All inspections: North Middlesex University Hospital

The North Middlesex University Hospital NHS Trust is a medium-sized acute trust with 633 beds, and employing just under 4000 staff (over half living in the local community); serving a population of around 640,000 people living across Enfield and Haringey. The trusts turnover in 2022/23 was £442.5m.

The trust’s services are provided at the North Middlesex University Hospital (NMUH) main site as well as a range of other hospital and community sites in the boroughs of Enfield and Haringey. They deliver services in collaboration with a range of partners, including local GPs, acute and mental health providers, and other community health service providers across North Central London.

The trust is part of North Central London integrated care system which brings together the NHS organisations and local authorities to meet the health and care needs of people in Camden, Islington, Barnet, Enfield, and Haringey. The community served by the trust is one of the most diverse in London and has high levels of deprivation. The trust is working with system partners to reduce health inequalities.

NMUH is a training unit for medical students from University College London and St George’s University Grenada (West Indies), and for nursing and midwifery students from the Middlesex University and many others.

The trust provides a full range of adult, elderly, and children's services across medical and surgical disciplines. It has some specialist services such as HIV, cardiology, blood disorders, diabetes, fertility, sickle cell and thalassaemia. In April 2023 the trust had taken on the provision of community health services in Enfield such as district nursing, with 600 staff joining the trust.

The majority of clinical activity happens at the main North Middlesex Hospital site. The trust also has an outpatient clinic at St Ann’s hospital, for sickle cell and thalassaemia, in Tottenham. The most recent addition is a step-down ward at Chase Farm (nursing led care with input from GPs). The trust offers integrated sexual health services in Enfield in partnership with the London borough of Enfield. The clinics offer free and confidential sexual health screening and/or treatment and general advice to all patients regardless of their age, sexuality or where the patients live.

This inspection covered the medical care core service provided by the trust and also looked at whether the trust was well led.

The trust has over 421 medical inpatient beds across 20 wards, mostly located at North Middlesex University Hospital. The trust has two wards located at the Chase Farm Hospital.

Medical specialities providing inpatient care are:

Acute medicine with ambulatory care
Cardiology with catheter laboratory and outpatient service for heart failure and arrythmia, rapid access chest pain and full range of cardiology technical services
Respiratory medicine, which includes a full range of diagnostic services including bronchoscopy and endobronchial bronchoscopy, a large tuberculosis cohort and cancer care
Gastroenterology services include hepatology and endoscopy, including consultant rota 24 hours a day seven days per week
Care of the elderly - day hospital and community and care home services
Diabetes and endocrine including outpatients and diagnostics
Haematology and anticoagulation - large tertiary cohort of haemoglobinopathy patients
Stroke unit with transient ischemic attack (TIA) clinic
Oncology services.

Admissions for the top three medical specialties were: general medicine (43%), gastroenterology 30%, clinical oncology (27%).

How we carried out this inspection

We carried out the medical care (including older people's care) core service inspection unannounced on 27 September and the well-led trust overall inspection announced on 5 and 6 December 2023. We inspected medical care because it is the trusts largest service and there had been concerns about sickle cell and elderly care raised with CQC. We also undertook a well led inspection because concerns had been raised with CQC by a number of staff members about the overall trust culture.

We visited areas relevant to the core service inspected and spoke with several patients, staff, and patient representatives. We spoke with staff at all levels of the organisation including healthcare assistants, nurses, junior doctors, pharmacy staff, consultants and administrative staff.

We also looked at a wide range of documents including policies, standard operating procedures, meeting minutes, action plans, risk assessments, training records and audit results. We attended staff handovers and safety huddles.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Pages 1 and 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at The North Middlesex University Hospital.

We inspected the maternity service at North Middlesex University Hospital NHS Trust (NMUHT) as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and to help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

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

Our ratings of the Maternity service did not change the ratings for the location overall. We rated safe as inadequate and well-led as inadequate and the overall rating for maternity services went down to inadequate.

How we carried out the inspection

We visited the Maternity Assessment Unit (Triage), Labour ward / Delivery Suite, the Antenatal, Postnatal Ward area which included Transitional Care, the Birth Centre, Labour Ward Theatre and the relevant Recovery area, Antenatal Clinic, and Bereavement room.

We spoke with 25 midwives and student midwives, we received information from a further 25 midwives, three support workers, five Doctors, five senior leaders, five women and birthing people and three birthing partners and or relatives during and following the inspection.

We received no responses to our give feedback on care posters which were in place during the inspection.

We reviewed eight patient care records, eight observation and escalation charts and 10 medicines records.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

We carried out this unannounced focussed inspection of the emergency department (ED) at North Middlesex University Hospital in July 2022, in response to concerning information we had about the quality of care in this department. CQC had noted the number of ambulances being delayed from handing over their patients was high which contributed to the reasons for inspecting the service. In addition, many patients who attended the department needed to wait for longer than expected before they received treatment.

The ED is open 24 hours a day, seven days a week and sees patients with serious and life-threatening emergencies. There is a separate paediatric emergency department dealing with all attendances under the age of 18 years. Patients present to the department either by walking into the ED and being streamed to one of the treatment areas or arrive by ambulance via a dedicated ambulance-only entrance.

At our last inspection in January 2020, we did not rate the department as this was responsive a focused inspection. The emergency department service was rated as good overall in October 2019 when we carried out a comprehensive service inspection.

We did not rate this service at this inspection. The previous rating of good remains. We found:

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.
Managers monitored the effectiveness of the service and made sure staff were competent.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.

