May 2019

Caring

Good

Updated 10 May 2019

Responsive

Requires improvement

Updated 10 May 2019

Well-led

Good

Updated 10 May 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 10 May 2019

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

  • Whilst the trust had effective systems for identifying risks and planning to reduce them, the trust could not evidence that risks were always being dealt with in a timely way.
  • The service provided mandatory training in key skills to all staff, but compliance for nursing and medical staff was below the trust target of 85%.
  • Although staff understood how to protect patients from abuse, compliance for safeguarding training for medical staff was below the trust target of 85%. However, staff we spoke with were aware of their responsibility to protect vulnerable children and adults.
  • Although the service generally controlled infection risk well, hand hygiene compliance was variable across the wards. Action plans had been put in place when compliance was low.
  • The service had suitable premises and equipment and looked after them well, but we observed potential trip hazards on the care of the elderly wards. However, there had not been any identifiable increase in falls on the wards.
  • Whilst many aspects of medicines were managed safely, some medicines were not stored in tamper evident boxes and staff did not always monitor ambient temperatures in medicine storage areas.
  • The trust was not following the Department of Health guidance 'Positive and Proactive Care'‎ (2014) and did not demonstrate that the use of mechanical restraint was exceptional, that other options had been attempted, or that it was reviewed rigorously (including by an independent clinician and that the board were sighted on it). The trust policy on restraint was out of date and did not follow current best practice guidance. For two patients there were no records that provided assurance that staff had undertaken the necessary checks when mittens were worn by patients.
  • People could access the service when they needed it, but there were a high number of patient bed moves and discharges at night which did not reflect best practice. The average length of stay for medical non-elective patients was higher than the England average.

However:

  • Managers at all levels in medicine and urgent care division had the right skills and abilities to run a service providing sustainable care.
  • The trust had a vision to for what it wanted to achieve which was to ‘deliver world class expertise and local and friendly hospital care to represent the NHS at its best’ and had plans to turn it into action.
  • Managers across the medicine and urgent care division promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The trust used a systematic approach to improve the quality of its services and care.
  • The trust was committed to improving services by learning, promoting training, research and innovation.
  • Staff kept records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.
  • Staff recognised incidents and reported them. Managers investigated incidents and shared lessons learned with the team and the wider service. When things went wrong, staff apologised.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary.
  • Staff assessed and monitored patients regularly to see if they were in pain.
  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Patients had access to medical consultants who provided cover seven days a week across the medical wards.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The trust planned and provided services in a way that met the needs of local people.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

Services for children & young people

Good

Updated 15 August 2016

The trust met the Royal College of Paediatrics and Child Health (RCPCH) standards for paediatric consultant staffing levels. Nursing levels were generally complaint to both Royal College of Nursing (2013) and British Association of Perinatal Medicine standards (2011) for staffing children’s wards and neonatal units .

There was generally good access and flow within the children’s service. Patients received evidenced based care and treatment and good multi-disciplinary working existed between the children’s services, external providers and the child and adolescent mental health service (CAMHS).

Training provision to staff was good with meticulous recording of mandatory training enhanced by the implementation of a new on line data base to monitor staff compliance.

Children’s service were effectively supported by children’s critical care and neonatal retrieval services.

Staff were caring, compassionate and respectful. Staff we spoke with were positive about working in the service and there was a culture of flexibility and commitment.

The service was well led and a clear leadership structure was in place. Individual management of the different areas providing acute children’s services were well led. A governance system was in place and we saw that clinical risks identified. Feedback from staff, parents and children and young people was generally good.

Although services provided evidenced based care as identified within evidenced based clinical guidelines, many of these were out of date posing potential risks to patients.

The poor post-operative recovery facilities for children exposed them to potential hostile sights and sounds and recovery nursing staff were not PILS trained.

