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North Middlesex University Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 September 2018

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.
Inspection areas

Safe

Requires improvement

Updated 14 September 2018

Effective

Requires improvement

Updated 14 September 2018

Caring

Good

Updated 14 September 2018

Responsive

Requires improvement

Updated 14 September 2018

Well-led

Requires improvement

Updated 14 September 2018

Checks on specific services

Critical care

Good

Updated 14 September 2018

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

  • Nurse staffing levels consistently met minimum standards set by the Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS). The matrons had significantly reduced nurse vacancies in the previous 12 months and at the time of our inspection there were no vacancies for staff nurses or senior staff nurses.
  • Since our last inspection there had been significant improvements in the working culture of the unit which resulted in more motivated staff and a stabilised team.
  • A new sustainability strategy included a nurse leadership development programme, an increase in the number of education and audit nurses and a new research programme from July 2018.
  • Fire safety training and practices had been significantly improved since our last inspection and a dedicated fire officer led new strategies and standards. Where we found areas for more embedded improvement, we were assured of swift action.
  • The unit was highly rated in most areas by a critical care network peer review in November 2017.
  • In May 2018 the unit was rated as fourth highest performing area in the hospital’s ‘perfect ward’ quality audit tool, reflecting 97% overall.
  • A dedicated audit and research team led innovative projects and studies to identify strategies to improve patient care and outcomes. They also contributed to the Intensive Care National Audit Research Centre (ICNARC) and ensured the audit programme effectively benchmarked practice. The unit was not a national outlier in any measure.
  • We found consistently good standards of risk assessment in patient documentation and in practice observations, including in relation to sepsis management.
  • The team demonstrated a proactive, motivated and multidisciplinary approach to learning from incidents, including the introduction of innovative or exploratory solutions.
  • Feedback from patients and relatives overall was positive and people told us staff delivered care with privacy and dignity.
  • Overall 2% of patients experienced a non-delayed, out-of-hours discharge to a ward. This was a significant improvement of 8% from the previous year.
  • The unit received low levels of complaints, with six received between June 2017 and June 2018.
  • There was a coherent leadership structure in place and all staff said they felt supported and respected.
  • The senior team encouraged staff to be involved in audits and research, which they designed to improve patient experience and outcomes.

However:

  • Doctor staffing levels did not meet FICM or ICS minimum standards during out of hours periods, including periods when the ratio of junior doctors to patients was 1:23.
  • Although we saw several areas of improvement, we were not assured these were fully embedded or consistently followed. This included with regards to fire safety in the environment, infection control standards, dementia screening and application of the Mental Capacity Act (2005).
  • The unit could not demonstrate consistently good practice in relation to infection control, including with hand hygiene.
  • Staff did not classify incidents consistently, which meant the senior team did not have assurance of a tracking system to identify trends and themes.
  • There was evidence from various sources of a need to further improve communication between doctors and nurses, including from incident reports and a critical care network peer review.
  • We found inconsistent and variable understanding of the Mental Capacity Act (2005) and of mental capacity assessment protocols.
  • The service had not successfully addressed long-term recurring instances of out of hours and delayed discharges.
  • At our last inspection in September 2016 we rated critical care as requires improvement overall, which reflected good in effective, caring and responsive and requires improvement in safe and well led.

After that inspection we told they trust they should improve the following areas:

  • Staff knowledge of safeguarding policies and procedures.
  • Nurse to patient ratios.
  • Support and supervision of staff.
  • Demonstration of appropriate personal skills by staff when delivering care.
  • Learning from infection prevention and control audits.

At that inspection we also found several issues with fire safety in the unit, including a lack of named fire wardens, a lack of staff training, incomplete electrical safety testing and a risk assessment action plan that had not been completed. A large number of staff had spoken with us on the condition of anonymity to raise concerns about the working culture and leadership. At this inspection we found the trust and critical care team had begun to address these issues, with some areas still in progress.

To come to our ratings, we spoke with 27 members of staff in a variety of roles and levels of seniority as well as five patients and two relatives. We reviewed the care records of 11 patients and looked at over 45 other pieces of evidence, including the minutes of meetings and audit records. We spent time observing staff deliver care and attended handovers, ward rounds and meetings.