However:

Although people could access the service on many occasions, they had to wait too long for treatment. Patients experienced long waits with many patients spending more than four hours before being discharged or admitted to the hospital.
Many ambulances were unable to leave the departments within 60 minutes from their arrival.
Not all staff were up to date with their infection prevention and control training.
Although patients were being kept safe, there was no evidence of hourly safety checks being consistently recorded as staff did not keep an accurate record to demonstrate they were taking place in regular intervals.

We carried out this unannounced focused inspection because we had concerns about the sickle cell services following a serious incident and because we received information giving us concerns about the safety and quality of care. This was a focused inspection, focusing on the quality of services delivered to patients with Sickle Cell Disease (SCD). Although we inspected all five key domains in relation to the services provided to patients with SCD (safe, effective, caring, responsive and well-led), we did not inspect any other aspects of the core service of Medical Care.

We have not rated this report because our inspection of the sickle cell pathway covered a number of core services within the trust and also sickle cell care is a small part of the medical care core service.

See the medical care section for what we found.

How we carried out the inspection

During the inspection we spoke with eight patients, 38 members of staff and reviewed six patient records. We visited the emergency department, acute medical unit, T4 ward and the haematology day unit. We spoke with different staff groups from different grades including: doctors, nurses, administration staff, managers, divisional leadership team and executive team. During our visit we looked at care pathways, reviewed records, inspecting the places where people were cared for, looking at documents and policies.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

We carried out an unannounced focused inspection in the maternity unit of North Middlesex University Hospital on 21 and 28 September 2021. We carried out our inspection in response to concerns about the safety of the maternity services and to see if the improvement plans the trust had put in place were working. The concerns related to the assessing and monitoring of patients and the culture within the service. As this was a focused inspection, our inspection activity focused only on parts of the safe, effective and well led key questions. This means we did not look at all key lines of enquiry in each of the domains.

Focused inspections can result in an updated rating for only key questions that were inspected if we have inspected the key question in full across the service and/or we have identified a breach of regulation and issued and requirement notice or taken further action under our enforcement powers. In these cases, the ratings will be limited to requires improvement or inadequate.

We inspected maternity care throughout the maternity unit so we could get to the heart of the patient experience. During the inspection to understand the patient journey and make sure that women and babies were kept safe we visited triage, the antenatal ward, the delivery suite, the midwifery led birth centre, and the maternity assessment unit.

We did not inspect the community midwifery teams because the services were carrying out care within the community and we did not visit services outside of the North Middlesex Hospital on this inspection.

Between July 2020 and July 2021, the maternity services had the following activity:

Total number of births: 4241
Total Caesarean (C) section rate: 33%
Elective C section rates: 14%
Emergency C section rates: 23%
Spontaneous unassisted vaginal deliveries: 51.7%
Proportion of vaginal deliveries in a midwifery led unit: 25.8%
Instrumental delivery rate: 9.9%

We did not rate this service at this inspection. The previous rating of Good remains. We found:

The service provided mandatory training in key skills to all staff and made sure everyone completed it. The training was comprehensive and met the needs of women and staff. Staff had received enhanced CTG training and as a result incidents involving CTG misinterpretation had decreased.
Staff understood how to protect women from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
Staff completed and updated risk assessments and identified and acted upon women at risk of deterioration. GAP growth assessments had improved, and the service was now above the national average for the detection of small growth babies. The service controlled infection risk well and kept equipment and premises visibly clean.
The service mostly had enough maternity midwives, nursing and medical staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank and agency staff a full induction.
The service managed safety incidents well. Staff recognised and reported incidents and near misses. 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. Managers ensured that actions from patient safety alerts were implemented and monitored.
Managers monitored the effectiveness of the service and made sure staff were competent. Training and learning opportunities were available for all staff. Staff worked well together for the benefit of women.
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 women and the community to plan and manage services and all staff were committed to improving services continually

However:

Induction for most staff was comprehensive and tailored to staff’s requirements. However, after feedback from junior doctors, the service recognised the junior doctor induction needed more work. There had been some good improvements made, but there was more work to be done.
The unit co-ordinator role within the service looked at staffing to make sure it was safe with the activity within the department. However, due to the caseload, the co-ordinator role was not always supernumerary, and this meant the service had to find other ways of looking at staffing and organising breaks for staff.
There was a poster campaign and leaflets available to women to raise awareness of the Covid vaccine. However, we did not find any evidence of conversations or records of advice given to pregnant women regarding the Covid vaccine, in terms of the advantages and risks so women could make an informed decision.
The service had handover meetings for each shift to discuss continuity of patient care patient. However, the anaesthetist did not attend the morning handover we observed, and this meant not all staff had received up to date information on each patient. This could lead to delays in treatment and diagnosis, inappropriate treatment and omission of care.
Bed occupancy levels for maternity have been higher than the England average since October 2019. Although there were complex issues that prevented smooth discharge, this meant the services capacity was limited and could pose difficulties in times of more demand.

We carried out an unannounced focused inspection of the emergency department at North Middlesex Hospital on 20 January 2020, in response to concerning information we had received in relation to care of patients in this department.

We did not inspect any other core service or wards at this hospital, however we did visit the winter pressure operations centre to discuss patient flow from the emergency department. During this inspection we inspected using our focused inspection methodology. We did not cover all key lines of enquiry and we did not rate this service at this inspection.

This was a focused inspection to review concerns relating to the emergency department. It took place between 12pm and 7pm on Monday 20 January 2020.

We did not inspect the whole core service therefore there are no ratings associated with this inspection.

Our high level findings were:

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them.
Risks to patients were assessed and their safety monitored and managed so they were supported to stay safe.
Although there was a relatively high vacancy rate within specific bands, there were enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care.
There were enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care.
Patients could access the service when they needed to.
The service had managers with the right skills and abilities to run a service which provided high quality, sustainable care.
The service had a vision for what it wanted to achieve and a strategy to turn in it into action, develop with stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. There was an appetite among staff to deliver outstanding care which was evidence based and improved patient outcomes.
Staff felt respected, supported and valued. There were focused on the needs of patients receiving care. The service had an open culture where patients, their families and staff could raise concerns.
Leaders operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular oppportunities to meet, discuss and learn from the performance of the service.

