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North Middlesex University Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 December 2016

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

Inspection areas

Safe

Requires improvement

Updated 16 December 2016

Effective

Requires improvement

Updated 16 December 2016

Caring

Requires improvement

Updated 16 December 2016

Responsive

Requires improvement

Updated 16 December 2016

Well-led

Requires improvement

Updated 16 December 2016

Checks on specific services

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 16 December 2016

We rated this service as requires improvement because:

  • Staff understood how to report incidents, however these were not always reported through the online reporting system and there appeared to be no formal process for feeding back to staff. Mortality and Morbidity review meetings did not always identify action points or lessons learnt.
  • 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.
  • There were adequate supplies of personal protective equipment (PPE); however staff did not always wash their hands between patients and wear gloves or aprons.
  • Staffing levels on the wards did not always reflect the safer staffing acuity tool to determine safe staffing levels.
  • Nursing staff we spoke with did not know about the settings for the pressure relieving mattress. They were unable to tell us how they set them up and staff showed no understanding of what the warning lights meant.
  • Compliance with mandatory training was below the trusts target for infection prevention and control training, health safety and welfare, information governance, safeguarding, safeguarding children and fire safety.
  • The trust participated in national audits which showed the trust’s performance was below the national targets and the hospital was achieving variable outcomes for patients compared with the national average. These included the Sentinel Stroke National Audit Programme (SSNAP), the Myocardial Ischemia National Audit Project (MINAP), and the National Diabetes Inpatient Audit (NaDIA).
  • At weekends a consultant was only available on site from 9am to 8pm to see new admissions and seriously ill patients. However, outside of these hours an on-call consultant provided cover.

  • Food and fluid charts were in place for patients who required monitoring, however we found that staff had not always completed these charts appropriately and accurately which could affect patients' care and treatment. Feeder cups and meals were not always left within easy reach of patients.
  • Staff knowledge of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberties Safeguards was variable. Mental Capacity Act 2005 (MCA) and DoLS training was not part of the trust’s mandatory and statutory training programme. We saw that patients' Deprivation of Liberties Safeguards (DoLS) applications had expired and patients were still subject to restraint. Staff did not always ask patients permission before care or treatment was given.
  • We spoke with 39 patients and their relatives about their experience. The feedback from patients indicated staff were not providing good care and treatment.
  • Patients were not treated with dignity and respect; we observed staff speaking unkindly and in a patronising way to patients.
  • Nursing staff and doctors did not always introduce themselves or tell the patients what they were doing.
  • Feedback from relatives was mixed.
  • We found no evidence of activities such as cards, games or puzzles on the care of the elderly wards.
  • We looked at 15 sets of patient records. We found that nursing assessments and care plans were mostly incomplete. This meant that patients' care needs were not all identified and that patients could be receiving care that was not appropriate to their needs.
  • The percentage of patients that started consultant led treatment within 18 weeks was consistently lower that the England average of 90%.
  • The trust reported the total number of bed moves across the medical wards at night between the hours of 10pm and 6am was 315. The largest number of moves involved patients in general medicine 54.6% (172) and care of the elderly 16.5% (51).
  • The average length of stay was longer (6.1 days) than the England average (3.9 days) for elective care between March 2015 and February 2016.
  • Staff we spoke with told us that they rarely had feedback about complaints or learning from them.
  • The trust had a dementia strategy in place; however, of the 23 action points seven had been completed and 16 remained outstanding. The trust had not prioritised the dementia strategy; however since the arrival of the new executive team this was beginning to change.
  • Complaints were discussed at monthly clinical governance meetings. We saw that complaints were monitored and outcomes recorded with details of action points and learning identified. However,Monthly ward meetings did not disseminate learning from incidents or complaints.
  • The trust had a zero tolerance policy for staff speaking in languages other than English. We observed this on some wards and saw no action was taken to address this.
  • Staff we spoke with that worked on Pymmes Zero ward told us that they had not been involved in any of the refurbishment plans to make the ward dementia friendly. However, we were told by the trust that the ward manager and matron for Pymmes Zero ward had been involved in planning the refurbishment.