Outpatients and diagnostic imaging

Requires improvement

Updated 16 December 2016

We rated this service as requires improvement because:

  • Staff reported patient safety incidents and there was some evidence of learning from incidents and patient complaints. However, feedback from staff did not demonstrate consistency in all areas. There was a process in place to report ionising radiation medical exposure (IR(ME)R) incidents and the correct procedures were followed. However, the governance and monitoring arrangements need to be strengthened as these had been lacking in past months.
  • 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 services we inspected were generally clean but there were some areas that needed further attention.
  • There was a shortage of key staff, in particular band 5 and 6 radiographers, ultrasonographers, histopathologists and outpatient nurses. Staff morale was mixed but we observed a good team spirit and optimism for the future.
  • There were policies and procedures in place in relation to consent and the Deprivation of Liberty Safeguards. However, the staff we spoke with had very limited understanding of these issues.
  • All staff we spoke with understood how to obtain informed consent. Safety measures were in place for consenting to diagnostic imaging procedures.
  • Records were not always available for clinics although improvements had been made in recent months.
  • Staff were aware of their responsibilities within adult and children safeguarding practices and good support was available within the hospital.
  • There was limited support for patients with a learning disability or living with dementia.
  • The diagnostic imaging department had produced a local workforce plan so that projected capacity would meet demand from 2015-2020. However, there was no capital improvement plan for ageing equipment.
  • 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.

However:

  • 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%.
  • Nursing staff vacancy levels were low. A few vacancies were currently being recruited to. The diagnostic imaging vacancies were higher, particularly ultrasonographers. However,there was an ongoing recruitment and retention plan in place.
  • There was evidence of service planning to meet patient need such as the emergency eye service offered Monday to Friday 8.30am to 4pm for patients with sight threatening eye conditions, requiring urgent specialist ophthalmic treatment. There were extended days for diagnostic imaging appointments. National waiting times were met for outpatient appointments and access to diagnostic imaging.
  • Staff had good access to evidence based protocols and pathways. There was limited audit of patient waiting times for clinics but patients received good communication and support during their time in the outpatients and diagnostics departments.
  • Staff were aware of the complaints policy and told us how most complaints and concerns were resolved locally.
  • Governance processes were in a process of change across outpatients and diagnostics and the new structure was not yet embedded. Clinical governance knowledge was limited within certain divisions of outpatients. However, good progress was evident for improving services for patients.
  • We found evidence of strong local leadership and a positive culture of support, teamwork and focus on patient care.

Urgent and emergency services

Requires improvement

Updated 14 September 2018

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

  • There was no written protocol or policy for staff to follow in order to prevent patients at risk of suicide from leaving the emergency department before they were assessed and treated.
  • Nursing staff were not fully compliant with mandatory training.
  • There was no separate mental health awareness training provided for staff.
  • Staffing vacancy rates were high for medical and nursing staff.
  • Record keeping was inconsistent.
  • Appraisal rates for nurses were low.
  • Mental health act training was not provided for staff.
  • The department did not achieve the four-hour Department of health standard on any occasion between May 2017 and April 2018.
  • There was no ‘frequent attenders’ policy.
  • There was a concern that current departmental improvements were not sustainable since there remained a heavy reliance on locum or agency medical and nursing staff.
  • The clinical governance structure was not yet fully embedded.
  • The trust did not keep numbers of episodes of restraint or monitor its use. This meant that the trust did not have oversight of the use of restraint.

However:

  • There was improved incident reporting.
  • Medical and nursing staff were compliant with safeguarding adult training.
  • Medical staff were compliant with adult and paediatric life support.
  • There was increased awareness of the needs of patients with dementia and learning disabilities.
  • There was protected teaching time for doctors of all grades and there was a Royal College of Emergency Medicine accredited teaching programme in place.
  • We observed staff being kind and caring to patients.
  • The urgent care centre and the paediatric emergency department performed well in the Department of health four-hour standard.
  • The introduction of the fast initial treatment zone meant patients were streamed by a consultant or senior doctor most of the time.
  • There was good multidisciplinary working and a good working culture in the department.
  • Staff spoke positively of the leadership team.