Professor Edward Baker

Chief Inspector of Hospitals

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

We found inconsistencies in stock management of medicines across the services we inspected. We found a significant amount of expired medicines including on the resuscitation trolley and grab bag despite regular checks being completed by staff. Therefore, we were not assured there were comprehensive governance processes in place at ward level.
Staff did not always complete all risk assessments for each patient swiftly and updated the assessments to minimise patients’ risk.
We found inconsistencies with the quality of documentation. Also, mental capacity assessments were not always completed for patients with deprivation of liberty safeguards.
In ED the completion rates for adult immediate life support level 3 for nursing staff and paediatric and adult intermediate and basic life support for medical staff was worse than trust target of 90%.
Large number of complaints were not investigated and closed with the complaints policy, which stated complaints should be resolved within 30 days.
Although the divisional leaders had good oversight on most risks in the division, not all risks identified at the time of inspection were noted on the risk register. For example, there was limited oversight of medications management on the ward.

However, we found the following areas of good practice:

The trust continued to use weekly ‘harm free panels’ to reduce pressure ulcers and improve overall safety awareness amongst staff. Staff found the panels to be educational and helpful.
Patients told us they felt involved in their care plans most of the time.
Staff understood how to protect patients (adult, children and young people) from abuse and the service worked collaboratively with other agencies to do so.
The service planned care to meet the needs of local people and took account of patients’ individual needs.
The refurbished ED had a new facility Horizon unit for patients in ED who need mental health support.
The trust addressed issues since the last inspection with the gastrointestinal bleeding rota. The rota was complete which was available seven days a week, 24 hours a day.
Staff in the care of elderly wards developed a three-year strategy for dementia awareness which was launched in 2018. It included re-invigorating use of the dementia care bundle, training all new clinical staff to tier two level in dementia awareness, continue to participate in the national audit for dementia and to learn from its outcomes.

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

The trust did not provide full cover for an out of hours rota to cover gastroenterology. This meant patients were at risk of delay to treatment should they experience upper gastrointestinal bleed during out of hours.
The hospital needed to improve in providing care for children, young people and adults who presented with mental health conditions.
The trust did not have oversight of the use of restraint.
Staff in outpatients felt they were discouraged from reporting incidents of verbal and physical abuse against staff.
Records we reviewed in medical care services were of variable quality. There were no care plans implemented to support patients with falls or dementia in the day hospital unit. Endoscopy patients sometimes underwent procedure under sedation but staff failed to ask them to sign a disclaimer form to confirm they understood risks related to it and that they should arrange to be escorted after the procedure.
Not all areas in maternity services were visibly clean during our inspection and we were not assured control were effectively in place to prevent the spread of infection.
There was not always an advanced paediatric life support (APLS) trained staff member on shift in services for children and young people.
Some of the data from trust’s pain assessment audit indicated that patients were not always offered sufficient analgesia or underwent regular pain assessment.
The trust did not have complete oversight over how many patients were placed on Deprivation of Liberties Safeguards authorisations (DOLS) in the hospital as the ward staff did not inform the safeguarding lead of all the authorisations that were signed by staff.
Mental capacity assessments had not always been completed by the clinician before filling out the best interests document.
The emergency department did not achieve the four-hour Department of Health standard on any occasion between May 2017 and April 2018.
The outpatient department did not monitor waiting times for patients.
Across the outpatient department we saw little evidence of health promotion information available for patients.
The chaplaincy and faith provision within the trust was mainly available for Christian and Muslim faiths.
Complaints were not always closed in accordance with timescales set out in the trust’s complaints policy.
The clinical governance structure was not yet fully embedded.
There was a concern that current improvements in emergency department were not sustainable since there remained a heavy reliance on locum or agency medical and nursing staff.
There was no board level lead for children’s services.

However:

Overall, we saw improvement in incident reporting and we saw evidence of learning from ‘never events’
Since the trust established ‘harm free panel’, the trust reported 57% reduction of hospital acquired pressure ulcers (grade 3 and above).
The introduction of the fast initial treatment zone in the emergency department meant patients were streamed by a consultant or senior doctor most of the time.
Risks to women were well-identified and managed by staff in antenatal care, intrapartum and postnatal care.
In critical care, we found consistently good standards of risk assessment in patient documentation and in practice observations, including in relation to sepsis management.
We observed effective multidisciplinary team working and good relationships and communication amongst various professionals involved in patients care and treatment.
The surgical service contributed to national clinical audits for surgery. The overall performance for elective admissions was better than the England average.
Women’s care and treatment in the maternity service was planned and delivered in line with current evidence-based guidance.
The maternity service met expected patient outcomes for women in most areas, and in some areas exceeded these.
We observed and were told patients were treated with kindness, compassion, dignity and respect.
The maternity service provision met the needs of local people.
There was increased awareness of the needs of patients with dementia and learning disabilities.
There was a good handover process for medical patients placed on surgical wards and surgical patients on medical wards (outliers).
The urgent care centre and the paediatric emergency department performed well in the Department of Health four-hour standard.
The outpatient department was meeting the referral to treatment time of seeing patients within 18 weeks.
Staff spoke positively of the leadership team.
Since our last inspection there had been significant improvements in the working culture of the critical care unit and maternity services.