However:

  • Most staff were aware of their responsibilities under duty of candour.
  • 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.
  • Staff had access to the trust’s safeguarding policy via the trust intranet and knew how to access the safeguarding team for advice and guidance when required.
  • Multidisciplinary (MDT) working was evident on medical wards. There was evidence of an MDT approach to discharge planning. Patients had access to the full range of allied health professionals such as speech and language therapists, dietitians, tissue viability and diabetic nurses.
  • Endoscopy, diagnostic services including imaging, physiotherapists and occupational therapists and pharmacy services and laboratory were available seven days per week.
  • Most staff had received an appraisal. The trust reported 84.5% of nursing staff within the medical services had received an appraisal. This was above the trust target of 80%.
  • Patients we spoke with told us they felt involved in their care and understood their treatment and care plans.
  • The trust used the Friends and Family Test (FFT) to gather patients’ views on whether they would recommend the service to family and friends. Overall, these showed satisfaction with the service, with the medical wards ranging from 58% to 100% during the period.
  • The hospital admitted patients for the day so that they could undergo tests. Relatives either brought patients in or the hospital arranged for patients to come via the patient transport service.

  • Staff in endoscopy had identified Turkish, French and Polish as the most commonly spoken languages other than English amongst their patients. To meet their needs information leaflets about preparing for endoscopic procedures were available in these languages.
  • Staff told us that some members of the new executive team were visible on the wards, some staff we spoke with felt more confident that things were changing.
  • The leadership team responsible for the endoscopy unit had included staff at all levels in plans for the temporary move of the unit, including how the unit would operate on their return after the refurbishment.

Urgent and emergency services (A&E)

Requires improvement

Updated 16 December 2016

We rated this service as requires improvement because:

  • Staffing remained fragile as it relied on a large amount of agency doctors to fill shifts. At the time of our inspection there were a number of temporary doctors working in the department including two doctors who were on short term secondments from other trusts.

  • 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.
  • Staff recorded incidents but were unclear about how learning was shared from these incidents.
  • Staff did not have sufficient understanding of the needs of patients living with dementia and those with a learning disability.

However:

  • Substantial improvements have been made since the last inspection in May 2016.
  • There was clear nursing and medical leadership visibility within the department, and staff felt able to highlight issues to them. The governance arrangements were clear to staff we spoke with.
  • There was improved clinical governance and leadership at department level and oversight of this at trust level.
  • There was an effective nurse led clinical assessment and ambulance triage process in place.
  • There was an increase in consultant and middle grade doctors and an increase in night time medical cover, since our last inspection.
  • Patient records were easily accessible.
  • Patients told us that staff were compassionate and respected their dignity and privacy.

Surgery

Good

Updated 16 December 2016

We rated this service as good because:

  • All observed interactions between staff and patients were positive. Feedback from patients and relatives was good and they felt they were treated with courtesy, respect and compassion by staff. Staff maintained patients’ privacy and dignity.
  • Patients’ nutritional needs were assessed and catered for appropriately.
  • Patients were supported with pain management and said someone regularly checked them to ensure they were comfortable and they were offered pain relief when needed.
  • Patients had access to an immediately available, fully staffed emergency theatre and a consultant 24 hours a day.
  • All staff we spoke with demonstrated a good awareness of policies and how to access them. Local policies and guidelines were based on appropriate national guidelines
  • The hospital consistently met the referral to treatment standard and performed better than an average English hospital.
  • The hospital participated in national audits such as joint registry, national hip fracture, and the national emergency laparotomy audit. The hip fracture audit indicated the hospital performed better than the England average for patients undergoing surgery within 36 hours of admission. The indicator related to patients admitted to an orthopaedic ward within four hours was significantly better than the average for London hospitals. The hospital performed better than the England averages for two of the three knee-replacement indicators.
  • Staff had access to data which supported service quality monitoring and they were able to use it to inform service delivery.
  • The rate of cancelled operations was consistently lower than the England average and if cancelations occurred, all patients were treated within the subsequent 28 days.
  • There were no delays in patient transfers from recovery to the ward. Most surgical patients were treated on surgical wards.
  • The hospital had developed innovative pathways where surgical patients could avoid re-admission by involving the ‘hospital at home’ team and surgical assessment unit in their care.
  • There were daily preoperative assessment clinics with a walk-in service available to all patients.
  • We observed good multidisciplinary team working across the department.
  • There was effective and well embedded clinical governance structure.
  • The local leadership was well established and could provide sufficient oversight of activity within the division. The division had a local annual strategy which reflected departmental needs.
  • Staff felt positive about the changes in the trust’s senior management team and said communication and organisational culture was improving. They felt respected and valued by the managers and matrons.
  • There were sufficient staffing, including doctors, nurses and theatre staff to meet patients’ needs.
  • We observed that there were effective infection prevention and control measures in place. We saw staff practice appropriate hand hygiene. The hospital was clean and there was a low rate of surgical site infection. There were no hospital acquired MRSA infections reported for the surgery division in 2015/2016.
  • In elective and non-elective treatment cases, the observed emergency readmissions rate was within expectations.
  • Emergency medicines and equipment was available to staff to allow prompt response in emergency.

However:

  • The departmental risk register did not fully indicate how risks were mitigated and who was responsible for implementing actions.
  • Actions in response to the never event were not fully implemented.
  • Patients with pressure ulcers had not had the incident electronically logged despite staff’s awareness of the requirement of recording pressure ulcers. They did not routinely raise a safeguarding alert in cases were a patient acquired a severe avoidable pressure ulcer during their stay at the hospital.
  • The hospital did not comply with the national guidance which recommends that the ratio of recovery beds to operating theatres should not be less than two.
  • Bowel cancer patients’ related data suggested the risk-adjusted two-year post-operative mortality rate was much higher than the national average. The clinical audit related to patients admitted with hip fracture in 2015 indicated that risk-adjusted 30-day mortality rate, although significantly better than during the previous year, was worse than expected.
  • None of the nursing staff working on surgical assessment unit completed advanced life support training. The Resuscitation Council recommends that all staff working in acute areas complete advanced life support training.
  • Reporting of actions from mortality and morbidity meetings was not formalised to allow learning and actions to be captured and shared across the trust.
  • Individual venous thromboembolism risk assessments (VTE) were not fully completed.
  • The pharmacy team did not meet their 2 hours target for average waiting time for a patient discharge prescription.
  • Average length of stay at the hospital was longer than the England average for elective trauma and orthopaedics, general surgery and urology patients. It was also longer than the England average for non-elective urology.
  • The utilisation rate for operating theatres was low and the hospital needed to improve efficiency within theatres.

Intensive/critical care

Requires improvement

Updated 16 December 2016

We rated this service as requires improvement because:

  • There was inconsistent learning and evidence of change management from clinical incidents. There was also limited evidence of learning or improvement following audits, complaints, patient feedback and morbidity and mortality meetings.
  • We found good infection prevention and control audit practices were in place but staff practice during our inspection did not always reflect this.
  • Nurse staffing levels could be unpredictable and did not always meet national guidance. Safety checks on agency nurses were inconsistent and poorly managed.
  • Levels of mandatory training did not meet the trust’s minimum target.
  • Multidisciplinary team working was of a high standard but low levels of staffing meant the unit could not meet the requirements of the National Institute of Health and Care Excellence (NICE) in relation to the rehabilitation of patients.
  • Patients and relatives had provided consistent feedback on variable communication and involvement by clinical staff. This included a lack of consistency between nurses and occasions where they felt staff were unfriendly and unapproachable.
  • There were limited resources on the unit for patients with dementia or learning disability. Staff knowledge was variable, including amongst nurses in relation to consent and mental capacity.
  • Out of hours discharges were significantly higher than the national average and clinicians actively tried to avoid discharging patients at a weekend due to short staffing on inpatient wards.
  • Staff morale was variable and we received a number of complaints about bullying and victimisation.
  • Staff morale was variable and we received a number of complaints about bullying and victimisation. We saw little evidence the senior team had taken appropriate action to address these concerns and staff we spoke with told us they lacked confidence in the trust's human resources department.