Maternity

Good

Updated 14 September 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

  • The trust had taken note of concerns raised about the maternity service at the previous inspection and made improvements in the areas of culture, waiting time in triage, monitoring of VTE assessment, bare below the elbow practice, carrying out still birth rate audit and providing one to one care in labour to women.
  • Risks to women were well-identified and managed by staff in antenatal care, intrapartum and postnatal care.
  • There were clearly defined and embedded systems and processes in place to keep people safe and safeguard them from abuse. Staff understood their responsibilities to safeguard patients from abuse and neglect, and had appropriate training and support. The service worked well with other healthcare professionals and agencies to ensure the needs of vulnerable women were met.
  • There was an open culture of incident reporting and a willingness to learn from incidents.
  • Staff understood their responsibilities to raise concerns and report patient safety incidents. There was a robust governance and risk management framework in place to ensure incidents were investigated and reviewed in a timely way.
  • The midwife to birth ratio was 1:28 which was in line with national recommendations and was achieved by the use of temporary staff.
  • Women’s care and treatment was planned and delivered in line with current evidence-based guidance. There was an effective system in place to ensure staff were aware of updated guidelines. National and local audits were carried out and actions were taken to improve care and treatment when needed. The service performed better than the national average in a number of audits.
  • The service met expected patient outcomes for women in most areas, and in some areas exceeded these, for example in having a low rate of planned caesarean sections. The service assessed themselves against external standards in published reports and sought continuous improvement.
  • Trainee doctors and student midwives were very positive about the support and teaching they received from senior clinicians, and mentors, and obstetric training and midwifery posts were sought after.
  • The service managed medicines and women’s pain well. They met the national standards for obstetric anaesthesia.
  • The governance arrangements were systematic and well understood. There was a responsive audit programme clearly focused on improving outcomes for women.
  • Staff engagement was strong and all staff shared the same aims and vision for the service.
  • Women were positive about their care and treatment. They were treated with kindness, compassion, dignity and respect. Women felt involved in their care and were given an informed choice of where to give birth. Actions were taken to improve service provision in response to complaints and feedback received.
  • Women we spoke with were happy with their care and praised staff for being inclusive and supportive. Service provision met the needs of local people. They worked closely with commissioners, clinical networks and service users to plan and improve the delivery of care and treatment for the local population.
  • Leadership was strong, supportive and visible. The leadership team understood the challenges to service provision and actions needed to address them.
  • At the previous inspection, we found poor relations between different groups of staff and a bullying culture. At this inspection, there was a positive culture, which was focused on improving patient outcomes and experience. Staff were committed and proud to work at the trust.
  • The service had a vision of what it wanted to achieve and clear objectives to ensure the vision was met.

However:

  • Staffing levels were often lower than planned and the service relied on bank and agency staff to meet planned staffing numbers. However, staffing levels were regularly reviewed by senior staff and women generally received one-to-one care in labour. Community midwives reported having high caseloads and the staffing needs in relation to the acuity of women were not regularly reviewed. The trust told us they did not provide caseload midwifery, rather they provided group practice care within the geographical area, with allocation to a named midwife clinic. The annual average number of women having post-natal care varies from 700 to 900 women per team.
  • Most areas of the maternity service we visited were tidy but not all were visibly clean during our inspection and we were not assured control were effectively in place to prevent the spread of infection. Women we spoke with said the maternity department was not always clean.
  • We were not assured effective governance arrangements were in place on the ward level to ensure safe storage of medicines and to check storage temperatures daily. Staff did not have systems to identify and replace out-of-date medicines were acted upon, when indicated.
  • There were inconsistencies in the monitoring of emergency equipment to ensure it was safe and effective for patient use.
  • Mandatory training was below the trust target for medical and midwifery staff. Although 94% of senior doctors including consultants had completed their mandatory training which was better than the trust target of 90%.
  • Safeguarding training was below the trust target for medical and midwifery staff. Although junior medical staff achieved 92% on the safeguarding adult level 2 which was better than the trust target of 90%.
  • Maternity specific training compliance did not always meet trust targets, such as cardiotocography (CTG) interpretation. Although staff had completed the CTG training, some had not completed the CTG competency assessment.
  • Not all staff had received an annual appraisal.

Outpatients

Requires improvement

Updated 14 September 2018

We previously inspected diagnostic imaging jointly with outpatients so we cannot compare our new ratings directly with previous ratings. We rated it as requires improvement because:

  • The OPD leadership team advised it did not have any risks on the divisional risk register and did not hold a local risk register. This meant that the department had no sight of any risks within the department which did not reflect our findings on inspection such as staffing levels, paediatric patients being treated in the OPD, and lost or missing records.
  • The OPD leadership team had a plan to improve patient services and an implementation plan in place. Both programmes were in the early stages of being rolled out. The leadership team was new with the clinical lead and acting head of OPD being in post less than 3 months and not yet had the time to make the improvements. This was similar to the last inspection.
  • The matron for the OPD was not responsible for all the clinics that operated out of the department which mean there was lack of oversight across the whole department.
  • Senior managers could not be assured that OPD staff were learning from incidents across the trust. A review of OPD nursing, administrative and phlebotomy staff meetings showed incidents were not discussed.
  • The trust did not monitor waiting times for patients, and this was one of the main concerns raised by patients that we spoke with during the inspection. Patients told us that there waits had varied from 15 minutes to an hour.
  • Staff reported that they did not feel able to report incidents of verbal and physical abuse against them and did not feel they had as they had the same rights as patients. They did not report these incidents at times because they did not think their voice would be heard.
  • Staff felt there were limited opportunities for progression within the OPD as it was a small staff team. Staff also reported there were limited learning and development opportunities and felt they were missing out on professional development. This was similar to the last inspection.
  • Staff we spoke with did not always demonstrate understanding of the safeguarding process. Staff in areas where children under age 18 attended were not aware who held Safeguarding level 3 training.
  • Safeguarding adults level 2 training were below the trust target of 90% for the fracture clinic (86%) and phlebotomy staff (40%). Safeguarding children level 2 level training for phlebotomy staff (81%) was also below the trust target.
  • Mandatory training in key skills for staff within the phlebotomy was below the trust targets of 90% in seven of the eight core areas. The overall completion rate was 50%.
  • There was no clear responsibility of who oversaw the cleaning of the children’s play areas or documentation to support this. Daily clinical and environmental schedules were not available in all the clinics, which meant the trust could not be assured that daily cleaning was being undertaken by staff in outpatients. This was similar to the last inspection.
  • Paediatric resuscitation equipment or paediatric resuscitation medications were not in areas where paediatric patients were seen.
  • There was no baseline acuity tool for nursing staff in outpatient clinic as staffing levels were based on the number of clinic that are run. Senior staff advised that the staffing levels within the OPD clinics were had not been reviewed whilst the number of clinic operating had increased. This was similar to the last inspection.
  • We did not see any evidence of appropriate tools for patients that were non-verbal, with learning disabilities, or dementia. In the pain management clinic there were no standardised pain assessment tools available.
  • Nursing staff we spoke with reported there were some limited learning and development opportunities, but frequently they were unable to attend due to staff shortage and there was not cover.
  • Across the OPD we saw little evidence of health promotion information available for patients.
  • During the inspection we observed that people could be over heard when reception staff checked people’s personal data on the electronic record, there was no signage asking people to wait at a discrete distance from the reception.
  • The outpatient department did not have a dedicated room that could be used when breaking bad news or holding private conversations.
  • Signage in the department was not always clear; it was not always clear where patients should sit in the main waiting areas. We also observed that patients were getting lost as some of the signage directing patients to clinics were not clear.
  • There were very few information leaflets for patients, relatives and carers available in other languages other than English. This was similar to what we found at the last inspection.

However:

  • The Trust was meeting the cancer waiting times for people seen within 2 weeks of an urgent GP referral performing better than the 93% operational standard for the period January to December 2017 for people being seen within two weeks of an urgent GP referral. Performance deteriorated in the latest two quarters from July to December 2017 although it was still above the operational standard.
  • The trust was meeting the referral to treatment time of seeing patients within 18 weeks. From March 2017 to February 2018 the trust’s referral to treatment time (RTT) for non-admitted pathways was consistently better than the England overall performance. The latest figures for February 2018 showed that 92.6% of patients were treated within 18 weeks versus the England average of 88.9%.
  • Staff described good team and peer support; they felt they worked well as a team. We observed good interactions between nursing, administrative, medical staff, patients and relatives working together to achieve good outcomes for patients.
  • We found that suitable arrangements were in place for the secure storage of prescription sheets and FP 10’s prescription pads as these were locked away at night and put into rooms at the start of clinics.
  • Records reviewed showed evidence that consent was gained for care and treatment where appropriate.
  • Staff were aware of their roles and responsibilities under the Mental Capacity Act 2005 (MCA) regarding mental capacity assessments and Deprivation of Liberty Safeguards (DoLS). Staff knew how to contact mental health liaison service
  • Staff provided treatment and care in a kind and compassionate way and treated people with respect. Staff were seen to be very considerate and empathetic patients. Patients we spoke with were positive about the staff that provided their care and treatment.
  • Patients who were living with dementia, had a learning disability, or suffered from mental ill health would be identified on their patient records and given priority in clinic to be seen quickly.
  • Staff were able to signpost patients to chaplaincy and counselling to patients who needed them, and nursing staff were available in some clinics to offer support.
  • Patients told us staff helped them to understand their care and treatment, and that medical staff took time to ensure they answered their questions and felt confident in treatment.