The North Middlesex University Hospital NHS Trust is a medium-sized acute trust with around 515 beds, serving approximately 590,000 people living in Enfield and Haringey and the surrounding areas, including Barnet and Waltham Forest. In the 2015 Indices of Multiple Deprivation, both Enfield and Haringey were ranked in the most deprived quintile.

The trust had an annual revenue of around £250 million, and reported a deficit of £8 million, at the time of the inspection. The trust employs 2,458 staff. The trust provides a full range of adult, older people’s and children’s services across medical and surgical disciplines.

In 2015/16 the trust reported activity figures of 56,880 inpatient admissions, 348, 276 outpatient attendances and 171,840 admissions through the Accident and Emergency department.

We inspected all eight core acute services including: Urgent and Emergency Care, Medicine (including older people’s care, Surgery, Critical Care, Maternity and Gynaecology, Services for children, End of life and Outpatients and diagnostic services.

We last undertook a comprehensive inspection at the trust in June 2014 when we rated the trust as requires improvement overall.

Following concerns we undertook an unannounced inspection of two medical wards and the ED in April and May 2016. We rated the medical service as requires improvement overall and the ED as inadequate. We also issued a Warning Notice to the trust requiring them to make improvements to the ED by the end of August 2016.

Our key findings were as follows:

The emergency department (ED) was not consistently achieving the 15 minutes performance standard for initial review of all patients arriving at ED.
The ED was not meeting the target time to admit, transfer or discharge 95% of patients within 4 hours of their arrival in the ED.

Substantial improvements have been made since the last inspection in May 2016. There was improved clinical governance and leadership at department level and oversight of this at trust level.

Patient records had not been completed consistently, frequency of intervention was not always recorded and there was no evidence that the care of patients had been increased to reflect individual needs. Patient records were not always kept confidential or stored securely.
Staffing levels on the wards did not always reflect the safer staffing acuity tool to determine safe staffing levels.
We found that medicines were generally stored securely and appropriately, including those requiring refrigeration. Regular expiry date checks were in place and there were suitable arrangements for ensuring medicines were available out of hours.

Most observed interactions between staff and patients were positive. Feedback from patients and relatives was generally good and they felt they were treated with courtesy, respect and compassion by staff. Staff maintained patients’ privacy and dignity.
The hospital consistently met the referral to treatment standard and performed better than an average English hospital.

The departmental risk register did not fully indicate how risks were mitigated and who was responsible for implementing actions.

Nurse staffing levels could be unpredictable and did not always meet national guidance. Safety checks on agency nurses were inconsistent and poorly managed.
Care and treatment was consultant led and medical staffing levels met national best practice guidance.

The culture was not one of fairness, openness, transparency, honesty, challenge and candour. Staff reported bullying, harassment and discrimination amongst staff at all levels in the maternity unit. They said when they raised concerns they felt they were not treated with respect. The culture was defensive with poor collaboration between the staff working in different departments. High levels of conflict were reported to us.
We were not assured that patients were being cared for in the right place at the right time, by adequately qualified staff. This meant that patients may not receive timely care in the appropriate part of the service and be cared for by competent staff which put them at risk.
The majority of women and those close to them were positive about the care and treatment they had received. Women were able to telephone Maternity Direct in working hours and triage out of hours for emotional support.

The service had a lack of ownership or oversight of children being cared for in other areas within the trust where the care environment was suboptimum and the service did not have oversight of young people over the age of 16 years who were cared for in adult clinical areas of the trust.
There was poor oversight of patients with learning disabilities who were not identified on admission.
The service had effective systems to identify children who might deteriorate whilst receiving care and used the recently introduced Royal College of Paediatrics and Child health SAFE Programme based on work undertaken at the Cincinnati Children’s Hospital in the USA.
NICE guidance for EoLC staffing showed a seven day service should be provided for EoLC, however this had not occurred. A business case was awaiting review.
There was no non-executive director on the board responsible for EoLC.
A minimum of 50% of registered nurses on every ward had received some form of training from the SPCT. This was the trust target.
Overall, patients were treated with dignity, respect and care by staff. Although, some patients told us staff were rude and uncaring. Most patients spoke positively about staff but did not always feel well informed about their care and the procedures being undertaken.
The proportion of people waiting less than 62 days from urgent GP referral to first definitive treatment was below the national average and had deteriorated in the first quarter of 2016/17.
The percentage of patients seen within two weeks for all cancers was higher than the national average. Also, the cancer waiting times for people waiting less than 31 days from diagnosis to first definitive treatment were higher than the national average and above the standard target of 96%.

We saw several areas of outstanding practice including:

The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
Outpatient and diagnostic services had strong leadership. Staff were inspired to provide an excellent service, with the patient at the centre.
The diagnostic imaging department worked hard to reduce the patient radiation doses and had presented this work at national and international conferences.
The paediatric clinical teams used the SAFE programme. North Middlesex Hospital had been one of 28 hospitals which had worked with the RCPCH in participating in a two year programme to develop and trial a suite of quality improvement techniques to improve communication, build a safety-based culture and deliver better outcomes for children and young people, known as SAFE. The SAFE programme was designed to reduce preventable deaths and error occurring in the UK’s paediatric departments.

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

Importantly, the trust must:

Urgent and Emergency Services

The trust must ensure learning from incidents is more robust and shared with all staff.
The trust must ensure that all medicines and instruments associated with a resuscitation are disposed of safely after use.
The trust must ensure the renewal of advanced paediatric life support (APLS) certificates of those doctors and consultants whose certificates had expired
The trust must improve mandatory training levels for medical and nursing staff.
The trust must improve safeguarding adults level 2 training for medical and nursing staff.
The trust must improve safeguarding children level 2 training for medical and nursing staff.
The trust must improve hand hygiene levels especially amongst medical staff.
The trust must ensure medical and nursing staff are fully trained and able to identify and support the needs of patients living with dementia.
The trust must ensure medical and nursing staff are fully trained and able to identify and support the needs of patients with learning disabilities.
The trust must improve appraisal rates of nurses.