Critical care

Requires improvement

Updated 10 May 2019

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

  • Issues found at last inspection in February 2016 continued to impact on the responsiveness of the service and had not been addressed by the hospital leadership.
  • Service delivery was impacted by the high number of patients staying on the unit longer than necessary, and the environment could not be flexed to accommodate them appropriately with the result that patients were regularly cared for in mixed sex accommodation in an environment that could be disturbing and frightening.
  • It was more difficult for staff to meet individual needs when patients were awake and on the unit longer than they needed.
  • Higher than acceptable, numbers of patients were transferred to a ward, or recovery unit, out of hours. High numbers of patients than usual were discharged home before a ward bed became available.
  • There was no agreed plan to address the issues of delayed discharges and resultant impact on patients. This was highlighted at our last inspection and had not progressed.
  • There was not yet a critical care strategy for the future and no involvement from patients, staff and wider stakeholders to develop this and turn it into action.
  • The governance around the management of protocols was not clear. There were no unit wide meetings or forums for assessing and monitoring the quality and safety of services, including risks arising from not fully adhering to professional guidance and standards.
  • Some identified risks had not been adequately addressed. Storage of some medicines and intravenous fluids was not always safe or secure, and the risks had not been adequately assessed and mitigated.
  • There was not always sufficient allied health professional staff to meet recommended standards. The pharmacist cover on the unit did not yet meet the standard for critical care. Therapist provision did not meet the guidelines for provision of intensive care standards.

However:

  • We found the effectiveness of the service was good. The service leaders promoted a positive culture that supported and valued staff creating a sense of common purpose based on shared values.
  • There were embedded systems, processes and practices to keep people safe. Infection risks were well controlled, and there was sufficient suitable equipment which staff were trained to use
  • The service managed patient safety incidents well. Managers investigated incidents and shared lessons learned. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service had enough nursing staff to keep patients safe and provide the right care and treatment.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers monitored the effectiveness of care and treatment and used findings to improve them.
  • The service made sure staff were competent for their roles. Staff of different kinds worked well together as a team to benefit patients.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.
  • Staff cared for patients with compassion and provided emotional support to patients to minimise their distress. Staff involved patients and those close to them in decisions about their care and treatment that was being provided.
  • The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
  • The service was committed to improving critical care by learning from when things went well and when they went wrong, promoting training and innovation.

End of life care

Good

Updated 15 August 2016

They was a dedicated team providing holistic care for patients with palliative and end of life care (EOLC) needs in line with national guidance.

The hospital provided mandatory EOLC training for staff. A current EOLC policy was evident and a steering group met regularly to ensure that a multidisciplinary approach was maintained.

The Royal Free London NHS Foundation Trust and its staff recognised that provision of high quality, compassionate end of life care to it’s patients was the responsibility of all clinical staff that looked after patients at the end of life. They were supported by the palliative care team, end of life care guidelines and an education programme.

The palliative care team was highly thought of throughout the hospital and provided support and education to clinical staff. The team worked closely with the practice educators and link nurses at the hospital to provide education to nurses and health care assistants. Medical education was led by the medical consultants and all team members contributed to the education of the allied healthcare professionals.

Medical records and care plans were completed and contained individualised end of life care plans. Most contained discussions with families and recorded cultural assessments. The ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms were all completed as per national guidance. However there were inconsistencies in the documentation in the recording of Mental Capacity Act assessments.

There was evidence that systems were in place for the referral of patients to the palliative care team for assessment and review to ensure patients received appropriate care and support. These referrals were seen and acted upon within 24 hours.

The EOLC service had supportive management and visible and effective board representation. This had resulted in a well led trust wide service that had a clear vision and strategy to provide a streamlined service for EOLC patients.

Maternity and gynaecology

Good

Updated 15 August 2016

A single management team oversaw the main maternity site at Barnet Hospital and a small birthing centre at Edgware Hospital.

At Barnet Hospital w

We saw examples of safety incident reporting systems, audits concerning safe practice, and compliance with best practice in relation to care and treatment.

Staff planned and delivered care to patients in line with current evidence-based guidance, standards and best practice. For example, we observed that staff carried out care in accordance with National Institute of Health and Care Excellence (NICE) and Royal College of Obstetricians and Gynaecologists (RCOG) guidelines.

The ratio of clinical midwives to births was one midwife to 29 women which is slightly higher than the national average of one to twenty eight women. The trust provided evidence of one-to-one care during labour which is recommended by the Department of Health. Women confirmed that they had one to one care in labour and told us they felt well informed and were able to ask staff if they were not sure about something.

Patients and their relatives spoke highly of the care they received in both the maternity and gynaecology services.