Maternity and gynaecology

Requires improvement

Updated 16 December 2016

We rated this service as requires improvement because:

  • We were not assured that the culture of the maternity services, staffing and capacity protected safe patient care.

  • Systems, processes and standard operating procedures in maternity were not always reliable or appropriate to keep people safe.

  • Staff were not confident their concerns were listened to or acted upon.

  • We were not assured that staff were recording incidents correctly or that actions plans were put in place and monitored.

  • Insufficient staffing levels meant midwives did not always provide one to one during labour. Only 80% of patients received one to one care in labour which was not in line with national guidance.

  • We were not assured that patients attending triage were attended to in a timely manner.

  • 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 overall compliance with mandatory training for nurses and midwives in CBU 5 was 82.5% compared to the trust target compliance of 90%.

  • 62% of midwives and 53% of obstetricians had attended multidisciplinary intrapartum care training against a trust target of 90%.

  • The trust was not meeting National Screening Committee targets for antenatal and newborn screening.

  • National specifications for the prevention and control of infection were not always adhered to. There were no cleaning schedules or checklists available in any of the inpatient or outpatient areas we visited.

  • There was no documentary evidence that any patients had a risk assessment to determine their individual risk of developing blood clots, or that this was being monitored.

  • Ambient temperatures of areas where medicines were stored were not monitored which meant that staff could not be sure that the manufacturers’ instructions for storage were followed.

  • We saw care and observation of a person receiving a blood transfusion in the gynaecology inpatient service was not in accordance with national or local guidance.

  • Staff in maternity did not always observe the ‘bare below the elbows’ policy.

  • The trust was offering group sessions for the first antenatal appointment known as the ‘booking’ appointment.

  • Patients did not have a named midwife.

  • We were not assured that the trust was implementing and reviewing audit recommendations.

  • We were not assured that the trust was effectively monitoring the number of stillbirths There was no action plan in place to address the stillbirth rate. The stillbirth rate was 6.7 per 1,000 births in 2015 which was greater than the national average of 4.7 per 1,000. The trust was not using customised growth charts to monitor fetal growth. We were not assured the service was monitoring and evaluating stillbirth rates to make improvements.

  • Multidisciplinary team (MDT) working was not always effective in the maternity service.

  • Patients’ privacy and dignity were not always protected.

  • Staff did not always address patients in an appropriate manner.

  • Patients, partners and relatives did not always feel involved in their care.

  • There were long waiting times in triage. We saw that a patient waited for 50 minutes before being seen. Staff told us that patients can be in triage for up to seven hours in labour due to the lack of capacity or the willingness of the midwives on labour ward to accept women.

  • Staff told us patients using the gynaecology service were generally seen promptly for treatment, however, this was not formally monitored.

  • The leadership, governance and culture did not always support the delivery of high quality person centred care. Leaders did not have the necessary experience, knowledge, capacity, or capability to lead effectively.

  • There was no clear vision and strategy for the maternity and gynaecology service. Staff could not tell us of future plans for the maternity service; however outpatient gynaecology staff described the relocation of their services to more suitable accommodation.

  • 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.

However:

  • Staff were trained to the appropriate level in safeguarding adults and children and were aware of their responsibilities to ensure patients and children were protected from abuse and avoidable harm.

  • In gynaecology, there were systems in place to recognise and manage deteriorating patients. Appropriate triggers were in place to ensure patients who had deteriorated were treated according to their clinical needs.

  • During the reporting period there were no reported incidents of hospital acquired infections.

  • All clinical staff had access to a microbiologist and specialist infection prevention and control nurse when required.

  • Staff were observed in the correct use of personal protective equipment.

  • Staff had access to and used evidence-based guidelines to support the delivery of effective treatment and care.

  • Termination of pregnancy for fetal abnormality was offered in line with legal requirements and professional guidance.

  • Women we spoke with felt that their pain had been well managed. Epidurals were available over a 24-hour period.

  • Access to medical support was available seven days a week. Community midwives were on call 24 hours a day to facilitate the home-birth service.

  • 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.

  • A bereavement midwife saw all patients who experienced pregnancy loss, including visits at home if required.

  • The trust had a chaplaincy team who were available to provide pastoral and religious support to patients and their families.

  • The maternity service was flexible and provided choice and continuity of care. Patients’ individual needs and preferences were considered when planning and delivering services.

  • The individual care needs of women at each stage of their pregnancy were acknowledged and acted on as far as possible. There were arrangements in place to support patients with particular needs.

  • Complaints about maternity and gynaecology services were initially managed and resolved locally. If complaints could not be resolved at ward level, they were investigated and responded to appropriately.