Surgery

The trust must ensure all actions in response to the never event are fully implemented.
The trust must review and identify causes for the higher than the national average mortality rate as suggested by the bowel cancer and the national hip fracture audit data.

Outpatients and Diagnostic Imaging

The trust must ensure there are appropriate processes and monitoring arrangements to reduce the number of cancelled outpatient appointments and ensure patients have timely and appropriate follow up.
The trust must ensure there are appropriate processes and monitoring arrangements in place to improve the 32 and 61 day cancer targets in line with national targets.
The trust must ensure there is improved access for beds to clinical areas in diagnostic imaging.

Maternity and gynaecology

The trust must carry out an audit of the stillbirth rate for the period January to December 2016 and develop an action plan to address themes.
The trust must provide one to one care in labour to all women.
The trust must replace all damaged equipment in EGU and triage.
The trust must monitor and report in VTE compliance.
The trust must monitor the temperature of medicines storage.
The trust must review waiting times in triage and develop an action plan to address themes.
The trust must ensure mandatory training and multidisciplinary intrapartum care training targets are met.
The trust must display cleaning schedules or checklists all clinical areas.
The trust must ensure staff in maternity observe the ‘bare below the elbows’ policy.
The trust must ensure patients have a named midwife.

End of Life Care

The trust must code their complaints correctly to reflect palliative and end of life care complaints.
The trust must send out bereavement surveys to the relatives of patients who have died within the hospital.
The trust must produce and ratify an end of life care strategy.

In addition the trust should:

Urgent and Emergency services

The trust should continue to make improvements to 15 minutes to triage time.
The trust should maintain consistent achievement of 80% target of 15 minutes to ECG.
The trust should ensure there is a supply of paediatric emergency medicines in the paediatric high dependency room.
The trust should develop statement of purpose for escalation when a patient with a mental health illness absconds from the department.
The trust should record children’s weights in paediatric patients' records.
The trust should rectify IT issues in paediatric ED to ensure all PEWS scores are recorded.
The trust should develop a chest pain pathway.
The trust should develop a frailty pathway.
The trust should ensure there is a sufficient number of wheelchairs available to facilitate timely ambulance handover of patients.
The trust should improve patient comfort with the availability of snacks for patients 24/7.
The trust should improve quality of major incident awareness amongst all staff.

Surgery

The trust should ensure departmental risk register indicates how risks are to be mitigated and who is responsible for implementing actions.
The trust should ensure staff improve recording of pressure ulcers, raise incidents and safeguarding alerts when appropriate.
The trust should ensure reporting of actions from mortality and morbidity meetings is formalised and ensure learning and actions are shared across the trust.
The trust should ensure individual venous thromboembolism risk assessments (VTE) are fully completed for all patients.
The trust should improve average waiting time for a patient discharge prescription.
The trust should improve utilisation rate for operating theatres and its efficiency.
The trust should review if all qualifying patients are screened for dementia.

Critical Care

The trust should ensure all staff have adequate knowledge of safeguarding policies and processes.
The trust should ensure nurse to patient ratios are managed in relation to the individual needs of patients, including whether they are bedbound and/or cared for in a side room and in relation to the guidance of the ICS core standards for intensive care.
The trust should ensure staff have appropriate support and supervision to meet their needs in relation to professional and contractual activity.
The trust should ensure all staff who care for patients have the appropriate personal skills to demonstrate understanding and kindness.
The trust should ensure learning from infection prevention and control audits are implemented by all staff.

Outpatients and Diagnostic Imaging

The trust should ensure its target for compliance with mandatory training is met by staff.
The trust should ensure there is access to seven day week working for radiology services.
The trust should ensure staffing is improved in radiology for sonographers.

Children and Young people services

The trust should ensure that all children and young people up to their 19th birthday wherever they are cared for in the hospital should come under the governance of children’s services which will ensure that they have oversight of all children and young people wherever they are treated in the hospital.
The trust should improve drug refrigerator temperature monitoring and replace faulty fridges with new equipment where required in order to ensure medication is safely stored.
The trust should gather feedback from children and young people who use their services and use this information to inform and improve service planning.
The trust should ensure that play provision for children in hospital should be enhanced to meet national standards.

Maternity and gynaecology

The trust should develop a clear vision and strategy for the maternity and gynaecology service.
The trust should review the group sessions for the first antenatal appointment.
The trust should carry out a review of culture within maternity and use tools such as ‘walk in my shoes’.

Medical care (including older people’s care)

The trust should ensure that staff report incidents through the online reporting system and there is a formal process for feeding back to staff.
The trust should ensure Mortality and Morbidity review meetings are used to identify action points or lessons learnt and that these are recorded.
The trust should ensure patient records are completed consistently and patient records are always kept confidential and stored securely.
The trust should ensure staff wash their hands between patients and wear appropriate PPE.
The trust should ensure that staffing levels on the wards reflect the safer staffing acuity tool to determine safe staffing levels.
The trust should ensure nursing staff know how to use the settings for the pressure relieving mattress.
The trust should ensure compliance with mandatory training meets the trusts target for infection prevention and control training, health safety and welfare, information governance, safeguarding, safeguarding children and fire safety.
The trust should ensure that feeder cups and meals are left within easy reach of patients.
The trust should ensure that staff are trained in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberties Safeguards and that staff seek patients’ consent before care or treatment is given.
The trust should ensure that activities, such as cards, games or puzzles, are provided on the care of the elderly wards.
The trust should ensure that staff have feedback about complaints or learning from them.