However:

  • Care and treatment was consultant led and medical staffing levels met national best practice guidance.
  • Medicines management was of a high standard, with consistent input and safety oversight from a dedicated pharmacist.
  • Staff used the national guidance of a number of organisations to benchmark their practice and to ensure care and treatment was safe.
  • A new practice development nurse was in post, which would significantly improve oversight of staff training and competency checks.
  • New training had been provided to staff in the care of patients with dementia and in communication skills. Both programmes were implemented in response to patient and relative feedback and aimed to improve quality of service.
  • Rates of delayed discharges were significantly lower than the national average.
  • The senior team had a clear vision and strategy for the unit and its staff team for 2016/17, which addressed staff turnover and skill mix.

Services for children & young people

Requires improvement

Updated 16 December 2016

We rated this service as requires improvement because:

  • 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.

  • Although some young people in transition had been consulted on their transition to adult services, audits to fully capture the voices of children and young people had not been undertaken.

  • There were some ongoing issues with staffing levels and only 56% of the nurses in the neonatal unit were qualified in that speciality.

  • There was poor oversight of patients with learning disabilities who were not identified on admission.

However:

  • This service provided generally good care to children and babies within good standards of accommodation where the environment in which children were cared for was reflective of their needs.

  • 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.

  • There was a good level of safeguarding awareness among staff we spoke with.

  • We saw that there was excellent multidisciplinary team (MDT) working and clinical teams worked collaboratively to enhance the provision of care to children. Parents told us that they were fully involved in the care delivered to their children and that health care professionals kept them informed at all times as to the progress of their individual children.

End of life care

Requires improvement

Updated 16 December 2016

We rated this service as requires improvement because:

  • The Royal College of Physicians states there should be a minimum of 1 WTE palliative care consultant per 250 beds. This means the trust was not meeting the minimum requirement set out as it only has a total WTE of 1 for 384 acute adult inpatient beds.

  • NICE guidance for EoLC staffing stated a seven day service should be provided for EoLC, however this had not occurred. A business case was awaiting review.
  • Complaints regarding the palliative or end of life care service were not being coded correctly, therefore there was a lack of awareness of concerns or complaints.
  • Incidents were recorded on the electronic reporting system used by the hospital although the same type of incidents reoccurred on a number of occasions. This suggests no learning was taken from the incident to prevent it reoccurring.
  • There was no clear EoLC strategy. The specialist palliative care team (SPCT) were aware of improvements required within their service however they felt these were due to trust financial constraints.
  • There was inconsistency found in DNACPR audits and no clear action plan to address the issues found.
  • Bereavement surveys were not carried out, therefore the trust could not monitor or benchmark its performance against other providers. The trust was now collaborating with other partners to introduce a London wide questionnaire, however this was still in the initial stages.
  • Mental capacity forms were not always completed for patients that lacked capacity and had a DNACPR order completed which was against trust policy.
  • Advanced care planning was not always taking place for patients and this was recognised by the trust as an area for improvement.
  • The risk register had only recorded one risk, although there were other concerns identified during our inspection. The risk register was not kept up to date.
  • We observed poor patient care and felt this was improved but not to a standard that was fully appropriate.

However:

  • Pain was managed appropriately and in a timely fashion. Records showed patients were monitored for signs of deterioration by completion of the national early warning score (NEWS) tool.
  • The mortuary had clear records and traceability for deceased patients.
  • Bereavement officers were compassionate towards bereaved relatives and were able to give good advice and guidance.
  • A minimum of 50% of registered nurses on every ward had received some form of training from the SPCT. This was the trust target.

Outpatients

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.