  • Guidelines we reviewed were in date, reflected current NICE guidance and best practice, and included evidence of learning from SI reviews.

  • There were good clinical working relationships between the medical staff.

  • The trust participated in the North Central London Maternity Services Liaison Committee (MSLC), a specialist user involvement forum which brought together users and health professionals to develop women-centred maternity services.

Medical care (including older people’s care)

Requires improvement

Updated 14 September 2018

  • We identified there were gaps in 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.
  • Learning from incidents was not robust.
  • Staff told us they often did not have any pumps for pressure-relieving mattress in the equipment library.
  • There was variation in the quality of records.
  • The trust had scored worse than expected in The National Cancer Patient Experience Survey with only 15, out of 59, responses similar to the England average.
  • The trust did not meet NICE guidance on falls assessment and prevention (2013) and delirium (2010) and National Patient Safety Agency (NPSA) guidance on the prevention and management of inpatient falls.
  • Mental capacity assessments were not always appropriately documented.
  • The trust did not have a good oversight over how many patients were placed on Deprivation of Liberties Safeguards authorisations (DOLS).
  • Discharge processes, length of stay and general bed management needed improvement.
  • There were a high proportion of patients remaining in hospital over 21 days.
  • The trust did not meet their target to investigate and close complaints.
  • There was a lack of joined up oversight and actions taken to improve areas of concern.
  • The governance around monitoring risk assessments, action plans delivery, responses to complaints and investigating incidents was not sufficiently robust.

However:

  • The trust reported 57% reduction of hospital acquired pressure ulcers (grade 3 and above) since the ‘harm free panel’ was established.
  • Results in the 2016 Heart Failure Audit were better than the England and Wales averages for two of the four of the standards relating to in-hospital care.
  • The hospital organised a number of GP hotlines to provide direct access to specialist advice.
  • There was a medical day hospital, which provided rapid, multi-disciplinary assessments for elderly patients.
  • Patients felt they were treated with courtesy, respect and compassion by staff.
  • The trust’s referral to treatment (percentage within 18 weeks - admitted performance: RTT) performance exceeded the England average between January to May 2017.

Surgery

Good

Updated 14 September 2018

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

  • The trust had dealt with areas we highlighted as needing to be improved in our previous inspection in September 2016. For example, in our previous report we reported that patients with pressure ulcers had not had the incident electronically logged. During this inspection we found he trust had not had any incidents of grade 3 or 4 pressure ulcers in the previous 12 months. However, staff were aware of the procedure for logging pressure ulcers as incidents.
  • In our previous report we reported that the reporting of actions from mortality and morbidity meetings was not formalised to allow learning and actions shared across the trust. During this inspection we found the trust had introduced actions logs and a named member of staff had responsibility for disseminating information across the trust.
  • There was evidence of learning from ‘Never Events’ and incidents. In our previous report dated September 2016 we reported that actions in response to never events were not fully implemented. However, during this inspection we found the trust had addressed this and clear action plans were in place and monitored by the trust.
  • Records were complete, well managed and stored securely. During our previous inspection, we found there was a lack of clarity in how changes to theatre lists were communicated to doctors and theatre staff. During this inspection we found this had improved as theatre lists indicated any changes implemented to the lists following dissemination to staff.
  • During our previous inspection we reported that the hospital did not comply with national guidance, Health Building Note 26 (HBN 26). However, work was in progress on a review of the catheterisation laboratory (cath lab) location to ensure the hospital met the requirements of HBN 26.
  • In our previous inspection in September 2016 we reported that theatre utilisation was low. In response theatres were monitored to determine reasons for delays. For example, theatre start and finish times were monitored.
  • In our previous report we reported that the departmental risk register did not fully indicate
  • how risks were mitigated and who was responsible for implementing actions. However, during this inspection we found the risk register contained mitigation of risk and a named person with responsibility for the risk.
  • We also found that staffing was sufficient to meet the needs of the patients. Staff moved across surgical services to ensure safe nursing staffing levels could be maintained. The trust used locum staff where required, there had been no unfilled medical shifts in the previous 12 months.
  • Patients and relatives told us they felt involved in decisions about their or their loved-ones care and treatment. We spoke to 12 patients across the surgical wards who felt the staff were friendly and listened carefully to their needs.
  • Patients’ needs were assessed and care was evidence based. Care delivery reflected national best practice guidelines. The trust had introduced a range of new clinical pathways since our previous report in September 2016.
  • Patients’ outcomes were monitored and compared with similar services. The service contributed to national clinical audits. This had resulted in theatres reporting 100% compliance with the WHO checklist.
  • The service contributed to national clinical audits for surgery. The overall performance for elective admissions was better than the England average.
  • There was good multidisciplinary working within different speciality surgery services. Staff from the surgical assessment unit (SAU) attended bed meetings with staff from the emergency department (ED). Risk assessments were reviewed at the meetings for all ‘outlier’ patients; these are patients who are in hospital wards that do not provide specialist care for their conditions.
  • Most staff had received annual appraisals. From February 2017 to January 2018, 90% of staff within surgery at the trust had received an appraisal compared to a trust standard of 90%.
  • Patients pain was managed effectively. The staff told us they had good access to pain management advice from the trust’s acute pain service following patients’ surgery.
  • Staff were caring and compassionate to patients’ needs. For example, from February to April 2018 Ward S3 achieved a response rate of 58%, with 100% of these patients responding they would recommend the service.
  • Patients we spoke with feedback were continually positive about staff and the care they received.
  • Patients received care that was centred on their individual needs. The trust had good support arrangements for patients with additional needs.
  • Divisional and team leaders had the capacity and capability to run a service providing quality sustainable care.
  • There was a strategic vision for surgery. The surgery and cancer division had produced divisional objectives for 2018 and 2019.
  • There was a supportive, honest and open culture among staff. Candour, openness, honesty and transparency were evident throughout the service.
  • There was an effective governance structure in place. There was a divisional dashboard which included all key performance indicator (KPI) metrics. A divisional performance report was produced monthly and shared with the trust’s board.