End of Life Care

The trust should ensure they meet the minimum requirements for consultant staffing as set out within the Royal College of Physicians guidelines.
The trust should provide a seven day face to face service as set out within NICE guidance for EoLC.
The trust should carry out mental capacity assessments on all patients deemed to lack capacity prior to completing a DNACPR form in line with trust policy.
The trust should keep the risk register up to date at all times.
The trust should ensure patient care is delivered in line with the patients' care plans at all times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We undertook an unannounced inspection at the North Middlesex University Hospital because of concerns raised by patients, commissioners and other stake holders in the health and care sector. A number of serious incidents had occurred in the Emergency Department (ED) which had raised concerns about the standards of care patients were receiving. We also had concerns about the high numbers of safeguarding incidents at the hospital for patients being cared for on medical wards.

In December 2013, the ED at Chase Farm Hospital was closed and the service replaced with an Urgent Care Centre (UCC). This had a significant impact on the demand for services at North Middlesex Hospital. In particular, this has led to significant increases in patient numbers attending the ED.

In June 2014, we completed a comprehensive inspection of the trust which was rated as Requires Improvement overall. Both the core services of Medical Care and ED were rated as Requires Improvement.

We inspected on 14 April 2016 and then returned to the ED on 4 and 5 May 2016.

We visited the ED and two of the hospital’s medical wards. The inspection was responsive and unannounced based on concerns we had about the care patients were receiving at the hospital.

Whilst we found many examples of caring and competent staff, systems are not in place or were not working to ensure the proper care of patients. We found that the trust leadership was seen by many staff as overbearing and not supportive to delivering safe treatment.

Our key findings were as follows:

Patients who came to the ED are not being seen quickly enough by clinical staff and are waiting too long to be seen by a doctor. At night, there are too few competent doctors who are able to assess and treat patients.
The Rapid Assessment and Treatment (RAT) of all patients arriving by ambulance is led and undertaken by Band 5 and 6 nurses without an input from a doctor.
ED staff are not monitoring the 15 minutes performance standard for initial clinical review.
There are excessive delays in seeing a doctor and moving patients to specialist wards.
Multi-disciplinary team working was poor. Doctors from other parts of the trust were slow to come and review patients and were not supportive of staff in ED.
Patient flow is poorly managed and the trust’s performance, with regard to waiting times, is poor. Performance has deteriorated in recent months. In February 2016, only 67.2% of patients were seen and treated within the national four hour target, compared to an England average of 88%.
There is insufficient middle grade medical leadership to direct patient care and treatment.
The department has lacked an established Clinical Director to provide leadership for more than six months. The leadership is shared among three consultants. The trust's senior clinical team has not been visible in providing leadership and support to the department, however the trust has recently appointed a new medical director whom staff hoped would give support and direction to the department.
Trust management is seen as oppressive and overbearing and not supportive to staff in the ED. The culture meant that staff did not feel comfortable in raising concerns.
The trust had not learnt from previous ‘never events’ and serious incidents. The trust is not seen to be open and transparent. Relevant information is not shared with staff.

The medical wards had good consultant support and availability and the number and skill mix of medical doctors is satisfactory. There is a daily multidisciplinary team meeting and good team working in patient care and on ward rounds. However, there is, on occasion, insufficient number of nurses per shift.

There is a lack of respect and dignity in the way patients are treated and their needs are not always met appropriately. Patients’ safety is being compromised through omissions in risk assessments, and through inconsistencies and inaccuracy in completing care records and observation charts.
Patients’ nutritional and hydration needs are not being met appropriately due to incorrect recording in the food and fluid charts. Trained staff are not following the medication policy in the safe storage, recording and administration of medicines.

The trust has an impressive dementia strategy but most of it has not been implemented. Staff are not completing mandatory training, including safeguarding. Basic dementia awareness training is not being completed by 40.6% of staff working in the wards for older people. There are no dementia champions/link nurses in the wards to support staff. Patients are therefore exposed to the risk of not receiving appropriate care and treatment. Similar findings were reported in the CQC report in 2014.

During our inspection, we observed no areas of outstanding practice.

There are a number of areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Ensure all patients attending the ED are seen more quickly by a clinician.
Ensure that the more seriously ill patients are properly identified and seen more quickly by a doctor.

Ensure middle grade doctors take greater leadership in clinical decision making and supporting junior colleagues.

Provide the ED with greater leadership and support from other specialties to ensure effective pathways and improve patient flow.

Seek and act on feedback from people using the service, those acting on their behalf, staff and other stakeholders to evaluate the service and drive improvement.

Take action to improve staff training – both mandatory and non-mandatory.

Ensure there is an adequate supply of equipment, especially vital and life sustaining equipment which is fit for purpose.

Ensure key data, such as waiting time performance and clinical outcomes, are recorded and used to drive improvement.

In addition, the trust should:

Ensure that ED staff undertake risk assessments for those patients at risk of falls or pressure sores.
Review arrangements for the consistent capture of learning from incidents and audits and ensure that learning and audit data is always conveyed to staff.
Ensure consistent ownership and knowledge of the risk register across all nursing and medical staff.
Improve multi-disciplinary team working with medical teams from other parts of the trust.
Undertake auditing of patient outcomes.
Endeavour to recruit full time staff in an effort to reduce reliance on agency staff.
Complete annual appraisals for all eligible nursing staff.
Consider including Mental Capacity Act 2005 as part of mandatory training.

Establish multi-disciplinary panels to review serious incidents and performance breaches.

Review how patient dignity can be improved in the UCC during the reception process.

Following our inspection, the Commission wrote to the trust on 18 April 2016 raising issues of concern about care in the ED and asking for additional information and a response from the trust. After receiving and reviewing the additional information and the trust response, the Commission served a statutory Warning Notice on the trust requiring them to improve the care of patients in the ED by 26 August 2016.