At Edgware Birth Centre we saw examples of safety incident reporting systems,audits concerning safe practice, and compliance with best practice in relation to care and treatment. Staff planned and delivered care to patients in line with current evidence-based guidance, standards and best practice. For example, we observed that staff carried out care in accordance with National Institute of Health and Care Excellence (NICE) guidelines.The trust provided evidence of one-to-one care during labour which is recommended by the Department of Health.

However,

the named midwife model was not yet in place.

Care and treatment did not always reflect current evidence-based guidance.Staff had access to and used evidence-based guidelines to support the delivery of effective treatment and care. However, some of these guidelines were out of date.

The management structure was top heavy with more band seven midwives than band six midwives.

Senior management and trust board members were not visible. Management had made important changes to the service without consultation.

Outpatients and diagnostic imaging

Good

Updated 15 August 2016

The areas we visited were clean and tidy. Staff on the whole demonstrated good infection control practices.

Staff reported incidents and there were good systems of incident feedback to staff and to governance committees.

Records management was good and over a 12 month period almost 100% of complete medical records were available for clinics.

The outpatient and radiology departments followed best practice guidelines and there were regular audits taking place to maintain quality.

Staff contributed positively to patient care and worked hard to deliver improvements in their departments.

Staff felt supported by their managers and

stated their managers were visible and provided clear leadership.

The trust had consistently not met the referral to treatment time standard or England average since April 2015.

There had been a deterioration in the 62 cancer wait times compared with the national standard.

The hospital cancelled 35% of outpatient appointments in the last year. From October to January 34% of short notice cancellations were due to annual leave, which was not in line with trust policy.

Surgery

Good

Updated 10 May 2019

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

  • Patients were treated and cared for with compassion, respect, and dignity. Staff understood the impact of patients care, treatment or condition to their wellbeing and those close to them. Patients’ needs and preferences were considered and acted on to ensure services were delivered to meet those needs.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service controlled infection risk well.
  • There were enough nursing staff on duty to meet the needs of the patients. Staff had the right qualifications, skills, training, and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • Staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff worked together as a team to benefit patients. Doctors, nurses, and other healthcare professionals supported each other to provide good care.
  • Records were clear, up-to-date, and easily available to all staff providing care.
  • Staff recognised incidents and reported them appropriately. There were processes ensure complaints were dealt with effectively. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
  • There was suitable provision of services at all times to ensure care and treatment delivery and supporting achievement of the best outcomes for patients.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.
  • Patient and those close to them were treated as active partners in the planning and delivering of their care and treatment. Patients were giving appropriate information and encouraged to make decisions about their care and treatment.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
  • Care and treatment were coordinated with other services and stakeholders, to ensure the needs of patients and their families were met. Managers across the department promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. The department collected, analysed, managed, and used information well to support all its activities, using secure electronic systems with security safeguards.
  • The department had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However, we also found:

  • Although the service provided mandatory training in key skills they did not make sure everyone completed it. The 85% target was met for none of the 18 mandatory training modules for which medical staff were eligible.
  • Although staff completed and updated most of the risk assessments for patients, they had not always followed a clear procedure to prioritise patients for surgery.
  • There was a high turnover rate amongst nursing staff and not all of the shifts were covered at all times. The service had vacancies for medical staff.
  • Medicines were not always stored in accordance with published guidance.

Urgent and emergency services

Requires improvement

Updated 10 May 2019

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

  • The service provided mandatory training in key skills to all staff. However, we found that not all staff completed this in a timely way.
  • We found staff completion rates for some safeguarding training modules were not meeting the trust’s 85% target. However, all staff we spoke with were aware of reporting processes.
  • Some staff did not always understand how and when to assess whether a patient had the capacity to make decisions about their care.
  • The service was not meeting the needs of local people at all times due to demand pressures on urgent and emergency care services. There was insufficient seating in the A&E patient waiting area to accommodate all patients and visitors.
  • 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.

However:

  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
  • The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff cared for patients with compassion. Staff provided emotional support to patients to minimise their distress. Staff involved patients and those close to them in decisions about their care and treatment.
  • The A&E treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • Managers in A&E promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The A&E engaged with patients, staff, and local organisations to plan and manage services.