However:

  • We found training compliance was not meeting the trust’s standards in some mandatory training modules. For example, 54% of staff had completed PREVENT, this is training to identify and prevent radicalisation.
  • During our previous inspection we reported that Individual venous thromboembolism risk
  • assessments (VTE) were not fully completed. During this inspection we identified that staff were still not recording VTE assessments fully. However, in mitigation the trust had identified this and work was in progress on the rolling out of new VTE assessment tools to simplify recording processes.
  • In our previous report dated September 2016 we reported bowel cancer patients’ related data suggested the risk-adjusted two-year post-operative mortality rate was much higher than the national average. Staff said the trust was of the opinion that there were discrepancies with the trust’s data submissions. In response a data clerk had been appointed in 2017 to rectify the issue. The trust also highlighted that individual surgeons had published mortality outcome measures that fell within accepted ranges.
  • During our previous inspection we reported average length of stay at the hospital was longer than the England average for elective trauma and orthopaedics, general surgery and urology patients. The trust said this was due to a coding issue and procedures in coding had been changed in response. However, the change in procedure wouldn’t be reflected in results until 2018 data was published.
  • Signage on lifts and corridors in the hospital’s tower block did not direct patients, staff and visitors to the correct surgical service.
  • Complaints were not always closed in accordance with timescales set out in the trust’s complaints policy.

Services for children & young people

Requires improvement

Updated 14 September 2018

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

  • The service was not meeting the trust target for mandatory training compliance. The overall completion rate for nursing and midwifery staff in services for children and young people was 78% which did not meet the trust target of 90%. The target was also not met for paediatric junior medical staff, with a compliance rate of 73%.
  • There was not always an advanced paediatric life support (APLS) trained staff member on shift. This was not in line with guidance from the Royal College of Nursing.
  • There was a high vacancy rate and high turnover rate for nursing staff. From February 2017 to January 2018, the trust reported a vacancy rate of 18.4% in children’s services. This was higher than the trust target of 7.5%. In the same period the trust reported a turnover rate of 24% in children’s services, compared to the trust target of 15%.
  • The service had a backlog of patients who required follow up appointments but were unable to book into outpatient clinics.
  • We noted from the meeting minutes of the children’s board in May 2018 that the changes relating to oversight of young people age 16 to 18 were only very recent changes.
  • The service faced challenges in providing care for children and young people who presented with mental health conditions. There was often a delay in accessing child and adolescent mental health services (CAMHS), particularly at weekends as they only worked 9am-5pm Monday to Friday. If a child was admitted on a Friday afternoon they would be likely to be there until at least the following Monday. The divisional risk register detailed this risk and the trust were working with the local CCGs and mental health trust to address the issues.
  • There was a board level lead for children’s services in line with the Department of Health National Service Framework for Children.
  • Whilst the service had introduced a children’s board since the last inspection, the board had not met regularly. There had been only three meetings, with no meeting between June 2017 and May 2018.