The Commission will be undertaking a full comprehensive inspection of the trust in September 2016.

Professor Sir Mike Richards

Chief Inspector of Hospitals

North Middlesex University Hospital is the main acute hospital for the North Middlesex University Hospital NHS Trust, which provides acute medical and surgical services to a population of 350,000 people across the London boroughs of Haringey, Barnet, and Enfield, and surrounding areas.

We carried out this comprehensive inspection because the trust is an aspirant foundation trust, prioritised by Monitor.

We inspected all the main departments of the hospital: accident and emergency, including the urgent care centre; medical wards, including care of the elderly; surgical wards and theatres; critical care; maternity and family planning; services for children and young people; end of life care and outpatient departments.

Overall, this hospital requires improvement.

We rated it good overall in the following departments: surgery, critical care, maternity and family planning, and services for children and young people. However, we rated accident and emergency, medical wards, end of life care and outpatients as requiring improvement.

While we rated the hospital good overall in caring and providing effective care, it requires improvement overall in providing safe care, being responsive to patients’ needs and being well-led.

Our key findings were as follows:

Most patient, carer and patient relative feedback was positive in relation to the care being provided by the hospital.
The hospital had fully embraced the increased workload brought about by the reconfiguration of hospital services under the Barnet, Enfield and Haringey strategy and the closure of Chase Farm Hospital accident and emergency department.
While the hospital had achieved much in absorbing increased numbers of patients, its infrastructure of staffing levels, training provision, complaints handling and governance had been stretched, and there had been an underestimate of the resources needed to maintain services at the current level.
The improved environment with the extensive rebuilding programme had undoubtedly enhanced patient experience.
We saw examples of good practice in most areas and of dedicated care in the maternity department (despite overstretched resources), ambulatory care unit and hospital mortuary.
We saw many examples in every area of the hospital of staff giving treatment in a caring and compassionate way.
In surgery, the clinical teams coped well with the pressures of high demand by working with commitment and flexibility while maintaining a calm and professional atmosphere.
We saw examples of good multidisciplinary working contributing to areas of good practice (for example, the use of the ‘five steps to safer surgery’ procedure and enhanced treatment and recovery pathways).

We saw several areas of outstanding practice including:

The trust had developed partnership working with local primary care providers to address the poor use of primary care services by the local population. This included regular teleconferences with local authorities and other services to tackle frequent inappropriate visits to the trust by the same patients, and delayed transfers of care.
The trust had recently launched a health bus to inform the local community about the availability of, and access to, primary care services, and to offer basic health checks to people in its catchment area.
The trust had developed an in-house database to improve the quality of care to patients with HIV; it was marketing this database to other providers.
The department had an innovative pathway for patients with sickle cell conditions. Staff displayed a high level of knowledge in diagnosing and treating this specialism.

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

Importantly, the trust must:

Take action to ensure that the outpatients department is responsive to the needs of patients, in that appointments are made in a timely manner, those with urgent care needs are seen within the target times, cancellations are minimised and complaints are responded to.
Take action to improve its training – both mandatory and non-mandatory – and its recording and administration of training records and training renewal requirements.
Ensure that the provision of ambulatory care maintains people’s privacy and dignity.

In addition the trust should:

Review the needs of people living with dementia across the hospital to ensure that they are being met.
Review the use of the decontamination room in A&E, which poses a contamination risk to the rest of the hospital. This was closed during our inspection following highlighting our concerns.
Ensure that medicines are stored safely in A&E and that systems for recording take home medication are consistent throughout the hospital.
Ensure that A&E staff undertake risk assessments for those patients at risk of falls or pressure sores.
Review the risk assessments for the ligature points noted in the psychiatric assessment room in A&E.
Ensure that there is adequate provision of food and drink for patients in A&E who are waiting for long periods, including at night.
Improve patient discharge arrangements at weekends.
Improve investigation and response times to complaints, particularly in A&E and outpatients.
Ensure that the lines of responsibility between A&E and children’s’ services over the responsibility for the paediatric A&E are clear to staff during a period of change.
Review arrangements for the consistent capture of learning from incidents and audits and ensure that learning and audit data is always conveyed to staff.
Improve medical recording to remove anomalies and inconsistencies in records, paying particular attention to elderly care wards and take steps to improve the security of records in surgery.
Review the provision of specialist pain nurse support across the whole hospital.
Ensure consistent ownership and knowledge of the risk register across all nursing and medical staff.
Review decisions made at a senior non-clinical level being unchallenged and having a potential clinical impact on patient welfare.
Review development and promotional prospects and progress for staff, such as healthcare assistants.
Review and implement a system for updating national guidelines in maternity and palliative care.
Improve documentation around assessment of mental capacity in end of life care.
Improve consistency of use of early warning scores for deteriorating patients.
Improve documented guidance for staff around referral of patients to palliative care.
Increase mortuary capacity beyond current temporary arrangements.
Appoint a non-executive director with responsibility for end of life care.
Review clinic cancellation processes to avoid clinic appointments being cancelled at short notice.
Review appointment arrangements to ensure that appointments are not booked at unsuitable times or clinics overbooked in error.
Review the waiting areas in outpatient clinics, particularly the eye, fracture and urology clinics at busy times to prevent people having to stand while waiting.
Review follow-up outpatient appointment arrangements to increase capacity to organise follow-up appointments in some of the outpatient clinics. This includes dietician, nephrology, paediatric urology and hepatology clinics where no appointments were available within 5 weeks.
Improve communication with outpatient staff and their involvement in the development of the service to ensure service vision and values are understood and fully supported by staff. Allow staff increased opportunity to express their concerns related to developments within the trust and how this affects their day-to-day work.
Accelerate plans to move to 7-day working across all core services. The support for patients recovering from surgery is limited at weekends with no access to occupational therapists, physiotherapists or clinical nurse specialists.
Improve the recording of care on the labour ward.
Improve access to records for community midwives.
Review the impact of the Barnet, Enfield and Haringey strategy, its impact on staff and its potential impact on quality of care.
Review the heavy reliance on agency staff due to a 20% shortage of paediatric nurses in the neonatal unit.
Review inconsistency around documentation of ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms.
Improve training for junior doctors on palliative care.
Improve the privacy and dignity of patients during the reception process and waiting times to see a clinician within the Urgent Care Centre during the reception process.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We carried out an inspection of the maternity unit at the hospital with a team of three inspectors and a specialist midwife advisor. We spoke with midwives, doctors, maternity support workers, a supervisor of midwives and the Head of Midwifery and Gynaecology. We spoke with 16 women and their partners, in the ante-natal clinic and in the post-natal ward, about their experiences of the maternity service. Most women told us their privacy and dignity had been respected by staff and they had received sufficient information to enable them to make choices about their care and treatment.

Most women were positive about the care they had received. For example, one woman told us 'the doctor has also been very helpful' and another woman said, 'it has been a great experience.' Staff were described as 'very welcoming,' 'very courteous' and 'professional.' Everyone we spoke with, who had delivered their baby, said they would consider having a baby at the hospital again in future.

We found all areas of the maternity unit to be clean and well-maintained. Midwives received appropriate training and support to enable them to provide the care and treatment that women needed. The maternity service was well-led and responsive to the needs of a diverse local population. Systems were in place to assess and monitor the quality of service that women received and ensure care was provided safely and effectively.

We carried out inspections of the hospital over a four day period with a team of ten inspectors, three specialist nurse advisors and an expert by experience. We visited the accident and emergency department (A&E), out-patient clinics and two wards for older people. We inspected an additional three wards and the operating theatres in respect of their cleanliness and standards of infection prevention and control. We spoke separately with individual doctors in training at the hospital as well as nurses, health care support workers, receptionists, therapists and other allied health professionals. We met with the Chief Executive, Medical Director, Director of Nursing, Head of Education and Career Development and the chair of the trust board.

We spoke with more than 50 patients and relatives about their experiences. Most people were happy with their care. They told us their privacy and dignity had been respected by staff and they had received clear explanations of their care and treatment. Staff assessed patients' needs and planned and delivered care compassionately and safely. Typical comments we received from patients included: 'the night staff were great, very attentive and the nurses were constantly checking on me' and 'I'm well looked after, the staff are wonderful.' We found all areas of the hospital we visited to be clean. A patient told us, 'I think it's a wonderful hospital. It's always clean.'

Staff received appropriate training and support to enable them to provide the care and treatment that patients needed. The trust was well-led and responsive to people's needs. Systems were in place to assess and monitor the quality of service that patients received and ensure care was provided safely and effectively.

We visited two surgical wards and the accident and emergency department (A&E) and spoke with patients and relatives. We also carried out spot checks of medicine management arrangements on two other wards. We observed surgical procedures in the operating theatres.

A patient told us they had been 'treated very well' and staff had gone to great lengths to make them comfortable. Another patient told us the care and treatment they had received was 'absolutely excellent, I've never seen a service like this.' Patients told us their pain was managed effectively. For example, one patient said, 'staff have bent over backwards to help with the pain.' Patients said surgical procedures had been explained to them in detail before they were asked to give their consent. Most patients told us they understood the medication they were taking and why. The possible side-effects of medicines had been explained to them. Surgical safety checks were carried out by staff before, during and after surgery, which helped ensure the safety of patients.

Staff worked in cooperation with others health professionals and shared information appropriately. The provider regularly monitored the service to make sure that risks to people were minimised and an appropriate standard of care and treatment provided. Complaints about the service were managed effectively.

When we visited the hospital we spoke to patients and relatives in Accident and Emergency, the children's ward and M1 (a medical ward) and S3 (a surgical ward). Overall, patients were positive about the care and treatment they had received. They said they were treated with dignity and their privacy was respected. Treatment options and medication were explained in ways that were understood by patients. A child told us, 'they are really good nurses, they do explain what they are doing'. Staff were described as 'helpful', 'caring' and 'supportive'. Some patients told us that staff seemed very busy and were concerned they sometimes took a long time to respond when the call bell was used. All patients we spoke to said they felt safe in the hospital and felt listened to by staff.

We visited the maternity unit and spoke to a number of women and their partners on T4, the antenatal and postnatal ward. Women were mostly very happy with the service provided to them. One woman told us that midwives 'gave loads of advice' and were 'really supportive', which was typical of the comments we received. Another woman told us that during the delivery of her baby staff were 'were always talking to me and answered mine and my partner's questions'. Scans and blood tests were fully explained and woman said they had received pain relief when they needed it. Some women felt there were not enough staff available on T4 at certain times but all felt safe on the unit.

All the patients and relatives we spoke to were happy with the care and treatment they received from staff. They were treated with dignity and respect and one patient said staff 'bent over backwards to help'. Staff were described as 'kind' and 'careful' and were said to respond quickly when patients needed assistance. Patients told us they had a wide selection of meals to choose from and there was plenty of it. There were mixed views on how appetising the food was and one person said 'no one really enjoys hospital food'. The food was described as 'always hot' and mealtimes were said to be unhurried.

All Inspections

Professor Edward Baker

We saw several areas of outstanding practice including:

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

End of Life Care

Professor Sir Mike Richards

Professor Sir Mike Richards