However:

  • We saw evidence of good multidisciplinary team working. Clinical teams worked well together to provide patient-centred care.
  • Staff treated patients with kindness, dignity, respect and compassion. Feedback from parents and carers was positive. Staff were sensitive to the needs of children and young people, and their families.
  • During the last inspection, we found that the trust did not have sufficient oversight of the care and treatment of 16-18 year old people, particularly in relation to them as inpatients. The trust policy was still that these patients were admitted to adult wards, however they now included the identification of these patients as part of the daily bed meeting. Staff told us that paediatricians and children’s nurses were involved in their care if required. Staff also told us that the adult wards had new guidance to ensure that staff knew what to do should they require support from paediatric staff.
  • The service achieved 97% for the 18-week referral to treatment standard from April 2017 to March 2018.
  • During our last inspection we found there was a lack of specialist nursing staff to provide effective asthma and allergy clinics. There was now an additional whole time equivalent (WTE) allergy nurse who had been in post for 6 months in addition to the 0.8 WTE nurse. The service also had two GPs with a special interest (GPSIs) in allergies on the team.
  • The trust had a community children’s nursing team which included clinical nurse specialists who undertook home visits and school visits, and held community outreach clinics.
  • At the last inspection we found that there was no children’s board. However, since the last inspection the trust had created a children’s board which reported to the clinical quality and patient safety committee.

End of life care

Requires improvement

Updated 14 September 2018

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

  • The SPCT operated Monday to Friday 9am until 5pm. During our previous inspection, they were working the same hours; this does not follow national guidance which states a seven day face to face service should be provided for palliative and EOLC patients. The trust had approved a business case to allow this service to comply with national guidance, however the SPCT was still to fully recruit.
  • We found cleaning fluids that should not be in use following a European Directive, were still being used by the trust. Sharp and dangerous items were being washed by hand in this disinfectant and this posed a health and safety risk. There were no risk assessments, SOP’s or IPC policies associated with the mortuary. Items of equipment were being reused, when disposable items were available and should have been used.
  • Within the mortuary, we found specimens stored in formalin were being kept in a non-ventilated room with no immediately accessible fire extinguisher. We were informed an IPC assessment and a risk assessment of the mortuary would take place as soon as possible.
  • Palliative and EOLC patients not under the care of the SPCT did not always have a mental capacity assessment (MCA) completed prior to a do not attempt cardio pulmonary resuscitation (DNACPR) order being considered.
  • Not all palliative or EOLC patients were given a treatment escalation plan (TEP). The SPCT also felt they needed to improve their processes to ensure all palliative and EOLC patients were offered advanced care planning (ACP) options to ensure they achieved their preferred place of care (PPC)/ preferred place of death (PPD).
  • Psychological support was available to all patients that were palliative and end of life; however, patients with cancer were offered counselling as a separate service and those patients with a terminal non-cancer diagnosis were offered counselling with the SPCT or chaplaincy instead. This was not an equivalent service and therefore non-cancer patients did not receive the same level of psychological care as those with a cancer diagnosis.
  • The chaplaincy and faith provision within the trust was mainly available for Christian and Muslim faiths. Some other religions were catered for by way of a religious script, however this was not always seen or available. We commented on this during our previous inspection, however no changes had been made.
  • We noted during our 2016 inspection that the multi-faith room was used as a trust meeting room. This meant it was unavailable to those who may have required access at various times. We brought this to the attention of the chaplaincy, however, we found on this inspection the room was still being used for meetings.

However:

  • Incidents and complaints for palliative and EOLC were being recognised by the trust and the SPCT. They had worked with the complaints team to capture trigger words that would send the incident to the SPCT. They were reviewed, investigated, and the learning was disseminated to the rest of the team and the trust. This was an improvement since our last inspection.
  • The trust had introduced innovative approaches to improve care; this included a flickering LED candle and an explanation being placed on the reception desk of each ward that had an EOLC patient. This alerted other people to the situation so that they were more mindful and would keep the ward more peaceful for the patient and their family.
  • Controlled drugs (CD’s) and syringe drivers were appropriately maintained, stored and used by the SPCT and wards. The CD’s were checked daily and in line with national guidance.
  • Pain relief was available as and when required by all palliative and EOLC patients. To cover out of hours situations, the SPCT did anticipatory prescribing for their patients as appropriate.
  • Since the 2016 inspection, the speech and language therapists (SLT) team had become more involved with patient care and decision making than before. They were more involved with palliative and EOLC patients.